Surgical Principles

doi:10.1017/9781108942751.046

Chapter 46 - Surgical Principles

from Section IV - Principles of Care for the Elderly

Published online by Cambridge University Press: 30 June 2022

Krista Haines ,

Vishnu R. Mani and

Sasha Adams

Edited by

Jan Busby-Whitehead ,

Mary H. Palmer and

Jan Busby-Whitehead: Affiliation:
University of North Carolina, Chapel Hill
Samuel C. Durso: Affiliation:
The Johns Hopkins University, Maryland
Christine Arenson: Affiliation:
Thomas Jefferson University, Philadelphia
Rebecca Elon: Affiliation:
The Johns Hopkins University School of Medicine
Mary H. Palmer: Affiliation:
University of North Carolina, Chapel Hill
William Reichel: Affiliation:
Georgetown University Medical Center

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Summary

Modern medicine has bolstered the life expectancy among older adults, which now averages around 80 years of age in developed nations. Older adults currently make up nearly 17% of the US population, with a projected rise to 25% of all adults in the coming decades. Older adults currently account for almost 50% of all surgical procedures performed in the USA, where overall health-related expenditures comprised 17.4% of the national GDP. The stress of surgery can be exacerbated with advancing age and is primarily determined by the preoperative physiological reserve and comorbid conditions. Any additional postoperative clinical challenges can significantly affect the stress response and ultimate recovery trajectory. This chapter systematically emphasizes the perioperative strategies to counteract the inadequate surgical stress response resulting from the age-related challenges in maintaining homeostasis. Unique preoperative considerations when evaluating older adults include: cognition, functional status frailty, care goals, advance directives, nutritional status, polypharmacy, and cardiopulmonary optimization with “prehabilitation” when possible. Optimization of the preoperative evaluation coupled with a preemptive postoperative approach to decrease the risk of delirium, falls, malnutrition, infections, pressure sores, aspiration, and other pulmonary complications, along with early mobilization and therapy, can yield the best possible outcomes in this population.

Keywords

surgery in the elderly geriatric surgery perioperative care trauma emergent surgery acute care surgery

Type: Chapter
Information: Reichel's Care of the Elderly
Clinical Aspects of Aging
, pp. 569 - 577

DOI: https://doi.org/10.1017/9781108942751.046 [Opens in a new window]

Publisher: Cambridge University Press

Print publication year: 2022

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References

www.statista.com/statistics/274514/life-expectancy-in-europe.Google Scholar

https://data.worldbank.org/indicator/SP.DYN.LE00.IN?locations=EU.Google Scholar

www.statista.com/statistics/274513/life-expectancy-in-north-america/#:~:text=Of%20continents%20worldwide%2C%20North%20America,for%20males%20and%20females%20respectively.Google Scholar

https://data.worldbank.org/indicator/SP.DYN.LE00.IN?locations=ZG.Google Scholar

www.un.org/en/development/desa/population/publications/pdf/ageing/WorldPopulationAgeing2019-Highlights.pdf.Google Scholar

www.un.org/en/sections/issues-depth/ageing.Google Scholar

United States Census Bureau. www.census.gov/topics/population/older-aging.html#:~:text=According%20to%20the%20U.S.%20Census,million%20on%20July%201%2C%202019.&text=The%20nation’s%2065%2Dand%2Dolder,born%20between%201946%20and%201964.Google Scholar

Lo, AX, Flood, KL, Biese, K, et al. Factors associated with hospital admission for older adults receiving care in U.S. emergency departments. J Gerontol A Biol Sci Med Sci. 2017 (Aug. 1); 72(8):1105–1109.Google Scholar PubMed

National Center for Health Statistics. 2010 NHAMCS micro-data file documentation. ftp://ftp.cdc.gov/pub/Health_Statistics/NCHS/Dataset_Documentation/NHAMCS/doc2010.pdf.Google Scholar

National Center for Health Statistics. 2009 NHAMCS micro-data file documentation. ftp://ftp.cdc.gov/pub/Health_Statistics/NCHS/Dataset_Documentation/NHAMCS/doc09.pdf.Google Scholar

Albert, M, McCaig, LF, Ashman, JJ. Emergency department visits by persons aged 65 and over: United States, 2009–2010. NCHS data brief, no 130. Hyattsville, MD: National Center for Health Statistics, 2013.Google Scholar

Healthcare Cost and Utilization Project Facts and Figures 2008. Statistics on Hospital-Based Care in the United States. Agency for Healthcare Research and Quality (AHRQ). www.hcup-us.ahrq.gov/reports/factsandfigures/2008/section1_TOC.jsp.Google Scholar

US Centers for Disease Control and Prevention. Number, percent distribution, rate, days of care with average length of stay, and standard error of discharges from short-stay hospitals, by sex and age: United States, 2010. www.cdc.gov/nchs/data/nhds/2average/2010ave2_ratesexage.pdf.Google Scholar

www.cms.gov/research-statistics-data-and-systems/statistics-trends-and-reports/nationalhealthexpenddata/downloads/highlights.pdf.Google Scholar

www.cdc.gov/nchs/fastats/health-expenditures.htm.Google Scholar

Yang, R, Wolfson, M, Lewis MC. Unique aspects of the elderly surgical population: An anesthesiologist’s perspective. Geriatr Orthop Surg Rehabil. 2011 (Mar.); 2(2):56–64.Google Scholar

Veering, BT. Management of anaesthesia in elderly patients. Curr Opin Anaesthesiol. 1999; 12(3):333–336.Google Scholar

Mirand, AL, Welte, JW. Alcohol consumption among the elderly in a general population, Erie County, New York. Am J Public Health. 1996; 86:978–984.CrossRef Google Scholar

Ewing, JA. Detecting alcoholism: The CAGE questionnaire. JAMA. 1984; 252(14):1905–1907.Google Scholar

Chow, WB, Rosenthal, RA, Merkow, RP, Ko, CY, Esnaola, NF. Optimal preoperative assessment of the geriatric surgical patient: A best practices guideline from the American College of Surgeons National Surgical Quality Improvement Program and the American Geriatrics Society. J Am Coll Surg. 2012; 215(4):453–466.Google Scholar

Eliasen, M, Grønkjær, M, Skov-Ettrup, LS, et al. Preoperative alcohol consumption and postoperative complications: A systematic review and meta-analysis. Ann Surg. 2013; 258(6):930–942.Google Scholar

Oppedal, K, Møller, A, Pedersen, B, Tønnesen, H. Preoperative alcohol cessation prior to elective surgery. Cochrane Database Syst Rev. 2012; 7:CD008343.Google Scholar

Fernandez, AC, Claborn, KR, Borsari, B. A systematic review of behavioural interventions to reduce preoperative alcohol use. Drug Alcohol Rev. 2015; 34(5):508–520.CrossRef Google Scholar PubMed

Grønkjær, M, Eliasen, M, Skov-Ettrup, LS, et al. Preoperative smoking status and postoperative complications: A systematic review and meta-analysis. Ann Surg. 2014; 259(1):52–71.Google Scholar

Thomsen, T, Villebro, N, Møller, AM. Interventions for preoperative smoking cessation. Cochrane Database Syst Rev. 2014; 3:CD002294.Google Scholar

Hustey, F, Meldon, S, Palmer, R. Prevalence and documentation of impaired mental status in elderly emergency department patients. Acad Emerge Med. 2000; 7(10):1166.Google Scholar

Inouye, SK, Foreman, MD, Mion, LC, Katz, KH, Cooney, LM Jr. Nurses’ recognition of delirium and its symptoms: Comparison of nurse and researcher ratings. Arch Intern Med. 2001; 161(20):2467–2473.CrossRef Google Scholar PubMed

Gajdos, C, Kile, D, Hawn, MT, Finlayson, E, Henderson, WG, Robinson, TN. The significance of preoperative impaired sensorium on surgical outcomes in nonemergent general surgical operations. JAMA Surg. 2015; 150(1):30–36.CrossRef Google Scholar PubMed

Inouye, SK, Westendorp, RG, Saczynski, JS. Delirium in elderly people. Lancet. 2014; 383(9920):911–922.Google Scholar

American Psychiatric Association Diagnostic and Statistical Manual of Mental Disorders, 5th edition. Washington, DC: American Psychiatric Association, 2013.Google Scholar

WHO. The ICD-10 Classification of Mental and Behavioural Disorders: Diagnostic Criteria for Research. Geneva: World Health Organization, 1993.Google Scholar

Adamis, D, Sharma, N, Whelan, PJ, Macdonald, AJ. Delirium scales: A review of current evidence. Aging Ment Health. 2010; 14:543–555.Google Scholar

Wong, CL, Holroyd-Leduc, J, Simel, DL, Straus, SE. Does this patient have delirium? Value of bedside instruments. JAMA. 2010; 304:779–786.Google Scholar

Ely, EW, Margolin, R, Francis, J, et al. Evaluation of delirium in critically ill patients: Validation of the confusion assessment method for the intensive care unit (CAM-ICU). Crit Care Med. 2001; 29:1370–1379.Google Scholar

Oh, ES, Fong, TG, Hshieh, TT, Inouye, SK. Delirium in older persons advances in diagnosis and treatment. JAMA. 2017 (Sep. 26); 318(12):1161–1174.CrossRef Google Scholar PubMed

Borson, S, Scanlan, JM, Chen, P, Ganguli, M. The Mini-Cog as a screen for dementia: Validation in a population-based sample. J Am Geriatr Soc. 2003; 51(10):1451–1454.CrossRef Google Scholar

Kroenke, K, Spitzer, RL, Williams, JB. The Patient Health Questionnaire-2: Validity of a two-item depression screener. Med Care. 2003; 41(11):1284–1292.CrossRef Google Scholar PubMed

Burke, WJ, Roccaforte, WH, Wengel, SP. The short form of the Geriatric Depression Scale: A comparison with the 30-item form. J Geriatr Psychiatry Neurol. 1991; 4(3):173–178.Google Scholar

Leung, JM, Sands, LP, Mullen, EA, Wang, Y, Vaurio, L. Are preoperative depressive symptoms associated with postoperative delirium in geriatric surgical patients? J Gerontol A Biol Sci Med Sci. 2005; 60(12):1563–1568.Google Scholar

Kothari, A, Phillips, S, Bretl, T, Block, K, Weigel, T. Components of geriatric assessments predict thoracic surgery outcomes. J Surg Res. 2011; 166(1):5–13.Google Scholar

Feng, MA, McMillan, DT, Crowell, K, Muss, H, Nielsen, ME, Smith, AB. Geriatric assessment in surgical oncology: A systematic review. J Surg Res. 2015; 193(1):265–272.Google Scholar

Silveira, MJ, Kim, SY, Langa, KM. Advance directives and outcomes of surrogate decision making before death. N Engl J Med. 2010 (Apr. 1); 362(13):1211–1218.Google Scholar

Temel, JS, Greer, JA, Muzikansky, A, et al. Early palliative care for patients with metastatic non–small-cell lung cancer. N Engl J Med. 2010; 363(8):733–742.Google Scholar

Kehlet, H, Nielsen, HJ. Impact of laparoscopic surgery on stress responses, immunofunction, and risk of infectious complications. New Horiz. 1998; 6(2 suppl.):S80–S88.Google Scholar PubMed

Wilmore, DW. From Cuthbertson to fast-track surgery: 70 years of progress in reducing stress in surgical patients. Ann Surg. 2002; 236(5):643–648.Google Scholar

Katz, S, Downs, TD, Cash, HR, Grotz, RC. Progress in development of the index of ADL. Gerontologist. 1970; 10(1):20–30.CrossRef Google Scholar PubMed

Lawton, MP, Brody, EM. Assessment of older people: Self-maintaining and instrumental activities of daily living. Gerontologist. 1969; 9(3):179–186.Google Scholar

Xue, Q-L. The frailty syndrome: Definition and natural history. Clin Geriatr Med. 2011; 27(1):1–15.Google Scholar

Jones, D, Song, X, Mitnitski, A, Rockwood, K. Evaluation of a frailty index based on a comprehensive geriatric assessment in a population based study of elderly Canadians. Aging Clin Exp Res. 2005; 17(6):465–471.Google Scholar

Nakhaie, M, Tsai, A. Preoperative assessment of geriatric patients. Anesthesiol Clin. 2015; 33(3):471–480.Google Scholar

Panel on Prevention of Falls in Older Persons, American Geriatrics Society and British Geriatrics Society. Summary of the Updated American Geriatrics Society/British Geriatrics Society clinical practice guideline for prevention of falls in older persons. J Am Geriatr Soc. 2011; 59(1):148–157.Google Scholar

Jones, TS, Dunn, CL, Wu, DS, Cleveland, JC Jr, Kile, D, Robinson, TN. Relationship between asking an older adult about falls and surgical outcomes. JAMA Surg. 2013; 148(12):1132–1138.Google Scholar

Brown, CJ, Flood, KL. Mobility limitation in the older patient: A clinical review. JAMA. 2013; 310(11):1168–1177.Google Scholar

Fleisher, LA, Fleischmann, KE, Auerbach, AD, et al. 2014 ACC/AHA guideline on perioperative cardiovascular evaluation and management of patients undergoing noncardiac surgery: executive summary: A report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. Circulation. 2014; 130(24):2215–2245.Google Scholar

Hajjar, ER, Cafiero, AC, Hanlon, JT. Polypharmacy in elderly patients. Am J Geriatr Pharmacother. 2007; 5(4):345–351.Google Scholar

Kwan, D, Farrell, B. Polypharmacy: Optimizing medication use in elderly patients. Can Geriatr J. 2014; 4(1):21–27.Google Scholar

American Geriatrics Society 2015 Updated Beers Criteria for potentially inappropriate medication use in older adults. J Am Geriatr Soc. 2015; 63(11):2227–2246.Google Scholar

O’Mahony, D, O’Sullivan, D, Byrne, S, O’Connor, MN, Ryan, C, Gallagher, P. STOPP/START criteria for potentially inappropriate prescribing in older people: Version 2. Age Ageing. 2015; 44(2):213–218.Google Scholar

Cholesterol Treatment Trialists’ Collaboration. Efficacy and safety of statin therapy in older people: A meta-analysis of individual participant data from 28 randomized controlled trials. Lancet. 2019 (Feb. 2); 393(10170):407–415.Google Scholar

Kenig, J, Olszewska, U, Zychiewicz, B, Barczynski, M, Mituś-Kenig, M. Cumulative deficit model of geriatric assessment to predict the postoperative outcomes of older patients with solid abdominal cancer. J Geriatr Oncol. 2015; 6(5):370–379.Google Scholar

Carli, F, Bousquet-Dion, G, Fiore, JF Jr. Prehabilitation vs Postoperative Rehabilitation for Frail Patients. JAMA Surg. 2020 (Sep. 1); 155(9):899–900.CrossRef Google Scholar PubMed

Wynter-Blyth, V, Moorthy, K. Prehabilitation: Preparing patients for surgery. BMJ. 2017; 358:j3702.Google Scholar

Walston, J, Buta, B, Xue, Q-L. Frailty screening and interventions: Considerations for clinical practice. Clin Geriatr Med. 2018 (Feb.); 34(1):25–38.Google Scholar

Ho, JWC, Wu, AHW, Lee, MWK, et al. Malnutrition risk predicts surgical outcomes in patients undergoing gastrointestinal operations: Results of a prospective study. Clin Nutr. 2015 (Aug.); 34(4):679–684.Google Scholar

Gibbs, J, Cull, W, Henderson, W, Daley, J, Hur, K, Khuri, SF. Preoperative serum albumin level as a predictor of operative mortality and morbidity: Results from National VA Surgical Risk Study. Arch Surg. 1999 (Jan.); 134(1):36–42.Google Scholar

Wischmeyer, PE, et al. Perioperative Quality Initiative (POQI) 2 Workgroup. American Society for Enhanced Recovery and Perioperative Quality Initiative Joint Consensus Statement on nutrition screening and therapy within a surgical enhanced recovery pathway. Anesth Analg. 2018 (Jun.); 126(6):1883–1895.Google Scholar

Kim, S, Brooks, AK, Groban, L. Preoperative assessment of the older surgical patient: Honing in on geriatric syndromes. Clin Interv Aging. 2015; 10:13–27.Google Scholar

Capezuti, E, Boltz, M, Kim, H. Geriatric models of care. In: Rosenthal, R, Zenilman, M, Katlic, M, eds. Principles and Practice of Geriatric Surgery. New York: Springer, 2011, pp. 253–266.Google Scholar

AGS Expert Panel on Postoperative Delirium in Older Adults. American Geriatrics Society Clinical Practice Guideline for Postoperative Delirium in Older Adults, 2014.Google Scholar

Flinn, DR, Diehl, KM, Seyfried, LS, Malani, PN. Prevention, diagnosis, and management of postoperative delirium in older adults. J Am Coll Surg. 2009; 209(2):261–268; quiz 294.Google Scholar

NICE. Delirium: Diagnosis, prevention and management. NICE Clinical Guideline 103 2010. www.nice.org.uk/CG103.Google Scholar

Smetana, GW, Lawrence, VA, Cornell, JE. Preoperative pulmonary risk stratification for noncardiothoracic surgery: Systematic review for the American College of Physicians. Ann Intern Med. 2006 (Apr. 18); 144(8):581–595.Google Scholar

Potter, J, Klipstein, K, Reilly, JJ, Roberts, M. The nutritional status and clinical course of acute admissions to a geriatric unit. Age Ageing. 1995 (Mar.); 24(2):131–136.CrossRef Google Scholar PubMed

Sullivan, DH. Risk factors for early hospital readmission in a select population of geriatric rehabilitation patients: The significance of nutritional status. J Am Geriatr Soc. 1992 (Aug.); 40(8):792–798.Google Scholar

Gould, CV, Umscheid, CA, Agarwal, RK, Kuntz, G, Pegues, DA. Guideline for prevention of catheter-associated urinary tract infections 2009. Infect Control Hosp Epidemiol. 2010 (Apr.); 31(4):319–326.Google Scholar

Lyder, CH. Pressure ulcer prevention and management. JAMA. 2003 (Jan. 8); 289(2):223–226.Google Scholar

Bergstrom, N, Braden, BJ, Laguzza, A, Holman, V. The Braden Scale for predicting pressure sore risk. Nurs Res. 1987 (Jul.–Aug.); 36(4):205–210.Google Scholar

Norton, D, McLaren, R, Exton-Smith, A. An Investigation of Geriatric Nursing Problems in Hospital. London: National Corporation for the Care of Old People, 1962.Google Scholar

Thorn, CC, Smith, M, Aziz, O, Holme, TC. The Waterlow score for risk assessment in surgical patients. Ann R Coll Surg Engl. 2013 (Jan.); 95(1):52–56.Google Scholar

Labib, N, Nouh, T, Winocour, S, et al. Severely injured geriatric population: Morbidity, mortality, and risk factors. J Trauma. 2011; 71:1908.Google Scholar

Schwab, CW, Kauder, DR. Trauma in the geriatric patient. Arch Surg. 1992; 127:701.Google Scholar

Fitz-Henry, J. The ASA classification and peri-operative risk. The Annals of The Royal College of Surgeons of England. 2011 (Apr.); 93(3):185–187.Google Scholar

Ely, EW, Margolin, R, Francis, J, May, L, Truman, B, Dittus, R, Speroff, T, Gautam, S, Bernard, GR, Inouye, SK. Evaluation of delirium in critically ill patients: Validation of the Confusion Assessment Method for the Intensive Care Unit (CAM-ICU). Critical Care Medicine. 2001 (Jul. 1); 29(7):1370–1379.Google Scholar

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Chapter 46 - Surgical Principles

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