Perioperative Evaluation and Management
This chapter addresses the following Geriatric Fellowship Curriculum Milestones: #5, #22, #29, #42, #44, #45
Understand perioperative concerns that are unique to older adults.
Identify strategies to optimize postoperative management in older adults, including pain control, prevention of delirium, and anticoagulation use.
Key Clinical Points
Age alone is not a reliable predictor of operative risk and should not be the sole criteria for deciding who should and who should not have surgery. However, advanced age is associated with a higher prevalence of chronic diseases, which are strong predictors of operative risk.
The basic preoperative assessment should include a review of physical function, cognitive ability, competency, availability of social support, and symptoms of depression.
Current data suggest that many “routine” preoperative screening tests are ordered because of preoperative “protocol” or for medicolegal concerns, rather than medical necessity. The need for many such tests can often be eliminated with thorough history and physical examination.
THE OLDER SURGICAL PATIENT
The anticipated rapid increase in the aging population will challenge the surgical and medical communities with an expanding group of patients who will require surgical interventions, often major, much later in life. Among the most frequently performed surgical procedures in this age group are hip and knee replacements, cataract extractions, coronary artery bypass grafting, colorectal resections, and cholecystectomies. In coming years, health care systems will struggle not only with the need to provide surgical care that prolongs life but also promotes the greatest level of functional independence for older patients, without an excessive risk of complications.
When factors influencing postoperative complications are examined, chronological age remains an independent risk for adverse surgical outcomes. Advancing age is a marker for significant medical comorbidities that can complicate surgical procedures. The age-associated reduction in the capacity to adapt to physiologic stress, a progression in functional frailty, and the number of comorbid illnesses are better predictors than age alone for tolerating the rigors of surgery poorly. In addition to increasing overall operative risk, these factors also prolong recovery times, contributing to postoperative functional declines, and increase the need for rehabilitation, nursing, and home care support after surgery. Therefore, a comprehensive review of each patient’s medical, social, cognitive, and functional status is essential. Whenever possible, the preoperative clinical assessment should include a discussion with the primary care provider. The primary care provider typically has the greatest experience with the patient and is often able to provide useful insights, such as history of developing delirium during hospitalizations, which prove useful in guiding the older adult through surgery. Lack of communication between the surgical and the medical providers leads to a failure to incorporate important clinical issues and patient concerns with subsequent impact on perioperative care of the older patient. Formal “comanagement” approaches have become increasingly common, involving both ...