Chapter 47: Surgical Considerations in the Elderly

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.

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 of optimal surgical care, and minimization of postoperative complications. It is also critical that a multidisciplinary approach be developed, which involves the patient and their home caregivers, geriatric physicians, surgeons, and, at times, specialists in intensive care.

It is estimated that, by the year 2030, there will be 70 million people >65 years old in the United States, a stark increase over the 35 million in 2000.⁴ This ever growing elderly population will increasingly require surgical care, and patients >65 years old already account for approximately 60% of the general surgeon’s workload.⁵ Patients >65 years old account for approximately 50% of all emergent operations and 75% of operative mortality.⁴ These statistics challenge a surgeon to have an ­in-depth understanding of the careful perioperative evaluation required in elderly patients and the tailoring of surgical interventions based on the unique changes in physiologic reserve and comorbid conditions that make elderly patients more susceptible to postoperative complications.

The goal of this chapter is to highlight salient management strategies for aged surgical patients to achieve optimal care and reduce postoperative complications. Particular problems in the elderly population which impact on surgical care include the potential delay in surgical treatment due to a missed or delayed diagnosis secondary to an atypical presentation of disease, and the postponement of needed elective surgery because of the misconception that an elderly patient will suffer a poor outcome as a result of advanced age alone. For example, elective inguinal and umbilical hernia repairs are often postponed due to age bias; this can lead to potentially devastating consequences of bowel ischemia, gangrene, and perforation, to which elderly patients respond poorly. As a result, emergency hernia repairs are among the most common procedures performed in older patients; approximately 40% of hernia repairs are performed for incarceration or bowel obstruction in patients >65 years old.⁵ Emergency repair of hernias is associated with an increased morbidity rate of approximately 50% and a mortality rate ranging between 8% to 14%; a significant increase from the 2% mortality rate following elective repair in age-matched patients.⁵

Another significant consideration with the geriatric population is the need to balance optimal health care delivery with rising health care costs. The goal of surgical therapy in the elderly is to provide needed interventions which result in maximum benefit to the patient without compromising quality of life or unwanted adverse outcomes. For example, screening for breast or colorectal cancer should be performed if the patient has a reasonable expectation of quality and quantity of life. An extensive and/or invasive workup should not be performed if the patient would not tolerate the anticipated therapeutic intervention.

Finally, a fifth of elderly patients die in ICU settings and half of them require mechanical ventilation and a quarter undergo cardiopulmonary resuscitation in the days before their death.⁶ Although Medicare expenditures in the last year of life are approximately five times higher than in nonterminal years, the actual quality of care at the end of life is often poor due to debilitating and persistent symptoms. Even more worrisome is the fact that some patients receive treatments which are inconsistent with their preferences for end of life measures. An additional component of geriatric surgery is therefore the provision of compassionate care that is more focused on symptomatic relief than on cure in patients who are near the end of life.

Elderly surgical patients are a heterogeneous cohort with various degrees of functional impairments and comorbid burdens. The “young old patient” may lead an active lifestyle with few, if any, comorbid conditions. But even for this seemingly healthy individual, it is crucial to remember that there are inherent physiologic changes that occur with aging and which affect every organ system. These physiologic changes may become more apparent and clinically consequential with the stress of major illness and operative interventions.

An important criterion in the geriatric surgery patient is the frailty score. Frailty is a syndrome associated with advanced age that results from decreased physiologic reserve and which makes patients less resistant to major stressors such as invasive surgical procedures. Frail patients are prone to poorer outcomes, due to falls, disability, impaired ability to perform activities of daily living (ADLs), prolonged hospitalizations and an increase in mortality.¹ Frail patients are more likely to require discharge to skilled nursing facilitiespostoperatively. Prior to surgery,frailpatients and their family members should be aware of this possibility. Therefore, the frailty score is a more accurate representation of the patient’s physiologic age.

Chronologic age is rarely an accurate predictor of morbidity and mortality from surgical interventions. It is, however, an accurate marker for declining physiologic reserve and the likelihood of the presence of comorbid conditions. These place elderly patients at higher risk because of impaired cardiac, pulmonary, renal, and neurological reserves, which increase the morbidity and mortality risk of surgical interventions. Physiologic age, in addition to comorbid conditions, more accurately predicts surgical outcomes in the elderly than chronologic age. The physiologic changes of aging are summarized in Table 47-1.

The terms “frailty,” “disability” and “comorbidity” have mistakenly been used interchangeably. These terms have very different connotations for the geriatric patient. Disability is defined as dependence on assistance with ADLs, and contributes to the risk of frailty. Comorbidity is defined as the presence of two or more existing diseases, and is quantified by the Charlson comorbidity index.⁷ Geriatric assessment markers for frailty and disability include cognition, albumin level, history of falls, hematocrit level, and dependance on assistance with ADLs. These objective measures have been shown to predict six month postoperative mortality or the need for long term institutionalized care after surgery.⁷ (Table 47-2)

It is critical in the assessment of any elderly patient to maintain a high index of suspicion for surgical pathology. Elderly patients often present with atypical symptoms and/or a misleadingly benign-appearing abdominal examination that may mask an intra-abdominal catastrophe. The effects of age-related impairments in immune function can be compounded by co-existent medical problems and altered mentation as a result of dementia, drugs, infection, or dehydration.

Acute appendicitis and acute cholecystitis are classic examples of common acute surgical pathologies in which elderly patients have a delay in diagnosis or misdiagnosis. This often leads to higher rates of perforation and complications that adversely affect morbidity and mortality.⁸ Biliary tract disease, including acute cholecystitis, is the most common indication for surgical intervention in the elderly. This is likely related to age-related changes within the biliary system, such as increased lithogenicity of bile and an increased prevalence of cholelithiasis. Delayed diagnosis due to atypical or misleading symptoms may lead to complications such as ascending cholangitis, gallbladder perforation, or gallstone ileus.

Elderly patients with acute peritonitis may not present with typical symptoms of acute abdominal pain, fever, or leukocytosis, due to a depressed immune response. In older patients presenting with acute appendicitis, the initial diagnosis is correct in less than half of the patients.⁸ A careful assessment and high index of suspicion are crucial to achieve timely operative intervention.

Surgical risk increases with advancing age as a consequence of physiologic decline and the development of comorbid conditions that make the elderly surgical patient more susceptible to postoperative complications. Geriatric patients may have masked vulnerabilities due to their unique physiologic state that requires a more detailed preoperative assessment. Comorbid illness serves as the basis for the American Society of Anesthesiologists’ (ASA) physical status classification. This is a valuable tool for identifying elderly patients who are at high risk for postoperative complications because it is based on organ system dysfunction and severity of functional impairment. It helps to identify subgroups of patients in whom appropriate measures should be taken to reduce the risk of adverse outcomes. Importantly, it also quantifies the risks of morbidity and mortality for emergency surgery.A careful assessment of potential problems in the perioperative period combined with implementation of preventative measures can significantly reduce complications associated with general anesthesia in the elderly patient.⁹ A useful algorithm for the preoperative assessment of an elderly surgical patient is provided in Fig. 47-1.

Cardiac complications are the leading cause of perioperative complications and death in surgical patients of all age groups, but particularly among the elderly. This is because patients often have co-existing cardiac dysfunction, combined with normal physiologic decline and poor functional reserve. The combined effect of depletion of intravascular volume, age-related impairment of response to catecholamines, and increased myocardial relaxation time adversely affects the cardiac function of an elderly patient under stress in the perioperative period.¹⁰ Aging has been demonstrated to cause a decrease in cardiac output by approximately 1% per year. Older individuals fail to augment heart rate to the same extent as younger individuals. More importantly, the ability to increase cardiac output with aging is dependent on ventricular dilatation, which is determined by preload.¹¹ Therefore careful attention must be paid to volume status in the perioperative period. Dehydration or poor resuscitation may occur in elderly surgical patients for a variety of reasons, and both are poorly tolerated. Over one half of all postoperative deaths in elderly patients and 11% of postoperative complications are a result of impaired cardiac function under physiologic stress. Incomplete emptying of the ventricle at end systole and subsequent reduction in ejection fraction is characteristic of the aging heart.¹⁰ Reduced distensibility, in addition to acute stressors, leads to impaired coronary perfusion and cardiac ischemia.

As a result, the physiologic stress of general anesthesia and surgical interventions can unmask the limited cardiac reserve of the elderly patient. Poor reserve may become evident with increased myocardial oxygen demand resulting from tachycardia or loss of vascular tone from the vasodilatory effects of many general anesthetic agents. An important predictor of surgical ­outcomes and cardiac complications in the elderly is congestive heart failure (CHF). CHF is present in approximately 10% of patients older than 65 years and is the leading cause of postoperative morbidity and mortality.¹² This prevalence will likely increase as percutaneous interventions and medical therapy prolongs survival from myocardial ischemia and acute myocardial infarction. Therefore, identifying correctable and uncorrectable cardiovascular disease is critical before elective surgical interventions.

Pulmonary complications are a major source of morbidity and mortality in elderly surgical patients. The age-related changes that occur in the respiratory system limits the maximal breathing capacity by age 70 to 50% of the capacity present at age 30.¹² In addition, there is a decline in the forced expiratory volume in 1 second (FEV1) with advancing age. It is estimated that humans lose 35 mL of their FEV1 per year over the age of 35 years old. There is a slow decline between ages 35 and 65 years old followed by a much more progressive decline at approximately 75 years of age.¹³ Pulmonary complications account for up to 50% of postoperative complications and 20% of preventable deaths.¹⁴ Risk factors for pulmonary complications include a positive smoking history, presence of shortness of breath, or clinical evidence of chronic obstructive pulmonary disease. All elderly patients undergoing major surgical interventions should have a baseline chest radiograph. Screening spirometry can be performed to determine forced vital capacity and FEV1. A baseline arterial blood gas measurement also will help to identify hypoxemia and hypercapnia, both of which may increase postoperative complications. If abnormalities are found, perioperative use of bronchodilators and incentive spirometry may be invaluable. When possible, regional anesthetic techniques may provide excellent analgesia while helping to reduce the postoperative pulmonary complications associated with general anesthesia and endotracheal intubation.

Renal complications are also increased in elderly surgical patients in the perioperative period. Renal size and volume decrease with age, accompanied by intrarenal vascular changes. There is a decrease in the number of glomeruli and nephron mass, resulting in decreased filtration area. Serum creatinine concentration is an insensitive indicator of renal function in the elderly, however.¹⁰ The physiologic age-related changes in renal function increase susceptibility to renal ischemia as well as to nephrotoxic agents. Age-related changes in renal function result from progressive glomerulosclerosis and reduction in renal mass resulting in decreased creatinine clearance and glomerular filtration rate. This is worsened by a decline in cardiac output with increasing age and subsequent decrease in renal blood flow. It has been shown that patients with impaired glomerular filtration rate are more susceptible to volume changes that occur in the perioperative period. Furthermore, decreased drug elimination can potentiate the effects of nephrotoxic drugs and prolong the sedative effects of anesthetics and narcotic used for postoperative pain management.¹² Acute renal failure is proven to dramatically increase morbidity and mortality in elderly patients. The mortality risk of perioperative renal failure in all patients is approximately 50% and may be even higher in elderly patients. Therefore, careful management of fluid and electrolyte status is prudent to avoid imbalances and limit exposure to nephrotoxic diagnostic studies and medications in the perioperative period. Patients >70 years old may be susceptible to the nephrotoxic effects of certain anesthetic agents, and thus should be protected by hydration and diuresis, as long as they can tolerate the fluid load.¹⁰ Prompt recognition of renal compromise, marked by an elevation of blood urea nitrogen or creatinine levels or oliguria, requires aggressive correction of underlying causes. Furthermore, electrolyte imbalances can lead to potentially devastating cardiac conduction abnormalities and arrhythmias.¹² Although not routinely advocated in younger patients, elderly patients should have routine electrolyte panels and urinalysis before all surgical interventions to identify potential renal dysfunction.¹⁵ Underlying causes of abnormalities found on screening should be corrected before surgery and may necessitate intravascular volume repletion to ensure adequate renal perfusion perioperatively.

A functional evaluation which includes an assessment of the cognitive level of functioning is an important part of the preoperative evaluation of elderly surgical candidates. This ensures that operative intervention will not significantly impair the quality of life of an elderly surgical candidate. The ability to withstand the stress of surgical interventions is dependent on functional reserve and the ability to build an appropriate response to peri-operative stress.¹⁰ The ability to perform ADLs such as feeding, dressing, bathing, and toileting have been correlated with postoperative morbidity and mortality (Table 47-2). Preoperative functional assessment can be measured by hand grip strength, timed “up and go,” and functional reach tests⁷. All of these tests independently predicted better recovery and shorter time to recover ADLs after major surgery. In addition, these tests provide an accurate assessment of a patient’s muscle mass, nutritional status, coordination, gait speed, balance, and mobility.⁵ Proper functional assessment will accurately predict rehabilitation needs, estimate biologic reserve, and indicate an enhanced risk of complications.¹⁰

The functional status of an elderly patient is directly and inversely correlated to pulmonary and cardiac complications that may ensue following surgical interventions. For example, functional impairment often leads to immobility, which can lead to increased risk of postoperative atelectasis, pneumonia, deep vein thrombosis (DVT), and pulmonary embolism. Furthermore, proper functional assessment has been shown to improve diagnostic and therapeutic outcomes as well as to lead to identification of previously undiagnosed conditions that may be treatable preoperatively or managed peri-operatively.¹⁰

Cognitive function often is overlooked in the preoperative assessment of patients, because patients are not typically formally evaluated before surgical intervention (i.e., mini-mental state examination). However, knowledge of baseline cognitive function provides invaluable information because subtle changes in cognition often herald postoperative complications, such as underlying infection. Cognitive impairment, including delirium and confusion commonly occur in the elderly patient during the early postoperative period and can result in increased morbidity, delayed functional recovery, and prolonged hospitalizations. The etiology of this postoperative cognitive dysfunction may be multifactorial. Advanced age, history of alcohol abuse, baseline cognitive disturbance, hypoxia, and hypotension have all been shown to be contributing factors.¹⁶ It is crucial that careful attention be paid to adequate postoperative analgesia to improve recovery while avoiding compromise of cognitive function. Methods such as “Beer’s Criteria” are useful tools to assess whether a particular drug is appropriate for the aged patient. Finally, dementia is a known predictor of poor long-term survival.

A formal nutritional assessment is invaluable in the perioperative assessment of elderly patients. Poor nutritional status in elderly patients is common and results from the interplay between physiologic, psychosocial, and economic changes that accompany the aging process. Elderly patients may have poor nutritional status because of either poor intake due to the underlying illness or pre-existing comorbid conditions. In the outpatient setting, it is estimated that 9% to 15% of persons >65 years old are malnourished. This increases to 12% to 50% and 25% to 60% in the acute inpatient hospital setting and chronic institutional settings, respectively.¹⁷ The cycle of frailty that occurs with chronic undernutrition or malnutrition can lead to progressive functional decline, loss of muscle mass, and decreased oxygen consumption and metabolic rate in this population.¹⁷ Therefore, adequate assessment of nutritional status of these patients preoperatively and the prompt institution of nutritional support is of utmost importance. This is an integral component of the preoperative assessment, considering that nutritional status is a proven independent predictor of surgical outcomes. Deterioration of a patient’s nutritional state in the perioperative period contributes to adverse outcomes. Poor nutrition can lead to increased nosocomial infections, multiorgan system dysfunction, poor wound healing, and impaired functional recovery. Therefore, nutritional assessment and support, if necessary, not only give patients additional reserve to minimize postoperative complications, but aid in appropriate wound healing, functional recovery, and rehabilitation.

Protein energy malnutrition (PEM) also can result from maintaining compromised surgical patients nil per os (NPO). PEM may occur quickly in the elderly, malnourished surgical patient in a hypermetabolic state induced by stress of illness and surgery. The physiologic consequences of PEM are multiple and include anorexia, hepatic dysfunction, decreased mucosal proliferation, and sarcopenia.¹⁷ A good marker of PEM is hypoalbuminemia, also shown to be an extremely accurate predictor of surgical outcomes. The incidence of postoperative complications is increased in patients with serum albumin levels <3.5 g/L.¹⁷ Current recommendations indicate that if patients demonstrate compromise of nutritional status as defined by >10% weight loss and serum albumin level <2.5 g/dL, they should be considered for a minimum of 7 to 10 days of nutritional repletion prior to surgery.¹⁰

The significant impact of nutritional status on surgical outcomes and functional recovery in the elderly population after surgical intervention underscores the importance of an accurate preoperative nutritional assessment. In busy surgical practices, the question arises as to whether this can be done in a simple, reproducible, and cost-effective manner while obtaining vital information. There are several methods of assessing nutritional status, including anthropomorphic measures (i.e., body mass index), biochemical laboratory values (i.e., transferrin, albumin, and prealbumin), and clinical assessments.¹⁷

The Mini Nutritional Assessment (MNA) is an established, validated nutritional assessment tool which can be useful for the preoperative assessment of the elderly surgical candidate. The MNA consists of a screening portion assessing the patient’s current body mass index, food intake and weight loss, mobility, and presence of stressors, depression, or dementia, all of which can exacerbate undernutrition or malnutrition in the elderly patient. The goal is to identify patients at risk for malnutrition, and who need further evaluation involving a more complete psychosocial assessment and determination of mode of feedings. This tool helps to identify undernutrition and malnutrition in older individuals, >65 years old, and helps to direct timely interventions which result in improved functional recovery.

The combined effects of poor nutrition, decreased cognition, and immune impairments due to nutritional or pharmacologic factors create a treacherous circumstance for elderly patients with poorly defined symptoms or who present with more advanced disease. In acute abdominal conditions, such as acute appendicitis and acute cholecystitis, one third of elderly patients will lack an elevated white blood cell count, one third will lack fever, and one third will lack physical findings of localized peritonitis. These deficits contribute to a threefold higher rate of perforated appendicitis and of gangrene of the gallbladder in elderly patients compared to young patients. An “unimpressive” physical exam in an elderly patient with acute onset of abdominal symptoms should never be taken as a sign of the absence of surgical disease.

The value of the multifaceted geriatric preoperative assessment led to the formation of an expert geriatric surgery panel by the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) and the American Geriatric Society (AGS). The panel formulated best practice guidelines for surgery in the elderly that have been adopted as standards for training programs (see Fig. 47-2). This checklist may prove to be a useful tool in the preoperative identification of issues that may play an important role in the outcome of a surgical procedure. This not only highlights the importance of the factors described previously but also provides a tool that physicians can utilize in the nonurgent setting to institute ­preventative or corrective measures to help the geriatric patient maintain their quality of life. (Table 47-3)

Cardiovascular

It is estimated that approximately 40% of the projected 25 million octogenarians comprising the U.S. population by the year 2025 will suffer cardiovascular symptoms, many of whom will require cardiovascular surgical treatment.¹⁸ With advances in cardiopulmonary bypass technique, myocardial protection, and improved perioperative care, coronary artery bypass grafting (CABG) and valve replacement operations can be safely performed in elderly patients. Senile calcific aortic stenosis is common within this population, and referral for aortic valve replacement is increasing, encompassing many patients who are >75 years old. Interestingly, despite some degree of age bias in the referral of patients for major cardiac surgery, advanced age alone is not a predictor of poorer outcomes or increased mortality compared to younger patients. It has been demonstrated that emergency operations, preoperative New York Heart Association (NYHA) functional class 3 or greater, and chronic renal failure were the main predictors of increased operative mortality, but not patient age, per se.¹⁸ In one study, preoperative renal dysfunction, cerebrovascular disease, valve surgery, and catastrophic state were independent predictors of increased mortality in elderly patients.¹⁹ Elderly patients with nondialysis-dependent renal dysfunction had a 60% chance of death during a 5-year follow-up period compared to 25% in elderly patients without a history of renal dysfunction. Similarly, the presence of cerebrovascular disease resulted in a two-fold increase in mortality among elderly patients.¹⁹ Even patients who were 80 years of age or more did not have any significant increase in surgical risk and within this population, the 4-year actuarial survival was 70.5% with an event-free survival of approximately 60.6%.¹⁹

There has been an increase in definitive operative intervention to elderly patients requiring CABG. Although older patients have higher morbidity and mortality rates after cardiac surgery than do younger patients, these rates are decreasing. The Society of Thoracic Surgeons reports that perioperative mortality rates range from 1.6% in patients 51 to 60 years of age to 7.7% in those 81 to 90 years of age.²⁰ This decline in morbidity and mortality rates likely reflects better preoperative assessment and patient selection. Furthermore, this decline has occurred despite the advancing age of cardiac patients at time of referral, advanced disease, and greater comorbid disease burden. Elderly patients are more likely to have significant triple-vessel disease accompanied by poor ejection fraction, left ventricular hypertrophy, significant valvular disease, and previous history of myocardial infarction than are younger patients.²⁰ Elderly patients also are more likely to be classified as NYHA functional class 3 or higher and are more likely to present on an emergent basis, in part because of reluctance to provide elective surgical intervention because of presumptive poorer outcome. Despite the increased risk of morbidity and mortality compared to younger patients, elderly patients, including those >80 years old, can undergo CABG with acceptable mortality risk. The overall mortality rate is approximately 7% to 12% for elderly patients, including those in whom CABG is performed under emergency conditions. The mortality rate decreases to ­approximately 2.8% when CABG is performed electively with careful preoperative evaluation.²¹

Valve Replacement

There also is an increasing percentage of the geriatric population who present with symptomatic valvular disease requiring intervention. The most common valvular abnormality present in elderly patients is calcific aortic stenosis, which can lead to angina and syncope.²² The operative mortality from aortic valve replacement is estimated to be between 3% and 10%, with an average of approximately 7.7%.²⁰ If aortic stenosis is allowed to progress without operative intervention, CHF will ensue. The average survival of these patients is approximately 1.5 to 2 years. If a patient is a candidate for operative intervention, age should not be a deterrent, especially considering the potential to increase life expectancy. It has been recommended that the carefully selected, minimally symptomatic octogenarian with aortic stenosis should be considered a low-risk patient and be expected to experience an uneventful operative course and expedient recovery. More importantly, if elective procedures are delayed until symptoms or left ventricular dysfunction develop, patients may suffer from unnecessary increased operative risk and mortality.¹⁸ Early intervention results in a demonstrable improvement in quality of life in these patients, with many improving their NYHA functional classification.

Elderly patients require surgery for mitral valve disease when ischemic regurgitation is present. Surgery for mitral valve disease carries a higher morbidity and mortality risk than for aortic intervention, with an estimated mortality rate as high as 20%.²⁰ Left ventricular function usually is compromised in patients requiring intervention, leading to a poorer outcome in these patients. The surgical outcome for mitral valve procedures depends on the extent of the disease, age of the patient, presence of pulmonary hypertension, and extent of coronary artery disease. The presence of comorbid conditions combined with the emergent nature of surgery in a large percentage of elderly patients further worsens the outcome. Therefore, a decision regarding management of mitral valve disease should be individualized to each patient with the previously mentioned below factors considered. Another concern regarding elderly patients who require surgery for valve disease is the additional requirement for coronary revascularization. This increases the morbidity and mortality from surgical intervention. An elderly patient with many comorbid conditions in need of a combined procedure should only have critically stenosed vessels bypassed.²² Therefore, advanced age is not a contraindication to performing combined procedures; however, a higher mortality rate should be expected. Neurologic complications from valve surgery are particularly common in elderly patients. It has been estimated that approximately 30% of patients >70 years old who undergo valve procedures develop either transient or permanent neurologic dysfunction.²² This often is a result of embolism from debris dislodged from the valve during the procedure or from a formed thrombus in the right atrium.

An important consideration in valve replacement procedures in elderly patients is the type of prosthesis to be used. Elderly patients are at increased risk from bleeding-associated anticoagulation complications. This is especially significant in patients who have experienced falls and minor trauma that have resulted in intracranial hemorrhage. To avoid the lifelong requirement for anticoagulants, bioprosthetic valves should be used in place of mechanical valves whenever possible.²² Although the bioprosthetic valves are not as durable as mechanical valves, studies demonstrate excellent structural integrity 10 years postprocedure, making it an appropriate choice in an elderly patient.

Cancer

The incidence of most cancers is age dependent, and the expanding aged population is rapidly increasing the number of elderly patients who require multimodal therapy for various oncologic diseases, including lung, breast, pancreas, esophagus, stomach, and colorectal malignancies. Approximately 50% of cancer diagnoses are currently made in patients aged 70 years or older.¹⁰ It is ­predicted that the increase in the elderly population will account for up to a 50% increase in the number of patients undergoing oncologic procedures by the year 2020. The increased life expectancy of the geriatric patient coupled with the increasing incidence of cancer with advancing age will lead to an increased prevalence of malignant disease requiring surgical intervention. This is an area of great interest given that randomized clinical trials to determine the outcomes of elderly patients undergoing curative resections, as well as neoadjuvant and adjuvant therapy, are lacking. In addition, elderly patients are rarely included in clinical trials; therefore, treatment decisions are often based on individual surgeon experience and non-geriatric data, and may be flawed by inherent biases regarding the outcome of complete oncologic resections in elderly patients. Surgeons may also be reluctant to expose older patients to the toxic effects of chemotherapy and radiation without proven efficacy in this geriatric population. This highlights the need for research targeting the specific needs of elderly patients with malignancy to aid in the development of specific treatment guidelines for various cancers within this age cohort.

Currently, the geriatric population is undertreated for malignant diseases and does not receive curative resections or adjuvant therapies afforded to same-stage younger patients.¹¹ Potential reasons include poorer functional status compared to younger patients, patient and family preference, age bias, life expectancy, and concerns regarding quality of life after major operative interventions.²³ Surgeons will be challenged to decide whether major surgery is justified in elderly patients, especially those with limited life expectancy. Effectiveness of oncologic surgery in elderly patients depends on whether a cure can be achieved safely without compromise to functional status or quality of life. Postoperative life expectancy should be improved by surgery, or, at the very least, not diminished. A useful treatment algorithm is provided in Fig. 47-3. A study undertaken using the Surveillance, Epidemiology and End Results database assessing cancer-directed surgery (CDS) for localized disease for solid malignancies found that the rates of CDS declined with increasing age for all cancers, especially noted for the aged elderly >70 years old. In addition, CDS was less likely to occur with patients found to have lung, esophagus, stomach, liver, or pancreatic cancer. A careful assessment of the general and cancer-related condition of the patient is crucial to planning the best surgical intervention and postoperative adjuvant therapy.

Formulating a comprehensive, multimodal treatment plan for an elderly patient with a malignancy amendable to surgical intervention is based on careful consideration of the patient’s expected life span, specifically if the life span is expected to exceed survival from the malignancy. Additionally, considerations include the patient’s ability to tolerate the surgery and any complications that may ensue, as well as the likelihood that the patient would suffer a complication from the cancer which would adversely impact quality of life.²⁴ An ongoing international study that is titled “Preoperative Assessment of Cancer in the Elderly (PACE)” is designed to evaluate a scoring system that aids in assessing the oncogeriatric patient for surgical intervention. The PACE study incorporates several validated instruments that assess the functional and physiologic status of patients, including the Mini Mental State Examination, capacity to perform ADLs, Geriatric Depression Scale, and the ASA classification among other useful instruments. Interestingly, the PACE assessment also includes The Physiological and Operative Severity Score which has been shown to predict morbidity and postoperative mortality in general surgery and in patients with lung and colorectal malignancy. This score includes the age of the patient and gives consideration to operative factors, including the type of surgical procedure used, the presence and extent of malignancy, and the timing of the operation (i.e., planned elective procedure or an emergency intervention).¹⁰ Palliative interventions are a part of the therapeutic armamentarium; however, a surgeon must weigh these variables carefully to determine which surgical intervention (i.e., palliative vs. curative) is appropriate.

Breast Cancer

It is projected that there will be a 72% increase in the number of elderly women diagnosed with breast cancer in the United States by 2025. Furthermore, 50% of breast cancers occur after the age of 65 years old and 25% after the age of 75 years old.²⁵ The estimated risk for development of new breast cancer is one in 14 women aged 60 to 79 years old compared to one in 24 in women aged 40 to 59 years old.²⁵ Mortality rates following breast cancer surgery in elderly women is <1%, and therefore, surgical interventions remain the cornerstone of therapy for breast cancer in elderly women. However, as expected, the presence of comorbid conditions affects clinical outcomes in elderly patients with breast cancer. A recent study demonstrated the presence of comorbid conditions in patients with breast cancer rose to as high as 55% in patients >80 years of age, with cardiovascular disease, diabetes, and previous cancer being most common.²⁶ As expected, the resulting 5-year survival rate was lower in patients with two or more comorbid conditions.

A recent study on risk factors for breast cancer in patients >75 years of age showed similarity to younger women and included obesity, nulliparity, family history, and advanced age at menopause.²⁷ Interestingly, although breast cancer presentation in elderly patients may be diagnosed at more advanced stages, both clinical and pathologic data demonstrate less aggressive disease in elderly women with more favorable biologic characteristics. Elderly breast cancer patients are more likely to have estrogen-positive tumors and increasing endocrine responsiveness.²⁷ Despite these relative advantages, a large number of elderly women are not offered conventional therapies for breast cancer. Moreover, elderly patients who are offered breast conservation surgery for breast ­cancer are less likely to have axillary dissection, postoperative radiation, and chemotherapy. This will undoubtedly influence surgical outcomes in elderly patients with breast cancer considering that local recurrence rates after conservative surgery without radiotherapy are reported as high as 47%. Advancing age has been demonstrated to be an independent predictor of nonconcordance with treatment guidelines for definitive surgical therapy and adjuvant chemotherapy, as well as hormonal therapy. One study demonstrated that the odds of receiving a recommendation for chemotherapy decreased by 22% for each year of advancing patient age.²³ The nonsurgical management of breast cancer in elderly patients is falling out of favor because there is currently no rationale for denying surgical therapy for elderly breast cancer patients. Surgery and hormonal therapy were the best options for overall survival, breast cancer–specific survival, and disease-free survival. A Cochrane Review concluded that treatment with tamoxifen alone is not an acceptable option because of higher local progression of disease; 81% compared to 38% with surgical intervention. Furthermore, the response rate only lasts for approximately 18 to 24 months.²³ The final conclusion is that surgery remains the standard of care for elderly patients with breast cancer. Alternative therapies should be reserved for patients who have multiple comorbid conditions leading to poor candidacy for operative intervention, those who are frail, or those who refuse surgery.

A timely study comparing the mortality after breast-conserving surgery (BCS) alone, BCS plus radiation therapy, mastectomy, and the receipt of adjuvant tamoxifen in elderly breast cancer patients confirmed that less than standard treatment for these patients resulted in increased mortality. Elderly women receiving BCS without radiotherapy have more than twice the rate of breast cancer mortality compared to women undergoing mastectomy. In addition, in older women with estrogen receptor and progesterone receptor positive tumors receiving tamoxifen, the rate of breast cancer death increased substantially with the decreasing duration of tamoxifen use.²⁸ The standard of treatment for elderly patients with breast cancer should be the same as younger patients; BCS plus radiotherapy when indicated. If patients decline postoperative radiotherapy or are medically unfit for radiotherapy, mastectomy should be performed. Furthermore, elderly patients with tumor size <2 to 3 cm and no clinical evidence of axillary involvement should be offered sentinel node biopsy.²⁹

One of the most interesting controversies surrounding breast cancer in elderly women is the appropriate age limits of screening. A retrospective study demonstrated a decline in cancer-related mortality among women who underwent regular screening mammography up to 75 years of age.²⁷ Women who underwent at least two mammographic examinations between the ages of 70 and79 years experienced a two-and-one-half–fold reduction in breast cancer mortality compared to elderly women who did not undergo screening.²³ The screening benefits depend on life expectancy. In women with multiple comorbidities, the decision to perform screening should be based on estimated life expectancy. People with <5 years of life expectancy are unlikely to benefit from screening. The American Geriatric Society recommends that screening should be individualized rather than set by age-specific guidelines. The current recommendation is that no upper age limit for screening be set as long as the estimated life expectancy is 4 or more years.

Colorectal Cancer

The incidence of colorectal cancer (CRC) increases with advancing age, similar to most other malignant conditions. Approximately 90% of cases of CRC are diagnosed in patients >55 years old.³³ Of concern is the increased postoperative morbidity and mortality following extensive surgical resections in elderly patients, with a significant increase in patients >70 years old. In fact, inhospital mortality for patients >85 years old undergoing surgery for colorectal malignancy is estimated to be nine-fold greater than for younger patients.³⁰ Furthermore, elderly patients often have decreased cancer-specific survival compared to younger patients. It has been proven that the 5-year cancer-specific survival for CRC is similar among the age cohorts. Therefore, age is not an independent factor accounting for the decreased survival among elderly patients. It is rather a consequence of comorbid conditions and impaired physical capacity necessary for recovery from perioperative physiological stress.³⁰ This leads to bias regarding poorer outcomes in elderly patients. For this reason, many elderly patients are receiving suboptimal cancer therapy and limited resections resulting in decreased survival rates and poorer outcomes. With the ever aging population, this must be addressed and clinical modifications implemented to improve outcomes of elderly patients undergoing surgical interventions for colorectal malignancies. Elderly patients should have continued, aggressive screening for colorectal malignancy and strict adherence to accepted surgical and adjuvant treatment guidelines.

One of the most important aspects to delivering appropriate care to elderly patients with CRC is to consider the patient’s wishes as well as expectations from the surgical intervention. In this respect, functional outcomes and quality of life take precedence in treating elderly patients, especially the aged elderly. Of patients >75 years old who underwent elective surgery, few demonstrated protracted decline in ADLs and most experienced significant improvement in quality of life.³¹ Approximately 10% of elderly patients >80 years old have protracted postoperative disability. Estimation of physical ability and surgical stress is useful for predicting decline in ADLs and postoperative disability. It has been shown that, in patients <80 years of age, a complete resection for cure is most important, whereas in patients >80 years old, avoidance of a stoma becomes paramount. These are important considerations for the geriatric surgeon.³⁰

A prospective study was recently undertaken to specifically evaluate the epidemiology and risk of surgical intervention for CRC in elderly patients. A large cohort of 47,455 patients was divided based on age <75 years old and >75 years old.³⁰ It was determined that a significant portion of elderly CRC patients are female, with multiple comorbidities leading to advanced ASA levels of 3 and above. The study determined that elderly patients underwent surgical interventions less often than younger patients (81% vs. 88%, respectively, P <.001), more frequently required urgent or emergency operations, and were more likely to have operative procedures in which the primary cancer was not resected. Obstructive tumors are significantly more common in patients >70 years old, and elderly patients are still presenting far too commonly with surgical emergencies resulting from obstruction and perforation in up to 40% of the cases.¹¹ In addition, elderly patients had higher postoperative mortality than younger patients (10.6% vs. 3.8%, respectively). Right colectomies, Hartmann’s procedures with colostomy, transanal endoscopic microsurgery, and transanal resection of tumors were more common in elderly patients, whereas formal resections, including low anterior and abdominoperineal resections, were more common in younger patients.³⁰ Elderly patients are less likely to undergo CDS; with each half a decade increase in age >70 years old, the odds of receiving cancer-directed surgery were reduced by 44%. Interestingly, many of these patients presented with lesions of lower-stage Duke’s cancer classification. However, this was not secondary to earlier presentations as one might assume, but rather secondary to understaging from surgical treatment. Accurate staging may not be possible with local resections, limiting the number of lymph nodes available for proper staging.³² Elderly patients also are less likely to undergo preoperative irradiation and neoadjuvant chemotherapy, reducing the likelihood of curative resection.³⁰

Liver resection for CRC liver metastases in properly selected elderly patients 70 years of age or greater is feasible with older patients having similar operative survival to younger patients. Palliative surgery remains a viable option for elderly patients with disseminated CRC and should be aimed at the reduction of symptoms such as pain, obstruction, or hemorrhage. Bowel obstruction can be relieved with intestinal bypass or a diverting colostomy. The most common site of disseminated disease is the liver, and uncontrolled liver metastases are responsible for pain, abdominal distention, jaundice, and inferior vena caval obstruction. Elderly patients with metastatic disease who are not candidates for curative resection may be considered for ablation of the lesions by local destruction, cryotherapy, or radiofrequency ablation. More traditional means such as chemotherapy, which can be administered via the hepatic artery or radiation, also may be used.³³

Similar to breast cancer, an upper age limit for CRC has not been clearly established. Screening for CRC may not lead to an observed survival benefit until 5 years or longer after screening had occurred. This would limit the benefit of screening in aged populations with limited life expectancy. An interesting way of looking at this controversy is from a recent study that determined that the number of screening colonoscopies needed to prevent one CRC-related death (the number necessary for survival or NNS) increased as with increasing age and comorbidities. For example, in healthy men and women aged 75 to 79 years old, the NNS was 50. The corresponding NNS in patients 90 years and older was 279 in women and 482 in men.³⁴ Consideration for continued screening in very elderly patients should take into account age and predicted life expectancy, comorbid burden, expected duration of the protective effect of screening, risk for cancer, results of previous screening colonoscopies, and patient preference.³⁴

Lung Cancer

Lung cancer is the leading cause of cancer-related deaths in the United States for patients >70 years old. National Cancer Institute statistics show that the peak incidence of lung cancer is between 75 and 79 years of age. Elderly lung cancer patients also have a higher mortality rate, and therefore, the peak mortality rate is between ages 75 and 84 years.³⁵ Non–small cell lung cancer accounts for roughly 80% of all lung cancer cases, and >50% of these patients are >65 years of age. Interestingly, approximately 30% of these patients are 70 years or older at diagnosis.³⁶ Lung cancer is highly prevalent among elderly patients, so much so that a 2-cm, asymptomatic, solitary pulmonary nodule in a 70-year-old male smoker has a >70% chance of being an occult lung cancer. Squamous cell carcinomas are more common among elderly patients than among younger patients, and these tumors are associated with a higher incidence of local disease, tend to have lower recurrence rates, and have longer survival times than nonsquamous cancers.³⁵ In cases of resectable primary lung cancer, surgery remains the treatment of choice independent of age.¹¹

The estimated life expectancy of untreated lung cancer is approximately 9 months. This can increase to as high as 18 months with palliative chemotherapy and radiation. ­However, the life expectancy of an elderly patient who has undergone a successful operative resection is estimated to be as high as 31 months, making this the preferred option when feasible.¹³ ­However, despite this and the fact that more elderly patients present with stage 1 disease, elderly patients are offered curative surgery less frequently than younger counterparts. The same holds true for chemotherapy and radiation.

Advanced age is an independent risk factor for death after thoracotomy, with significantly increased mortality after age 65. These reasons are multifactorial partly due to the physiologic debilitation that occurs with division of the intrathoracic muscles that aid in respiratory function and the loss of lung volume after resections.¹³ One study demonstrated that patients 70 years of age or older who underwent thoracotomy for lung cancer had an operative mortality rate of 14%, which is directly related to the extent of the pulmonary resection. In one of the largest prospective, multi-institutional trials conducted, The Lung Cancer Study Group, increasing age led to a ­significant increase in 30-day mortality for patients undergoing thoracotomy and lung resection.¹³ They found overall mortality to be approximately 3.5% in patients <65 years old, which rose to 7.3% for patients 70 years or older and as high as 8.1% for ­octogenarians. However, with improved surgical options, including minimally invasive video-assisted thoracic surgery (VATS) in the past decade, the mortality rate has ranged from 3% to 5% in carefully selected patients.² In a recent study conducted to determine if VATS resulted in lower morbidity in the elderly population in comparison to open, rib-spreading thoracotomy, the overall morbidity for minimally invasive surgery was 28%; this increased to 45% with traditional open procedures.³⁶ Furthermore, elderly patients undergoing VATS tended to have less severe complications compared to patients undergoing thoractomy.³⁶ Limited resections (segmentectomies) may be a consideration in elderly patients with limited life expectancy or poor cardiac and pulmonary reserve who may not tolerate a more extensive procedure. Some studies have shown that limited resections may provide a comparable survival rate to lobectomies in elderly patients as long as the resection includes all foci of tumors and provides a microscopically free margin. The most striking finding was that any survival difference between treatment modalities disappeared after 71 years of age. Interestingly, even smaller resections such as VATS and wedge resection may be a viable oncologic option in an elderly patient with resectable disease but limited life expectancy.¹³ This is limited to very small tumors <7 mm in diameter and not yet proven to be clinically efficacious. Of particular interest is that VATS procedures may result in lower rates of postoperative confusion in elderly patients and this may be secondary to the decreased physiologic stress of minimally invasive procedures, faster recovery rates, and decreased narcotic requirement for pain control.¹³ Careful preoperative selection and optimization combined with aggressive postoperative care and rehabilitation make surgical intervention for resectable ­disease feasible in aged populations.

Trauma

Patients >65 years of age currently account for approximately 23% of total hospital trauma admissions—many of which are multisystem and life threatening.³⁷ Geriatric trauma will continue to challenge surgeons in understanding the physical and physiologic impact of various mechanisms of injury, the need for careful assessment of comorbid conditions with particular attention to medication regimens, the rehabilitative capacity of an elderly trauma patient, and the knowledge of specific interventions that help to minimize morbidity and mortality in this population following traumatic injury.

The current geriatric population has fewer disabilities and is considerably more active than previous generations, which predisposes them to traumatic injuries. The most common type of trauma is blunt injury resulting from falls and motor vehicle collisions or pedestrian accidents. Falls currently account for 20% of severe injuries in elderly patients. Many underlying chronic and acute diseases common to elderly patients place them at increased risk for falls. These diseases include postural hypotension, leading to syncopal “drop attacks”; dysrhythmias from sick sinus syndrome; autonomic dysfunction; polypharmacy with improper dosage of antihypertensive and oral hypoglycemic agents resulting in hypotension; and hypoglycemia, respectively.³⁸

Elderly patients also can fall victim to penetrating trauma, especially in elderly patients who may have underlying depression and suicidal ideations or are victims of elder abuse. It is estimated that approximately 40% of all trauma patients by 2050 will be >65 years old.³⁹ With the expanding elderly population, this will be an increasing source of morbidity and mortality; the risk of death after major trauma with multi-system and life-threatening injuries rises steeply after age 45 years old and doubles by age 75 years old. In contrast to what is observed for abdominal and thoracic surgery, even after controlling for injury severity and pre-existing medical conditions, patients aged 65 years and older sustaining traumatic injury were 4.6 times more likely to die than younger patients.³⁹ Of note, there are several interesting aspects of care of the acutely injured elderly patient that must be kept in mind. First, physiologic reserve can be challenged by trauma. For example, previously unknown disease such as cardiac impairment may be acutely unmasked. Secondly, medications common to elderly patients, such as beta blockers and anticoagulation, cannot only inhibit the physiologic response to stress but may even worsen injury. Finally, elderly patients with impaired functional status posttrauma are more likely to lose their ability to function independently without the support of a nursing home.

Elderly patients are particularly susceptible to trauma due to changes that occur with aging, specifically, gait instability, decreased hearing and visual acuity, presence of confusion or dementia, underlying comorbid conditions, and poor to tolerate the physiologic stress of traumatic injuries. Pre-existing medical conditions increase the risk of death after trauma significantly (up to ­three-fold).³⁷ This is worsened when combined with an elderly patient’s decreased functional reserve for handling physiologic abnormalities accompanying major trauma, such as hypotension and hypoxia. It is important to consider a trauma patient’s age, as patients aged 65 to 80 years old have a 6.6% overall mortality rate after traumatic injury, which rises to 10% in patients 80 years or older.⁴²

Despite the increased risk of morbidity and mortality after traumatic injury, it is interesting to note that there is currently an undertriaging of elderly patients to level 1 trauma centers despite high injury severity scores.³⁹ In one study, elderly patients >65 years old were five times more likely to be ­undertriaged to nondesignated trauma hospitals than younger counterparts.³⁹ However, a reduction in morbidity and mortality and posttraumatic complications as well as faster rehabilitation can result from better triaging practices. In one particular study involving acutely injured octogenarians with injury severity scores between 21 and 45, inhospital survival was as high as 56% in trauma centers, and this dramatically decreased to 8% in those treated at nontrauma hospitals.³⁹

It is important to determine the medication regimen of elderly trauma patients. Medications such as beta blockers, calcium channel blockers, diuretics, and afterload reduction agents may impair critical augmentation of myocardial function in trauma patients, especially if they are hypovolemic. Approximately 20% of the elderly population with coronary artery disease and 10% of those with hypertension are currently on beta blocker therapy.³⁹ Therefore, tachycardia, one of the most valued signs of continued hypovolemia from either ongoing blood volume loss or underresuscitation, is lost in the elderly patient on beta blocker therapy. This makes interpretation of hemodynamic parameters in elderly patients inaccurate and, at times, misleading, which could lead to delays in appropriate interventions and resuscitation. However, it is important to keep in mind that, to date, evidence supporting early hemodynamic monitoring in elderly patients is lacking.

The other medication class that can be detrimental to an elderly, acutely injured patient is anticoagulation, ranging from aspirin and clopidogrel (Plavix) to warfarin, which may, at times, be supratherapeutic. Massive intracranial hemorrhages resulting from minor falls from standing in elderly patients are demonstrated in Fig. 47-4. Warfarin therapy may be used in patients with atrial fibrillation, DVT, and prosthetic heart valves. The mortality rate of elderly patients on warfarin with a traumatic intracranial hemorrhage was 48% compared with 10% in an age-matched cohort not on anticoagulation therapy; it is unknown for the newer factor Xa inhibitors.³⁹ One of the most important caveats to treating elderly patients on anticoagulation with blunt head injury is the potential for significant, life-threatening intracranial hemorrhage despite initial normal head (computed tomography) CT scans. In one study, >70% of patients with minor mechanisms and negative CT scan, admitted for observation subsequently, clinically deteriorated within 12 hours of admission with a Glasgow Coma Scale of <10 and were subsequently found to have significant intracranial hemorrhages.³⁹ Therefore, prompt reversal of anticoagulation, particularly if supratherapeutic, is warranted to reduce morbidity and mortality following blunt head injury. In addition to increased risk of mortality in elderly patients sustaining blunt head trauma, a significant portion fail to resume functional independence after traumatic injury. It is estimated that approximately 20% to 25% of elderly trauma patients require discharge to a skilled nursing facility for long-term care and rehabilitation.³⁷ Poor functional outcome has been attributed to several factors among which are age >75 years old, presence of shock on admission, severe head injury, and development of infectious complications.

Laparoscopy

Open abdominal procedures may require more intensive postoperative care, longer hospital stays, and an increased need for postoperative rehabilitation and possible institutionalization for elderly patients with limited reserve. However, the increasing experience with laparoscopic techniques, combined with minimized pain, decreased length of hospital stay, and low morbidity and mortality rates, has led to the increased use of minimal access procedures among elderly patients. It has expanded from cholecystectomies to more complex procedures, including colon resections, gastrectomies, and cardiac surgery.

Minimally invasive laparoscopic surgery reduces common postoperative complications such as atelectasis, gastrointestinal ileus, and wound infections. In elderly surgical patients, these complications easily progress to pneumonia, DVT, and metabolic and electrolyte disturbances.⁴⁰ Decreased postoperative pain from smaller incisions leads to faster return to a preoperative level of functioning, including early ambulation, which decreases complications from prolonged bed rest, such as DVT and pneumonia from compromised pulmonary mechanics. The latter is especially important for elderly patients because deconditioning occurs with long hospital stays, which depresses their ability to return to preoperative functional status. Laparoscopic surgery also provides the added benefit of reduction of the inflammatory, hormonal, and metabolic stress induced by major open surgical operations. The net result is that patients who undergo laparoscopic procedures may do better; in colon surgery it has been shown to increase the chance that the patient returns home over an interim rehabilitation center.

However, these benefits must be balanced against the potential adverse effects of carbon dioxide (CO₂) insufflation and hemodynamic alterations induced by pneumoperitoneum and increased intra-abdominal pressure with concomitant decrease in venous return.⁴¹ Therefore, decisions to perform minimal access procedures in the elderly must be individualized to the patient with careful consideration of the impact of comorbid conditions and the potential for poor cardiopulmonary reserves. This helps to provide the optimal circumstance for intervention resulting in improved surgical outcomes.

It is important to consider using a reduced intra-abdominal insufflation pressure during a laparoscopic procedure in an elderly patient. Pressures up to 20 mmHg are associated with increased filling pressures and cardiac output. However, further increased elevations result in decreased central venous pressures and cardiac output, which can be life threatening in a patient with preexisting cardiac dysfunction and poor functional reserve.

Studies have demonstrated that both advanced age >70 years old and an ASA classification of 3 or 4 are ­associated with higher conversion rates for laparoscopic cholecystectomy to open cholecystectomy.⁴² These additional challenges, ­however, are not a contraindication to attempting the less invasive approach because conversion to an open procedure does not adversely impact the overall morbidity and mortality of the patient.

A particularly useful application of minimally invasive techniques is to rule out a surgical abdomen in an elderly patient presenting with acute abdominal pain. Vague, poorly localized pain, further obscured by several underlying confounding comorbid conditions, as is the case with ischemic colitis and mesenteric ischemia, may subject an elderly patient with poor reserve to the risk of general anesthesia and a negative exploratory laparotomy (Fig. 47-5). Analysis of several studies directed at the application of laparoscopic techniques for the patient with acute abdominal pain demonstrated that approximately 41% had pathology necessitating open laparotomy, 10% had pathology amendable to laparoscopic intervention (i.e., acute cholecystitis), and 48% had nonsurgical disease that was subsequently managed nonoperatively, avoiding a negative exploration.⁴² Therefore, laparoscopic evaluation of abdominal pain in the critically ill elderly patient may prove to be a valuable tool.

Endovascular Surgery

Abdominal aortic aneurysm (AAA) is a disease that primarily affects the elderly male patient. With increasing use of screening abdominal CT scans and ultrasounds for evaluation of various abdominal complaints, AAAs are being identified with greater frequency, most of which are diagnosed in elderly patients, given the increased prevalence of AAA with increasing age. In fact, the percentage of AAA rises from about 1% at age 55 to 60 years to approximately 10% in patients 80 years of age or older.⁴³ Elderly patients, and octogenarians in particular, were deemed poor operative candidates for the traditional open repair given the frequent presence of comorbid conditions and limited cardiopulmonary reserve to tolerate a major operation or the many hours of required operative time and general ­anesthesia. Elderly patients had an increased perioperative morbidity and mortality following open aortic surgery in comparison to younger cohorts. However, the introduction of endovascular techniques for repair of AAA has shifted the risk-benefit ratio for operative intervention, allowing greater life expectancy for the elective repair of this potentially life-threatening condition with the benefits of minimally invasive techniques as previously described.

Studies have demonstrated that endovascular aortic repair (EVAR) is feasible and efficacious in elderly patients, including those previously considered unfit for open repair. EVAR is a minimally invasive technique in which a prosthetic graft is introduced into the aortic lumen via the common femoral artery to exclude the aortic aneurysm sac. EVAR significantly reduces operative and anesthesia times, blood loss, intensive care needs, length of stays, and major postoperative morbidity associated with open AAA repair. The most common complication following EVAR in elderly patients is renal impairment. Typically, patients are discharged 1 to 2 days following surgery and the graft is deployed via small bilateral groin incisions, obviating the need for a major laparotomy incision. Figure 47-6 demonstrates the endovascular repair of AAA and right iliac artery aneurysm via bilateral groin access in an 82-year-old man who was discharged from the hospital on postoperative Day 2. This procedure also can be done using epidural anesthesia for high-risk candidates who may tolerate general anesthesia poorly. Endovascular repair has even been described under local anesthesia in patients at extreme high risk of rupture and death or after rupture and hemodynamic instability, precluding the ability to tolerate general anesthesia.⁴⁴

Careful consideration of the life expectancy and the risk of rupture dictate the necessity for intervention. EVAR remains a viable option in elderly patients. Nonoperative management is justified in frail elderly patients with multiple comorbidities and reduced life expectancy whose operative risks outweigh the risk of rupture and in those who are unlikely to survive long enough to benefit from the repair.

The prevalence of thyroid disease increases with advancing age. The etiologies, risk factors, and presentations of thyroid disease are similar across all ages, and therefore, are not discussed in detail. Of note, however, is that elderly patients more often present with cardiac manifestations of hyperthyroidism, such as atrial fibrillation, than do their younger counterparts. A common finding requiring evaluation in elderly patients is the presence of a thyroid nodule, usually detected by physical examination. These nodules usually are single and four times more common in women, making them a particular concern for postmenopausal elderly women. Papillary carcinoma in elderly patients tends to be sporadic with a bell-shaped distribution of age at presentation, occurring primarily in patients aged 30 to 59 years old. The incidence of papillary carcinoma decreases in patients >60 years of age.⁴⁵ However, patients >60 years of age have increased risk of local recurrence and for the development of distant metastases. Metastatic disease may be more common in this population secondary to delayed referral for surgical intervention because of the misconception that the surgeon will be unwilling to operate on an elderly patient with thyroid disease. Age is also a prognostic indicator for patients with follicular carcinoma. There is a 2.2 times increased risk of mortality from follicular carcinoma per 20 years of increasing age.⁴⁶ Therefore, prognosis for elderly patients with differentiated thyroid carcinomas is worse compared to younger counterparts. The higher prevalence of vascular invasion and extracapsular extension among older patients is, in part, responsible for the poorer prognosis in geriatric patients. Advancing age leads to increased mortality risk for patients with thyroid cancer and is demonstrated by the AMES (age, metastases, extent of primary tumor, and size of tumor) classification system developed by the Lahey Clinic.

Approximately 2% of the geriatric population, including 3% of women 75 years of age or older, will develop primary ­hyperparathyroidism.⁴⁷ Geriatric patients are usually referred to surgery only when advanced disease is present because of ­concerns regarding the risks of surgery, but low rates of ­morbidity and negligible mortality combined with high cure rates of approximately 95% to 98% make parathyroidectomy safe and effective. Convincing evidence of the benefit of surgery is the usual marked symptomatic improvement, which greatly improves the quality of life for most patients. The National Institutes of Health Consensus Development Statement recommends curative therapy after diagnosis of primary hyperthyroidism is established in a patient regardless of age. Specific indications for operative intervention regardless of age include a 30% decrease in creatinine clearance, 24-hour urinary calcium excretion >400 mg, and decreased bone density.⁴⁸

Elderly patients are especially prone to developing mental manifestations of hyperparathyroidism that may be severe enough to produce a dementia-like state. There often is a significant improvement in mental status after parathyroidectomy. Another specific symptom of hyperparathyroidism that may easily be mistaken for osteoporosis and can be present in postmenopausal, elderly women is orthopedic disease; specifically back pain, and possibly, the occurrence of vertebral fractures. This pain can be of moderate intensity, leading to impaired mobility and severely affecting the quality of life of elderly patients. The decreased bone density observed in elderly patients with hyperparathyroidism tends to improve during the first 2 years after successful parathyroid surgery.

Limited parathyroidectomies with minimal dissection in geriatric patients are an effective alternative. This is a viable option in patients with multiple comorbid conditions in whom the increased risk of surgical intervention or general anesthesia remains a concern. One study demonstrated that preoperative localization of the hyperfunctioning gland with the aid of ^99mTc-sestamibi nuclear scanning, as well as intraoperative parathyroid hormone (PTH) assays to rapidly confirm that all hypersecreting glands have been removed, allows limited parathyroidectomy to be performed with accuracy in elderly patients.⁴⁷ This procedure is described as “limited” because bilateral neck dissection for identification and biopsy of the remaining glands to determine if they are hypersecreting becomes unnecessary. The half-life of intact PTH is approximately 3 to 4 minutes. Therefore, a drop in the intraoperative PTH level at approximately 10 minutes after resection of the suspect hypersecreting gland suggests a 98% probability that the patient will return to normocalcemic levels postoperatively.⁴⁷

Palliative surgery is defined as surgical intervention targeted to alleviate a patient’s symptoms, thus improving the patient’s quality of life despite minimal impact on the patient’s survival.⁵⁴ With an increasing number of aging surgical patients who often present with advanced disease, surgeons must be familiar with the concept of palliation to control disease. This concept focuses on providing the maximal benefit to the patient using the least-invasive intervention. Ultimately, this leads to symptom relief and preservation of the quality of life in terminal disease states. The uses of palliative surgery can range from extensive debulking operations aimed at aiding in the effectiveness of chemotherapy and radiation, to less complex operations to alleviate symptoms such as intractable vomiting, severe pain, cachexia, and anorexia that are common to terminal disease states. The success of palliative surgery is a careful balance between achieving symptom relief while ensuring that the development of new symptoms from the palliative intervention itself does not occur.

The need for surgical input in helping elderly patients make decisions has never been more important. Inherent biases to age exist, such that patients who can be cured or palliated by surgical procedures are in many cases not being helped. For example, O’Connell demonstrated a decrease in referrals to surgery in aged patients with potentially curable oncologic illnesses, including those of breast, gastrointestinal, and lung (Fig. 47-7).⁵⁰ Only a surgeon with knowledge of the current best practice approach for the aged patient can help a patient—and his or her referring physicians—understand the real risks and potential benefits of an intervention, be it curative or palliative.

The challenge for us is to improve perioperative care of the elderly surgical patient using new tools for careful patient selection, accurately assess risk factors to reduce postoperative morbidity and mortality, and deliver quality surgical interventions without compromising functional vitality.