Operating On The Elderly
Mike Magee

As a large segment of the U.S. population ages in the coming years, operating on the elderly will become increasingly common. (1)  In fact, the number of people over age 65 will reach about 70 million by 2030, compared to 35 million people in 2000. And the number of people over age 85 will grow from 4 million to 8.5 million in that same time period. (2)

Even so, today’s seniors are quite familiar with the operating suite. 40 percent of all surgical procedures are associated with people over 65, as well as 50 percent of all emergency operations and 75 percent of all surgery-related deaths. (1)

Aging, itself, carries some inherent risks. For example, the skin of elderly patients is slower to heal and generates weaker scars than the skin of younger patients. (3) The heart changes functionally with age as well, not only in the elasticity of the walls, but also in the small vessels that feed the heart muscle and the large vessels through which the heart pushes blood. (4) Similarly, the lungs lose capacity with demonstrated changes in both the upper and lower airways and with the weakening of the respiratory muscles. (5)  As for the kidneys, they lose about 10 percent of their filtering capability every decade after age 30. (6)

Progress in medicine and surgery has improved surgical outcomes for all patients. That said, surgery remains riskier for older patients than for younger ones. Surgery-related deaths for patients over 65 occur 5 percent to 10 percent of the time, while younger patients suffer surgery-related deaths at a rate of about 1.5 percent. A particular area of concern for elders is emergency surgery, where risk of death is two to four times greater than with elective, planned surgery. (1)

America’s surgeons approach operating on seniors with a cautious respect that, at times, converts what could have been an elective case into an emergency. This can eliminate the possibility of preparing for preexisting conditions such as cardiovascular, respiratory, and kidney problems, which increases the risk of complications. (1,7)

While performing surgery on elderly people requires careful evaluation, related decisions will grow increasingly more common as the population ages. Surgeons look at a number of issues beyond patients’ chronologic age, including their physiologic age, or how old they look and feel and their level of vitality. Formal evaluation of elderly patients’ current functional status should be routine. What is the degree of impairment, if any? How complex is the proposed surgery? What would be an acceptable outcome for the patient, the family, and the surgeon? Are they all in agreement? (1)

While assigning degree of risk is improving, it remains an inexact science that augments, but does not replace, the value of an experienced surgeon with good judgment. Old adages still hold, including “treating the patient, not the disease” and “elderly patients will tolerate an operation, but not the complication.” (1)

In avoiding the complication, step one is choosing the right patient. The American Society of Anesthesiologists’ risk-classification system segments patients into five categories. These are: Class 1 – normal; Class 2 – a controlled medical problem; Class 3 – a medical problem resulting in some functional deficits; Class 4 – a poorly controlled medical problem resulting in life-threatening dysfunction; and Class 5 – a critical medical condition that leaves little chance of survival. In a study of patients over 80 years old, the surgery-related death rate was less than 1 percent for those in Class 2, but in Class 4 patients, the death rate was 25 percent. (1)

So what does all this mean? First, operating on the elderly will be increasingly common in the coming years. Second, it is generally better to operate on a stable elderly patient electively, even if the patient has medical problems and is at some risk, rather than wait until the problem explodes and requires emergency intervention. Third, careful and thorough evaluation of functional and mental status should be standard practice when an operation on an elderly patient is being considered. This should include realistic expectations and agreement among all concerned on the risks and benefits of surgery.

References:

1.Richardson JD, Cocanour CS, Kern JA, et al. Perioperative risk assessment in elderly and high-risk patients. J Am Coll Surg. 2004;199:133-146.

2.Medical Never-Never Land: Ten Reasons Why America is Not Ready for the Coming Age Boom. Washington, D.C.: Alliance for Aging Research; 2002.

3.Lavker RM, Zheng PS, Dong G. Morphology of aged skin. Clin Geriatr Med. 1989;5:53-67.

4.Lakatta EG. Cardiovascular aging research: the next horizons. J Am Geriatr Soc. 1999;47:613-625.

5.Berry DT, Phillips BA, Cook YR, et al. Sleep disordered breathing in healthy aged persons: possible daytime sequelae. J Gerontol. 1987;42:620-626.

6.Rowe JW, Andres RA, Tobin FD, et al. The effect of age on creatinine clearance in man: a cross-sectional and longitudinal study. J Gerontol. 1976;31:155-163.

7.Palmberg S, Hirsjarvi E. Mortality in geriatric surgery: with special reference to the type of surgery, anaesthesia, complicating diseases and prophylaxis of thrombosis. Gerontology. 1979;25:103-112.