International Journal of Gerontology
Volume 1, Issue 2 , Pages 89-97, June 2007

Perioperative Care of the Elderly

  • Shih-Ping Cheng

      Affiliations

    • Department of Surgery, Mackay Memorial Hospital, Taipei, Taiwan
    • ,
  • Tsen-Long Yang

      Affiliations

    • Department of Surgery, Mackay Memorial Hospital, Taipei, Taiwan
    • Mackay Medicine, Nursing and Management College, Taipei, Taiwan
    • ,
  • Kuo-Shyang Jeng

      Affiliations

    • Department of Surgery, Mackay Memorial Hospital, Taipei, Taiwan
    • ,
  • Jie-Jen Lee

      Affiliations

    • Department of Surgery, Mackay Memorial Hospital, Taipei, Taiwan
    • Graduate Institute of Pharmacology, Taipei Medical University, Taipei, Taiwan
    • ,
  • Tsang-Pai Liu

      Affiliations

    • Department of Surgery, Mackay Memorial Hospital, Taipei, Taiwan
    • Mackay Medicine, Nursing and Management College, Taipei, Taiwan
    • ,
  • Chien-Liang Liu

      Affiliations

    • Department of Surgery, Mackay Memorial Hospital, Taipei, Taiwan
    • Mackay Medicine, Nursing and Management College, Taipei, Taiwan
    • Corresponding Author InformationCorrespondence to: Dr Chien-Liang Liu, Department of Surgery, Mackay Memorial Hospital, 92, Section 2, Chung-Shan North Road, Taipei 10449, Taiwan

Accepted 1 November 2006.

Article Outline

SUMMARY 

The geriatric population is growing in number and complexity in modern surgical practice. This challenging group presents differences in physiology and outcomes that make a more comprehensive and multidisciplinary approach necessary. This review emphasizes the meticulous assessment and preparation in all facets before surgery, including a thorough examination, nutrition evaluation and intervention, and preoperative optimization of pulmonary function and cardiovascular hemodynamics. This article highlights the importance of age-related pharmacokinetic and pharmacodynamic considerations, effective pain control, as well as prevention and treat-ment of hypothermia, fluid and electrolyte imbalance, and postoperative delirium. The vulnerable elderly patient with multiple medical problems and functional impairment is best served by a surgeon with a particular interest and working knowledge of the changes associated with aging and the physiology of surgery and anesthesia.

Key Words:  age factors , geriatrics , risk assessment , surgery

No full text is available. To read the body of this article, please view the PDF online.

 

Back to Article Outline

References 

  1. Etzioni DA , Liu JH , Maggard MA , Ko CY . The aging population and its impact on the surgery workforce . Ann Surg . 2003;238:170–177
  2. Bland KI , Isaacs G . Contemporary trends in student selection of medical specialties: the potential impact on general surgery . Arch Surg . 2002;137:259–267
  3. Hutchins LF , Unger JM , Crowley JJ , Coltman CA , Albain KS . Underrepresentation of patients 65 years of age or older in cancer-treatment trials . N Engl J Med . 1999;341:2061–2067
  4. MacDonald P , Johnstone D , Rockwood K . Coronary artery bypass surgery for elderly patients: is our practice based on evidence or faith? . CMAJ . 2000;162:1005–1006
  5. Welch CS . Surgery in the aged . N Engl J Med . 1948;238:821–832
  6. Samet J , Hunt WC , Key C , Humble CG , Goodwin JS . Choice of cancer therapy varies with age of patient . JAMA . 1986;255:3385–3390
  7. Busch E , Kemeny M , Fremgen A , Osteen RT , Winchester DP , Clive RE . Patterns of breast cancer care in the elderly . Cancer . 1996;78:101–111
  8. Primatesta P , Goldacre MJ . Inguinal hernia repair: incidence of elective and emergency surgery, readmission and mortality . Int J Epidemiol . 1996;25:835–839
  9. Pedersen T . Complications and death following anaesthesia. A prospective study with special reference to the influence of patient-, anaesthesia-, and surgery-related risk factors . Dan Med Bull . 1994;41:319–331
  10. Edwards AE , Seymour DG , McCarthy JM , Crumplin MK . A 5-year survival study of general surgical patients aged 65 years and over . Anaesthesia . 1996;51:3–10
  11. Brookes B . Surgery in patients of advanced age . Ann Surg . 1937;105:481–501
  12. Seymour DG , Pringle R . Post-operative complications in the elderly surgical patient . Gerontology . 1983;29:262–270
  13. Vaz FG , Seymour DG . A prospective study of elderly general surgical patients: I. Pre-operative medical problems . Age Ageing . 1989;18:309–315
  14. Polanczyk CA , Marcantonio E , Goldman L , Rohde LE , Orav J , Mangione CM , et al.   Impact of age on perioperative complications and length of stay in patients undergoing noncardiac surgery . Ann Intern Med . 2001;134:637–643
  15. Lubin MF . Is age a risk factor for surgery? . Med Clin North Am . 1993;77:327–333
  16. Audisio RA , Bozzetti F , Gennari R , Jaklitsch MT , Koperna T , Longo WE , et al.   The surgical management of elderly cancer patients; recommendations of the SIOG surgical task force . Eur J Cancer . 2004;40:926–938
  17. Ramesh HS , Pope D , Gennari R , Audisio RA . Optimising surgical management of elderly cancer patients . World J Surg Oncol . 2005;3:17
  18. Goodwin JS , Samet JM , Hunt WC . Determinants of survival in older cancer patients . J Natl Cancer Inst . 1996;88:1031–1038
  19. Prough DS . Anesthetic pitfalls in the elderly patient . J Am Coll Surg . 2005;200:784–794
  20. Wang L , van Belle G , Kukull WB , Larson EB . Predictors of functional change: a longitudinal study of nondemented people aged 65 and older . J Am Geriatr Soc . 2002;50:1525–1534
  21. Reuben DB , Rubenstein LV , Hirsch SH , Hays RD . Value of functional status as a predictor of mortality: results of a prospective study . Am J Med . 1992;93:663–669
  22. Rockwood K , Stadnyk K , MacKnight C , McDowell I , Hebert R , Hogan DB . A brief clinical instrument to classify frailty in elderly people . Lancet . 1999;353:205–206
  23. Jansen PL . Liver disease in the elderly . Best Pract Res Clin Gastroenterol . 2002;16:149–158
  24. Goulding MR . Inappropriate medication prescribing for elderly ambulatory care patients . Arch Intern Med . 2004;164:305–312
  25. Keats AS . The ASA classification of physical status—a recapitulation . Anesthesiology . 1978;49:233–236
  26. Leung JM , Dzankic S . Relative importance of preoperative health status versus intraoperative factors in predicting postoperative adverse outcomes in geriatric surgical patients . J Am Geriatr Soc . 2001;49:1080–1085
  27. Knaus WA , Zimmerman JE , Wagner DP , Draper EA , Lawrence DE . APACHE-acute physiology and chronic health evaluation: a physiologically based classification system . Crit Care Med . 1981;9:591–597
  28. Knaus WA , Draper EA , Wagner DP , Zimmerman JE . APACHE II: a severity of disease classification system . Crit Care Med . 1985;13:818–829
  29. Copeland GP , Jones D , Walters M . POSSUM: a scoring system for surgical audit . Br J Surg . 1991;78:355–360
  30. Prytherch DR , Whiteley MS , Higgins B , Weaver PC , Prout WG , Powell SJ . POSSUM and Portsmouth POSSUM for predicting mortality. Physiological and Operative Severity Score for the enUmeration of Mortality and morbidity . Br J Surg . 1998;85:1217–1220
  31. Copeland GP . The POSSUM system of surgical audit . Arch Surg . 2002;137:15–19
  32. Goldman L , Caldera DL , Nussbaum SR , Southwick FS , Krogstad D , Murray B , et al.   Multifactorial index of cardiac risk in noncardiac surgical procedures . N Engl J Med . 1977;297:845–850
  33. Guidelines for assessing and managing the perioperative risk from coronary artery disease associated with major noncardiac surgery  . American College of Physicians . Ann Intern Med . 1997;127:309–312
  34. Inouye SK , Peduzzi PN , Robison JT , Hughes JS , Horwitz RI , Concato J . Importance of functional measures in predicting mortality among older hospitalized patients . JAMA . 1998;279:1187–1193
  35. Walter LC , Brand RJ , Counsell SR , Palmer RM , Landefeld CS , Fortinsky RH , et al.   Development and validation of a prognostic index for 1-year mortality in older adults after hospitalization . JAMA . 2001;285:2987–2994
  36. Desai MM , Bogardus ST , Williams CS , Vitagliano G , Inouye SK . Development and validation of a riskadjustment index for older patients: the high-risk diagnoses for the elderly scale . J Am Geriatr Soc . 2002;50:474–481
  37. Rosenthal RA . Nutritional concerns in the older surgical patient . J Am Coll Surg . 2004;199:785–791
  38. Avenell A , Handoll HH . Nutritional supplementation for hip fracture aftercare in the elderly . Cochrane Database Syst Rev . 2000;4:CD001880
  39. Koruda MJ , Sheldon GF . Surgery in the aged . Adv Surg . 1991;24:293–331
  40. Bozzetti F . Surgery in the elderly: the role of nutritional support . Clin Nutr . 2001;20:103–116
  41. Campbell GS . Respiratory failure in surgical patients . Curr Probl Surg . 1976;13:5–67
  42. Peterson DD , Pack AI , Silage DA , Fishman AP . Effects of aging on ventilatory and occlusion pressure responses to hypoxia and hypercapnia . Am Rev Respir Dis . 1981;124:387–391
  43. Jackson CV . Preoperative pulmonary evaluation . Arch Intern Med . 1988;148:2120–2127
  44. Aronow WS , Stein PD , Sabbah HN , Koenigsberg M . Resting left ventricular ejection fraction in elderly patients without evidence of heart disease . Am J Cardiol . 1989;63:368–369
  45. Kawaguchi M , Hay I , Fetics B , Kass DA . Combined ventricular systolic and arterial stiffening in patients with heart failure and preserved ejection fraction: implications for systolic and diastolic reserve limitations . Circulation . 2003;107:714–720
  46. Mangano DT , Layug EL , Wallace A , Tateo I . Effect of atenolol on mortality and cardiovascular morbidity after noncardiac surgery. Multicenter Study of Perioperative Ischemia Research Group . N Engl J Med . 1996;335:1713–1720
  47. Poldermans D , Boersma E , Bax JJ , Thomson IR , van de Ven LL , Blankensteijn JD , et al.   The effect of bisoprolol on perioperative mortality and myocardial infarction in high-risk patients undergoing vascular surgery. Dutch Echocardiographic Cardiac Risk Evaluation Applying Stress Echocardiography Study Group . N Engl J Med . 1999;341:1789–1794
  48. Eagle KA , Brundage BH , Chaitman BR , Ewy GA , Fleisher LA , Hertzer NR , et al.   Guidelines for perioperative cardiovascular evaluation for noncardiac surgery. Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. Committee on Perioperative Cardiovascular Evaluation for Noncardiac Surgery . Circulation . 1996;93:1278–1317
  49. Dajani AS , Taubert KA , Wilson W , Bolger AF , Bayer A , Ferrieri P , et al.   Prevention of bacterial endocarditis. Recommendations by the American Heart Association . JAMA . 1997;277:1794–1801
  50. Francis J . Perioperative management of the older patient . In:  Hazzard WR ,  Blass JP ,  Ettinger WH ,  Halter JB ,  Ouslander JG editor. Principles of Geriatric Medicine and Gerontology . 4th edition. New York: McGraw-Hill; 1999;p. 365–376
  51. Pfeifer MA , Weinberg CR , Cook D , Best JD , Reenan A , Halter JB . Differential changes of autonomic nervous system function with age in man . Am J Med . 1983;75:249–258
  52. Frank SM , Beattie C , Christopherson R , Norris EJ , Rock P , Parker S , et al.   Epidural versus general anesthesia, ambient operating room temperature, and patient age as predictors of inadvertent hypothermia . Anesthesiology . 1992;77:252–257
  53. Frank SM , Higgins MS , Breslow MJ , Fleisher LA , Gorman RB , Sitzmann JV , et al.   The catecholamine, cortisol, and hemodynamic responses to mild perioperative hypothermia. A randomized clinical trial . Anesthesiology . 1995;82:83–93
  54. Schmied H , Kurz A , Sessler DI , Kozek S , Reiter A . Mild hypothermia increases blood loss and transfusion requirements during total hip arthroplasty . Lancet . 1996;347:289–292
  55. Haley RW , Culver DH , Morgan WM , White JW , Emori TG , Hooton TM . Identifying patients at high risk of surgical wound infection. A simple multivariate index of patient susceptibility and wound contamination . Am J Epidemiol . 1985;121:206–215
  56. Leslie K , Sessler DI , Bjorksten AR , Moayeri A . Mild hypothermia alters propofol pharmacokinetics and increases the duration of action of atracurium . Anesth Analg . 1995;80:1007–1014
  57. Cheng AT , Plank LD , Hill GL . Prolonged overexpansion of extracellular water in elderly patients with sepsis . Arch Surg . 1998;133:745–751
  58. Beliveau MM , Multach M . Perioperative care for the elderly patient . Med Clin North Am . 2003;87:273–289
  59. Rosenthal RA , Kavic SM . Assessment and management of the geriatric patient . Crit Care Med . 2004;32(4 Suppl):S92–105
  60. Hebert PC , Yetisir E , Martin C , Blajchman MA , Wells G , Marshall J , et al.   Is a low transfusion threshold safe in critically ill patients with cardiovascular diseases? . Crit Care Med . 2001;29:227–234
  61. Marcantonio ER , Goldman L , Mangione CM , Ludwig LE , Muraca B , Haslauer CM , et al.   A clinical prediction rule for delirium after elective noncardiac surgery . JAMA . 1994;271:134–139
  62. Hogue CW , Goodnough LT , Monk TG . Perioperative myocardial ischemic episodes are related to hematocrit level in patients undergoing radical prostatectomy . Transfusion . 1998;38:924–931
  63. Nelson AH , Fleisher LA , Rosenbaum SH . Relationship between postoperative anemia and cardiac morbidity in high-risk vascular patients in the intensive care unit . Crit Care Med . 1993;21:860–866
  64. Neumayer LA , Smout RJ , Horn HG , Horn SD . Early and sufficient feeding reduces length of stay and charges in surgical patients . J Surg Res . 2001;95:73–77
  65. Frankenfield D , Cooney RN , Smith JS , Rowe WA . Agerelated differences in the metabolic response to injury . J Trauma . 2000;48:49–57
  66. Oates JD , Snowdon SL , Jayson DW . Failure of pain relief after surgery. Attitudes of ward staff and patients to postoperative analgesia . Anaesthesia . 1994;49:755–758
  67. Weber DM . Laparoscopic surgery: an excellent approach in elderly patients . Arch Surg . 2003;138:1083–1088
  68. Ballesta Lopez C , Cid JA , Poves I , Bettonica C , Villegas L , Memon MA . Laparoscopic surgery in the elderly patient . Surg Endosc . 2003;17:333–337
  69. Brunt LM , Quasebarth MA , Dunnegan DL , Soper NJ . Outcomes analysis of laparoscopic cholecystectomy in the extremely elderly . Surg Endosc . 2001;15:700–705
  70. Stouten EM , Armbruster S , Houmes RJ , Prakash O , Erdmann W , Lachmann B . Comparison of ketorolac and morphine for postoperative pain after major surgery . Acta Anaesthesiol Scand . 1992;36:716–721
  71. Yeager MP , Glass DD , Neff RK , Brinck-Johnsen T . Epidural anesthesia and analgesia in high-risk surgical patients . Anesthesiology . 1987;66:729–736
  72. Dyer CB , Ashton CM , Teasdale TA . Postoperative delirium. A review of 80 primary data-collection studies . Arch Intern Med . 1995;155:461–465
  73. Cole MG , Primeau FJ , Elie LM . Delirium: prevention, treatment, and outcome studies . J Geriatr Psychiatry Neurol . 1998;11:126–137
  74. Loran DB , Hyde BR , Zwischenberger JB . Perioperative management of special populations: the geriatric patient . Surg Clin North Am . 2005;85:1259–1266
  75. Lawrence VA , Hazuda HP , Cornell JE , Pederson T , Bradshaw PT , Mulrow CD , et al.   Functional independence after major abdominal surgery in the elderly . J Am Coll Surg . 2004;199:762–772
  76. McGory ML , Shekelle PG , Rubenstein LZ , Fink A , Ko CY . Developing quality indicators for elderly patients undergoing abdominal operations . J Am Coll Surg . 2005;201:870–883
  77. Jin F , Chung F . Minimizing perioperative adverse events in the elderly . Br J Anaesth . 2001;87:608–624

PII: S1873-9598(08)70028-0

doi:10.1016/S1873-9598(08)70028-0

International Journal of Gerontology
Volume 1, Issue 2 , Pages 89-97, June 2007

Article Tools