The continued aging of the population will be perhaps the greatest force affecting healthcare. Conditions that often require surgery—atherosclerosis, degenerative joint disease, prostate disease, among others—increase in incidence with advancing age. With a few exceptions, it’s time for all surgeons to consider themselves geriatric surgeons.
Guidance for Surgeons Treating the Elderly
Several general principles can help guide surgeons who treat the elderly. First, the clinical presentation of surgical problems in the elderly may be subtle or somewhat different from that of the general population. This may lead to delays in diagnosis. In appendicitis, for example, a classic presentation occurs in less than one-third of elderly patients, resulting in perforation in over half of patients before surgery. Second, the elderly handle normal stress satisfactorily but handle severe stress poorly because of lack of organ system reserve.
Optimal preoperative preparation is essential. Hypovolemia, hypertension, bronchitis, and severe anemia should be corrected. When preparation is suboptimal or insufficient time is allotted for adequate preparation, perioperative risk increases. The results of elective surgery in the elderly are good in many centers. Results of emergency surgery are poorer but better than non-operative treatment for most conditions. The risk of emergency surgery may be many times that of similar elective surgery.
“Scrupulous attention to detail yields great benefit because the elderly tolerate complications poorly.”
Scrupulous attention to detail yields great benefit because the elderly tolerate complications poorly. Perioperative blood loss, for example, is the factor over which surgeons have the most control. Postoperative complications are stronger risk factors for hospital deaths than preoperative comorbidities and procedural variables.
Ageism Is Unjustified
A patient’s age should be treated as a scientific fact, not with prejudice. No particular chronologic age, of itself, should be viewed as a contraindication to surgery. Even an 80-year-old man is projected to have a life expectancy of 8 years. If such a person is in need of a lung cancer resection, he should be offered it because no other treatment is likely to give him those 8 years. Unfortunately, prejudice based on chronologic age—“ageism”—exists in both society and in medicine. In many cases, cardiac surgery may not even be discussed as an option for octogenarians with mitral valve disease. Studies also indicate that elderly patients with cancer are more likely to experience suboptimal staging and less aggressive treatment.
When compared with younger patients, the elderly will have decreased physiologic reserve and a greater likelihood of comorbidities. They’re also more likely to have a longer hospital stay and have higher costs for care. Importantly, however, there is great physiologic variability among older patients. Results of studies assessing surgery outcomes among the elderly do not support prejudices based on age alone. In the coming years, the number of elderly patients is expected to increase. It’s also likely that more research on surgical problems in this patient population will emerge. As greater emphasis is placed on optimizing outcomes for geriatric individuals, it’s paramount that all surgeons work hard to become better geriatric surgeons. In turn, we’ll become better surgeons for patients of all ages.
Readings & Resources (click to view)
World Population Aging 1950-2050. Available at: http://www.un.org/esa/population/publications/worldageing19502050/.
Storm-Dickerson TL, Horattas MC. What have we learned over the past 20 years about appendicitis in the elderly? Am J Surg. Mar 2003;185:198-201.
de Liguori Carino N, van Leeuwen BL, Ghaneh P, et al. Liver resection for colorectal liver metastases in older patients. Crit Rev Oncol Hematol. 2008;67:273-278.
Naughton C, Feneck RO, Roxburgh J. Early and late predictors of mortality following on-pump coronary artery bypass graft surgery in the elderly as compared to a younger population. Eur J Cardiothorac Surg. 2009;36:621-627.
Zingone B, Gatti G, Rauber E, et al. Early and late outcomes of cardiac surgery in octogenarians. Ann Thorac Surg. Jan 2009;87:71-78.
Siu LL. Clinical trials in the elderly–a concept comes of age. N Engl J Med. 2007;356:1575-1576.