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Chapter 46 - Surgical Principles

from Section IV - Principles of Care for the Elderly

Published online by Cambridge University Press:  30 June 2022

By
Krista Haines ,
Vishnu R. Mani  and
Sasha Adams
Edited by
Jan Busby-Whitehead ,
Samuel C. Durso ,
Christine Arenson ,
Rebecca Elon ,
Mary H. Palmer  and
William Reichel
Jan Busby-Whitehead
Affiliation:
University of North Carolina, Chapel Hill
Samuel C. Durso
Affiliation:
The Johns Hopkins University, Maryland
Christine Arenson
Affiliation:
Thomas Jefferson University, Philadelphia
Rebecca Elon
Affiliation:
The Johns Hopkins University School of Medicine
Mary H. Palmer
Affiliation:
University of North Carolina, Chapel Hill
William Reichel
Affiliation:
Georgetown University Medical Center
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Summary

Modern medicine has bolstered the life expectancy among older adults, which now averages around 80 years of age in developed nations. Older adults currently make up nearly 17% of the US population, with a projected rise to 25% of all adults in the coming decades. Older adults currently account for almost 50% of all surgical procedures performed in the USA, where overall health-related expenditures comprised 17.4% of the national GDP. The stress of surgery can be exacerbated with advancing age and is primarily determined by the preoperative physiological reserve and comorbid conditions. Any additional postoperative clinical challenges can significantly affect the stress response and ultimate recovery trajectory. This chapter systematically emphasizes the perioperative strategies to counteract the inadequate surgical stress response resulting from the age-related challenges in maintaining homeostasis. Unique preoperative considerations when evaluating older adults include: cognition, functional status frailty, care goals, advance directives, nutritional status, polypharmacy, and cardiopulmonary optimization with “prehabilitation” when possible. Optimization of the preoperative evaluation coupled with a preemptive postoperative approach to decrease the risk of delirium, falls, malnutrition, infections, pressure sores, aspiration, and other pulmonary complications, along with early mobilization and therapy, can yield the best possible outcomes in this population.

Keywords

surgery in the elderlygeriatric surgeryperioperative caretraumaemergent surgeryacute care surgery
Type
Chapter
Information
Reichel's Care of the Elderly
Clinical Aspects of Aging
 , pp. 569 - 577
Publisher: Cambridge University Press
Print publication year: 2022

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References

www.statista.com/statistics/274514/life-expectancy-in-europe.Google Scholar
https://data.worldbank.org/indicator/SP.DYN.LE00.IN?locations=EU.Google Scholar
www.statista.com/statistics/274513/life-expectancy-in-north-america/#:~:text=Of%20continents%20worldwide%2C%20North%20America,for%20males%20and%20females%20respectively.Google Scholar
https://data.worldbank.org/indicator/SP.DYN.LE00.IN?locations=ZG.Google Scholar
www.un.org/en/development/desa/population/publications/pdf/ageing/WorldPopulationAgeing2019-Highlights.pdf.Google Scholar
www.un.org/en/sections/issues-depth/ageing.Google Scholar
United States Census Bureau. www.census.gov/topics/population/older-aging.html#:~:text=According%20to%20the%20U.S.%20Census,million%20on%20July%201%2C%202019.&text=The%20nation’s%2065%2Dand%2Dolder,born%20between%201946%20and%201964.Google Scholar
Lo, AX, Flood, KL, Biese, K, et al. Factors associated with hospital admission for older adults receiving care in U.S. emergency departments. J Gerontol A Biol Sci Med Sci. 2017 (Aug. 1); 72(8):1105–1109.Google ScholarPubMed
National Center for Health Statistics. 2010 NHAMCS micro-data file documentation. ftp://ftp.cdc.gov/pub/Health_Statistics/NCHS/Dataset_Documentation/NHAMCS/doc2010.pdf.Google Scholar
National Center for Health Statistics. 2009 NHAMCS micro-data file documentation. ftp://ftp.cdc.gov/pub/Health_Statistics/NCHS/Dataset_Documentation/NHAMCS/doc09.pdf.Google Scholar
Albert, M, McCaig, LF, Ashman, JJ. Emergency department visits by persons aged 65 and over: United States, 2009–2010. NCHS data brief, no 130. Hyattsville, MD: National Center for Health Statistics, 2013.Google Scholar
Healthcare Cost and Utilization Project Facts and Figures 2008. Statistics on Hospital-Based Care in the United States. Agency for Healthcare Research and Quality (AHRQ). www.hcup-us.ahrq.gov/reports/factsandfigures/2008/section1_TOC.jsp.Google Scholar
US Centers for Disease Control and Prevention. Number, percent distribution, rate, days of care with average length of stay, and standard error of discharges from short-stay hospitals, by sex and age: United States, 2010. www.cdc.gov/nchs/data/nhds/2average/2010ave2_ratesexage.pdf.Google Scholar
www.cms.gov/research-statistics-data-and-systems/statistics-trends-and-reports/nationalhealthexpenddata/downloads/highlights.pdf.Google Scholar
www.cdc.gov/nchs/fastats/health-expenditures.htm.Google Scholar
Yang, R, Wolfson, M, Lewis MC. Unique aspects of the elderly surgical population: An anesthesiologist’s perspective. Geriatr Orthop Surg Rehabil. 2011 (Mar.); 2(2):56–64.Google Scholar
Veering, BT. Management of anaesthesia in elderly patients. Curr Opin Anaesthesiol. 1999; 12(3):333–336.Google Scholar
Mirand, AL, Welte, JW. Alcohol consumption among the elderly in a general population, Erie County, New York. Am J Public Health. 1996; 86:978–984.CrossRefGoogle Scholar
Ewing, JA. Detecting alcoholism: The CAGE questionnaire. JAMA. 1984; 252(14):1905–1907.Google Scholar
Chow, WB, Rosenthal, RA, Merkow, RP, Ko, CY, Esnaola, NF. Optimal preoperative assessment of the geriatric surgical patient: A best practices guideline from the American College of Surgeons National Surgical Quality Improvement Program and the American Geriatrics Society. J Am Coll Surg. 2012; 215(4):453–466.Google Scholar
Eliasen, M, Grønkjær, M, Skov-Ettrup, LS, et al. Preoperative alcohol consumption and postoperative complications: A systematic review and meta-analysis. Ann Surg. 2013; 258(6):930–942.Google Scholar
Oppedal, K, Møller, A, Pedersen, B, Tønnesen, H. Preoperative alcohol cessation prior to elective surgery. Cochrane Database Syst Rev. 2012; 7:CD008343.Google Scholar
Fernandez, AC, Claborn, KR, Borsari, B. A systematic review of behavioural interventions to reduce preoperative alcohol use. Drug Alcohol Rev. 2015; 34(5):508–520.CrossRefGoogle ScholarPubMed
Grønkjær, M, Eliasen, M, Skov-Ettrup, LS, et al. Preoperative smoking status and postoperative complications: A systematic review and meta-analysis. Ann Surg. 2014; 259(1):52–71.Google Scholar
Thomsen, T, Villebro, N, Møller, AM. Interventions for preoperative smoking cessation. Cochrane Database Syst Rev. 2014; 3:CD002294.Google Scholar
Hustey, F, Meldon, S, Palmer, R. Prevalence and documentation of impaired mental status in elderly emergency department patients. Acad Emerge Med. 2000; 7(10):1166.Google Scholar
Inouye, SK, Foreman, MD, Mion, LC, Katz, KH, Cooney, LM Jr. Nurses’ recognition of delirium and its symptoms: Comparison of nurse and researcher ratings. Arch Intern Med. 2001; 161(20):2467–2473.CrossRefGoogle ScholarPubMed
Gajdos, C, Kile, D, Hawn, MT, Finlayson, E, Henderson, WG, Robinson, TN. The significance of preoperative impaired sensorium on surgical outcomes in nonemergent general surgical operations. JAMA Surg. 2015; 150(1):30–36.CrossRefGoogle ScholarPubMed
Inouye, SK, Westendorp, RG, Saczynski, JS. Delirium in elderly people. Lancet. 2014; 383(9920):911–922.Google Scholar
American Psychiatric Association Diagnostic and Statistical Manual of Mental Disorders, 5th edition. Washington, DC: American Psychiatric Association, 2013.Google Scholar
WHO. The ICD-10 Classification of Mental and Behavioural Disorders: Diagnostic Criteria for Research. Geneva: World Health Organization, 1993.Google Scholar
Adamis, D, Sharma, N, Whelan, PJ, Macdonald, AJ. Delirium scales: A review of current evidence. Aging Ment Health. 2010; 14:543–555.Google Scholar
Wong, CL, Holroyd-Leduc, J, Simel, DL, Straus, SE. Does this patient have delirium? Value of bedside instruments. JAMA. 2010; 304:779–786.Google Scholar
Ely, EW, Margolin, R, Francis, J, et al. Evaluation of delirium in critically ill patients: Validation of the confusion assessment method for the intensive care unit (CAM-ICU). Crit Care Med. 2001; 29:1370–1379.Google Scholar
Oh, ES, Fong, TG, Hshieh, TT, Inouye, SK. Delirium in older persons advances in diagnosis and treatment. JAMA. 2017 (Sep. 26); 318(12):1161–1174.CrossRefGoogle ScholarPubMed
Borson, S, Scanlan, JM, Chen, P, Ganguli, M. The Mini-Cog as a screen for dementia: Validation in a population-based sample. J Am Geriatr Soc. 2003; 51(10):1451–1454.CrossRefGoogle Scholar
Kroenke, K, Spitzer, RL, Williams, JB. The Patient Health Questionnaire-2: Validity of a two-item depression screener. Med Care. 2003; 41(11):1284–1292.CrossRefGoogle ScholarPubMed
Burke, WJ, Roccaforte, WH, Wengel, SP. The short form of the Geriatric Depression Scale: A comparison with the 30-item form. J Geriatr Psychiatry Neurol. 1991; 4(3):173–178.Google Scholar
Leung, JM, Sands, LP, Mullen, EA, Wang, Y, Vaurio, L. Are preoperative depressive symptoms associated with postoperative delirium in geriatric surgical patients? J Gerontol A Biol Sci Med Sci. 2005; 60(12):1563–1568.Google Scholar
Kothari, A, Phillips, S, Bretl, T, Block, K, Weigel, T. Components of geriatric assessments predict thoracic surgery outcomes. J Surg Res. 2011; 166(1):5–13.Google Scholar
Feng, MA, McMillan, DT, Crowell, K, Muss, H, Nielsen, ME, Smith, AB. Geriatric assessment in surgical oncology: A systematic review. J Surg Res. 2015; 193(1):265–272.Google Scholar
Silveira, MJ, Kim, SY, Langa, KM. Advance directives and outcomes of surrogate decision making before death. N Engl J Med. 2010 (Apr. 1); 362(13):1211–1218.Google Scholar
Temel, JS, Greer, JA, Muzikansky, A, et al. Early palliative care for patients with metastatic non–small-cell lung cancer. N Engl J Med. 2010; 363(8):733–742.Google Scholar
Kehlet, H, Nielsen, HJ. Impact of laparoscopic surgery on stress responses, immunofunction, and risk of infectious complications. New Horiz. 1998; 6(2 suppl.):S80–S88.Google ScholarPubMed
Wilmore, DW. From Cuthbertson to fast-track surgery: 70 years of progress in reducing stress in surgical patients. Ann Surg. 2002; 236(5):643–648.Google Scholar
Katz, S, Downs, TD, Cash, HR, Grotz, RC. Progress in development of the index of ADL. Gerontologist. 1970; 10(1):20–30.CrossRefGoogle ScholarPubMed
Lawton, MP, Brody, EM. Assessment of older people: Self-maintaining and instrumental activities of daily living. Gerontologist. 1969; 9(3):179–186.Google Scholar
Xue, Q-L. The frailty syndrome: Definition and natural history. Clin Geriatr Med. 2011; 27(1):1–15.Google Scholar
Jones, D, Song, X, Mitnitski, A, Rockwood, K. Evaluation of a frailty index based on a comprehensive geriatric assessment in a population based study of elderly Canadians. Aging Clin Exp Res. 2005; 17(6):465–471.Google Scholar
Nakhaie, M, Tsai, A. Preoperative assessment of geriatric patients. Anesthesiol Clin. 2015; 33(3):471–480.Google Scholar
Panel on Prevention of Falls in Older Persons, American Geriatrics Society and British Geriatrics Society. Summary of the Updated American Geriatrics Society/British Geriatrics Society clinical practice guideline for prevention of falls in older persons. J Am Geriatr Soc. 2011; 59(1):148–157.Google Scholar
Jones, TS, Dunn, CL, Wu, DS, Cleveland, JC Jr, Kile, D, Robinson, TN. Relationship between asking an older adult about falls and surgical outcomes. JAMA Surg. 2013; 148(12):1132–1138.Google Scholar
Chow, WB, Rosenthal, RA, Merkow, RP, Ko, CY, Esnaola, NF. Optimal preoperative assessment of the geriatric surgical patient: A best practices guideline from the American College of Surgeons National Surgical Quality Improvement Program and the American Geriatrics Society. J Am Coll Surg. 2012; 215(4):453–466.CrossRefGoogle Scholar
Brown, CJ, Flood, KL. Mobility limitation in the older patient: A clinical review. JAMA. 2013; 310(11):1168–1177.Google Scholar
Chow, WB, Rosenthal, RA, Merkow, RP, Ko, CY, Esnaola, NF. Optimal preoperative assessment of the geriatric surgical patient: A best practices guideline from the American College of Surgeons National Surgical Quality Improvement Program and the American Geriatrics Society. J Am Coll Surg. 2012; 215(4):453–466.CrossRefGoogle Scholar
Fleisher, LA, Fleischmann, KE, Auerbach, AD, et al. 2014 ACC/AHA guideline on perioperative cardiovascular evaluation and management of patients undergoing noncardiac surgery: executive summary: A report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. Circulation. 2014; 130(24):2215–2245.Google Scholar
Hajjar, ER, Cafiero, AC, Hanlon, JT. Polypharmacy in elderly patients. Am J Geriatr Pharmacother. 2007; 5(4):345–351.Google Scholar
Kwan, D, Farrell, B. Polypharmacy: Optimizing medication use in elderly patients. Can Geriatr J. 2014; 4(1):21–27.Google Scholar
American Geriatrics Society 2015 Updated Beers Criteria for potentially inappropriate medication use in older adults. J Am Geriatr Soc. 2015; 63(11):2227–2246.Google Scholar
O’Mahony, D, O’Sullivan, D, Byrne, S, O’Connor, MN, Ryan, C, Gallagher, P. STOPP/START criteria for potentially inappropriate prescribing in older people: Version 2. Age Ageing. 2015; 44(2):213–218.Google Scholar
Cholesterol Treatment Trialists’ Collaboration. Efficacy and safety of statin therapy in older people: A meta-analysis of individual participant data from 28 randomized controlled trials. Lancet. 2019 (Feb. 2); 393(10170):407–415.Google Scholar
Kenig, J, Olszewska, U, Zychiewicz, B, Barczynski, M, Mituś-Kenig, M. Cumulative deficit model of geriatric assessment to predict the postoperative outcomes of older patients with solid abdominal cancer. J Geriatr Oncol. 2015; 6(5):370–379.Google Scholar
Carli, F, Bousquet-Dion, G, Fiore, JF Jr. Prehabilitation vs Postoperative Rehabilitation for Frail Patients. JAMA Surg. 2020 (Sep. 1); 155(9):899–900.CrossRefGoogle ScholarPubMed
Wynter-Blyth, V, Moorthy, K. Prehabilitation: Preparing patients for surgery. BMJ. 2017; 358:j3702.Google Scholar
Walston, J, Buta, B, Xue, Q-L. Frailty screening and interventions: Considerations for clinical practice. Clin Geriatr Med. 2018 (Feb.); 34(1):25–38.Google Scholar
Ho, JWC, Wu, AHW, Lee, MWK, et al. Malnutrition risk predicts surgical outcomes in patients undergoing gastrointestinal operations: Results of a prospective study. Clin Nutr. 2015 (Aug.); 34(4):679–684.Google Scholar
Gibbs, J, Cull, W, Henderson, W, Daley, J, Hur, K, Khuri, SF. Preoperative serum albumin level as a predictor of operative mortality and morbidity: Results from National VA Surgical Risk Study. Arch Surg. 1999 (Jan.); 134(1):36–42.Google Scholar
Wischmeyer, PE, et al. Perioperative Quality Initiative (POQI) 2 Workgroup. American Society for Enhanced Recovery and Perioperative Quality Initiative Joint Consensus Statement on nutrition screening and therapy within a surgical enhanced recovery pathway. Anesth Analg. 2018 (Jun.); 126(6):1883–1895.Google Scholar
Kim, S, Brooks, AK, Groban, L. Preoperative assessment of the older surgical patient: Honing in on geriatric syndromes. Clin Interv Aging. 2015; 10:13–27.Google Scholar
Capezuti, E, Boltz, M, Kim, H. Geriatric models of care. In: Rosenthal, R, Zenilman, M, Katlic, M, eds. Principles and Practice of Geriatric Surgery. New York: Springer, 2011, pp. 253–266.Google Scholar
AGS Expert Panel on Postoperative Delirium in Older Adults. American Geriatrics Society Clinical Practice Guideline for Postoperative Delirium in Older Adults, 2014.Google Scholar
Flinn, DR, Diehl, KM, Seyfried, LS, Malani, PN. Prevention, diagnosis, and management of postoperative delirium in older adults. J Am Coll Surg. 2009; 209(2):261–268; quiz 294.Google Scholar
NICE. Delirium: Diagnosis, prevention and management. NICE Clinical Guideline 103 2010. www.nice.org.uk/CG103.Google Scholar
Smetana, GW, Lawrence, VA, Cornell, JE. Preoperative pulmonary risk stratification for noncardiothoracic surgery: Systematic review for the American College of Physicians. Ann Intern Med. 2006 (Apr. 18); 144(8):581–595.Google Scholar
Potter, J, Klipstein, K, Reilly, JJ, Roberts, M. The nutritional status and clinical course of acute admissions to a geriatric unit. Age Ageing. 1995 (Mar.); 24(2):131–136.CrossRefGoogle ScholarPubMed
Sullivan, DH. Risk factors for early hospital readmission in a select population of geriatric rehabilitation patients: The significance of nutritional status. J Am Geriatr Soc. 1992 (Aug.); 40(8):792–798.Google Scholar
Gould, CV, Umscheid, CA, Agarwal, RK, Kuntz, G, Pegues, DA. Guideline for prevention of catheter-associated urinary tract infections 2009. Infect Control Hosp Epidemiol. 2010 (Apr.); 31(4):319–326.Google Scholar
Lyder, CH. Pressure ulcer prevention and management. JAMA. 2003 (Jan. 8); 289(2):223–226.Google Scholar
Bergstrom, N, Braden, BJ, Laguzza, A, Holman, V. The Braden Scale for predicting pressure sore risk. Nurs Res. 1987 (Jul.–Aug.); 36(4):205–210.Google Scholar
Norton, D, McLaren, R, Exton-Smith, A. An Investigation of Geriatric Nursing Problems in Hospital. London: National Corporation for the Care of Old People, 1962.Google Scholar
Thorn, CC, Smith, M, Aziz, O, Holme, TC. The Waterlow score for risk assessment in surgical patients. Ann R Coll Surg Engl. 2013 (Jan.); 95(1):52–56.Google Scholar
Labib, N, Nouh, T, Winocour, S, et al. Severely injured geriatric population: Morbidity, mortality, and risk factors. J Trauma. 2011; 71:1908.Google Scholar
Schwab, CW, Kauder, DR. Trauma in the geriatric patient. Arch Surg. 1992; 127:701.Google Scholar
Fitz-Henry, J. The ASA classification and peri-operative risk. The Annals of The Royal College of Surgeons of England. 2011 (Apr.); 93(3):185–187.Google Scholar
Ely, EW, Margolin, R, Francis, J, May, L, Truman, B, Dittus, R, Speroff, T, Gautam, S, Bernard, GR, Inouye, SK. Evaluation of delirium in critically ill patients: Validation of the Confusion Assessment Method for the Intensive Care Unit (CAM-ICU). Critical Care Medicine. 2001 (Jul. 1); 29(7):1370–1379.Google Scholar

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