Perioperative Care of Elderly Patients
James R. Webster Jr., M.S., M.D.
The demographics of aging
and the advances in the science of anesthesia and surgery make
the pre-, intra-, and postoperative care of elderly patients a
common and important issue for all physicians. The overall surgical
mortality for the elderly has decreased dramatically in the past
two decades, at the same time that 40% of elderly inpatients are
on surgical services. These are not, however, the "average"
elderly, since there are marked increases in concurrent disease
and co-morbidities in this population.
When age and severity of illness are directly compared, severity
of illness is a much better predictor of outcome than is age.
Careful clinical assessment is therefore crucial in determining
preoperative risk. The crux of this is the initial history and
physical examination stressing functional status, using principles
of geriatric medicine, and ferreting out specific common significant
problems. Activities of daily living, cognitive and nutritional
status, and postoperative social supports have become important
prognostic components of the this evaluation. Atypical presentations
of disease and decreased physiologic reserves are especially common
pitfalls in the evaluation of these patients. With respect to
cardiovascular disease, a modified Goldman risk index is an especially
important reference point. Pulmonary disease greatly increases
the risk of postoperative complications (40% of total complications
and 20% of deaths), and thus is a particularly important aspect
of the evaluation. This involves assuring that the patient has
the ability to generate sufficient cough to clear secretions,
a motivation to cough and sufficient pulmonary reserve to overcome
postanesthetic declines in respiratory function. Specific risk
factors include obesity, dyspnea, history of cigarette smoking,
abnormal pulmonary function studies and a prolonged duration of
anesthesia. Upper abdominal procedures are particularly troublesome
for the elderly. High risk patients should have preoperative pulmonary
function studies looking for reversible aspects; e.g., bronchoconstriction
or hypoxemia. It is also crucial to evaluate medications preoperatively.
For example, aspirin may cause bleeding, sedative and anticholinergic
medications increase the risk for delirium; diuretics are particularly
troublesome since stiff elderly hearts need adequate pre-load
and sending patients to surgery in a hypovolemic state invites
postoperative renal failure.
The menu of potential postoperative problems is long. For example,
1) atypical presentations of infections without fever or an elevated
white count; 2) shock without tachycardia; 3) delirium as a non-specific
symptom; or 4) MI's without chest pain are all surprises that
have eluded even the best of clinicians. Urinary tract infections
are the most common infectious complication and an indwelling
catheter is frequently the vector. Atrial fibrillation is an especially
serious cause of decreased cardiac output in the elderly due to
their tendency to have diastolic dysfunction and may be a serious
cause of postoperative decline requiring immediate attention.
Finally, postoperative pain control should be "just right,"
not too much, but not too little.
Patients should never be denied surgery on the basis of age, but
the surgical procedure will be the ultimate stressor on their
physiology and test of your professional skills. In view of this,
true preoperative informed consent is absolutely essential and
your function as a consultant is to carefully assess the patient
as to risk factors and to be sure that all potentially reversible
conditions are
optimized prior to surgery. Specific recommendations for perioperative
management of older patients are as follows:
Thomas DR, Ritchie CS. Perioperative assessment of older adults.
J Amer Geriatr Soc 1995;43:811-21. [Citation]
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Copyright ©1999. Northwestern
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