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In many developed countries, the proportion of the population that is
older is growing. The oldest old (80 years or older) are the fastest growing
segment of the older population. Currently, this group accounts for 11%
of those 60 years of age and older. By the year 2030, 17% of the
population in the United States will be older than 65
years.1 Improvements in surgical techniques, anesthesia,
and intensive care units make surgical interventions in older and sicker
patients possible. It is estimated that over half of the population older
than 65 years will require surgical intervention at least once during the
remainder of their lives2 (Figure 56–1).
Consequently, elderly patients are becoming an even larger part of
anesthetic practice. Regional anesthesia is frequently used in elderly
patients, especially during orthopedic surgery, genitourologic and
gynecologic procedures, and hernia repair. Although age can no longer be
considered as a contraindication to anesthesia and surgery,
anesthesia-related morbidity and mortality remain higher among elderly than
among young adult surgical patients.
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To effectively treat elderly patients, clinicians must have an
understanding of aging, how it occurs, how it affects specific organ
systems, and how it influences clinical care when a patient is subjected to
surgery. Aging is a normal phenomenon, although the basic mechanisms that
cause aging are still poorly understood. Aging per se is represented by
those manifestations of irreversibly altered organ function that are common
in all elderly persons and are usually progressive. The physiologic process
of aging varies considerably from person to person; hence variation in organ
capabilities increases with age. Different organs in the same individual may
age at different rates; each system has its own temporal pattern of age
change. The organ reserves, which are so essential to ensure homeostasis,
gradually decrease, resulting in an increased sensitivity to internal and
external environmental stressful stimuli3 (Figure
56–2).
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Age alone is not a major factor in predicting the risks to a patient
undergoing anesthesia and operation. The overall physical status or disease
state or both are better predictors of outcome. Risk is directly related to
the number and extent of coexisting preoperative diseases. Ischemic heart
disease, diabetes mellitus, and hypertension are the preoperative conditions
most indicative of a higher risk of peri- and postoperative morbidity and
mortality.4 The type of operation appears to be important;
upper abdominal surgery procedures are associated with the highest ...