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Perioperative care of the elderly patient: An update*

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ABSTRACT

Elderly patients pose unique challenges perioperatively. They are more likely than younger surgical patients to be mentally and physically compromised at baseline, which increases the risk of delirium and postoperative cognitive dysfunction. Postoperative cognitive risk can be predicted, however, and effective strategies exist to reduce this risk. Elderly patients are also at increased risk of a precipitous postoperative decline in physiologic reserve, which can lead to organ failure. General recommendations for the perioperative care of elderly patients include avoiding drugs that raise the risk of delirium, ensuring adequate caloric and fluid intake, getting the patient out of bed and into physical therapy as soon as possible, and early planning for discharge. An elderly patient’s postoperative cognitive risk and its impact on quality of life should be factored into the decision whether to undergo surgery. Family conferences are recommended to address the many questions and challenges that surgery in an elderly person can pose.

KEY POINTS

  • Postoperative cognitive dysfunction and delirium are distinct conditions, though both are common in the elderly. Postoperative cognitive dysfunction may persist for weeks to months and may not be obvious, whereas delirium, a disorder of attention and cognition, is easier to detect clinically.
  • Major predictors of postoperative delirium are severe illness, baseline dementia, dehydration, and sensory impairment.
  • Drugs that raise dementia risk include anticholinergics, benzodiazepines, meperidine, tricyclic antidepressants, first-generation antihistamines, and high-dose H2-receptor blockers.
  • Early performance of hip fracture surgery in the elderly (ie, within 24 hours of admission) has not been shown to lower mortality but appears to improve other outcomes.
  • Identifying and managing frail elderly patients is important. Signs of frailty are minimal activity, generalized muscle weakness, slowed performance, fatigue, and weight loss.


 

References

Acute hospital care is fast becoming acute geriatric care: people aged 65 years or older are only 13% of the population but account for 44% of days of care in nonfederal hospitals and 38% of discharges. 1 In general, the elderly have longer hospital stays, incur greater costs, and have a higher risk of adverse outcomes than do their younger counterparts. 2

Among the most common surgical procedures for patients older than 65 are percutaneous coronary intervention with stenting, coronary artery bypass graft surgery, and open reduction internal fixation for hip fracture; the latter is the most common operation in patients aged 85 years or older. 3

Elderly patients frequently pose many challenges perioperatively that are not often seen in younger patients. Dementia, frailty, impaired ability to care for oneself, and malnourishment may be present at baseline and are likely to worsen postoperatively. The elderly are at increased risk of acute delirium and cognitive impairment post­operatively, which often complicates recovery and discharge placement.

This article uses a case study to review perioperative problems commonly encountered in elderly surgical patients, particularly those undergoing hip surgery. As the case is presented, I will review strategies to assess risks and prevent and mitigate postoperative cognitive dysfunction and other barriers to recovery.

CASE: AN 82-YEAR-OLD WOMAN WITH HIP FRACTURE

An 82-year-old woman is admitted to undergo open reduction internal fixation for hip fracture. She has a history of osteoarthritis, systolic hypertension, and visual impairment (20/70). Her medications include a beta-blocker, a thiazide diuretic, analgesics as needed, and a multivitamin. She was independent in all activities of daily living before the fracture. She is a social drinker and does not smoke. She has no known cardiovascular, lung, or renal disease.

Her laboratory test results are as follows:

  • Blood urea nitrogen (BUN), 24 mg/dL
  • Creatinine, 1.0 mg/dL
  • Hemoglobin, 12.8 g/dL
  • Albumin, 3.8 gm/dL
  • Normal levels of thyroid-stimulating hormone and vitamin B 12.

Thus, her lab results are normal except for the BUN:creatinine ratio being a bit high, at 24:1 (normal is 10:1, with ratios greater than 18:1 being associated with an increased risk of delirium 4).

ASSESSING COGNITIVE RISK: POSTOPERATIVE COGNITIVE DYSFUNCTION VS DELIRIUM

Question: Which of these statements about this patient is most correct?

A. She is at high risk (> 40%) of postoperative cognitive dysfunction

B. Her risk of postoperative delirium is 5% to 10%

C. Postoperative delirium cannot be prevented

D. Preoperative haloperidol (1.5 mg/day for 3 days) will reduce the risk of delirium by 25%

The best answer is A. Postoperative cognitive dysfunction is different from delirium, though it is part of a spectrum of cognitive impairment that may occur after surgery and even persist for a prolonged period. The patient’s risk of postoperative delirium is actually a bit higher than 10% (see “Estimating the risk of delirium” below). Some evidence shows that postoperative delirium can be prevented, at least in hip fracture patients. Kalisvaart et al found that preoperative treatment with low-dose haloperidol reduced the duration and severity of delirium in elderly patients following hip surgery but did not reduce its incidence. 5

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