Surgery in Elderly People
SURGERY IN ELDERLY PEOPLE
Surgery on elderly people was once uncommon, but as the population has aged it has become much more frequent. There has also been a change in who is thought of as old, and studies based on someone sixty-five years old provide incomplete insight into the issues surrounding appropriate therapies for the ‘‘new’’ geriatric patient.
The traditional view of risk for surgical procedures has focused more on chronological than biological age. Advanced age has generally been considered to carry a higher risk of illness and complications (morbidity), and of death (mortality). In consequence, life-saving procedures such as cardiac, vascular, or oncology procedures can be delayed or withheld. However, relying on age alone to determine a patient’s response to surgery can be inappropriate.
Chronological age can, of course, serve as a marker for increased physiological frailty. Frail older adults (the ‘‘new’’ geriatric patient) frequently suffer from multisystem disease, several comorbidities, and polypharmaceutic regimens (an excessive number of medications). Frailty implies not just lower reserve capacity, but also an interaction of social and medical problems. In consequence, the decision to perform surgery should be multidisciplinary in nature, encompassing not only the suitability to withstand the stress of surgery, but also the rehabilitation and social supports required for hospital discharge.
Anesthetic considerations and operative issues
Complications seen in frail elderly people ore more often multifactorial than specific to any given process or organ system. Age-related anatomic changes (decreases in body surface area), physiologic changes (reduced cardiac function), and metabolic changes (e.g., reduced ability to metabolize and clear drugs) increase the risk of overdosing of any medication, including anesthetics. This leads to longer recovery from drugs, increased delirium (see below), poor mobility, and longer stays in an ICU or hospital setting.
It is uncertain whether regional anesthesia alters perioperative survival or reduces anesthetic-related complications. However, the use of anesthetic techniques that allow patients to remain conscious (such as spinal, epidural, or regional blockade) are increasingly being used in minor procedures, such as hernia repair, and major surgery, such as hip and arm procedures, carotid endarterectomy, and procedures in the lower abdomen and pelvis. Nevertheless, it is important to note that regional techniques can produce the same problems with blood pressure (hypotension) and stress to the heart as general anesthesia, and therefore are not without risk.
Less invasive surgery. Current trends in surgery are increasingly moving towards minimalization. ‘‘Keyhole’’ surgery using fiber-optic cameras, less radical tumor resections with utilization of adjuvant radiotherapy and chemotherapy, and cardiac procedures performed on a beating heart (off-pump surgery) are a few examples. The desired effect of this technological advancement is to reduce intraoperative risk, the trauma of the invasive procedure, postoperative pain, infective complications, and length of hospital stay.
Atypical symptoms and impaired inflammatory responses. Older adults frequently have a reduced capacity to mount the normal immune/ inflammatory response when confronted with injury, infection, or disease (e.g., eroding peptic ulcer, pneumonia). This manifests as a fever or pain as the inner surface of the thoracic or abdominal cavity becomes inflamed. In consequence, disease presentation in older adults can be subtle. With reduced ability to generate an inflammatory response, older adults often present later in the disease process, and they may not demonstrate the normal progression of the disease process. For example, an elderly patient who initially presents with early diverticulitis (inflammation of outpouches in the colon) may not demonstrate progressive symptoms until the point where a diverticula becomes necrotic and perforates. Patients with low physiologic reserves typically decompensate rapidly, and subsequently face a higher risk of a surgical emergency. In consequence, careful vigilance by the nursing staff and physicians via serial physical examination and bloodwork has the potential to reduce a delayed surgery, and thus reduce morbidity and mortality. In addition, the mortality rate is lower when certain elective procedures (e.g., major vascular surgery) are performed after the appropriate cardiac workup.
In addition to reduced inflammatory responses, comorbidities such as diabetes and hypertension are more prevalent in elderly people. These disease processes can produce a dysautonomia (failing or remodeling of the autonomic nervous system) resulting in altered baroreflex, vasomotor, and cardiac function.
Perioperative pain management
Pain control in older adults carries its own set of challenges. Compared with younger people, older adults typically experience and report less subjective pain. Conversely, they are more sensitive to any side effects of analgesics and narcotics. Monitoring of pulse, blood pressure, respiratory rate, and mental status are therefore important when administrating opiates. Adequate pain management should utilize a multidisciplinary approach involving anesthesia, acute-pain team services, and nursing and pharmacy support.
Adequate pain control is important for many reasons. A decrease in ventilatory function, partly due to splinting (the inability to take a deep breath due to incision discomfort), is often experienced after thoracic or upper abdominal surgery and is exacerbated if there is poor pain management. Pain management helps prevent splinting and thereby enables patients to breath deeply and expectorate more efficiently. This avoids atelectasis (microcollapse of lung tissue involved in respiration) and assists in clearing mucous secretions, which in turn reduces the postoperative risk of pneumonia and hypoxia. Conversely, an overdose of narcotic agents can reduce respiratory drive and level of consciousness, increasing the risk of delirium, hypoxia, and aspiration.
Pain management reduces circulating catecholamines (e.g., epinephrine and norepinepherine) released during the stress of surgery. This lessens cardiovascular demand, which is of particular importance in elderly people with coronary artery disease, in whom it can exacerbate postoperative myocardial ischemia and infarction.
Proper postoperative pain management helps patients walk and rehabilitate early and reduces the length of stay in an acute care setting. However, the response is highly variable between patients, and careful drug administration and individualization is necessary.
Delirium and postoperative cognitive dysfunction
Delirium (an acute state of confusion) is a common complication of surgery in older adults and causes significant anxiety and stress for both patients and their families. Postoperative delirium is characterized by fluctuating levels of consciousness and cognition, often interspersed with episodes of transient lucidity. Characteristically, the sleep/wake cycle is altered through disruption, agitation, slowed locomotion, paranoia, and hallucinations. Postoperative cognitive dysfunction, as measured by psychometric tests, is frequently seen in the elderly perioperatively. The etiology of this impairment is unknown, though it is generally felt to be a transient phenomenon. In some cases, however, (e.g., following some cardiac surgery procedures) cognitive dysfunction can be permanent. Approximately 25 to 50 percent of elderly patients experience some degree of delirium following surgery. The incidence of perioperative delirium increases due to:
- Major cardiac, thoracic and vascular surgery.
- Anesthetic and narcotic overdosing—particularly certain anesthetics, opiods (e.g., meperidine, morphine), sedatives and tranquilizers (e.g., benzodiazepines), and anticholinegics.
- Pre-existing cognitive impairment, such as pre-existing dementia or alcohol abuse.
- Metabolic disturbances, including hypoxia, fluid and electrolyte disturbances, alterations in glycemic control, thyroid disturbances, or impaired renal or hepatic function.
- Prolonged ICU stay, causing intensive care unit psychosis : Noisy ventilator and monitor machinery, anesthetic and opiod use, sleep deprivation, frequent interruptions for nursing care, altered circadian rhythms, and an inability to keep track of time can all contribute to this type of confusion and disorientation.
Agitation is a frequent component of the symptomology of delirium. Patients may cause harm to themselves by removing intravenous catheters, surgical drains, and temporary pacemaker wires, or they may fall and injure themselves when getting out of bed. Other patients experience silent delirium. These frequently unrecognized patients comprise approximately one-third of patients suffering from delirium. They suffer the same disorientation and alteration in consciousness; but they do not display the agitation experienced by others.
The etiology of delirium is often multifactorial, and there is no specific treatment available other than supportive care. Correcting metabolic disturbances, safely minimizing narcotic usage, and reducing interruption in the normal sleep/ wake cycle can minimize confusion and disorientation. Additionally, keeping patient rooms brightly lit, placing a calendar and clock in plain view, and having a family member by the bedside are also important components in reducing delirium.
Occasionally, a patient’s agitation can become a great enough risk that extra precautions are necessary. Constant nighttime attendance (e.g., by a family member or special aide) is often used and is preferable to the use of physical or chemical restraints. Physical restraints have been shown to increase the risk of harm to elderly patients, and therefore should not be used unless absolutely necessary. If adjuvant sedation is required, the uses of antiagitation/antipsychotic drugs (e.g., haloperidol) with low anticholinergic properties are preferable to tranquilizers (e.g., diazepam or lorazepam). Additionally, minimizing exposure to noisy intensive care unit or recovery room environments is often helpful.
Hypertension. How best to control blood pressure around the time of surgery is controversial. Patients with longstanding hypertension may be relatively hypotensive and have low organ perfusion pressures, which would otherwise be considered tolerable by younger patients without hypertension. Additionally, antihypertensive and antianginal drugs such as beta-blockers and calcium channel blockers may not allow a patient to respond appropriately to hypotension and hypovolemia (dehydration), putting them at greater risk of inadequate tissue/organ perfusion.
Common causes of perioperotive hypotension include:
- Hypovolemia. The most common causes of postoperative hypotension are inadequate replacement of intraoperative fluid loss, surgical hemorrhage, or third-space losses (i.e., peritoneal or pleural cavities).
- Sepsis. This complication may occur following abdominal surgery (e.g., intra-abdominal sepsis), burns, wound infection, pneumonia, or urinary tract infections.
- Low Cardiac Output. Many frail elderly patients have limited cardiac reserves and are extremely sensitive to small changes in intravascular volume status. Before surgery, congestive heart failure and myocardial ischemia should be ruled out in patients who have unrevascularized coronary artery disease or known heart failure problems.
- Polypharmacy. Most older adults are on at least one drug preoperatively. Opiates. anti-cholinergics (e.g., antinausea medications) and sedation agents can depress myocardial function.
Renal dysfunction. Kidney function is reliably shown to decrease with age, increasing the risk of renal dysfunction (kidney failure) after surgery. This can be exacerbated by inappropriate fluid administration following a surgical procedure, by the toxic effect of medications used (e.g., NSAIDS, certain antibiotics) or by poor or incomplete bladder emptying due to an anatomical obstruction (e.g., large prostate, blocked urinary catheter tube), or autonomic failure. Drug administration must also account for a reduced clearance due to this reduced renal capacity, and dosages need to be adjusted accordingly.
Complications due to mobility and nutritional problems. Older adults whose mobility is compromised are more prone to complications seen with immobility at any age. They are more likely to suffer from lung microcollapse (atelectasis), which also predisposes them to pneumonia. Similarly, they are more likely to develop blood clots in the legs (deep vein thrombosis) that can break off and travel (embolize) to the lung. This potentially serious complication can aggravate hypoxia and myocardial stress, and can be fatal in some cases.
Nutritional deficiencies that either existed preoperatively or develop after surgery can significantly impact recovery by impairing wound healing, preventing adequate mobilization, and through pressure-sore development. Aggressive nutritional support should be implemented early in malnourished patients, in those with significant complications or infection (e.g., sepsis), and in those who have lost more than 10 percent of their pre-illness body weight.
Decreased mobility predisposes patients to develop pressure sores, in which the skin overlying bony surfaces breaks down and ulcerates. In some cases these can be quite extensive and require debridement and reconstructive repair. In the majority of cases these actions can be avoided through vigilant nursing care, adequate nutrition, and early mobilization and/or physical therapy.
Surgical intensive care
Another controversial and ethically challenging area of geriatric medicine involves patient care in an intensive care setting. Frail, debilitated patients who undergo major surgery typically require prolonged ventilation on a mechanical breathing machine.
Traditionally, age is associated with a greater incidence of negative outcomes and a poorer quality of life for surgery patients who have a prolonged postoperative ICU stay. An examination of this issue was performed by Udekwu et al., using perceived quality of life and activities of daily living survey scores as an indication of value of care, in surgical ICU survivors over seventy years of age. The investigators found that age, by itself, did not increase the level of death experienced in a surgical intensive care unit, and therefore age should not restrict access to critical care. The investigators concluded that while overall functional levels fell for these patients, perceived quality of life was high. Additionally, full dependency (e.g., full-time nursing care) rose only slightly from a baseline level. The status of the whole patient needs to be considered when evaluating the appropriateness of utilization of critical care resources by the older adult.
Early mobilization and comprehensive discharge planning are essential to return elderly patients back to a reasonable quality of life following a surgical procedure. Optimally, this should be a multidisciplinary approach consisting of people who can anticipate the sorts of complications to which older adults, especially those who are frail, are liable.
Directives for rehabilitation should ideally be initiated on admission to the hospital. Issues concerning an older patient’s premorbid state (e.g., physical deconditioning, living alone) and the nature of the procedure are most efficiently dealt with through early involvement of the patient, nurses, allied health professionals (physical therapists, occupational therapists, speech therapists, social workers), psychologists, and family members.
Complications that arise from surgery (e.g., prolonged ventilation, delirium, and cognitive impairment) should not excessively delay early mobilization and rehabilitation. The appropriate use of an interdisciplinary team should be utilized early to help debilitated persons maintain or recover physical capacities.
In many ways, surgical management of elderly patients reflects procedures seen in other areas of clinical medicine. For example, special considerations are also necessary when dealing with the pediatric population or pregnant women. The appropriate study of surgical outcomes in the older adult has been incomplete, however, and care of this growing population has tended to be somewhat marginalized as a result. There is a growing body of knowledge that indicates that outcomes following surgery are not a product of age, but rather of the whole-body physiology of the individual. An increasing life expectancy among older adults mandates a re-examination of the rationalization of health care resources and considerations of quality of life following surgical intervention. To achieve these goals, an approach is required to ensure adequate quality of care and to expedite the return of patients to their baseline level of function and home environment.
Rakesh C. Arora Kenneth Rockwood
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