17: Perioperative Care in Older Surgical Patients

More than a third of all surgical procedures are performed in individuals older than age 65 years and one-third of older adults undergo a surgical procedure in the last year of life. In 2007, more than 4 million major operations were performed on older adults. Use of less-invasive procedures is also increasing. With advancements in technology, coronary angioplasty and lower-extremity endovascular procedures have surpassed rates of coronary artery bypass grafting and lower-extremity bypass. These minimally invasive approaches broaden the scope of illness that can be treated and together with the aging of the population is contributing to an increase in the number of older patients undergoing surgical interventions.

Caring for the older surgical patient presents unique problems: older individuals present with more advanced disease, have more comorbidities and suffer more complications than younger patients. Appropriate patient selection and perioperative care is essential for optimizing surgical outcomes in this population. The benefits of the most commonly performed surgical procedures are well established. 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 sometimes follow these operations.

Nationally representative large cohort studies provide the most realistic information about surgical risk in older adults. In a national sample of patients undergoing high-risk cancer operations, patients older than age 80 years who were undergoing esophageal resections had an operative mortality of 20% with only 19% of patients experiencing long-term survival beyond 5 years. Morbidity after surgery in older adults is also high. Bentrem et al found that medical complications, such as strokes, myocardial infarction, pneumonia, and renal failure, occur at much higher rates in older adults. These severe medical complications are the proximal cause of the high perioperative mortality seen in older patients. Surgical complications, such as wound infections, bleeding, and need for reoperation, are not more frequent, but the occurrence of nonfatal postoperative complications is independently associated with decreased long-term survival.

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. It is unclear whether it is acute illness, anesthesia, or surgery that is the primary contributor to this condition. Functional changes following surgery can also be prolonged and irreversible. More than half of patients undergoing abdominal operations experience significant functional decline that persists for up to a year after surgery. A recent study assessing functional status following colectomy in nursing home residents found that the most active patients suffer the greatest decline as they have the most to lose. These findings emphasize the importance of addressing the risk of functional decline in all older patients, even the most active. 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.

Preoperative Assessment

Cognition

Older individuals’ cognitive capacity, decision-making capacity, and risk for postoperative delirium should be assessed preoperatively. For patients without a known history of dementia, a cognitive assessment using the Mini-Cog test (see Chapter 6, “Geriatric Assessment”) should be performed. The Mini-Cog is a 3-item recall and clock draw test that efficiently screens for cognitive impairment. One point is awarded for each item recalled and 2 points for a normal-appearing clock. A score of 0–2 points indicates a positive screen for dementia. This screening is the initial step in identifying patients that may lack the capacity to make medical decisions and who are at high risk for delirium. When initial evaluation identifies cognitive impairment, assessment of decision-making capacity is essential. For patients lacking capacity advance directives or a surrogate decision maker should be used (see Chapter 12, “Ethics & Informed Decision Making”). Older adults who are at risk for delirium should be identified preoperatively. Major risk factors for delirium are dementia, hearing impairment, depression, preoperative narcotic use, medical comorbidities, electrolyte abnormalities, malnutrition, and poor functional status. Identifying patients who are at risk for delirium is crucial as a number of measures implemented early in the patient’s hospital course can reduce this risk. Comanagement by a geriatrician, appropriate use of analgesics and prophylactic use of atypical antipsychotics have been evaluated in clinical trials and found to significantly decrease the incidence and severity of delirium.

Cardiovascular

Cardiovascular complications are associated with high operative mortality rates. To identify and help reduce this risk, the American College of Cardiology and the American Heart Association (ACC/AHA) has developed recommendations for cardiac evaluation and care for non-cardiac surgery. For older adults with active cardiac disease or coronary artery disease (CAD) risk factors and poor functional status who are about to undergo elective intermediate or high-risk surgery, strong consideration should be given to non invasive preoperative cardiac testing and evaluation by a cardiologist (Table 17–1).

Pulmonary

Prolonged intubation (>48 hours), pneumonia, atelectasis and bronchospasm occur after surgery in more than 15% of patients older than age 70 years. Risk factors for these complications include active pulmonary disease, current cigarette smoking, congestive heart failure, chronic renal failure, cognitive disorders, and functional dependence. Routine pulmonary testing beyond assessment for these risk factors on history and physical should be based on clinical criteria. Preoperative chest x-ray is recommended for older individuals undergoing major surgery who have cardiopulmonary disease and have not had a chest x-ray in the last 6 months. It may also be obtained as a baseline for patients requiring ICU admission postoperatively. Pulmonary function tests are rarely required and are mainly reserved for those undergoing lung resections and patients with severe chronic obstructive pulmonary disease (COPD). To decrease the risk of pulmonary complications smoking cessation should be initiated at least 2 months prior to elective surgery and active pulmonary diseases should be adequately treated.

Functional Status

Functional dependence is an independent predictor of mortality following surgery in older adults. Robinson et al recently reported that dependence with even 1 activity of daily living significantly increased the risk of 6-month mortality (odds ratio [OR] 13.9; 95% confidence interval [CI] 2.9, 65.5). The ability to perform activities of daily living (ADLs) and instrumental activities of daily living (IADLs) should be assessed preoperatively. This identifies older adults who will benefit from occupational and physical therapy in the postoperative period.

Nutritional Status

Older patients with functional dependence are at high risk of malnutrition. Fourteen percent of nursing home residents, 39% of inpatients, and 50.5% of individuals in rehabilitation are malnourished. All older patients should be screened for malnutrition preoperatively. Patients with unintentional weight loss of >10% to 15% of the last 6 months, body mass index (BMI) <18.5 and serum albumin <3 g/dL are described as being at severe nutritional risk. Preoperative nutritional support should be provided to these patients. Enteral nutrition is the preferred route for nutritional support; when this option is not available secondary to gastrointestinal conditions, parenteral nutrition should be used.

Frailty

Evaluation of frailty is emerging as an important means of preoperative risk assessment in older adults. Using the “eyeball test” physicians have long tried to predict which older patients were at high risk of complications following surgery. Assessments of frailty now quantify these previously intuitive assumptions. Frail patients have been found to have over twice the odds of postoperative complications as compared to nonfrail patients and are more likely to be discharged to a nursing facility. Current measures of frailty remain primarily research tools; work is ongoing to validate frailty measures that are easy to use in clinical settings.

Postoperative Care

The aim of postoperative care is to return older patients to a high level of functioning as quickly as possible. This goal is achieved with measures that promote recovery and prevent complications. Through a review of the literature and expert interviews, McGory et al have compiled measures that constitute the basic level of postoperative care that should be provided to older patients undergoing any kind of surgery. Table 17–1 is adapted from this work and highlights important aspects of routine postoperative care for older adults.

When possible, patients should be out of bed and walking by the first postoperative day. Physical therapy and occupational therapy consultation should be obtained for patients with functional impairment. Early ambulation along with chest physiotherapy using incentive spirometers decreases the risk of pulmonary complications. Appropriate fluid resuscitation should be provided and fluid balance should be monitored through documentation of intake, output and daily weights. Oral or enteral nutrition should be resumed as soon as the gastrointestinal tract is functional. To prevent infectious complications, aspiration precautions should be instituted, Foley catheters should be removed within 48 hours and the need for central lines and drains should be reviewed daily and removed once no longer needed.

Management of Common Postoperative Issues in Older adults

Pain—

Older patients are at higher risk of undertreated pain. Inadequate treatment of pain impedes recovery, prevents the patient from participating in activities and can lead to delirium, depression and pulmonary complications. To avoid these complications, pain levels should be assessed frequently and a pain management plan that delivers adequate analgesia while avoiding untoward effects of the analgesics should be implemented. The numeric rating scale is the preferred pain-intensity rating scale for use in older adults. Postoperative pain is best managed with regional anesthesia. For patients undergoing major surgery, epidural regional analgesia with opioids and local anesthetic agents initiated intraoperatively provides the most effective pain control. Intravenous and oral analgesics such as opioids, acetaminophen and nonsteroidal antiinflammatory drugs (NSAIDs) also provide effective pain relief. They may be used as supplements to regional anesthesia or as the primary analgesics for less-invasive operations. These medications are best delivered as patient-controlled analgesics (PCAs) or on a scheduled dose. This is preferred over as-needed doses of medication, because patients spend less time in pain. Although effective pain control is important, providers need to be vigilant for side effects of analgesics. Older patients are at increased risk of hypotension, respiratory depression, over sedation and constipation than can occur as a side effect of analgesics. Use of regional analgesics; short-acting agents; smaller, less-frequent doses; and frequent patient assessment can decrease the risk of these complications.

Delirium—

Delirium occurs in between 15% and 50% of older patients postoperatively. It is associated with increased mortality and medical complications. The physiologic conditions most commonly responsible for delirium in the postoperative setting are pain, hypoxia, hypoglycemia, electrolyte imbalance, and infection. The initial evaluation of the delirious patient should be focused on identifying these disorders. Pain should be adequately treated, serum electrolytes and glucose should be checked, an infectious work-up should be performed and other postoperative complications ruled out. Further measures in the prevention and management of delirium include optimization of environmental stimuli and a review of current medications. Older patients should have their eyeglasses and hearing aids made readily available. The Beers criteria identifies a number of potentially inappropriate medications for older patients. Avoiding anticholinergics, antihistamines and benzodiazepines may help decrease the incidence of delirium in older patients. For patients with agitated delirium who at risk of injury, frequent reorientation is required, this may be provided by family members or a sitter; restraints should be avoided. When these measures are unsuccessful low doses of antipsychotics such as quetiapine or Haldol can be prescribed. Their use, however, remains controversial and they should be used with caution.

Cardiac Complications—

Cardiac complications occur frequently in older patients. The most common postoperative cardiac complications requiring urgent treatment are atrial fibrillation and myocardial infarction. Atrial fibrillation can occur as a result of the increased sympathetic tone associated with the stress of surgery, volume overload, hypoxia/hypercarbia, electrolyte abnormalities, or as a result of underlying heart disease. Management of new-onset atrial fibrillation begins with an assessment of hemodynamic stability and rate control. In patients with hemodynamic instability emergent cardioversion is required. Rate control is achieved using either β blockers or diltiazem. Intravenous amiodarone may be used when the first-line drugs are ineffective. Most cases of new-onset atrial fibrillation spontaneously revert to sinus rhythm. However, atrial fibrillation persists for more than 24–48 hours; anticoagulation should be considered to reduce the risk of stroke.

Perioperative myocardial infarction occurs mainly as a result of prolonged myocardial oxygen supply–demand imbalance and only rarely as a result of acute coronary syndrome (ACS). It is diagnosed based on a rise and fall of troponins in the setting of myocardial ischemia as evidenced by electrocardiogram (ECG) changes, imaging findings or cardiac symptoms. Tachycardia, tachyarrythmias, hypertension, anemia and hypoxia all contribute to myocardial oxygen supply–demand imbalance and can result in non–ST-segment elevation myocardial infarction (NSTEMI) in the perioperative period. When NSTEMI is suspected, management begins with heart rate and blood pressure control with β blockers and appropriate pain control. For patients with ST-segment elevation and suspected ACS, immediate cardiology consultation should be obtained.

Prehabilitation, enhanced recovery programs (ERPs), and geriatric comanagement are some of the innovative models being implemented to improve the outcomes of surgical care for older patients. In prehabilitation programs, older adults participate in structured exercise programs in the weeks prior to elective surgery. These programs have been found to significantly improve older patients’ preoperative functional status and may enhance postoperative recovery. Current research on prehabilitation is focused on identifying the optimal exercise regimen and on improving compliance with the programs. ERPs are another model aimed at promoting early physiologic and physical recovery after surgery. These programs use structured evidence based protocols to optimize preoperative patient preparation, minimize the surgical stress response and encourage early postoperative nutrition and mobilization. ERPs decrease hospital lengths of stay and complication rates in older patients. Lastly, models in which surgeons and geriatricians work closely together to care for the older surgical patient are being developed. Collaboration should begin at the time of patient and procedure selection and continue through the recovery period. This model will certainly improve the quality of surgical care received by the older adult.