By Dr. Nina Radcliff
It is estimated that in the United States, 15 million surgeries per year are performed on patients who are aged 65 and older. Surgery in this group, however, requires special considerations. In addition to organs having a steady decline of functional reserve, the presence of chronic diseases such as hypertension, diabetes, and coronary and cerebrovascular disease are more likely to be present. It is important for patients to understand the preoperative process and ask questions in order to remain informed, understand their risks, and make appropriate decisions that meet their needs and align with their wishes.
When appropriate, surgery may be scheduled in an ambulatory surgery center, often referred to as “day surgery.” This may be done for certain surgical procedures, including cataracts, colonoscopies, carpal tunnel repairs, knee arthroscopies and hernia repairs. However, these procedures may need to be done in a hospital if the patient has a complicated medical history or needs assistance after surgery.
Functional status assessments of the patient’s ability to perform Activities of Daily Living (ADL) without assistance must be made. The 5 activities in ADL include eating, dressing, using the toilet, transferring and walking, and bathing. The patient should discuss with their family, surgeon, and primary care physician if they are suitable for ambulatory surgery and whether they will need home health care.
The surgeon may request preoperative testing. There are no mandatory preoperative tests or studies based solely on age. Rather, the decision to order tests depends on the presence of disease and type of surgical procedure. Studies may be ordered to establish a baseline, screen for common disease or assess the severity of a known disease in order to optimize a patient before their procedure. Some common tests include an electrocardiogram (EKG), basic metabolic panel (lab test of electrolytes and urine function) and hematocrit (concentration of red blood cells). Chest x-rays are seldom obtained in patients whose history does not suggest lung disease or in non-smokers.
Patients with complicated medical histories or scheduled for general anesthesia are often sent for medical clearance by their primary care physician who is more familiar with their medical history. In certain circumstances, a patient may need clearance by a specialist such as a cardiologist, pulmonologist or endocrinologist. These physicians can assist with optimizing a patient’s health and ordering specialized tests before surgery that can improve their overall course. Primary care physicians often refer patients to their surgeon and are aware that a surgery may be indicated. However, it is recommended that patients inform their primary care doctor and specialists if they are scheduled to have a procedure or surgery.
Patients should be given instructions on their medication schedule for the days prior to the surgery and on the morning of the procedure.
This decision is based upon the primary care physician, surgeon and anesthesiologist’s expertise and policies. Despite being instructed not to eat or drink on the day of surgery, the patient may be asked to take certain medications, particularly blood pressure medications, with a small sip of water. Conversely, certain types of blood pressure medications such as angiotensin converting enzyme inhibitors (ACEIs) or diuretics, blood thinners or oral diabetes medications are often stopped before surgery. Appropriate management and adherence to instructions can avoid cancellation of surgery and decrease the risk for complications.
Depending on the surgical setting, type of surgery, and medical history, the patient may be asked to schedule an appointment in a preoperative anesthesia clinic or receive a phone call the day prior.
If a patient has questions or concerns about their anesthesia, they have the right to contact the anesthesia department and discuss them before their scheduled surgery. On the day of surgery, the patient will meet their anesthesiologist face-to-face and a thorough medical history will be attained and/or confirmed including allergies, last meal or drink, medication list, history of previous surgeries, problems with anesthesia, as well as heart, lung, brain and kidney function.
An airway exam will be performed on all patients and involves asking the patient to open their mouth and say “ahhh.” This simple exam allows the anesthesiologist to assess the ease of inserting airway devices to assist with breathing and deliver inhaled anesthetic medications in patients who are receiving a general anesthetic. In patients undergoing sedation for their procedure, information from this exam can become useful if the patient develops difficulty with breathing.
Based upon the doctor’s assessment of the patient’s overall health, an ASA (American Society of Anesthesiologists) score of 1-5 will be assigned. This classification system is not affected by chronological age. The score is used to assess the risk that a patient may have in the perioperative period.
The anesthesiologist will formulate and describe a plan of care and will attain consent from the patient. The patient will have the opportunity to ask specific questions about the type of anesthesia that will be administered, how their pain will be managed and what the reasonable risks are.
Pain relief during or after the surgery may be provided by intravenous or oral medications. In certain circumstances, regional or neuraxial (epidural, spinal) nerve blocks with local anesthetics may be appropriate and can provide excellent pain relief, good functional outcome, reduced length of hospitalization and improved patient
satisfaction when compared to other forms of pain relief.
Chronological age, in and of itself, does not increase the risk of postoperative complications. However, because patients over the age of 65 are more likely to have chronic disease as compared to younger patients, the frequency of overall complications is increased. One study of Medicare beneficiaries showed 40 percent of inpatients suffered a minor or major medical, surgical or anesthesia-related complication during hospitalization for non-cardiac surgery.
Complications most frequently involve the heart, brain, lungs and kidneys. Your anesthesiologist should be able to discuss these with you after evaluating your history.
Cognitive issues, including delirium and postoperative cognitive dysfunction (POCD), are seen at a greater frequency after surgery in those who are elderly. Postoperative delirium is an acute state that is characterized by a fluctuating course, disorganized thinking and alterations in the level of consciousness with inattention. Patients may be agitated, withdrawn or have a combination of both. Delirium may present immediately after waking up from anesthesia or one to three days after. One study showed that it occurred in 13.2 percent of elderly patients following general surgical procedures but can vary depending on several factors. Treatment consists of removing potential causes, supportive care, and, if appropriate, medications. The occurrence of delirium is associated with an increase in other adverse events, length of hospital stay, need for transfer to nursing facilities instead of home and mortality.
Postoperative cognitive dysfunction (POCD) describes a deterioration of cognition after surgery and anesthesia. It is an evolving concept that is characterized by a persistent deterioration of mental performance. Studies show that POCD may be present in approximately 25 percent of elderly patients at one week following surgery and decreases to 10 percent at three months and 1 percent at two years following surgery. Diagnosis of this condition is via neuropsychological cognitive testing. It remains an active area of ongoing research and a major concern for the future given the growing elderly population and their increased need for surgical procedures.
Although age appears to be the strongest predictor of POCD, additional risk factors include a longer duration of operation, limited formal education, repeat operation, postoperative infections, respiratory complications, cardiopulmonary bypass, on-pump cardiac surgery, major surgery, severe illness, orthopedic surgery, acute postoperative pain and preoperative cognitive impairment.
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Dr. Nina Radcliff is dedicated to her profession, her patients and her community, at large. She is passionate about sharing truths for healthy, balanced living as well as wise preventive health measures.
She completed medical school and residency training at UCLA and has served on the medical faculty at The University of Pennsylvania. She is a Board Certified Anesthesiologist and a member of the American Society of Anesthesiologists where she serves on committees for Young Physicians and Communications. Author of more than 200 textbook chapters, research articles, medical opinions and reviews; she is often called upon by media to speak on medical, fitness, nutrition, and healthy lifestyle topics impacting our lives, today.