Skip to main content
×
Home
    • Aa
    • Aa

Peri-operative management of older people undergoing surgery

  • DJH Shipway (a1), D Harari (a1) (a2) and JK Dhesi (a1)
Abstract
Summary

Increasing numbers of older people are undergoing both emergency and elective surgery. However, they remain at increased risk of adverse outcome in comparison with younger patients. This may relate to the association of ageing with physiological deterioration, multi-morbidity and geriatric syndromes such as frailty, all of which are independent predictors of adverse post-operative outcome. Although there is an emerging evidence base for the identification and management of these predictors, this has not yet translated into routine clinical practice. Older patients undergoing surgery often receive sub-optimal care and surgical pathways are not well suited to complex older patients with multi-pathology. Evidence is emerging for alternative models of care that incorporate the evolving evidence base for optimal peri-operative management of the older surgical patient, including risk assessment and optimization. This article aims to provide a practical overview of the literature to all disciplines working in this field.

Copyright
Corresponding author
Address for correspondence: Dr DJH Shipway, Older Persons Assessment Unit, Guy's Hospital, Great Maze Pond, London SE1 9RT, UK. Email: Shipway@doctors.net.uk
Linked references
Hide All

This list contains references from the content that can be linked to their source. For a full set of references and notes please see the PDF or HTML where available.

2 K Christensen , G Doblhammer , R Rau , JW Vaupel . Ageing populations: the challenges ahead. Lancet 2009; 374: 1196–208.

3 F Birrell , O Johnell , A Silman . Projecting the need for hip replacement over the next three decades: influence of changing demography and threshold for surgery. Ann Rheum Dis 1999; 58: 569–72.

4 JJ Roche , RT Wenn , O Sahota , CG Moran . Effect of comorbidities and postoperative complications on mortality after hip fracture in elderly people: prospective observational cohort study. BMJ 2005; 331: 1374.

5 JS Farhat , V Velanovich , AJ Falvo et al.Are the frail destined to fail? Frailty index as predictor of surgical morbidity and mortality in the elderly. J Trauma Acute Care Surg 2012; 72: 1526–30; discussion 1530–31.

7 D Harari , A Hopper , J Dhesi et al.Proactive care of older people undergoing surgery (‘POPS’): designing, embedding, evaluating and funding a comprehensive geriatric assessment service for older elective surgical patients. Age Ageing 2007; 36: 190–96.

8 WB Chow , RA Rosenthal , RP Merkow et al.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: 453–66.

9 D Harari , J Dhesi . Surgery in older people: an update. Rev Clin Gerontol 2007; 17: 119–37.

11 LA Fleisher , JA Beckman , KA Brown et al.American College of Cardiology; American Heart Association Task Force on Practice Guidelines (writing Committee to Revise the 2002 Guidelines on Perioperative Cardiovascular Evaluation for Non-cardiac Surgery). J Am Coll Cardiol 2007; 50: e159241.

13 G Heyburn , ME McBrien . Pre-operative echocardiography for hip fractures: time to make it a standard of care. Anaesthesia 2012; 67: 1189–93.

14 CK Morris , K Ueshima , T Kawaguchi , A Hideg , VF Froelicher . The prognostic value of exercise capacity: a review of the literature. Am Heart J 1991; 122: 1423–31.

15 R Sicari , P Nihoyannopoulos , A Evangelista et al.Stress Echocardiography Expert Consensus Statement – Executive Summary: European Association of Echocardiography. Eur Heart J 2009; 30: 278–89.

16 DN Wijeysundera , HC Wijeysundera , L Yun et al.Risk of elective major non-cardiac surgery after coronary stent insertion: a population-based study. Circulation 2012; 126: 1355.

17 W Burger , JM Chemnitius , GD Kneissl , G Rücker . Low-dose aspirin for secondary cardiovascular prevention – cardiovascular risks after its perioperative withdrawal versus bleeding risks with its continuation – review and meta-analysis. J Intern Med 2005; 257: 399414.

18 EI Kapetanakis , DA Medlam , SW Boyce et al.Clopidogrel administration prior to coronary artery bypass grafting surgery: the cardiologist's panacea or the surgeon's headache? Eur Heart J 2005; 26: 576–83.

19 JD Douketis , AC Spyropoulos , FA Spencer et al.Perioperative management of antithrombotic therapy: Antithrombotic Therapy and Prevention of Thrombosis, 9th edn: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. Chest 2012; 141 (suppl): e326S.

20 R Klamroth , S Gottstein , E Essers , H Landgraf . Bridging with enoxaparin using a half-therapeutic dose regimen: safety and efficacy. Vasa 2010; 39: 243.

21 AC Spyropoulos . Pro: ‘Bridging anticoagulation is needed during warfarin interruption in patients who require elective surgery’. Thromb Haemost 2012; 108: 213.

22 JD Douketis . Contra: ‘Bridging anticoagulation is needed during warfarin interruption when patients require elective surgery’. Thromb Haemost 2012; 108: 210.

23 H Heidbuchel , P Verhamme , M Alings et al.European Heart Rhythm Association Practical Guide on the use of new oral anticoagulants in patient with non-valvular atrial fibrillation. Europace 2013; 15: 625–51.

24 D Poldermans , E Boersma , JJ Bax et al.The effect of bisoprolol on perioperative mortality and myocardial infarction in high-risk patients undergoing vascular surgery. Dutch Echocardiographic Cardiac Risk Evaluation Applying Stress Echocardiography Study Group. N Engl J Med 1999; 341: 1789–94.

26 S Bangalore , J Wetterslev , S Pranesh , S Sahney , C Gluud , FH Messerli . Perioperative b blockers in patients having non-cardiac surgery: a meta-analysis. Lancet 2008; 372: 1962–76.

27 K Hindler , AD Shaw , J Samuels , S Fulton , CD Collard , B Riedel . Improved postoperative outcomes associated with preoperative statin therapy. Anesthesiology 2006; 105: 1260–72.

28 TM Williams , AH Harken . Statins for surgical patients. Ann Surg 2008; 247: 3037.

29 AD Ryding , S Kumar , AM Worthington , D Burgess . Prognostic value of brain natriuretic peptide in noncardiac surgery: a meta-analysis. Anesthesiology 2009; 111: 311–19.

30 D Leibowitz , D Planer , D Rott , Y Elitzur , T Chajek-Shaul , AT Weiss . Brain natriuretic peptide levels predict perioperative events in cardiac patients undergoing non-cardiac surgery: a prospective study. Cardiology 2008; 110: 266–70.

31 AA Fox , SC Body . Assessment of preoperative B-type natriuretic peptide in adult surgeries: is it useful? Anesthesiology Analgesia 2011; 112: 1005–7.

32 ME Stone , B Salter , A Fischer . Perioperative management of patients with cardiac implantable electronic devices. Br J Anaesth. 2011; 107 (suppl 1): i1626.

33 GW Smetana . Postoperative pulmonary complications: an update on risk assessment and reduction. Cleve Clin J Med 2009; 76 (suppl 4): S6065.

34 K Myers , P Hajek , C Hinds , H McRobbie . Stopping smoking shortly before surgery and postoperative complications: A systematic review and meta-analysis. Arch Intern Med 2011; 171: 983–89.

35 A Qaseem , V Snow , N Fitterman et al.Risk assessment for and strategies to reduce perioperative pulmonary complications for patients undergoing non-cardiothoracic surgery: a guideline from the American College of Physicians. Ann Intern Med. 2006; 144: 575–80.

37 AO Adesanya , W Lee , NB Greilich , GP Joshi . Perioperative management of obstructive sleep apnea. Chest 2010; 138: 1489–98.

38 JM Lopes Neto , LO Brandão , A Loli , CV Leite , SA Weber . Evaluation of obstructive sleep apnea in obese patients scheduled for bariatric surgery. Acta Cir Bras 2013; 28: 317–22.

43 UO Gustafsson , A Thorell , M Soop , O Ljungqvist , J Nygren . Haemoglobin A1c as a predictor of postoperative hyperglycaemia and complications after major colorectal surgery. Br J Surg 2009; 96: 1358–64.

44 A Frisch , P Chandra , D Smiley et al.Prevalence and clinical outcome of hyperglycemia in the perioperative period in noncardiac surgery. Diabetes Care 2010; 33: 1783–88.

46 LG Glance , AW Dick , DB Mukamel et al.Association between intraoperative blood transfusion and mortality and morbidity in patients undergoing noncardiac surgery. Anesthesiology 2011; 114: 283–92.

47 LT Goodnough , A Maniatis , P Earnshaw et al.Detection, evaluation, and management of preoperative anaemia in the elective orthopaedic surgical patient: NATA guidelines. J Anaesth 2011; 106: 1322.

48 P Beris , M Muñoz , JA García-Erce , D Thomas , A Maniatis , P Van der Linden . Perioperative anaemia management: consensus statement on the role of intravenous iron. Br J Anaesth 2008; 100: 599–60.

49 ME Hardwick , BM Morris , CW Colwell Jr. Two-dose epoetin alfa reduces blood transfusions compared with autologous donation. Clin Orthop Relat Res 2004; 423: 240–44.

51 JL Carson , ML Terrin , H Noveck et al.Liberal or restrictive transfusion in high-risk patients after hip surgery. N Engl J Med 2011; 365: 2453–62.

52 NB Foss , MT Kristensen , PS Jensen , H Palm , M Krasheninnikoff , H Kehlet . The effects of liberal versus restrictive transfusion thresholds on ambulation after hip fracture surgery. Transfusion 2009; 49: 227–34.

54 JL Carson , BJ Grossman , S Kleinman et al.Clinical Transfusion Medicine Committee of the AABB. Red blood cell transfusion: a clinical practice guideline from the AABB. Ann Intern Med 2012; 157: 4958.

55 JS Partridge , D Harari , JK Dhesi . Frailty in the older surgical patient: a review. Age Ageing 2012; 41: 142–47.

56 MA Makary , DL Segev , PJ Pronovost et al.Frailty as a predictor of surgical outcomes in older patients. J Am Coll Surg 2010; 210: 901–8.

57 M Dasgupta , DB Rolfson , P Stolee , MJ Borrie , M Speechley . Frailty is associated with postoperative complications in older adults with medical problems. Arch Gerontol Geriatr 2009; 48: 7883.

58 QL Xue . The frailty syndrome: definition and natural history. Clin Geriatr Med 2011; 27: 115.

60 O'Doherty , M West , S Jack , M Grocott . Preoperative aerobic exercise training in elective intra-cavity surgery: a systematic review. Br J Anaesth 2013; 110: 679–89.

61 Y Rolland , C Dupuy , G Abellan van Kan , S Gillette , B Vellas . Treatment strategies for sarcopenia and frailty. Med Clin North Am 2011; 95: 427–38.

62 NA Singh , S Quine , LM Clemson et al.Effects of high-intensity progressive resistance training and targeted multidisciplinary treatment of frailty on mortality and nursing home admissions after hip fracture: a randomized controlled trial. J Am Med Dir Assoc 2012; 13: 2430.

63 ID Cameron , N Fairhall , C Langron et al.A multifactorial interdisciplinary intervention reduces frailty in older people: randomized trial. BMC Med 2013; 11: 65.

65 S Borson , JM Scanlan , P Chen , M Ganguli . The Mini-Cog as a screen for dementia: validation in a population-based sample. J Am Geriatr Soc 2003; 51: 1451–54.

66 G Crosby , DJ Culley , BT Hyman . Preoperative cognitive assessment of the elderly surgical patient: a call for action. Anesthesiology 2011; 114: 1265–68.

67 TN Robinson , CD Raeburn , ZV Tran , EM Angles , LA Brenner , M Moss . Postoperative delirium in the elderly: risk factors and outcomes. Ann Surg 2009; 249: 173–78.

68 ER Marcantonio , JM Flacker , RJ Wright , NM Resnick . Reducing delirium after hip fracture: a randomized trial. J Am Geriatr Soc 2001; 49: 516–22.

69 CC Chen , MT Lin , YW Tien , CJ Yen , GH Huang , SK Inouye . Modified hospital elder life program: effects on abdominal surgery patients. J Am Coll Surg 2011; 213: 245–52.

70 P Teslyar , VM Stock , CM Wilk , U Camsari , MJ Ehrenreich , S Himelhoch . Prophylaxis with antipsychotic medication reduces the risk of post-operative delirium in elderly patients: a meta-analysis. Psychosomatics. 2013; 54: 124–31.

71 T Al-Aama , C Brymer , I Gutmanis , SM Woolmore-Goodwin , J Esbaugh , M Dasgupta . Melatonin decreases delirium in elderly patients: a randomized, placebo-controlled trial. Int J Geriatr Psychiatry. 2011; 26: 687–94.

73 JT Moller , P Cluitmans , LS Rasmussen et al.Long-term postoperative cognitive dysfunction in the elderly ISPOCD1 study. ISPOCD investigators. International Study of Post-Operative Cognitive Dysfunction. Lancet 1998; 351: 857–61.

75 SR Kristjansson , C Spies , BTH Veering et al.Perioperative care of the elderly oncology patient: a report from the SIOG task force on the perioperative care of older patients with cancer. J Ger Oncol 2012; 3: 147–62.

76 D Gnjidic , SN Hilmer , FM Blyth et al.Polypharmacy cut-off and outcomes: five or more medicines were used to identify community-dwelling older men at risk of different adverse outcomes. J Clin Epidemiol 2012; 65: 989–95.

77 CJ Balentine , J Hermosillo-Rodriguez , CN Robinson , DH Berger , AD Naik . Depression is associated with prolonged and complicated recovery following colorectal surgery. J Gastrointest Surg 2011; 15: 1712–17.

78 KJ Bozic , E Lau , S Kurtz , K Ong , DJ Berry . Patient-related risk factors for postoperative mortality and periprosthetic joint infection in medicare patients undergoing TKA. Clin Orthop Relat Res 2012; 470: 130–37.

80 A Kudoh , H Katagai , T Takazawa . Antidepressant treatment for chronic depressed patients should not be discontinued prior to anesthesia. Can J Anaesth 2002; 49: 132–36.

81 A Abdulla , N Adams , M Bone , AM Elliott , J Gaffin , D Jones , R Knaggs , D Martin , L Sampson , P Schofield . Guidance on the management of pain in older people. Age Ageing 2013; 42 (suppl 1): i157.

83 C Farrell , P McConaghy . Perioperative management of patients taking treatment for chronic pain. BMJ 2012; 345: 3942.

84 KY Ho , TJ Gan , AS Habib . Gabapentin and postoperative pain – a systematic review of randomized controlled trials. Pain 2006; 126: 91101.

85 F Aubrun , F Marmion . The elderly patient and postoperative pain treatment. Best Pract Res Clin Anaesthesiol 2007; 21: 109–27.

87 J Edington , J Boorman , ER Durrant et al.Prevalence of malnutrition on admission to four hospitals in England. The Malnutrition Prevalence Group. Clin Nutr 2000; 19: 191–95.

88 K Charlton , C Nichols , S Bowden et al.Poor nutritional status of older subacute patients predicts clinical outcomes and mortality at 18 months of follow-up. Eur J Clin Nutr 2012; 66: 1224–28.

90 VV Lomivorotov , SM Efremov , VA Boboshko et al.Evaluation of nutritional screening tools for patients scheduled for cardiac surgery. Nutrition 2013; 29: 436–42.

91 M Braga , O Ljungqvist , P Soeters , K Fearon , A Weimann , F Bozzetti . ESPEN Guidelines on Parenteral Nutrition: surgery. Clin Nutr 2009; 28: 378–86.

94 DJ Genther , CG Gourin . The effect of alcohol abuse and alcohol withdrawal on short-term outcomes and cost of care after head and neck cancer surgery. Laryngoscope 2012; 122: 1739–47.

96 R Agabio , GL Gessa , A Montisci et al.Use of the screening suggested by the National Institute on Alcohol Abuse and Alcoholism and of a newly derived tool for the detection of unhealthy alcohol drinkers among surgical patients. J Stud Alcohol Drugs 2012; 73: 126–33.

97 YL Nguyen , DC Angus , A Boumendil , B Guidet . The challenge of admitting the very elderly to intensive care. Ann Intensive Care 2011; 1: 29.

99 E Simchen , CL Sprung , N Galai et al.Survival of critically ill patients hospitalized in and out of intensive care units under paucity of intensive beds. Crit Care Med 2004; 32: 1654–61.

101 W Stringer , R Casaburi , P Older . Cardiopulmonary exercise testing: does it improve perioperative care and outcome? Curr Opin Anaesthesiol 2012; 25: 178–84.

102 P Tran Ba Loc , ST du Montcel , JJ Duron et al.Elderly POSSUM, a dedicated score for prediction of mortality and morbidity after major colorectal surgery in older patients. Br J Surg 2010; 97: 396403.

103 AF Kamath , CL McAuliffe , KD Baldwin , JB Lucas , LM Kosseim , CL Israelite . Unplanned admission to the intensive care unit after total hip arthroplasty. J Arthroplasty 2012; 27: 1027–32.

108 T Kamal , RM Conway , I Littlejohn , D Ricketts . The role of a multidisciplinary pre-assessment clinic in reducing mortality after complex orthopaedic surgery. Ann R Coll Surg Engl 2011; 93: 149–51.

Recommend this journal

Email your librarian or administrator to recommend adding this journal to your organisation's collection.

Reviews in Clinical Gerontology
  • ISSN: 0959-2598
  • EISSN: 1469-9036
  • URL: /core/journals/reviews-in-clinical-gerontology
Please enter your name
Please enter a valid email address
Who would you like to send this to? *
×

Keywords:

Metrics

Full text views

Total number of HTML views: 9
Total number of PDF views: 36 *
Loading metrics...

Abstract views

Total abstract views: 332 *
Loading metrics...

* Views captured on Cambridge Core between September 2016 - 29th May 2017. This data will be updated every 24 hours.