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 ...