The percentage of Americans aged 65 and older is projected to more than double between 2010 and 2050. In 2006, 35% of inpatient and 32% of outpatient surgical procedures were performed in the elderly, percentages that will likely increase as the older population continues to expand. Caring for the elderly is different in many respects from taking care of younger patients, according to Clifford Y. Ko, MD, FACS. “The elderly tend to have more comorbidities and take more medications than younger patients,” he says. “They also tend to have disproportionately longer lengths of stay in the hospital following inpatient surgery.”
A Systematic Approach to Preoperative Evaluations of the Elderly
In 2012, a guideline was released by the American College of Surgeons (ACS) and the American Geriatrics Society (AGS) to help physicians with preoperative evaluations for elderly patients. A key recommendation from the guideline is that multiple clinical features be reviewed during preoperative evaluations of elderly patients. “Several areas should be reviewed more deeply before surgery in older patients, including heart, lung, and kidney function,” says Dr. Ko, who was a co-author of the guidelines. “With older patients, physicians have a greater likelihood of uncovering issues that need to be addressed prior to surgery.”
The guidelines also recommend that clinicians explore social situations and transportation issues. Furthermore, elderly patients should be assessed for vision and hearing challenges and ambulatory function prior to surgery. The ACS/AGS guidelines recommend and specify 13 key issues of preoperative care for the elderly (Table 1). Each area is explored in depth in the full guideline.
Dr. Ko notes that all items described in the guideline recommendations are equally important in providing quality surgical care for the elderly. “It’s difficult to prioritize recommendations because each patient will have different needs,” he says. “The individual’s hospital experience will vary from institution to institution. For example, if a surgical team is experienced in and comfortable with assessing functional status but not comfortable with reviewing nutritional status, then nutritional status would likely become the top priority to address.” Ultimately, Dr. Ko says it is key to use the recommendations in the ACS/AGS guideline in a comprehensive and systematic, organized manner along with a targeted and thoughtful patient evaluation in order to optimize care for the elderly.
Elderly & Surgery: Keys to Success
When managing the elderly with surgery, there are complex problems that must be assessed during preoperative evaluations. These include the use of multiple medications, functional status, frailty, risk of malnutrition, cognitive impairment, and comorbidities. According to Dr. Ko, surgeons should know how many medications and what specific drugs are being used by their elderly patients before surgery. “This will allow surgical teams to be aware of potential complications during surgery,” he says.
“It also allows physicians to address any risks for interactions with pain medications before, during, and after surgery.”
The guidelines recommend identifying therapies that should be discontinued before surgery or avoided altogether. It is also beneficial to identify the potential need for dose reductions or substituting potentially inappropriate medications.Research indicates that elderly patients are significantly more vulnerable to perioperative cardiac adverse events than younger patients. As such, the guidelines state that evaluating patients for risk of developing cardiovascular disease and having a heart attack is critical. It is recommended that all elderly patients be evaluated for cardiac risks before surgery to determine perioperative management and effectively communicate operative risk.
Studies have also linked poor preoperative functional status with mortality and poor surgical outcomes. When evaluating functional status, the guidelines recommend that clinicians:
• Assess patients’ ability to perform daily activities.
• Document deficits in vision, hearing, or swallowing.
• Inquire about history of falls and determine risk.
• Evaluate limitations in gait and mobility.
Preoperative Tests for Select Elderly Patients
For selected elderly surgical patients, the guidelines recommend 10 preoperative tests, including pulmonary function, electrocardiogram, chest radiograph, non-
invasive stress, urinalysis, white blood count, serum glucose, electrolyte, coagulation, and platelet count tests. Just three preoperative tests are recommended
for all elderly surgical patients (Table 2). “Surgeons should tailor the use of these tests to the patients being treated so that it becomes part of an effective delivery care style,” Dr. Ko says. “As the population in the United States continues to age, so too will the surgical patient population. Using these evidence-based guidelines can help improve the quality of surgical care that is provided to this growing group of people.”
Chow B, Rosenthal R, Merkow R, et al. 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;215:453-466. Available at www.journalacs.org/article/S1072-7515%2812%2900493-0/fulltext.
McGory M, Kao K, Shekelle P, et al. Developing quality indicators for elderly surgical patients. Ann Surg. 2009;250:338-347.
Woolger J. Preoperative testing and medication management. Clin Geriatr Med. 2008;24:573-583.
Monk T, Weldon B, Garvan C, et al. Predictors of cognitive dysfunction after major noncardiac surgery. Anesthesiology. 2008;108:18-30.
Brookmeyer R, Evans D, Hebert L, et al. National estimates of the prevalence of Alzheimer’s disease in the United States. Alzheimers Dement. 2011;7:61-73.
American Geriatrics Society 2012 Beers Criteria Update Expert Panel. American Geriatrics Society updated Beers criteria for potentially inappropriate medication use in older adults. J Am Geriatr Soc. 2012;60:616-631.