Preoperative Management of the Older Patient—A Surgeon’s Perspective: Part I
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INTRODUCTION
Similar to most other health care providers, surgeons are seeing an ever-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 Bacchetti,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 an operation but not suffering a complication. 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 discusses factors, including cardiac, pulmonary, and renal, that can lead to postoperative complications.
FACTORS AFFECTING OUTCOME
Cardiac factors
Cardiovascular decline has been one of the most studied effects of aging. The most common cardiac complication in older patients is myocardial ischemia.6 The prevalence of coronary artery disease increases with age and is present at autopsy in more than 50% of individuals over age 70 years.7 With aging, there is also a decreased arterial elasticity and diminished relaxation to normal stimuli.8 This can lead to a chronic elevation of systolic pressure and eventual aortic dilatation. This increased aortic impedance can progress to ventricular hypertrophy, which increases both wall stress and myocardial oxygen demand and makes the ventricle more prone to ischemia.9 The reduction in ventricular compliance, coupled with a blunted response to catecholamines, compromises the heart’s ability to respond to significant changes in circulatory volume.
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