Surgery in older people: an update

Abstract

In the past two decades, the rate of surgery in older people has increased more rapidly than the rate of aging of the population, so both a larger proportion and a greater number of older people are now undergoing surgery. This may partly reflect a cultural change in surgery and anaesthesia with respect to a greater willingness to undertake elective procedures in older people, although there remain areas where they have less access to surgery than do younger patients. For instance, older people are less likely to undergo operative procedures after a cancer diagnosis. Furthermore, in those who do have surgery, resection rate (i.e. curative therapy) is lower than in younger people with equivalent tumour stages, and even more so in older patients with COPD, cardiovascular disease or diabetes. This article explores the complex relationship between age and surgical outcome, provides an evidence-based overview of risk assessment and common postoperative problems in older people, and summarizes good practice points (at times necessarily pragmatic) for clinical management of the older surgical patient. There has been a substantial expansion in the literature examining risks, outcomes and interventions in older surgical patients since the previous review article of this subject published in this journal. Although we do not cover anaesthesia in older people, the review of that topic remains relevant. The American Society of Anaesthesiologists' Classification of Risk which illustrates that risk is disease- rather than age- based, is shown in Table 1. Most publications examine elective rather than emergency surgery in older people (with the exception of hip fracture), and this is reflected in the content of the paper.

Aortic aneurysm trials in octogenarians: Are we really measuring the outcomes that matter?

“…From other studies comparing older surgical patients to younger patients, we hypothesize that functional decline, increased care requirements, decreased QOL, risk to cognition, and poor symptom control are more important concerns than survival time for patients aged 80 and over. 5,62,63 Our definition of patient-centered outcomes is based on these findings. Our study found that studies in aortic aneurysm surgery, despite being focused on patients aged 80 and over, rarely or never measured patient-centered values in their outcome indicators.…”

“…When complications arise, the consequences are often worse for older patients. 5,6 Older patients also have greater risk of specific complications such as delirium, falls, pressure sores, pneumonia, and decreased mobility. 5…”

Peri-operative management of older people undergoing surgery

“…9 Since then there have been a number of important advances with the publication of several guidelines and a growing evidence base. 9 Since then there have been a number of important advances with the publication of several guidelines and a growing evidence base.…”