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KEY POINTS

Key Points

  • image Frailty, dementia, and functional impairment are significant contributors to morbidity and mortality after surgery. Assessment of these risk factors is essential in an older population.

  • image Geriatric perioperative pathways are effective in preventing delirium, a morbid and costly postoperative complication that is associated with cognitive decline.

  • image Population-based data demonstrate that mortality after emergency surgery and high-risk cancer surgery is substantially higher in older adults that in a younger population.

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

  • image Many frail elders experience significant and sustained functional decline after surgery.

  • image Older adults with acute abdominal pathology—appendicitis, cholecystitis—often do not have fever, elevated white blood cell count, or physical findings of peritonitis.

INTRODUCTION

As the population ages, an increasing number of older adults will develop surgical diseases. The segment of the U.S. population age 65 and older is expected to double by 2050. Older adults present unique challenges in surgical management and decision-making. The accumulation of comorbid conditions and physiologic vulnerability that occurs with age put older adults at high risk for major morbidity and mortality after surgery. It is essential that surgeons approach this population with a new set of skills and knowledge to provide optimal care for this vulnerable population. A comprehensive understanding of the unique vulnerabilities of older adults—geriatric syndromes and risk factors—are required to accurately estimate surgical risk, inform surgical decision-making, and guide perioperative management. In this chapter, we will (a) discuss the physiologic conditions that are common in older adults that are essential for surgical risk assessment of older adults considering surgery, (b) describe best practices in perioperative care in the older adult, and (c) discuss special considerations and common pitfalls for surgical conditions that are common in the older adult.

GERIATRIC SYNDROMES

Approximately one-third of older individuals undergoing vascular image and urologic surgery suffer from geriatric syndromes.1,2 This term is used to describe clinical conditions that do not fit into discrete disease categories but that can substantially negatively impact quality of life and result in disability. Geriatric syndromes often involve multiple underlying factors and organ systems (i.e., multiple causation of a unified manifestation3) and include frailty, falls, delirium, malnutrition, dizziness, syncope, urinary incontinence, and pressure ulcers among others. These syndromes can be present before surgery and/or develop as a result of surgery and hospitalization.1,2 Furthermore, close attention to both the presence and development of geriatric syndromes among surgical candidates is important and often overlooked, making caring for older surgical patients unique compared to their younger and healthier counterparts.

Frailty

Frailty is among the most widely studied geriatric syndrome in the surgical literature. Frail older individuals are at high risk for adverse events in the face ...

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