Chapter 47: Surgical Considerations in the Elderly

KEY POINTS

1. Frailty, dementia, and geriatric syndromes have recently been identified as major factors in the development of postoperative complications in the elderly.

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

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 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.

5. 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.

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

7. New tools exist to help assess perioperative risk in geriatric patients, in addition to medical comorbidities. They include identification of geriatric syndromes, frailty indicators.

GENERAL CONSIDERATIONS

As our population ages, a dramatic increase is anticipated in the number of geriatric patients that will require various surgical interventions. The U.S. Census Bureau estimates that the number of people age 65 years and older will double between 2010 and 2050.¹ By 2030, people 65 years of age or older will account for 20% of the overall population. Furthermore, half of all Americans currently alive can expect to reach the ninth decade of life.² Geriatric patients represent a unique surgical challenge due to the complexity of comorbid conditions coupled with the physiologic changes that occur with aging. As a result of these considerations, and in response to research and specialized care protocols which are tailored for its age range, geriatric surgery has emerged as a subspecialty of surgery much as pediatric surgery developed decades ago.

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 respond to a challenge, with surgical stress being a prime example. The age of 70 years is typically accepted as the start of senescence because age-related organ dysfunction and the development of comorbid conditions sharply increases between ages 70 and 75 years.³ This criterion for senescence is in ­contrast to clinical studies published just 50 years ago that categorized elderly patients as those over the age of 55 years. 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 preoperative assessment, delivery ...