Surgery in the Elderly

OUTLINE

• INTRODUCTION

• PHYSIOLOGICAL CHANGES IN THE ELDERLY

• CHALLENGES OF ELDERLY SURGICAL PATIENTS

• PRINCIPLES OF MGT. OF ELDERLY SURGICAL PX

• PRE-OPERATIVE

• INTRA-OPERATIVE

• POST-OPERATIVE

• COMPLICATIONS

• REGIONAL CHALLENGES

• CONCLUSION

INTRODUCTION

• Elderly patients are arbitrarily defined as those that are 65 years and above.

• “The Elderly” = 65 – 74yrs
• • “The Aged” = 75 – 84yrs
• • “Very old” = 85yrs or more ( UK definition)
• • Though there is no correlation between chronological and biological age.

• With increasing age, morbidity/mortality is increased due to decrease physiological reserves and comorbidities.

INTRODUCTION

• In the USA, about 11% of the population is

65yrs or older.

• It is estimated that about 50% of these

geriatric patients will require surgery before

death.

• Mortality increases after 65yrs and is doubled

at 75yrs and tripled over 85yrs.INTRODUCTION CONTD.

• OBJECTIVE OF SURGERY IN THE ELDERLY IS

PROLONGATION OF ACTIVE, ENJOYABLE AND

WORTHWHILE LIFE.

• Successful return to gainful employment or to

vigorous leisure pursuits is seldom necessary .PHYSIOLOGICAL CHANGES IN THE

ELDERLY

• Chronological age is rarely an accurate

predictor of morbidity and mortality from

surgical interventions.

• It is however an accurate marker for declining

physiological reserve and presence of multiple

co-morbid conditions.

• Therefore, physiologic age plus the presence

of co-morbid conditions more accurately

predict the surgical outcome in these patients.PHYSIOLOGICAL CHANGES IN THE

ELDERLY

• The aging process is usually associated with

physiological changes in the following systems:

• CENTRAL NERVOUS SYSTEM

• CARDIOVASCULAR

• PULMONARY

• RENAL

• GASTROINTESTINAL AND HEPATOBILIARY

• ENDOCRINE

• MUSCULOSKELETALPHYSIOLOGICAL CHANGES IN THE

ELDERLY

• CENTRAL NERVOUS SYSTEM;

• There is progressive decline in CNS activity

due to loss of neurons particularly in the

cerebral cortex.

• Cerebral atrophy also leads to dementia and

impairment in cognitive function.

• Gradual slowing of conduction velocity in

peripheral nerves .PHYSIOLOGICAL CHANGES IN THE

ELDERLY

• CARDIOVASCULAR SYSTEM;

• Cardiac output declines by 1% every year after age 30yrs.

• Heart muscle gradually replaced with fibrous and senile amyloid

• Valvular calcification( aortic).

• Mucoid degeneration(mitral).

• Left ventricular wall thickness increases with age age.

• Function of the conducting systems of the heart is reduced.

• Prolongation of myocardial contraction.

• Decreased baroreceptor sensitivity therefore tendency to have

fluctuations in BP.

• Decreased heart rate, ejection fraction and cardiac output, leading

to increased reliance on stroke volume, and end diastolic volume to

increase cardiac output.PHYSIOLOGICAL CHANGES IN THE

ELDERLY

• RESPIRATORY SYSTEM.

• Increased fibrous connective tissues in the lungs.

• Chest wall calcifications

• Diaphragm loses strength with age

• Intercostal muscle atrophy

• Decreased elastin

• Alveolar septal breakbown

• Alveolar duct becomes wider and shallower

• Decreased tidal volume, vital capacity, forced expiratory

volume in 1second.

• Decreased partial pressure of oxygen leading to increased

risk of hypoxaemia.PHYSIOLOGICAL CHANGES IN ELDERLY.

• RENAL SYSTEM;

• Normal GFR = 120ml/min.

• GFR, falls by 8mls per every decade after 20yrs of age(e.g 85yr old GFR is about 65ml/min.)

• There is a reduction of about 50% of the functioning neprons

• There is progressive decline in the renal blood flow and renal function manifested by decrease in

GFR and urine concentration.

• Impaired responsiveness to ADH.

• Impaired distal (but not proximal) tubular function makes elderly patients less able to concentrate

urine.

• Mechanisms to maintain volume and composition of extracellular fluids are impaired, thus reduced

ability to conserve sodium.

• Renin activity and aldosterone concentration decreases by 30 %– 50% , leading to hyperkalaemia..

• Combination of decreased renal and cardiac function makes Geriatric patients more vulnerable to

fluid over load as well as impaired renal elimination of drugs.

• HYPOVOLAEMIA, ELECTROLYTE DISTURBANCES, HYPEROSMOLAR STATES, INCREASE D

SENSITIVITY TO NEPHROTOXIC AGENTS AND LESS EFFICIENT EXCRETION OF DRUGS.PHYSIOLOGICAL CHANGES IN THE

ELDERLY

• GASTROINTESTINAL AND HEPATOBILIARY;

• Reduced G.I perfusion

• Reduced gastric emptying

• Reduced gastric cell function, which in turn leads

to impaired acid secretion and increased PH.

• Reduced hepatic tissue mass

• Decreased production of albumin

• Decreased activity of hepatic microsomal

enzymes leading to reduced plasma clearance of

drugs.PHYSIOLOGICAL CHANGES IN THE

ELDERLY

• ENDOCRINE:

• Low basal metabolic rate

• Decreased pancreatic function with high

incidence of DM and glucose intolerance.

• Subclinical hypothyroidismPHYSIOLOGICAL CHANGES IN ELDERLY

• By age 65yrs, there is decrease of total body

weight by 25% in men and 18% in women.

• Loss of skeletal mass

• Increase in lipid fraction

• Severe osteoporosis in 20% of aged women

• Osteomalacia in 5% of aged population

• Paget disease in 3% and up to 11% by age 90yrs.

• Osteoarthritis in major joints in about 85% of

cases

• Anaemia in 12% over 65yrs.Common co-morbid conditions in the

elderly

• Hypertension

• BHP/CAP

• Diabetes mellitus

• Congestive cardiac failure

• Coronary artery disease

• COPD

• Osteoarthritis

• Malnutrition

• Occult malignancyCommonly Performed Surgical

Operations in the Elderly

• Cataract extraction

• Prostatectomy

• Hernia repair

• Cholecystectomy

• Reduction and fixation of a fractured bones

• Joint arthroplasties

• Aneurysm repair

• Surgeries for malignant leisions

9/14/2020 16CHALLENGES OF ELDERLY SURGICAL

PATIENTS

• Difficulties in History taking - due to impaired mental

activity or emotional disturbances or dementia.

• Increase risk of CVA

• Difficult intubation due to cervical spondylosis

• Difficult chin lift and jaw thrust due to temporomandibular joint stiffness.

• Fluid challenges.

• DVT

• Pressure sores

• Pathological fracture due to osteoporosisCHALLENGES OF ELDERLY SURGICAL

PATIENT.

• DRUG METABOLISM/EXCRETION;

• Relative increase in the lipid fraction of the

body compositionCHALLENGES OF ELDERLY SURGICAL

PATIENT.

• Decreased functional reserve

• Co-morbidities / Multiple system disease

• Signs & symptoms of disease may be

altered/masked by ageing process

9/14/2020 19General Basic principles of Surgery in

the Elderly

• Weigh benefits of the surgery with possible

post-op. Morbidity / Mortality

• Proper timing of surgery .

• Team work ( Surgeon, Physician, Anesthetist,

Geriatrician, Rehabilitative services, Family

members)

9/14/2020 20General principles

• Full and detailed pre-operative assessment

for:

1. Precise pre-op diagnosis

2. Enhancing safety & speed of management

• Open communication - explain the

diagnosis and prognosis.

9/14/2020 21General Principles

• Prophylactic antibiotics - due to proneness to

wound infection

• Avoid pressure points during positioning for

surgery - to avoid pressure sore

• Avoid adhesive skin tapes – due to senile atrophy

• Early ambulation

9/14/2020 22General principles

• Drug history must be emphasized

• Avoid unpleasant, invasive, hazardous and

costly investigations

• Routine anticoagulant measures

9/14/2020 23Pre-operative Preparation

• Full Hx & thorough clinical + nutritional

assessment.

• Identify & treat co-morbid disease -HTN, DM,

COPD, osteoarthritis

• Airway evaluation- edentulous, poor dentition,

dentures

• Cognitive function

• ASA Score - fitness for surgery

• APACHE Score – predicts mortality

• Goldman’s Cardiac Risk assessment

9/14/2020 24ASA Classification

• ASA I= Normal/healthy patient , does not smoke, low or

minimal alcohol intake.

• ASA II= Mild systemic disease, e.g, obesity, well controlled

DM/HTN, mild lung disease, smoker , social alcohol drinker.

• ASA III= Severe systemic disease, e.g poorly controlled

DM/HTN, COPD, ESRD on dialysis, previous history of

TIA/CVA, alcohol dependence, implanted pace maker.

• ASA IV= Severe systemic disease that is constant threat to

life, e.g recent MI, CVA, TIA, DIC, ESRD.

• ASA V= Moribund patient not expected to survive without

the surgery e.g ruptured aortic aneurism.

• ASA VI= Brain dead/organ donor.APACHE SCORE

• APACHE= Acute physiology and chronic health

evaluation.

• Used to predict hospital mortality.

• APACHE II has 12 variables.

• Each variable scores 0 – 4

• A score of 25 predicts a mortality of about 50%,

and a score of 35 predicts mortality of about 80.

• The parameters includes temperature, MABP,

Heart rate, Respiratory rate, Pa02, HCO3, Serum

Na, K, Creatinine, PCV, WBC, GCS.Goldman’s Cardiac Risk Assessment.

• Impaired cardiac function is responsible for more than 50% of the post

operative deaths in the elderly patients.

• GOLDMAN CARDIAC RISK FACTORS

• Nine(9) independent cardiac risk factors are evaluated on a point scale;

• 1) Age greater than 70yrs = 5

• 2) Third heart sound(S3)=4

• 3) Signs of CHF or elevated JVP=11

• 4) MI in the past 6months=10

• 5) Abnormal ECG findings=7

• 6) Cardiac arrhythmias=7

• 7) Emergency procedures=4

• 8) Intra-thoracic/Intra-abdominal surgeries= 3

• 9) Poor general health status or bedridden = 3Goldman Cardiac Risk Assessment

• 0 – 5 points = class I= 1% complications

• 6 – 12 points=class II= 7% complications

• 13 – 25 points= class III= 14% complications

• 26 – 53 points=class IV= 78% complicationsPre-op Preparation

• Thorough investigation :

ECG, CXR, Urinalysis, Lung Function test,

Blood gas analysis, FBC with Platelet count, Clotting

profile, LFT.

Renal function -E/U/Cr

Spirometry to determine forced vital capacity.

Informed Consent

• Anticoagulation

• Should be among the first patient on the operation

list.

9/14/2020 29Intra-operative Care

• Regional anaesthesia(epidural, nerve block) -

preferred to GA

• Inhalational agents- suitable as they are

minimally metabolized.

• Maintenance of body temperature

9/14/2020 30Intra-op Care

Conservation of heat can be achieved by

using blanket to cover patient, fluid warmers

& active warm air systems if available .

• Meticulous Fluid mgt.

9/14/2020 31Post-op Care

• +/- Supplemental O2 therapy

• Adequate analgesia.

• Post-op fluid & electrolyte balance

• Antibiotics coverage.

• Pressure areas-most pressure sores develop

within the 1st 24hrs.

should be avoided as they prolong

hospital stay, delay rehabilitation & may

cause sepsis.

9/14/2020 32• Good nursing care

• Early Ambulation & Physiotherapy

• Adequate monitoring

1. Pulse oximetry

2. ECG

3. CVP

4. ABG

9/14/2020 33Clinical Correlate

• PROGERIA

1 syndrome characterised by premature ageing

2 inherited as autosomal recessive disoder

3 unknown aetiology,no effective treatment

4 clinical manifestations after 6/12 of age

5 develops problems of the elderly

6 mean survival age 13yrs,death usually by 25yrs

7 have narrowed glottic opening,mandibular

hypoplasia

8 surgery in them-related to ageing processEthical considerations

• Open discussions on

1. end-of-life care early in the course of the

disease

2. All treatment options with risks & benefits

• Patient autonomy - Avoid surrogate decisionmaking

• Documentation of patient’s preference in time of

mental competency

• Avoid life-sustaining treatment deemed medically

futile

9/14/2020 35CURRENT TRENDS

• Day care surgery

• Minimally invasive proceduresREGIONAL CHALLENGES

• Late presentation

• Poverty

• Lack of expertise for minimally invasive

procedures

• Cultural beliefCONCLUSION

• Surgery in the elderly can be uneventful.

• This can be achieved by careful Pre-op

assessment, Meticulous anaesthetic

technique & good Post-op care.

9/14/2020 38Thank YouReferences

• Schwartz principles of surgery, 10th edition

• Postgraduate surgery, AL-FALLOUJI.

• Compendium for surgery tutorials by Dr Bashir

• Viva in surgical principles by Dr Kesieme.

• Surgery in the elderly ppt by Dr Nwashili,

UBTH.