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GENERAL PRINCIPLES

More than half of all surgical procedures are performed in individuals older than age 65 years, and one-third of older adults undergo a procedure in the last year of life. In 2007, >4 million major operations were performed on older adults. As the aging population continues to grow, the number of older patients undergoing surgical interventions is expected to continue to increase.

SURGICAL RISK IN THE OLDER ADULT

Caring for the older surgical patient presents unique problems: older individuals present with more advanced disease, have more chronic conditions, and suffer more complications than younger patients. Careful patient selection and perioperative care are essential for optimizing surgical outcomes in this population. The benefits of the most commonly performed surgical procedures are well established. For example, colon resections increase colorectal cancer–free survival, and hip replacements significantly improve joint pain and functional ability. These benefits, however, must be weighed against the risk of mortality, morbidity, and decreased quality of life that may follow with these surgical interventions.

Nationally representative large cohort studies have highlighted the high risk of mortality in frail, older adults who undergo surgery. In a national sample of older nursing home residents undergoing breast cancer operations ranging from a lumpectomy to a mastectomy with a lymph node dissection, patients had an operative 1-year mortality of 29% to 41%, and those with the highest likelihood of mortality were those with poor preoperative function.

Major operations may also result in a diminished quality of life by causing postoperative cognitive and functional decline. The risk of postoperative cognitive dysfunction following cardiac surgery is well studied, and there is now increasing evidence that postoperative cognitive dysfunction also occurs after noncardiac procedures. Up to 10% of patients older than age 60 years suffer from memory problems 3 months out from noncardiac surgery. Recent research has shown that surgery and anesthesia exposure are not risk factors for cognitive impairment after major noncardiac surgery and critical illness, but cognitive impairment is predicted by in-hospital delirium. Functional changes following surgery can also be prolonged and irreversible. More than half of frail older patients undergoing abdominal operations experience significant functional decline that persists for up to a year after surgery. A recent study assessing functional status following breast cancer surgery in nursing home residents found that many patients suffer functional decline beyond the general expected decline seen in the nursing home population, regardless of breast surgery type. These findings emphasize the importance of addressing the risk of functional decline in all older patients, even for the most “minor” procedures. For some patients, loss of independence weighs heavier than mortality when deciding whether to undergo a high-risk operation. Awareness of these risks is essential for appropriate patient selection. It also allows clinicians to offer a realistic expectation of outcomes, which, in turn, informs decision making by the older individual and their families.

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