Surgery for elderly women is likely to increase steadily as the population of elderly people increases globally. Although increasing age increases perioperative morbidity and mortality, the functional age and physiologic reserve rather than chronological age is more important in preventing complications. Preparation for surgery, with special attention to functional capacity and activity, mental status, and existing comorbid conditions, can improve outcomes. Perioperative management must be tailored to physiologic changes of ageing, which affect respiratory, cardiac and renal function, as well as guidelines for preventing infection and thrombotic events. Of particular note is the enhanced effect of narcotic medications in elderly people, which affects intraoperative and postoperative management of pain. Prevention of postoperative delirium is accomplished through preoperative and postoperative planning. Discharge planning, particularly for frail elderly people, must start before surgery.
Introduction
Surgery is increasingly common in elderly women (over 75 years) as the global population ages; overall, however, perioperative morbidity and mortality is 2.9 to 6.7 times higher even adjusting for differences in comorbidities. Age is one of the most important risk factors for morbidity and mortality after surgery. Even the most active and seemingly healthy elderly person is at greater risk for problems with the stress of surgery. The following can reduce the risk of problems, enhance the success of surgery, and improve the functioning of elderly people after surgery: understanding the components of risk; carefully assessing individuals before surgery; managing the prevention of complications; and being diligent to early signs of complications after surgery.
Few studies have evaluated outcomes in elderly people undergoing surgery. In one study, low body mass index (BMI) and low haemoglobin levels were predictive of mortality in people undergoing elective and urgent surgery. In people requiring urgent surgery, low functional independence (measured by Activities of Daily Living) and more severe comorbid conditions, were also found to be independent predictors of mortality. Studies have focused on the physiologic reserve of people rather than chronological age, with frailty and dementia as key components of predicting risk. Overall, the axiom that functional reserve capacity of all organ systems decreases with age represents the most important element of surgery in elderly women: that increased stress to those systems is not handled as well and can create major problems more quickly than in younger people.
Additionally, the site of surgery (ambulatory versus inpatient) may influence outcomes, such as cognitive dysfunction, by returning the elder to their familiar environment more quickly from the ambulatory surgery environment. Other benefits of outpatient surgery may be less respiratory and intubation-related events, and a relative reduction of postoperative complications. Consideration of the site of surgery and whether ambulatory surgery is an option is an additional function of the preoperative evaluation.
Preoperative evaluation
Comprehensive geriatric assessments are used to assess functional and nutritional status, comorbid medical conditions, falls, incontinence, functional decline, and delirium. These can be helpful to identify patients at greatest risk of postoperative complications, mortality, disability, and cognitive decline. The preoperative assessment ‘Cancer in the Elderly’ has been suggested as one tool, and consists of a comprehensive geriatric assessment, the Brief Fatigue Inventory, performance status, and the American Society of Anesthesiologists grade. No evidence, however, supports a single standard pre-surgical assessment or even a unique surgical approach for elderly people. As Suh et al. comment, ‘what we have to consider when deciding to perform extensive surgery is not the chronological age of the elderly patients but their preoperative co morbidities that may affect their survival.’
Studies of standard preoperative screening laboratory tests have found that the most important test for elderly people was urinalysis and the identification of unknown urinary tract infections. Other than that, preoperative screening should be guided by the type of surgery and the underlying comorbidities of each individual, rather than a routine list of tests. The areas that might have the most relevance are preoperative assessments of pulmonary and cardiac function, electrolyte, and nutritional status (including serum albumin).
Preoperative counselling (teaching people about postoperative pain management, mobilisation, rehabilitation, and efforts to address questions and familiarise elderly people with the hospital environment) has shown some ability to enhance healing and recovery after surgery. Assuring a robust education and postoperative plan for mobilisation, rehabilitation, or both, is a key to recovery after surgery. Additionally, improving functional status preoperatively with structured training programmes for frail elderly people has been shown to improve outcome for major surgery procedures.
Cognitive function
Older people are more likely to have some cognitive decline or early dementia, and the stress of major surgery can exacerbate or unmask underlying issues. Geriatric assessments looking at severe frailty and disability predict a higher 6-month postoperative mortality and institutionalisation in people who undergo major abdominal, thoracic and vascular surgery with this combination. Depression can also be an issue in elderly people, and is a major risk factor for postoperative delirium. One study looking at people undergoing cardiac valvular surgery found depressed people were 1.9 times more likely to die after surgery compared with non-depressed people. Preoperative assessment of mental capacity may be difficult. If a patient is accompanied by a spouse or caretaker, there may be warning signs that the patient is having difficulty performing activities of daily living alone. Further discussion with family members or the general practitioner may reveal mild dementia or cognitive decline. The mini-mental status exam can be administered in the office with a score of over 25 as normal. There is also the three word recollection test where the patient is asked to repeat three words after one minute, and the six-item score where they need to remember three words and be oriented to month, day and year. If a person has difficulty with these tests, referral to a specialist may be warranted. Postoperative delirium risk seems to be quantified by the sum or predisposing and precipitating factors present, so any preoperative management that can be provided will decrease that risk. Furthermore, consideration of the use of risperidone with anaesthesia to provide prophylaxis for individuals who meet the criteria for ‘subsyndromal’ delirium on the Intensive Care Delirium Screening checklist scale may be worth discussing with the anaesthesia team.
Pulmonary function, including smoking
Ageing causes changes in lung mechanics as well as function. Both forced expiratory volume 1 and vital capacity decrease, chest wall stiffness increases, and elasticity of the lung diminishes, leading to issues with compliance. In addition, expiratory flow and diffusion capacity are diminished, and ventilation-perfusion heterogeneity increases, adding to underlying pulmonary pathology. People who smoke, or are former smokers, may have chronic obstructive pulmonary disease, which may be exacerbated with major surgery. Patients undergoing surgery should be asked about their functional status beforehand (i.e. are they able to climb a flight of stairs or walk a block without becoming short of breath). Formal pulmonary function testing is infrequently used but may be warranted in individuals at high risk with underlying pulmonary disease. This is to determine, in particular, whether a reversible component to their disease exists. This is a critical evaluation if minimally invasive surgery is contemplated because of the positioning of the patient and the effect on cardiovascular and pulmonary function with the narrow margin of reserve for most elderly people.
Smoking cessation is worth considering for elderly smokers, as even 24 or 48 h of no smoking can have some benefits, although only intensive preoperative smoking cessation has shown an effect (pooled risk ratio of 0.6). Smoking cessation can have benefits at any age, including elderly people. Some evidence also suggests that perioperative cessation of smoking is more likely in elderly people, and a ‘teachable’ moment for providing this behaviour change.
Cardiac function and vascular disease
Blood pressure, cardiac conduction, and ventricular and valvular function are affected by ageing. Systolic arterial pressure increases with age, and diastolic pressure increases less in elderly people. Age-related hypertension increases arterial stiffness and systemic vascular resistance. With age, heart rate changes from stress are blunted and stroke volume is more likely to increase to compensate for increased demand. Diastolic dysfunction is common because of increased afterload from atherosclerosis or arterial hypertension. Fibrosis can also form and amyloid deposits can accumulate in the heart. All of these changes affect anaesthetic risk for hypotension as well as fluid overload during and after anaesthesia.
Risk factors associated with ischaemic heart disease, including perioperative risk factors include arterial hypertension, smoking, hyperlipidaemia, and diabetes. The American College of Cardiology and the American Heart Association recommend preoperative non-invasive stress testing on people with risk factors for cardiac complications. Other studies have found that non-invasive cardiac stress testing before major surgery is associated with an improved 1-year survival in intermediate to high-risk surgery, but that testing in people at low risk is not warranted.
Many elderly people are on a number of cardiac medications. The general consensus is to continue most chronic cardiac medications up to the day of surgery, particularly statins and beta blockers. Whether or not to continue calcium channel blockers is not clear, and it may be best to stop angiotensin-converting enzyme inhibitors and angiotensin-receptor blocking drugs because of the potential for hypotension. If, stopped, these should be about 24 h before surgery. Consultation with the anaesthetic team is warranted, as the choice of anaesthesia may also be affected by the medication continuance or not.
Gastrointestinal evaluation
Overall, the gastrointestinal tract functions normally in most elderly people. Screening for a history of Helicobacter pylori infection, dysphagia, reflux and other circumstances that would lead to higher rates of gastroduodenal ulcer disease and aspiration, is of value in planning preventive treatment with anaesthesia and thereafter. Hepatic disease management is similar to that of any age, with the exception that cirrhosis in elderly people carries such a high mortality risk that surgery may be contraindicated.
Genitourinary evaluation
Renal function can be deceptively normal in elderly people with reduced muscle mass, change in serum albumin, and overall body water changes. A continuing loss of parenchymal thickness and a decline in renal blood flow occurs, leading to a 30–50% decrease in creatinine, clearance between the ages of 20 and 90 years. A careful evaluation of the risks for renal disease is warranted. Consideration of creatinine clearance testing to help guide choices for anaesthetic and analgesic options and drug dosing is also worth including in all evaluations of elderly people where there is concern for renal function (e.g. diabetes). In addition, the incidence of asymptomatic genito-urinary infections can be high among elderly people, and routine screening and treatment of identified urinary infections reduces risks for postoperative infections and renal compromise.
Mobility and musculoskeletal concerns
Assessment of overall conditioning or deconditioning and mobility is important in preoperative assessment. Erekson et al. refer to the ‘Get Up and Go’ screening test, which asks patients to get up out of a chair without using armrests, walk 10 feet, return and sit down. This should be carried out to determine if referral is required for a more comprehensive mobility assessment. People who can do this in 10–12 s or less do not need referral if they have no other observed balance or gait challenges. Doing this preoperatively allows for postoperative and discharge planning that will address the issues, encourage mobility, and prevent falls.
Diabetes, endocrine and nutritional concerns
Adequate nutritional reserves are important for healing and preventing infection. Nutritional status can be assessed by albumin or pre-albumin levels or screening tests. One test, the Mini-Nutritional Assessment was designed to assess nutritional status in elderly people. It stratifies people into well-nourished, at risk of malnutrition, and under nourished based on body measurements, a global and dietary assessment, and a subjective perception of the individual. It can identify people who are malnourished and those who are have diminished nutritional intake but who do not yet have weight loss or a fall in serum albumin. This was used preoperatively at an anaesthesia preoperative evaluation for elective surgery. Vellas et al. found that 67.6% of 408 patients were well nourished, 25% of patients were identified as at risk, and 6.9% were suffering from overt malnutrition. This study concluded that American Society of Anesthesiologists ASA score alone could not predict nutritional status.
Obesity is also a form of malnutrition, and little research has been focused on issues of obesity and surgery in elderly people. Similar to younger people, increased odds of wound infections, renal dysfunction, urinary tract infection, hypotension, and respiratory events have been reported. More importantly, the risk of readmission for complications was reported to be 40% greater. Although little can be done in most preoperative circumstances to change body-mass index, assuring careful assessment of renal, cardiac and pulmonary function, and careful postoperative attention to these areas, may prevent some of these risks. Furthermore, preoperative counselling about increased risks allows the individual to participate in early identification and treatment of postoperative problems (e.g. urinary tract infections or wound infections).
Medication issues, evaluation and modification preoperatively
Changes in body-fat composition and lower albumin concentrations can lead to higher tissue concentrations, longer half-lives, and increased free fraction of drugs in elderly people. Renal function may also decline with age, and may be exacerbated by people taking loop diuretics or those taking non-steroidal anti-inflammatory medications. Elderly people may be taking multiple medications for various co-morbid conditions, and may see several clinicians for care (e.g. general practitioner, cardiologist, rheumatologist, and neurologist). Preoperatively, an accurate medication list should be verified, and any concerns about specific medications (e.g. coumadin for atrial fibrillation and seizure medications) should be addressed with the patient’s individual providers. Of note, stopping carbidopa and levodopa for Parkinson’s disease can lead to a return of symptoms, so these medications should be given as soon as possible. Individuals taking oral hypoglycaemics should discontinue their medication on the morning of surgery.
Preoperative evaluation
Comprehensive geriatric assessments are used to assess functional and nutritional status, comorbid medical conditions, falls, incontinence, functional decline, and delirium. These can be helpful to identify patients at greatest risk of postoperative complications, mortality, disability, and cognitive decline. The preoperative assessment ‘Cancer in the Elderly’ has been suggested as one tool, and consists of a comprehensive geriatric assessment, the Brief Fatigue Inventory, performance status, and the American Society of Anesthesiologists grade. No evidence, however, supports a single standard pre-surgical assessment or even a unique surgical approach for elderly people. As Suh et al. comment, ‘what we have to consider when deciding to perform extensive surgery is not the chronological age of the elderly patients but their preoperative co morbidities that may affect their survival.’
Studies of standard preoperative screening laboratory tests have found that the most important test for elderly people was urinalysis and the identification of unknown urinary tract infections. Other than that, preoperative screening should be guided by the type of surgery and the underlying comorbidities of each individual, rather than a routine list of tests. The areas that might have the most relevance are preoperative assessments of pulmonary and cardiac function, electrolyte, and nutritional status (including serum albumin).
Preoperative counselling (teaching people about postoperative pain management, mobilisation, rehabilitation, and efforts to address questions and familiarise elderly people with the hospital environment) has shown some ability to enhance healing and recovery after surgery. Assuring a robust education and postoperative plan for mobilisation, rehabilitation, or both, is a key to recovery after surgery. Additionally, improving functional status preoperatively with structured training programmes for frail elderly people has been shown to improve outcome for major surgery procedures.
Cognitive function
Older people are more likely to have some cognitive decline or early dementia, and the stress of major surgery can exacerbate or unmask underlying issues. Geriatric assessments looking at severe frailty and disability predict a higher 6-month postoperative mortality and institutionalisation in people who undergo major abdominal, thoracic and vascular surgery with this combination. Depression can also be an issue in elderly people, and is a major risk factor for postoperative delirium. One study looking at people undergoing cardiac valvular surgery found depressed people were 1.9 times more likely to die after surgery compared with non-depressed people. Preoperative assessment of mental capacity may be difficult. If a patient is accompanied by a spouse or caretaker, there may be warning signs that the patient is having difficulty performing activities of daily living alone. Further discussion with family members or the general practitioner may reveal mild dementia or cognitive decline. The mini-mental status exam can be administered in the office with a score of over 25 as normal. There is also the three word recollection test where the patient is asked to repeat three words after one minute, and the six-item score where they need to remember three words and be oriented to month, day and year. If a person has difficulty with these tests, referral to a specialist may be warranted. Postoperative delirium risk seems to be quantified by the sum or predisposing and precipitating factors present, so any preoperative management that can be provided will decrease that risk. Furthermore, consideration of the use of risperidone with anaesthesia to provide prophylaxis for individuals who meet the criteria for ‘subsyndromal’ delirium on the Intensive Care Delirium Screening checklist scale may be worth discussing with the anaesthesia team.
Pulmonary function, including smoking
Ageing causes changes in lung mechanics as well as function. Both forced expiratory volume 1 and vital capacity decrease, chest wall stiffness increases, and elasticity of the lung diminishes, leading to issues with compliance. In addition, expiratory flow and diffusion capacity are diminished, and ventilation-perfusion heterogeneity increases, adding to underlying pulmonary pathology. People who smoke, or are former smokers, may have chronic obstructive pulmonary disease, which may be exacerbated with major surgery. Patients undergoing surgery should be asked about their functional status beforehand (i.e. are they able to climb a flight of stairs or walk a block without becoming short of breath). Formal pulmonary function testing is infrequently used but may be warranted in individuals at high risk with underlying pulmonary disease. This is to determine, in particular, whether a reversible component to their disease exists. This is a critical evaluation if minimally invasive surgery is contemplated because of the positioning of the patient and the effect on cardiovascular and pulmonary function with the narrow margin of reserve for most elderly people.
Smoking cessation is worth considering for elderly smokers, as even 24 or 48 h of no smoking can have some benefits, although only intensive preoperative smoking cessation has shown an effect (pooled risk ratio of 0.6). Smoking cessation can have benefits at any age, including elderly people. Some evidence also suggests that perioperative cessation of smoking is more likely in elderly people, and a ‘teachable’ moment for providing this behaviour change.
Cardiac function and vascular disease
Blood pressure, cardiac conduction, and ventricular and valvular function are affected by ageing. Systolic arterial pressure increases with age, and diastolic pressure increases less in elderly people. Age-related hypertension increases arterial stiffness and systemic vascular resistance. With age, heart rate changes from stress are blunted and stroke volume is more likely to increase to compensate for increased demand. Diastolic dysfunction is common because of increased afterload from atherosclerosis or arterial hypertension. Fibrosis can also form and amyloid deposits can accumulate in the heart. All of these changes affect anaesthetic risk for hypotension as well as fluid overload during and after anaesthesia.
Risk factors associated with ischaemic heart disease, including perioperative risk factors include arterial hypertension, smoking, hyperlipidaemia, and diabetes. The American College of Cardiology and the American Heart Association recommend preoperative non-invasive stress testing on people with risk factors for cardiac complications. Other studies have found that non-invasive cardiac stress testing before major surgery is associated with an improved 1-year survival in intermediate to high-risk surgery, but that testing in people at low risk is not warranted.
Many elderly people are on a number of cardiac medications. The general consensus is to continue most chronic cardiac medications up to the day of surgery, particularly statins and beta blockers. Whether or not to continue calcium channel blockers is not clear, and it may be best to stop angiotensin-converting enzyme inhibitors and angiotensin-receptor blocking drugs because of the potential for hypotension. If, stopped, these should be about 24 h before surgery. Consultation with the anaesthetic team is warranted, as the choice of anaesthesia may also be affected by the medication continuance or not.
Gastrointestinal evaluation
Overall, the gastrointestinal tract functions normally in most elderly people. Screening for a history of Helicobacter pylori infection, dysphagia, reflux and other circumstances that would lead to higher rates of gastroduodenal ulcer disease and aspiration, is of value in planning preventive treatment with anaesthesia and thereafter. Hepatic disease management is similar to that of any age, with the exception that cirrhosis in elderly people carries such a high mortality risk that surgery may be contraindicated.
Genitourinary evaluation
Renal function can be deceptively normal in elderly people with reduced muscle mass, change in serum albumin, and overall body water changes. A continuing loss of parenchymal thickness and a decline in renal blood flow occurs, leading to a 30–50% decrease in creatinine, clearance between the ages of 20 and 90 years. A careful evaluation of the risks for renal disease is warranted. Consideration of creatinine clearance testing to help guide choices for anaesthetic and analgesic options and drug dosing is also worth including in all evaluations of elderly people where there is concern for renal function (e.g. diabetes). In addition, the incidence of asymptomatic genito-urinary infections can be high among elderly people, and routine screening and treatment of identified urinary infections reduces risks for postoperative infections and renal compromise.
Mobility and musculoskeletal concerns
Assessment of overall conditioning or deconditioning and mobility is important in preoperative assessment. Erekson et al. refer to the ‘Get Up and Go’ screening test, which asks patients to get up out of a chair without using armrests, walk 10 feet, return and sit down. This should be carried out to determine if referral is required for a more comprehensive mobility assessment. People who can do this in 10–12 s or less do not need referral if they have no other observed balance or gait challenges. Doing this preoperatively allows for postoperative and discharge planning that will address the issues, encourage mobility, and prevent falls.
Diabetes, endocrine and nutritional concerns
Adequate nutritional reserves are important for healing and preventing infection. Nutritional status can be assessed by albumin or pre-albumin levels or screening tests. One test, the Mini-Nutritional Assessment was designed to assess nutritional status in elderly people. It stratifies people into well-nourished, at risk of malnutrition, and under nourished based on body measurements, a global and dietary assessment, and a subjective perception of the individual. It can identify people who are malnourished and those who are have diminished nutritional intake but who do not yet have weight loss or a fall in serum albumin. This was used preoperatively at an anaesthesia preoperative evaluation for elective surgery. Vellas et al. found that 67.6% of 408 patients were well nourished, 25% of patients were identified as at risk, and 6.9% were suffering from overt malnutrition. This study concluded that American Society of Anesthesiologists ASA score alone could not predict nutritional status.
Obesity is also a form of malnutrition, and little research has been focused on issues of obesity and surgery in elderly people. Similar to younger people, increased odds of wound infections, renal dysfunction, urinary tract infection, hypotension, and respiratory events have been reported. More importantly, the risk of readmission for complications was reported to be 40% greater. Although little can be done in most preoperative circumstances to change body-mass index, assuring careful assessment of renal, cardiac and pulmonary function, and careful postoperative attention to these areas, may prevent some of these risks. Furthermore, preoperative counselling about increased risks allows the individual to participate in early identification and treatment of postoperative problems (e.g. urinary tract infections or wound infections).
Medication issues, evaluation and modification preoperatively
Changes in body-fat composition and lower albumin concentrations can lead to higher tissue concentrations, longer half-lives, and increased free fraction of drugs in elderly people. Renal function may also decline with age, and may be exacerbated by people taking loop diuretics or those taking non-steroidal anti-inflammatory medications. Elderly people may be taking multiple medications for various co-morbid conditions, and may see several clinicians for care (e.g. general practitioner, cardiologist, rheumatologist, and neurologist). Preoperatively, an accurate medication list should be verified, and any concerns about specific medications (e.g. coumadin for atrial fibrillation and seizure medications) should be addressed with the patient’s individual providers. Of note, stopping carbidopa and levodopa for Parkinson’s disease can lead to a return of symptoms, so these medications should be given as soon as possible. Individuals taking oral hypoglycaemics should discontinue their medication on the morning of surgery.
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