Preoperative Management of the Older Patient—A Surgeon’s Perspective: Part II
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INTRODUCTION
Similar to most other health care providers, surgeons are seeing an increasing proportion of elderly patients in their practices. Furthermore, this patient population is more likely to require operations. Patients age 65 and older currently account for approximately 60% of the average general surgeon’s work.1 The growth in general surgery over the next decade is expected to outpace the population growth due to a large increase in the number of older Americans. In specialties that care for a greater proportion of elderly patients, such as ophthalmology, urology, and cardiothoracic surgery, this growth is projected to increase 35-47%. This growth is driven by the post-war “baby boom” coupled with greater longevity. Given this increase, it is important for surgeons and practitioners who refer to surgeons to understand the appropriate perioperative evaluation and management of older patients.
In a study by Manku and Leung,2 21% of patients age 70 and older undergoing noncardiac surgery experienced postoperative complications. Elderly patients suffering postoperative complications had greater than twice the risk of death in the first 3 months when compared with elderly patients undergoing operation but not suffering complications. Postoperative renal and pulmonary complications have been found to have the greatest impact on survival.3 In addition, another study reported that quality of life and functional status were worse among the elderly patients who suffered postoperative complications.4 These studies reinforce the need for optimal perioperative care to avoid complications in this at-risk population.
The physiologic impact of surgery and implications of postoperative complications differ among procedures. They also vary depending on whether the procedure is performed as an emergency or as an elective operation. Many elderly patients tolerate elective operations quite well, with postoperative complication and death rates of 6.8% and 1.9%, respectively.5 In contrast, the morbidity and mortality rates associated with emergency operations are much higher, at 31% and 20%, respectively. For elective operations, the focus of this review, preoperative evaluation is aimed at identifying and reducing factors that lead to postoperative complications. In certain instances, factors can be identified but cannot be modified. Age, in and of itself, is not a risk factor for postoperative complications. The underlying comorbidities that develop as part of the aging process are risk factors.
This two-part article outlines current strategies to identify and modify these factors, and highlights important points in the preparation of elderly patients for surgery. Part I (Clinical Geriatrics 2006;14[6]:24-28) discussed various factors that can lead to postoperative complications. Part II focuses on preoperative assessment and management in the older patient, which includes physiologic, cognitive, nutritional, and functional assessment.
IMPORTANCE OF PREOPERATIVE ASSESSMENT AND MANAGEMENT
Surgical outcomes in elderly patients are affected by patient comorbidity, functional and physiologic status, type of operation, and the need for emergent operation. The primary goal of preoperative assessment is the identification of factors that can be optimized prior to surgery to improve outcomes. Preoperative assessment also serves to alert care providers of premorbid conditions that may affect perioperative management, allow risk assessment for decision-making purposes, and provide a baseline for comparison after surgery. Preexisting comorbid conditions such as coronary artery disease, emphysema, or renal insufficiency have a greater impact on surgical outcome than chronologic age. Elderly patients are at higher risk for complications due to the increased likelihood of comorbid disease and diminished physiologic reserves.
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