Perioperative Management of Special Populations: The Geriatric Patient

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Preoperative assessment

With aging, baseline functions of almost every organ system undergo progressive decline resulting in a decreased physiologic reserve and ability to compensate for stress. Coexisting disease has more impact on morbidity and mortality than age alone in the geriatric population [2]. An elderly patient has increased risk of morbidity and mortality if the patient:

  • has severe systemic disease (American Society of Anethesiologists (ASA) Class III or IV);

  • requires an emergency procedure;

  • suffers from

Cardiovascular physiology

Cardiac disease is the most common comorbid condition in the elderly [3] as 80% of patients over 80 have identifiable cardiovascular disease. Starting in the third decade, cardiac output and the maximum rate of oxygen use (VO2max) steadily decline. Congestive heart failure (CHF) is present in 10% of individuals over 65 years of age and is the leading cause of postoperative morbidity and mortality following surgical procedures. Patients with CHF have an increased rate of stroke, myocardial

Pulmonary physiology

Evidence of age-related changes in the pulmonary system include a loss of elastic recoil of the lung and impaired chest wall movement caused by muscle atrophy, joint stiffening, and skeletal changes. Impaired elasticity causes air trapping and ventilation-perfusion (V/Q) mismatching leading to decreased oxygen transfer [8]. Oxygenation is further impaired by the closure of an increasing number of small airways and decreased surface area for gas exchange. Vital capacity decreases with age,

Renal physiology

Age-related changes in the renal system are characterized by a progressive reduction in renal mass and creatinine clearance. Glomerulosclerosis results in a decline in renal plasma flow (RPF) and in glomerular filtration rate (GFR) [9]. Additionally, age-related decline in cardiac output also causes the RPF and the GFR to decline. Patients with an impaired GFR are more susceptible to volume overload in the perioperative period as well as accumulation of metabolic substances and drugs that rely

Nutrition

Risk factors associated with nutritional deficiency among elderly patients have been documented [15]. Low weight is the most significant factor. Other factors include:

  • poverty

  • alcohol abuse

  • deterioration in physical and cognitive function

  • change in the number or type of medications

  • recent hospitalization or surgery

  • micturition dysfunction

Although history and physical examination are as effective as any biochemical marker in assessing nutrition [16], low preoperative albumin correlates directly with

Anesthesia

The physiologic changes seen in the elderly and their effects on drug bioavailability and side effect profiles can define the type and dose of agent used for anesthesia in the elderly patient. A decrease in total body water seen with aging leads to higher peak drug concentrations following bolus or rapid infusion. A relative reduction in perfusion to organs such as the liver and kidneys can prolong a drug's duration of action by slowing metabolism and excretion [19]. Most anesthetic drugs have

Pain control

Better analgesic techniques for the elderly need to be discovered [24]. Elderly often communicate less pain because of cognitive impairment or fear of being a “bad patient.” Physicians may perceive this as evidence that elderly feel less pain than younger patients. In fact, up to 45% of patients may feel their pain is undertreated while hospitalized [25]. Scheduled dosing invariably leads to inadequate pain control or overdosing.

Inadequate pain control can increase morbidity and mortality in

Postoperative delirium and cognitive assessment

Postoperative cognitive impairment can be classified as postoperative delirium (PD) or postoperative neurocognitive disorder (POCD). PD is characterized by fluctuating levels of consciousness and temporary abnormalities in memory and perception. POCD is a condition with a variable time course characterized by impaired concentration, language comprehension, and social integration. These characteristics can become evident days to weeks after surgery.

The incidence of PD in the elderly varies

Quality-of-life and end-of-life issues

Most patients would rather maintain an independent lifestyle rather than gain a few months of life in a debilitated state. When weighing the risks and benefits for an elderly patient, a surgeon must consider the predicted life expectancy of the patient and quality of life after intervention. Unfortunately, literature concerning surgery in the elderly is often based on cases with an inherent selection bias for the healthiest patients.

The patient should be aware of the specific risks involved

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