Perioperative care of the elderly patient: An update*
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.
Several drug classes raise dementia risk
Anticholinergic medications and other drugs with anticholinergic properties, ie, benzodiazepines and the opioid agent meperidine, also raise the risk for delirium. In general, the older an elderly patient is, the less appropriate these agents are. Many drugs that are not typically recognized as anticholinergics may have potent anticholinergic activity, including tricyclic antidepressants, first-generation antihistamines (eg, diphenhydramine), and high-dose H2-receptor blockers (particularly cimetidine); these agents too should be avoided in elderly patients.12
Strategies to reduce postoperative delirium risk
How can we lower the risk of postoperative delirium in elderly hip fracture patients? Marcantonio et al13 randomized 126 patients undergoing hip fracture repair to receive usual care alone or supplemented with the following additional measures:
- Supplemental oxygen during surgery
- Optimization of electrolytes and blood glucose preoperatively
- Discontinuation of high-risk medications
- Adequate nutritional intake (by parenteral route if necessary)
- Encouragement to get out of bed on the first postoperative day
- Treatment of severe pain.
The incidence of delirium was reduced from 50% in the usual-care group to 32% in the intervention group, and the incidence of severe delirium was reduced even more, from 29% to 12%, respectively.13
OTHER BEST PRACTICES IN PERIOPERATIVE HIP FRACTURE MANAGEMENT
In a systematic literature review to identify best practices for perioperative management of elderly patients with hip fracture, Beaupre et al14 found the following measures to be among those with the strongest evidence of benefit:
- Use of spinal or local anesthesia rather than general anesthesia
- Use of pressure-relieving mattresses to prevent pressure ulcers
- Perioperative administration of antibiotics
- Deep vein thrombosis prophylaxis.
The review concluded that providing nutritional supplementation also is probably helpful although the evidence is not robust. Additionally, it was unclear whether minimizing the delay between hospital admission and surgery has any impact on mortality.14
Is early surgery better?
Early studies suggested that the sooner a hip fracture patient goes to surgery, the lower the mortality, but this has not been supported in well-controlled trials: no difference in mortality has been found whether the patient’s conditions are first optimized to reduce the risk of surgery or if the operation commences within 24 hours.
Although mortality does not appear to be affected, avoiding delay of hip fracture repair yields improvement in other outcomes. In a well-designed prospective cohort study, Orosz et al found that medically stable patients with hip fracture (mean age, 82 years) who underwent surgery within 24 hours had fewer days of pain and less intense pain postoperatively than those whose surgery was delayed beyond 24 hours.15 The early-surgery group also had a 1.94-day reduction in average length of stay compared with the late-surgery group.
A role for clinical pathways
To determine how the application of evidence-based perioperative practices affects actual outcomes in elderly hip fracture patients, Beaupre et al used a pre/post study design to evaluate the impact of an evidence-based clinical pathway at their institution.16 Though there were no differences in in-hospital mortality or the overall costs of inpatient care in elderly hip surgery patients before and after pathway implementation, the patients undergoing surgery after pathway implementation were significantly less likely to have postoperative delirium, heart failure, pressure ulcers, and urinary tract infections compared with those undergoing surgery before implementation. The outcomes benefits of this type of multimodal intervention are likely to extend to abdominal surgical procedures as well.
CASE CONTINUED: POSTOP DAY 2―PATIENT IS CONFUSED AND CRYING IN PAIN
On the second postoperative day, our patient appears weak and slightly confused. She is not eating and is crying in pain. Her neurological exam is normal.
Question: Which is the most appropriate next step?
A. Increase physical therapy
B. Begin an antidepressant
C. Insert a nasoenteric feeding tube
D. Increase doses of analgesics
The best answer is D. With no prior history of depression, an antidepressant would probably not be useful. It is premature to recommend nasoenteric feeding. Because pain hampers physical therapy, an increase in physical therapy would likewise be premature. Because we know the patient is in pain, the correct answer perhaps seems obvious. But keep in mind that relieving pain also has many other positive ramifications: intense pain can be a cause of delirium or at least worsen its symptoms, and pain relief is a prerequisite for the physical therapy that this patient needs.
Strategies for pain control
In general, the treatment of choice for postoperative pain is low-dose morphine sulfate (eg, 1–4 mg every 2 hours, titrated as needed). Acetaminophen can be given safely to virtually all patients. Patient-controlled analgesia is reasonable for select patients but not for older patients with cognitive impairment. Nonsteroidal anti-inflammatory drugs might be helpful in younger patients and even in robust elderly patients, but they must be used very cautiously in the older population because of the risk of gastric ulcers and bleeding, acute kidney injury, fluid retention, and exacerbation of congestive heart failure.
POSTOP DAY 3: PATIENT REPORTS LONG-STANDING FATIGUE
On postoperative day 3, the patient is weak and complains of fatigue. She says that before the fracture, she was experiencing mild weight loss, fatigue, and reduced activity.
Question: What is the most likely reason for her symptoms before the fracture?
A. Frailty
B. Occult heart failure
C. Adverse drug reaction to her beta-blocker
D. Clinical depression
The best answer is A. Occult heart failure is a reasonable second choice, as it is very common in older patients and the diagnosis is easy to miss unless florid pulmonary edema or associated symptoms (eg, chest pain) are present. But this patient had no history of heart disease and was only on medications for hypertension. An adverse drug reaction, such as to the beta-blocker, is unlikely and would probably not cause weight loss. The patient had no history of depression, so clinical depression is unlikely. That said, all the choices are reasonable to consider in elderly patients reporting fatigue and weakness.
