Chapter 46

1. Emergency surgery in the elderly carries a mortality rate that is 3–4 times that seen after elective surgery.

2. Physiologic age, not chronologic age, is the consequence of diminished functional reserve due to comorbid conditions, and is the major predictor of perioperative morbidity and mortality in the elderly.

3. Impaired cardiac function is responsible for more than half of the postoperative deaths in elderly patients, so careful attention must be paid to intravascular volume status in the perioperative period.

4. In addition to cardiac impairment, deficiencies in pulmonary, renal, nutritional, and cognitive function are major factors in the development of postoperative complications in the elderly.

5. In elderly patients with acute appendicitis or acute cholecystitis, one third lack fever, one third lack an elevated white blood cell count, and one third lack physical findings of peritonitis.

6. Laparoscopic approaches to surgical management, including the use of exploratory laparoscopy to rule out surgical disease, is associated with fewer complications and more rapid recovery in the elderly.

7. Analgesic doses should be reduced and titrated carefully in the elderly to avoid delirium; meperidime (Demerol R) should not be used for pain control in elderly patients.

8. The goal of palliative care is to relieve symptoms and preserve physical and mental well-being.

The old pediatric surgery adage that children are not just “small people” holds true for the other end of the age spectrum, the growing geriatric surgery population. With the aging and expanding U.S. population, a dramatic increase is anticipated in the number of geriatric patients that will require various surgical interventions. By 2030, people >65 years of age will account for 20% of the overall population.1 Furthermore, half of all Americans currently alive can expect to reach the ninth decade of life.2 Elderly patients represent a unique surgical challenge due to the complexity of comorbid conditions and physiologic changes that occur with aging. These physiologic changes, inherent to the aging process, result in decline of physiologic reserve, development of cognitive and functional impairments, and, not uncommonly, development of multiple comorbid conditions. Physiologic age is of greater importance in perioperative management of elderly surgical patients than chronologic age because it takes into account the burden of comorbid disease. It is, therefore, an accurate predictor of postoperative morbidity and mortality. The hallmark of physiologic aging or “senescence” is decreased functional reserve of critical organ systems, resulting in the decreased ability of these systems to cope with challenge, with surgical stress being a prime example. The age of 70 years typically is accepted as the start of senescence because age-related organ dysfunction and development of comorbid conditions sharply increases between ages 70 and 75 years.3 With improved technologies and expanded criteria for surgical interventions in extremely aged patients, increased awareness of the special needs of this population is required to ensure a comprehensive ...

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