Surgery in Elderly People

Complications seen in frail elderly people ore more often multifactorial than specific to any given process or organ system. Age-related anatomic changes (decreases in body surface area), physiologic changes (reduced cardiac function), and metabolic changes (e.g., reduced ability to metabolize and clear drugs) increase the risk of overdosing of any medication, including anesthetics. This leads to longer recovery from drugs, increased delirium (see below), poor mobility, and longer stays in an ICU or hospital setting.

It is uncertain whether regional anesthesia alters perioperative survival or reduces anesthetic-related complications. However, the use of anesthetic techniques that allow patients to remain conscious (such as spinal, epidural, or regional blockade) are increasingly being used in minor procedures, such as hernia repair, and major surgery, such as hip and arm procedures, carotid endarterectomy, and procedures in the lower abdomen and pelvis. Nevertheless, it is important to note that regional techniques can produce the same problems with blood pressure (hypotension) and stress to the heart as general anesthesia, and therefore are not without risk.

Less invasive surgery. Current trends in surgery are increasingly moving towards minimalization. ‘‘Keyhole’’ surgery using fiber-optic cameras, less radical tumor resections with utilization of adjuvant radiotherapy and chemotherapy, and cardiac procedures performed on a beating heart (off-pump surgery) are a few examples. The desired effect of this technological advancement is to reduce intraoperative risk, the trauma of the invasive procedure, postoperative pain, infective complications, and length of hospital stay.

Atypical symptoms and impaired inflammatory responses. Older adults frequently have a reduced capacity to mount the normal immune/ inflammatory response when confronted with injury, infection, or disease (e.g., eroding peptic ulcer, pneumonia). This manifests as a fever or pain as the inner surface of the thoracic or abdominal cavity becomes inflamed. In consequence, disease presentation in older adults can be subtle. With reduced ability to generate an inflammatory response, older adults often present later in the disease process, and they may not demonstrate the normal progression of the disease process. For example, an elderly patient who initially presents with early diverticulitis (inflammation of outpouches in the colon) may not demonstrate progressive symptoms until the point where a diverticula becomes necrotic and perforates. Patients with low physiologic reserves typically decompensate rapidly, and subsequently face a higher risk of a surgical emergency. In consequence, careful vigilance by the nursing staff and physicians via serial physical examination and bloodwork has the potential to reduce a delayed surgery, and thus reduce morbidity and mortality. In addition, the mortality rate is lower when certain elective procedures (e.g., major vascular surgery) are performed after the appropriate cardiac workup.

In addition to reduced inflammatory responses, comorbidities such as diabetes and hypertension are more prevalent in elderly people. These disease processes can produce a dysautonomia (failing or remodeling of the autonomic nervous system) resulting in altered baroreflex, vasomotor, and cardiac function.