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General Principles in Older Adults
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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.
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Surgical Risk in the Older Adult
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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.
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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.
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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 ...