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Currently, more than 20% of people older than 60 years undergo surgery and anesthesia as compared with fewer than 15% of those ages 45 to 60 years. These proportions are expected to increase in the future. Despite the higher numbers of elderly patients having surgery, mortality and morbidity rates have been declining.169
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Because all types of surgical operations are being offered to increasingly older people, it is important to differentiate the effects of aging from the pathology of individual disease processes and to control for comorbid conditions. In general, preoperative testing is not determined on the basis of age but in consideration of the procedure, the coexistent disease states, and the overall condition of the patient.170 However, it is reasonable to search for common, but perhaps asymptomatic, comorbid problems, such as subclinical cardiac disease or glucose intolerance. Common procedures in the elderly are briefly reviewed next.
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All types of cardiac procedures, including coronary artery bypass grafting (CABG), valvular repair or replacement, and ventricular assist device placement, are being offered to older patients, even those patients older than 80 years. The morbidity and mortality of these procedures increase with age, but the benefits are a greater life expectancy as well as a better quality of life.
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In-hospital mortality for CABG is approximately 8% for patients older than 80 years and is similar in highly selected patients older than 90 years.171 Although there are limited studies, the data appear to suggest that elderly patients at higher risk have better outcomes with revascularization than with medical therapy alone.171,172
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AVR-combined procedures (AVR and CABG) and, to a lesser extent, mitral valve surgery are increasingly offered to the elderly. The risk appears to be similar to CABG alone; 2 authors reported in-hospital mortality rates of 7.9% and 8.5% for mitral and aortic valve surgery, respectively.173,174, Certainly age and comorbid disease states play a role both in morbidity and mortality but also in the choice of valve repair versus the type of prosthetic valve use.175
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Heart failure is an increasingly common problem, which affects more than 5 million Americans and 15 million Europeans.176 Left ventricular assist devices have evolved as destination therapy for advanced heart failure patients who are not candidates for heart transplant, leading to a significant increase in use in elderly patients with this condition.177 This surgical procedure is likely to increase over time as the population ages and patients reach the limit of effective medical management for advanced heart failure.
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Vascular disease is prevalent in the elderly population, with major vascular procedures most commonly performed to treat the effects of peripheral vascular disease and carotid artery atherosclerosis. Therefore many elderly patients undergo aortic repair (open and endovascular), femoral-to-popliteal bypass grafting, and carotid endarterectomy. In general, the morbidity and mortality of many vascular operations are not different between a healthy elderly patient and a younger patient, but the elderly are often not diagnosed until late in the disease process, leading to higher risk procedures with higher mortality rates.178 Endovascular interventions have made vascular surgery less invasive; one comparison of aortic endovascular repair to open repair revealed a reduced incidence of perioperative complications compared with open vascular surgery.179 However, long-term follow-up determined that the incidence of cardiac mortality and myocardial infarction was similar.
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Cardiac Conduction Procedures
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With the significant increase in conduction abnormalities, CAD, and CHF in the elderly, it is logical to anticipate an increased incidence of procedures to treat these abnormalities. In fact, half of all pacemakers implanted in the United States are for patients age 75 years and older.180 Additionally, biventricular pacing for heart failure and cardioverter-defibrillator implantation are also being increasingly used in the care of the elderly, although efficacy and benefit in the elderly are less than those in younger patients.181,182
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The choice to undertake thoracic procedures must be carefully weighed against the risks and benefits in an elderly population. For example, an oncologic indication for a procedure may carry more weight than a quality-of-life indication (eg, surgery for emphysema) in this higher-risk population. A study of 356 patients older than 70 years after lung resection found a 33% to 48% 30-day morbidity and a 4% to 69% 30-day mortality rate.183 Independent predictors for postoperative complications included a low predicted postoperative forced expiratory volume in 1 second (FEV1), concurrent CAD, and extended resection. Others have found that post–lung resection morbidity is predicted by a reduction in the ability to carry out activities of daily living, decreased cognition, and length of surgery.184 Brunelli et al suggested that a simple screening test for surgical fitness is the ability to climb stairs because it was determined that concomitant cardiac disease and a low stair height climbed preoperatively predicted cardiopulmonary complications in the elderly after lung resection.185 The type of procedure contemplated may also affect the decision to offer a surgical intervention, in that a minimally invasive procedure may lead to less immediate morbidity, although the overall long-term mortality may be similar. Esophageal resection has a particularly high morbidity and mortality at baseline, but age as a sole criterion has only a minor influence on overall outcome.186 There appear to be fewer age-related concerns for other types of smaller thoracic procedures such as bronchoscopies, mediastinoscopies, and esophagoscopies.
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Transplant Procedures
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Organ transplant is also becoming increasingly common among the elderly as the contraindications for transplant with respect to age are being relaxed. An especially interesting program is the Eurotransplant Senior Program that allocates kidneys within a narrow geographic area from donors age 65 years or older to recipients 65 years or older regardless of human leukocyte antigen. Graft and patient survival were not adversely affected, but a 5% to 10% higher rejection rate was noted as compared with younger recipients or younger donors.187 In contrast, survival of elderly heart transplant patients is significantly lower than in young recipients with increased risk of renal failure and malignancy among elderly patients.188 As above, destination a ventricular assist device may be used to complement heart transplant to treat advanced heart failure. Similarly, lung transplants are being offered to patients up to 70 years but must be cautiously allocated to those most likely to benefit.189 One group found that the risk of death increased dramatically after age 70 and concluded that lung transplant should be very limited for those older than 70 years.189
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Orthopedic Procedures
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As osteoarthritis and rheumatoid arthritis increase with age, so do the procedures to treat these conditions, primarily knee and hip replacements. Furthermore, the high prevalence of skeletal disease, combined with an increased predisposition to fall, leads to a high incidence of fractures (especially of the hips, the vertebrae, and the wrists) in older people who then present for treatment on an emergency basis (Fig. 21-13).
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Hip replacement and repair of hip fracture are exceedingly common operations in the elderly and aged populations. Unfortunately, hip fracture also carries a very high mortality rate of 20% in the first year after fracture.190 A Cochrane review of the treatment of evidence-based best practices for elderly hip fracture patients revealed that spinal anesthesia, pressure-relieving mattresses, perioperative antibiotics, and deep venous thromboses prophylaxis were beneficial, whereas preoperative traction was not beneficial, and types of surgical management, postoperative wound drainage, and even "multidisciplinary" care lacked sufficient evidence to determine either benefit or harm.191 A large study of 2390 patients older than 60 years with hip fracture found a 9.6% 30-day mortality and a 33% 1-year mortality after hip fracture surgery; preoperative variables that predicted mortality included 3 or more comorbid conditions, preexisting chest infection, and concurrent malignancy.192
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Total knee replacement (TKR) is primarily a surgery for the elderly, with younger patients less likely to be referred for surgery than older patients.193 As the population ages, TKR is now almost as common as total hip replacement. Long-term results in patients older than 70 years are excellent, but infection and loosening and malpositioning of the implants are common complications.194
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Genitourinary Treatment
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Elderly men are subject to abnormalities of the urethra primarily related to benign prostatic hypertrophy and prostate cancer; commonly leading to a transurethral prostrate procedure. In contrast, elderly women are prone to bladder and vaginal relaxation with urinary incontinence and prolapse symptoms. Thus many urethral and urethrovaginal procedures are performed on patients older than 65 years. In one study, preexisting cardiovascular disease increased the risk of perioperative complications in elderly women undergoing urogynecologic surgery, but the overall perioperative morbidity rate was low.195 Procedures to treat benign prostatic hypertrophy are commonly performed and usually well tolerated in the elderly. Although age is a prognostic factor for bladder cancer resection, this surgical procedure is also being performed frequently in the elderly patient.196
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Abdominal procedures are undertaken in the elderly for a variety of reasons. As surgical and anesthesia techniques have developed, age is no longer considered a contraindication to an intra-abdominal procedure, in part due to increased use of minimally invasive approaches.197 However, one should be aware of mesenteric ischemia as the cause for abdominal surgery in combination with vascular procedures. This condition typically presents in patients older than 70 years and carries a high incidence of morbidity and mortality due to both the predisposing factors of arteriosclerosis, hypertension, CAD, CHF, diabetes, and obesity but also due to the range and inconsistency of presenting symptoms leading to confusion with other abdominal processes.198
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Visual impairment conditions increase with age, as do corrective surgical procedures to restore sight; elderly patients represent the majority of the surgical population scheduled for ophthalmologic surgery.199 Eye surgery is usually minimally invasive and performed as day-case surgery despite the high comorbidity of these patients.
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Overall Surgical Risk
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Overall surgical risk is related to physiologic organ system age, comorbid diseases, and the risks of the procedure to be undertaken. In general, an otherwise healthy elderly patient can expect a good outcome with continued quality of life. However, there are known overall risks for surgery in the elderly. Emergency procedures have especially high mortality in the elderly, in part because they take longer to exhibit symptoms and thus present with more advanced diseases, such as perforation or necrosis.200 An example is a study of 48-hour emergency surgery mortality rates in 795 patients in which patients older than 90 years had a mortality of 7.8% as compared with a 0.6% for age-matched patients undergoing elective surgery.201
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The type and number of coexisting diseases are exceedingly important because it has been proposed that the effects from coexisting disease outweigh the effects of age alone on anesthesia outcome.169 When age and severity of illness are compared, the number of coexisting diseases is more significant. Additionally, the albumin level may serve as a marker for preoperative health status of the elderly patient because albumin level has been linked to perioperative mortality.202
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Of elderly patients undergoing surgery, 10% to 40% develop a postoperative complication that can lead to serious adverse events.203 According to a recent study, even seemingly mild initial complications may profoundly alter postoperative prognosis, beginning a cascade of other complications that result in death.203 Silber et al examined Pennsylvania Medicare claims and determined that the odds of an elderly patient dying within 60 days after surgery increased 3.4-fold in patients with complications compared with those without complications.203 Certain complications increased the risk substantially, such as respiratory compromise, associated with a 7.2-fold increase in the risk of dying, and CHF, resulting in a 5-fold risk in the odds of dying compared with patients without any perioperative complications.
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One must consider, however, that advances in surgical and anesthetic techniques may allow the stabilization of an elderly patient with an emergent condition. For example, a minimally invasive emergency procedure performed with a regional anesthetic may allow stabilization of an elderly patient, thus affording the opportunity for full resuscitation and optimization before a definitive surgical procedure.204
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Altered Perioperative Mental Status and Cognitive Dysfunction
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Perioperative delirium is common in high-risk surgery and associated with age, education, preoperative cognitive functioning, preexisting medical conditions, and postoperative complications. However, the pathophysiology is poorly understood. As well as being linked to narcotics, sedatives, and anticholinergics, delirium is associated with urinary tract infection, pneumonia, hypoxia or hypercarbia, fever, blood loss, and electrolyte disturbances. For example, 102 patients between 41 and 88 years of age underwent elective open abdominal aortic aneurysm surgery. Delirium occurred in 33% of the patients during the first 6 days after surgery. With multivariate analysis, the most powerful preoperative predictors of delirium were number of pack-years smoked, mental status scores, and number of perioperative psychoactive medications.205 Longer duration of delirium was related to lower education, preoperative depression, and greater preoperative psychoactive medication use. Unrelated variables were characteristics of the surgery and hospital stay.
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Persistent postoperative cognitive dysfunction is also a common problem after surgical procedures, estimated by some to be as high as 14% in patients older than 70 years.206 Monk et al further evaluated 1064 patients before, just after, and 3 months after noncardiac surgery.160 They found at 3 months, young and middle-age patients had similar incidences of cognitive dysfunction (5.7%) but that elderly patients still had significantly more dysfunction at 12%. The risk factors identified were similar to those for postoperative delirium and included increased age, lower educational level, and a history of a prior cerebrovascular accident without residual impairment. Persistent postoperative cognitive dysfunction is important because patients were both more likely to die within 3 months of surgery and in the first year after surgery (p = 0.02).160
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Given the devastating consequences of postoperative cognitive dysfunction in the elderly, the role of anesthetic choice has been investigated. Forty-seven patients older than 60 years who were undergoing major surgery were randomly allocated to receive either regional or general anesthesia. Overall, elderly patients subjected to general anesthesia displayed more frequent cognitive impairment during the immediate postoperative period in comparison with those who received a regional technique.207
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However, several studies have failed to demonstrate any long-term differences in postoperative cognitive function between general and regional anesthesia. Williams-Russo et al examined 262 patients older than 40 who were undergoing total knee arthroplasty, randomly assigned to either epidural or general anesthesia.208 No differences were found between the patients for either cognitive or cardiovascular outcome. Rather, at 1 week postoperatively, both anesthetic groups had significant decreases from their preoperative neurocognitive test scores. At 6 months postoperatively, both groups improved, but the incidence of long-term postoperative cognitive deficit remained at 5% regardless of anesthesia group. Rasmussen and colleagues also examined patients older than 60 years randomly allocated to general or regional anesthesia for major noncardiac surgery.209 They demonstrated that a substantial proportion of patients experienced postoperative cognitive dysfunction at 1 week and 3 months postsurgery (incidence: 10%-20%). There was no significant difference in the incidence of postoperative cognitive dysfunction between the groups at 3 months after surgery. The authors concluded that the choice of anesthesia should be based on an open discussion of patients' preferences, general postoperative complications, and the experience of the anesthetist.
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It is generally supported in the literature that the elderly have unique needs for analgesia compared with younger patients, including the problem of increased sensitivity to opioids.210 However, this should not be interpreted to mean that elderly patients do not need pain medication because some have withheld analgesics for fear of prolonged action or increased side effects.211 To care for the elderly patient in pain, one must also consider the coexisting diseases and their effects on the distribution of analgesics, elimination of analgesics, and the potential for exacerbated or unique side effects from analgesic medications in the elderly. Furthermore, the high incidence of postoperative confusion, delirium, or altered mental status may complicate the assessment and communication of postoperative pain. Consideration should be given to the use of nonopioid analgesics, reduced doses of opioid analgesics, and alternative routes of analgesic administration. One solution is to use regional anesthetic techniques with local anesthetics so that opioids are avoided.
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Multiple studies have demonstrated that the type of anesthesia (general vs regional anesthesia) has no substantial effect on perioperative morbidity, but some claim differences in perioperative morbidity.212,213 However, it intuitively makes sense that elderly patients benefit from an anesthesia technique that allows for minimal cognitive depression with excellent postoperative pain control. It is essential to recognize that many factors influence the outcome; the quality of the anesthetic administered rather than the type of anesthetic is most important.212
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We know that improved quality of care (QOC) received by patients is strongly associated with better survival among community-dwelling vulnerable older adults.214 QOC begins with adequate information being obtained from a patient and related to a patient about proposed surgical interventions. An interesting challenge, however, is the finding that there is a strong negative correlation with patient's age and the desire for extensive information about medical care.215 This may mean that QOC must include family members as well as the elderly individual both for obtaining and relating medical information. Perioperative QOC in elderly patients is also of great importance because of the increasing number of older adults undergoing operations.216 QOC indicators have been developed in 7 domains: comorbidity assessment (cardiopulmonary disease), elderly issues (cognition), medication use (polypharmacy), patient-to-provider discussions (life-sustaining preferences), intraoperative care (preventing hypothermia), postoperative management (preventing delirium), and discharge planning (home health care), with most indicators rated addressing processes of care not routinely performed in younger surgical populations.216 However, to address these varied goals, interdisciplinary team care has been applied successfully in hospital, outpatient, home, and nursing home settings.217 Optimal outcomes are achieved in the elderly patient when clinical care is multidisciplinary and integrated beginning from preoperative assessment to supportive care after discharge.218