The progressive aging of the American population is challenging the surgical and medical communities with an expanding group of patients who will require surgical interventions much later in life. In coming years, our health care system will continue to be stressed by the need to provide surgical care that not only prolongs life but also promotes the greatest level of functional independence for older patients, without an excessive risk of complications. Among the most frequently performed surgical procedures in this age group are hip repairs, cataract extractions, coronary artery bypass grafting, cholecystectomies, and hernia repairs.
When factors influencing postoperative complications are examined, chronologic 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 stress, a progression in functional frailty, and the number of comorbid illnesses are better predictors than age alone for doing poorly with the rigors of surgery. In addition to increasing operative risk, these factors also prolong recovery times, promote 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 paramount. Whenever possible, the preoperative clinical assessment should include a discussion with the primary-care physician. The primary-care physician 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 patient through surgery. The availability of high-quality geriatric medical care is also essential. A lack of communication between the surgical and the medical providers is a frequent reason why important clinical issues are overlooked, concerns that may have an adverse impact on the older patient's perioperative care. Formal “comanagement” approaches have emerged, which involve both medical and surgical specialists in the perioperative period and appear to improve overall quality of care, including decreased length of stay. The critical nature of the transition between in- and outpatient and subacute care has been recognized as an important area for quality improvement at many institutions.
Because the medical and surgical managements of older patients often overlap, a comprehensive review of the medical and surgical goals and any ethical implications should be routinely completed. The primary goal of surgery is to maximize the life span of these patients in a manner that ensures dignity, self-esteem, and independent function; limits suffering and pain; and occasionally palliates adverse clinical symptoms. To accomplish these goals, an ongoing dialogue between medical and surgical providers is essential.
The effect of age on risk of surgery is reviewed in Chapter 37. An effort to identify reversible factors associated with perioperative morbidity in geriatric surgical patients is critical to improving surgical outcomes (Table 35-1). In patients older than 80 years, the most prevalent operative risk factors are a history of hypertension, coronary artery ...