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Surgery_Schwartz. during cardiopulmonary resuscitation. 25. Avidan MS, Jacobsohn E, Glick D, et al. Prevention of intraoperative awareness in a high-risk surgical population. N Engl J Med. 2011;365:591-600. This landmark study dem-onstrated no reduction of intraoperative awareness rates with use of the bispectral index monitor over monitoring anesthetic gas concentration. 26. Lien CA, Kopman AF. Current recommendations for monitor-ing depth of neuromuscular blockade. Curr Opin Anaesthesiol. 2014;27:616-622. 27. Hopkins TJ, Raghunathan K, Barbeito A, et al. Associations between ASA physical status and postoperative mortality at 48 h: a contemporary dataset analysis compared to a historical cohort. Perioper Med (London, England). 2016;5:29. 28. Mallampati SR, Gatt SP, Gugino LD, et al. A clinical sign to predict difficult tracheal intubation: a prospective study. Can Anaesth Soc J. 1985;32:429-434. Dr. Mallampati’s land-mark study set the standard for preoperative airway exami-nation, and the


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Surgery_Schwartz. sign to predict difficult tracheal intubation: a prospective study. Can Anaesth Soc J. 1985;32:429-434. Dr. Mallampati’s land-mark study set the standard for preoperative airway exami-nation, and the classification system described assists with prediction of difficult intubation. 29. Crosby ET. Airway management in adults after cervical spine trauma. Anesthesiology. 2006;104:1293-1318. 30. Shiga T, Wajima Z, Inoue T, et al. Predicting difficult intuba-tion in apparently normal patients: a meta-analysis of bedside screening test performance. Anesthesiology. 2005;103:429-437. 31. Riad W, Vaez MN, Raveendran R, et al. Neck circumference as a predictor of difficult intubation and difficult mask ventilation in morbidly obese patients: a prospective observational study. Eur J Anaesthesiol. 2016;33:244-249. 32. Fleisher LA, Fleischmann KE, Auerbach AD, et al. 2014 ACC/AHA guideline on perioperative cardiovascular evaluation and management of patients undergoing noncardiac surgery: executive


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Surgery_Schwartz. 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;130:2215-2245. The ACC/AHA guidelines have set the standard for preoperative cardiovascular evaluation and management for patients undergoing noncardiac surgery. 33. London MJ, Hur K, Schwartz GG, et al. Association of peri-operative beta-blockade with mortality and cardiovascu-lar morbidity following major noncardiac surgery. JAMA. 2013;309:1704-1713. 34. Blessberger H, Kammler J, Domanovits H, et al. Periopera-tive beta-blockers for preventing surgery-related mortality and morbidity. Cochrane Database Syst Rev. 2014;Cd004476. 35. Devereaux PJ, Yang H, Yusuf S, et al. Effects of extended-release metoprolol succinate in patients undergoing non-cardiac surgery (POISE trial): a


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Surgery_Schwartz. Cochrane Database Syst Rev. 2014;Cd004476. 35. Devereaux PJ, Yang H, Yusuf S, et al. Effects of extended-release metoprolol succinate in patients undergoing non-cardiac surgery (POISE trial): a randomised controlled trial. Lancet (London, England). 2008;371:1839-1847. 36. American Society of Anesthesiologists. Practice advisory for the perioperative management of patients with cardiac implantable electronic devices: pacemakers and implantable cardioverter-defibrillators: an updated report by the American Society of Anesthesiologists task force on perioperative management of patients with cardiac implantable electronic devices. Anesthesiology. 2011;114:247-261. 37. Mutlu GM, Factor P, Schwartz DE, et al. Severe status asthmat-icus: management with permissive hypercapnia and inhalation anesthesia. Crit Care Med. 2002;30:477-480. 38. American Society of Anesthesiologists. Practice guidelines for the perioperative management of patients with obstructive sleep apnea: an updated report by


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Surgery_Schwartz. Crit Care Med. 2002;30:477-480. 38. American Society of Anesthesiologists. Practice guidelines for the perioperative management of patients with obstructive sleep apnea: an updated report by the American Society of Anesthesi-ologists task force on perioperative management of patients with obstructive sleep apnea. Anesthesiology. 2014;120:268-286. 39. Stryker LS, Abdel MP, Morrey ME, et al. Elevated postop-erative blood glucose and preoperative hemoglobin A1C are Brunicardi_Ch46_p2027-p2044.indd 204101/03/19 11:04 AM 2042SPECIFIC CONSIDERATIONSPART IIassociated with increased wound complications following total joint arthroplasty. J Bone Joint Surg. 2013;95:808-814, s801-s802. 40. Alserius T, Anderson RE, Hammar N, et al. Elevated glycosyl-ated haemoglobin (HbA1c) is a risk marker in coronary artery bypass surgery. Scand Cardiovasc J. 2008;42:392-398. 41. Halkos ME, Puskas JD, Lattouf OM, et al. Elevated preopera-tive hemoglobin A1c level is predictive of adverse events after


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Surgery_Schwartz. in coronary artery bypass surgery. Scand Cardiovasc J. 2008;42:392-398. 41. Halkos ME, Puskas JD, Lattouf OM, et al. Elevated preopera-tive hemoglobin A1c level is predictive of adverse events after coronary artery bypass surgery. J Thorac Cardiovasc Surg. 2008;136:631-640. 42. Dhatariya K, Levy N, Kilvert A, et al. NHS Diabetes guideline for the perioperative management of the adult patient with dia-betes. Diabet Med. 2012;29:420-433. 43. Joshi GP, Chung F, Vann MA, et al. Society for Ambulatory Anesthesia consensus statement on perioperative blood glucose management in diabetic patients undergoing ambulatory sur-gery. Anesth Analg. 2010;111:1378-1387. 44. Sudhakaran S, Surani SR. Guidelines for perioperative manage-ment of the diabetic patient. Surg Res Pract. 2015;2015:284063. 45. Sebranek JJ, Lugli AK, Coursin DB. Glycaemic control in the perioperative period. Br J Anaesth. 2013;111(suppl 1):i18-i34. 46. Duncan AE. Hyperglycemia and perioperative glucose man-agement. Curr Pharm


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Surgery_Schwartz. JJ, Lugli AK, Coursin DB. Glycaemic control in the perioperative period. Br J Anaesth. 2013;111(suppl 1):i18-i34. 46. Duncan AE. Hyperglycemia and perioperative glucose man-agement. Curr Pharm Des. 2012;18:6195-6203. 47. Lipshutz AKM, Gropper MA. Perioperative glycemic control: an evidence-based review. Anesthesiology. 2009;110:408-421. 48. American Society of Anesthesiologists. Practice guidelines for preoperative fasting and the use of pharmacologic agents to reduce the risk of pulmonary aspiration: application to healthy patients undergoing elective procedures: an updated report by the American Society of Anesthesiologists com-mittee on standards and practice parameters. Anesthesiology. 2011;114:495-511. 49. American College of Surgeons. Statement on advance direc-tives by patients: “do not resuscitate” in the operating room. Bull Am Coll Surg. 2014;99:42-43. 50. American Society of Anesthesiologists. Ethical guidelines for the anesthesia care of patients with do-not-resuscitate


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Surgery_Schwartz. “do not resuscitate” in the operating room. Bull Am Coll Surg. 2014;99:42-43. 50. American Society of Anesthesiologists. Ethical guidelines for the anesthesia care of patients with do-not-resuscitate orders or other directives that limit treatment. Available at: https://www .asahq.org/resources/ethics-and-professionalism. Accessed August 20, 2018. 51. Bilimoria KY, Liu Y, Paruch JL, et al. Development and evalu-ation of the universal ACS NSQIP surgical risk calculator: a decision aid and informed consent tool for patients and sur-geons. J Am Coll Surg. 2013;217:833-842.e831-833. 52. Prins C, De Villiers Jonker I, Smit FE, et al. Cardiac surgery risk-stratification models. Cardiovasc J Africa. 2012;23:160-164. 53. Johnson C, Campwala I, Gupta S. Examining the validity of the ACS-NSQIP Risk Calculator in plastic surgery: lack of input specificity, outcome variability and imprecise risk calculations. J Invest Med. 2017;65:722-725. 54. Lascarrou JB, Boisrame-Helms J, Bailly A, et al.


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Surgery_Schwartz. Risk Calculator in plastic surgery: lack of input specificity, outcome variability and imprecise risk calculations. J Invest Med. 2017;65:722-725. 54. Lascarrou JB, Boisrame-Helms J, Bailly A, et al. Video laryngoscopy vs direct laryngoscopy on successful first-pass orotracheal intubation among ICU patients: a randomized clinical trial. JAMA. 2017;317:483-493. This recent study showed no difference in rates of successful first-pass intubation between direct laryngoscopy and video laryngoscopy. 55. Apfelbaum JL, Hagberg CA, Caplan RA, et al. Prac-tice guidelines for management of the difficult airwayan updated report by the American Society of Anesthesiologists task force on management of the difficult airway. Anesthesi-ology. 2013;118:251-270. The ASA Difficult Airway Algorithm, last updated in 2013, provides guidelines for management of patients with expected or unexpected difficult airways. 56. Popping DM, Elia N, Marret E, et al. Protective effects of epi-dural analgesia on


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Surgery_Schwartz. updated in 2013, provides guidelines for management of patients with expected or unexpected difficult airways. 56. Popping DM, Elia N, Marret E, et al. Protective effects of epi-dural analgesia on pulmonary complications after abdominal and thoracic surgery: a meta-analysis. Arch Surg. (Chicago, IL 1960). 2008;143:990-999; discussion 1000. 57. Manion SC, Brennan TJ. Thoracic epidural analgesia and acute pain management. Anesthesiology. 2011;115:181-188. 58. Bashandy GMN, Elkholy AHH. Reducing postoperative opioid consumption by adding an ultrasound-guided rectus sheath block to multimodal analgesia for abdominal cancer surgery with midline incision. Anesthesiol Pain Med. 2014; 4:e18263. 59. Ris F, Findlay JM, Hompes R, et al. Addition of transversus abdominis plane block to patient controlled analgesia for lapa-roscopic high anterior resection improves analgesia, reduces opioid requirement and expedites recovery of bowel function. Ann R Coll Surg Engl. 2014;96:579-585. 60. Palumbo P,


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Surgery_Schwartz. analgesia for lapa-roscopic high anterior resection improves analgesia, reduces opioid requirement and expedites recovery of bowel function. Ann R Coll Surg Engl. 2014;96:579-585. 60. Palumbo P, Tellan G, Perotti B, et al. Modified PADSS (post anaesthetic discharge scoring system) for monitoring outpa-tients discharge. Ann Ital Chir. 2013;84:661-665. 61. Phillips NM, Street M, Kent B, et al. Post-anaesthetic discharge scoring criteria: key findings from a systematic review. Int J Evid Based Healthc. 2013;11:275-284. 62. Phillips NM, Haesler E, Street M, et al. Post-anaesthetic dis-charge scoring criteria: a systematic review. JBI Libr Syst Rev. 2011;9:1679-1713. 63. Watcha MF, White PF. Postoperative nausea and vomit-ing. Its etiology, treatment, and prevention. Anesthesiology. 1992;77:162-184. 64. Habib AS, Chen YT, Taguchi A, et al. Postoperative nausea and vomiting following inpatient surgeries in a teaching hospital: a retrospective database analysis. Curr Med Res Opin. 2006;22:


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Surgery_Schwartz. AS, Chen YT, Taguchi A, et al. Postoperative nausea and vomiting following inpatient surgeries in a teaching hospital: a retrospective database analysis. Curr Med Res Opin. 2006;22: 1093-1099. 65. Eskicioglu C, Forbes SS, Aarts MA, et al. Enhanced recovery after surgery (ERAS) programs for patients having colorectal surgery: a meta-analysis of randomized trials. J Gastrointest Surg. 2009;13:2321-2329. 66. Sammour T, Zargar-Shoshtari K, Bhat A, et al. A programme of enhanced recovery after surgery (ERAS) is a cost-effective intervention in elective colonic surgery. N Z Med J. 2010; 123:61-70. 67. Reurings JC, Spanjersberg WR, Oostvogel HJ, et al. A prospec-tive cohort study to investigate cost-minimisation, of Traditional open, open fAst track recovery and laParoscopic fASt track mul-timodal management, for surgical patients with colon carcinomas (TAPAS study). BMC Surg. 2010;10:18. 68. Carroll I, Barelka P, Wang CK, et al. A pilot cohort study of the determinants of longitudinal


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Surgery_Schwartz. management, for surgical patients with colon carcinomas (TAPAS study). BMC Surg. 2010;10:18. 68. Carroll I, Barelka P, Wang CK, et al. A pilot cohort study of the determinants of longitudinal opioid use after surgery. Anesth Analg. 2012;115:694-702. 69. Clarke H, Soneji N, Ko DT, et al. Rates and risk factors for pro-longed opioid use after major surgery: population based cohort study. BMJ. 2014;348:g1251. 70. CDC grand rounds: prescription drug overdoses—a U.S. epi-demic. MMWR Morb Mortal Wkly Rep. 2012;61:10-13. 71. Rosenberg H, Pollock N, Schiemann A, et al. Malignant hyper-thermia: a review. Orphanet J Rare Dis. 2015;10:93. 72. Jaber S, Lescot T, Futier E, et al. Effect of noninvasive ventila-tion on tracheal reintubation among patients with hypoxemic respiratory failure following abdominal surgery: a randomized clinical trial. JAMA. 2016;315:1345-1353. 73. Hernandez G, Vaquero C, Gonzalez P, et al. Effect of postextu-bation high-flow nasal cannula vs conventional oxygen therapy


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Surgery_Schwartz. surgery: a randomized clinical trial. JAMA. 2016;315:1345-1353. 73. Hernandez G, Vaquero C, Gonzalez P, et al. Effect of postextu-bation high-flow nasal cannula vs conventional oxygen therapy on reintubation in low-risk patients: a randomized clinical trial. JAMA. 2016;315:1354-1361. 74. Corley A, Bull T, Spooner AJ, et al. Direct extubation onto high-flow nasal cannulae post-cardiac surgery versus standard treatment in patients with a BMI >/=30: a randomised con-trolled trial. Intensive Care Med. 2015;41:887-894. 75. Ansari BM, Hogan MP, Collier TJ, et al. A randomized con-trolled trial of high-flow nasal oxygen (optiflow) as part of an enhanced recovery program after lung resection surgery. Ann Thorac Surg. 2016;101:459-464.Brunicardi_Ch46_p2027-p2044.indd 204201/03/19 11:04 AM 2043ANESTHESIA FOR SURGICAL PATIENTSCHAPTER 46 76. Parke R, McGuinness S, Dixon R, et al. Open-label, phase II study of routine high-flow nasal oxygen therapy in cardiac sur-gical patients. Br J Anaesth.


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Surgery_Schwartz. FOR SURGICAL PATIENTSCHAPTER 46 76. Parke R, McGuinness S, Dixon R, et al. Open-label, phase II study of routine high-flow nasal oxygen therapy in cardiac sur-gical patients. Br J Anaesth. 2013;111:925-931. 77. Stephan F, Barrucand B, Petit P, et al. High-flow nasal oxygen vs noninvasive positive airway pressure in hypoxemic patients after cardiothoracic surgery: a randomized clinical trial. JAMA. 2015;313:2331-2339. 78. Vijayakumar B, Elango P, Ganessan R. Post-operative delirium in elderly patients. Indian J Anaesth. 2014;58:251-256. 79. Monk TG, Weldon BC, Garvan CW, et al. Predictors of cogni-tive dysfunction after major noncardiac surgery. Anesthesiology. 2008;108:18-30. 80. Crosby G, Culley DJ, Hyman BT. Preoperative cognitive assessment of the elderly surgical patient: a call for action. Anesthesiology. 2011;114:1265-1268.Brunicardi_Ch46_p2027-p2044.indd 204301/03/19 11:04 AM


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Surgery_Schwartz. Surgical Considerations in Older AdultsAnne M. Suskind and Emily Finlayson 47chapterINTRODUCTIONAs the population ages, an increasing number of older adults will develop surgical diseases. The segment of the U.S. popu-lation age 65 and older is expected to double by 2050. Older adults present unique challenges in surgical management and decision-making. The accumulation of comorbid conditions and physiologic vulnerability that occurs with age put older adults at high risk for major morbidity and mortality after sur-gery. It is essential that surgeons approach this population with a new set of skills and knowledge to provide optimal care for this vulnerable population. A comprehensive understanding of the unique vulnerabilities of older adults—geriatric syndromes and risk factors—are required to accurately estimate surgical risk, inform surgical decision-making, and guide perioperative management. In this chapter, we will (a) discuss the physiologic conditions that are common in older


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Surgery_Schwartz. to accurately estimate surgical risk, inform surgical decision-making, and guide perioperative management. In this chapter, we will (a) discuss the physiologic conditions that are common in older adults that are essential for surgical risk assessment of older adults considering surgery, (b) describe best practices in perioperative care in the older adult, and (c) discuss special considerations and common pitfalls for surgical conditions that are common in the older adult.GERIATRIC SYNDROMESApproximately one-third of older individuals undergoing vascu-lar and urologic surgery suffer from geriatric syndromes.1,2 This term is used to describe clinical conditions that do not fit into discrete disease categories but that can substantially negatively impact quality of life and result in disability. Geriat-ric syndromes often involve multiple underlying factors and organ systems (i.e., multiple causation of a unified manifesta-tion3) and include frailty, falls, delirium, malnutrition,


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Surgery_Schwartz. Geriat-ric syndromes often involve multiple underlying factors and organ systems (i.e., multiple causation of a unified manifesta-tion3) and include frailty, falls, delirium, malnutrition, dizziness, syncope, urinary incontinence, and pressure ulcers among oth-ers. These syndromes can be present before surgery and/or 1develop as a result of surgery and hospitalization.1,2 Further-more, close attention to both the presence and development of geriatric syndromes among surgical candidates is important and often overlooked, making caring for older surgical patients unique compared to their younger and healthier counterparts.FrailtyFrailty is among the most widely studied geriatric syndrome in the surgical literature. Frail older individuals are at high risk for adverse events in the face of stressors such as surgery. They are more likely to experience surgical complications, delayed recovery, falls, and to develop functional impairment. Frailty is also associated with a higher risk of


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Surgery_Schwartz. stressors such as surgery. They are more likely to experience surgical complications, delayed recovery, falls, and to develop functional impairment. Frailty is also associated with a higher risk of death. It Is believed that frailty is a chronic, progressive condition that represents a spec-trum; less frail individuals may be responsive to strategies or interventions to ameliorate its clinical manifestations, while more frail individuals may demonstrate an irreversible predeath condition with limited life expectancy.4Frailty has been shown to be independently predictive of poor postoperative outcomes. Makary et al studied 594 older patients presenting for elective surgery at a university hospital and demonstrated that frail individuals were at increased risk of postoperative complications (OR 2.54; 95% CI 1.12–5.77), lon-ger length of stay (incidence rate ratio 1.69; 95% CI 1.28–2.23), and discharge to a skilled or assisted living facility after previ-ously living at home (OR 20.48;


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Surgery_Schwartz. (OR 2.54; 95% CI 1.12–5.77), lon-ger length of stay (incidence rate ratio 1.69; 95% CI 1.28–2.23), and discharge to a skilled or assisted living facility after previ-ously living at home (OR 20.48; 95% CI 5.54-75.68).5 Similar findings have been echoed throughout the surgical literature inclusive of vascular, colorectal, cardiac, urologic, and other types of procedures.6-11Definitions of frailty fall into two broad models; a pheno-typic model and a deficits accumulation model. The phenotypic model was originally described by Linda Fried using data from the Cardiovascular Health Study, which is an observational study of community-dwelling men and women age 65 years and Introduction 2045Geriatric Syndromes 2045Frailty / 2045Falls / 2047Delirium / 2047Preoperative Assessment 2047Best Practices: Preoperative Assessment / 2048Frailty Assessment / 2049Cognitive and Behavioral Assessment / 2049Medical Assessment / 2050Nutritional Assessment / 2051Psychosocial Considerations / 2052Medication


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Surgery_Schwartz. Preoperative Assessment / 2048Frailty Assessment / 2049Cognitive and Behavioral Assessment / 2049Medical Assessment / 2050Nutritional Assessment / 2051Psychosocial Considerations / 2052Medication Review / 2052Patient Counseling / 2052Preoperative Preparation 2052Patient Goals, Preferences, and Advance Directives / 2052Preoperative Fasting / 2053Antibiotic Prophylaxis and Venous Thromboembolism Prevention / 2053Surgical Prehabilitation / 2053Palliative Care Services for Older Surgical Patients / 2053Special Considerations 2054Functional Recovery / 2054Cancer Surgery / 2055Emergency Surgery / 2055Cardiovascular Surgery / 2055Valve Replacement / 2055Endovascular Aortic Surgery / 2056Palliative Surgery / 2056Summary 2056Brunicardi_Ch47_p2045-p2060.indd 204528/02/19 2:08 PM 2046Table 47-1Criteria used to define frailty• Weight loss: “In the last year, have you lost more than 10 pounds unintentionally (i.e., not due to dieting or exercise)?” If yes, then frail for weight loss


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Surgery_Schwartz. 47-1Criteria used to define frailty• Weight loss: “In the last year, have you lost more than 10 pounds unintentionally (i.e., not due to dieting or exercise)?” If yes, then frail for weight loss criterion. At follow-up, weight loss was calculated as: (Weight in previous year – current measured weight)/(weight in previous year) = K. If K ≥0.05 and the subject does not report that he/she was trying to lose weight (i.e., unintentional weight loss of at least 5% of previous year’s body weight), then frail for weight loss = Yes.• Exhaustion: Using the CES-D Depression Scale, the following two statements are read. (a) I felt that everything I did was an effort; (b) I could not get going. The question is asked “How often in the last week did you feel this way?” 0 = rarely or none of the time (<1 day), 1 = some or a little of the time (1–2 days), 2 = a moderate amount of the time (3–4 days), or 3 = most of the time. Subjects answering “2” or “3” to either of these questions are categorized as


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Surgery_Schwartz. day), 1 = some or a little of the time (1–2 days), 2 = a moderate amount of the time (3–4 days), or 3 = most of the time. Subjects answering “2” or “3” to either of these questions are categorized as frail by the exhaustion criterion.• Physical Activity: Based on the short version of the Minnesota Leisure Time Activity questionnaire, asking about walking, chores (moderately strenuous), mowing the lawn, raking, gardening, hiking, jogging, biking, exercise cycling, dancing, aerobics, bowling, golf, singles tennis, doubles tennis, racquetball, calisthenics, swimming. Kcals per week expended are calculated using standardized algorithm. This variable is stratified by gender. Men: Those with Kcal of physical activity per week <383 are frail. Women: Those with Kcals per week <270 are frail.• Walk Time, stratified by gender and height (gender-specific cutoff a medium height). Men Height ≤173 cm Height >173 cmCutoff for time to walk 15 feet criterion for frailty≥7 seconds≥6


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Surgery_Schwartz. are frail.• Walk Time, stratified by gender and height (gender-specific cutoff a medium height). Men Height ≤173 cm Height >173 cmCutoff for time to walk 15 feet criterion for frailty≥7 seconds≥6 seconds Women Height ≤159 cm Height >159 cm≥7 seconds≥6 seconds• Grip Strength, stratified by gender and body mass index (BMI) quartiles: Men BMI ≤24 BMI 24.1–26 BMI 26.1–28 BMI >28Cutoff for grip strength (Kg) criterion for frailty≤29≤30≤30≤32 Women BMI ≤23 BMI 23.1–26 BMI 26.1–29 BMI >29≤17≤17.3≤18≤21Reproduced with permission from Fried LP, Tangen CM, Walston J, et al. Frailty in older adults: evidence for a phenotype, J Gerontol A Biol Sci Med Sci. 2001 Mar;56(3):M146-M156.older. Individuals in this cohort underwent baseline evaluations and had 4 to 7 years of follow-up with annual examinations and surveillance for the following outcomes: incident disease, hos-pitalization, falls, disability, and mortality. Based on observa-tions in these individuals over time, the following criteria were


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Surgery_Schwartz. and surveillance for the following outcomes: incident disease, hos-pitalization, falls, disability, and mortality. Based on observa-tions in these individuals over time, the following criteria were identified to define frailty: weight loss, exhaustion, physical activity, walk time, and grip strength (Table 47-1). The pres-ence of one or two of these factors is associated with intermedi-ate risk for poor outcomes, i.e., a “prefrail” phenotype, and the presence of three or more of these factors is associated with high risk for poor outcomes, i.e., a “frail” phenotype.12 This study additionally demonstrated that frailty is strongly associated Key Points1 Frailty, dementia, and functional impairment are significant contributors to morbidity and mortality after surgery. Assess-ment of these risk factors is essential in an older population.2 Geriatric perioperative pathways are effective in preventing delirium, a morbid and costly postoperative complication that is associated with cognitive


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Surgery_Schwartz. factors is essential in an older population.2 Geriatric perioperative pathways are effective in preventing delirium, a morbid and costly postoperative complication that is associated with cognitive decline.3 Population-based data demonstrate that mortality after emer-gency surgery and high-risk cancer surgery is substantially higher in older adults that in a younger population.4 Impaired cardiac function is responsible for more than half of the postoperative deaths in older adult patients, so careful attention must be paid to intravascular volume status in the perioperative period.5 Many frail elders experience significant and sustained func-tional decline after surgery.6 Older adults with acute abdominal pathology—appendicitis, cholecystitis—often do not have fever, elevated white blood cell count, or physical findings of peritonitis.Brunicardi_Ch47_p2045-p2060.indd 204628/02/19 2:08 PM 2047SURGICAL CONSIDERATIONS IN OLDER ADULTSCHAPTER 47with several major chronic diseases,


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Surgery_Schwartz. cell count, or physical findings of peritonitis.Brunicardi_Ch47_p2045-p2060.indd 204628/02/19 2:08 PM 2047SURGICAL CONSIDERATIONS IN OLDER ADULTSCHAPTER 47with several major chronic diseases, including cardiovascular disease, pulmonary disease, and diabetes; however, not all frail individuals demonstrated these associations. The same is true for disability. While there is some overlap between frailty and disability, not all frail individuals are disabled. These findings suggest that while there may be overlap between these three constructs in some individuals, frailty is a distinct process from both comorbidity and disability.12Alternatively, the deficit accumulation model, developed by Rockwood et al, suggests that frailty is defined by discrete failures of redundant physiologic systems. The more deficits that occur, the more likely it is that adverse outcomes will result. Using data from the Canadian Study of Health and Aging, a longitudinal study of individuals age 65 and


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Surgery_Schwartz. systems. The more deficits that occur, the more likely it is that adverse outcomes will result. Using data from the Canadian Study of Health and Aging, a longitudinal study of individuals age 65 and older, the authors developed a frailty index represented by the cumulative pro-portion of 92 accumulated deficits, which include symptoms, signs, functional impairments, and laboratory abnormalities. They demonstrated that deficits accumulated at a rate of 3% per year in their cohort, represented a gamma distribution, and increased with chronological age; they proposed that this model be used as a proxy for aging and mortality.13While these models are helpful to conceptualize frailty, no one model is all inclusive, and each may have applicability in different settings. For example, the frailty phenotype does not include items on cognition or mood and may not be easily appli-cable to the busy clinical setting.14 The deficits accumulation model is ideal for use in large databases, such as


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Surgery_Schwartz. phenotype does not include items on cognition or mood and may not be easily appli-cable to the busy clinical setting.14 The deficits accumulation model is ideal for use in large databases, such as the American College of Surgeons National Surgical Quality Improvement Project (ACS-NSQIP),15 and may be helpful for research and public health and policy purposes, but it is not practical for clini-cal care. Measurement of frailty in the clinical setting will be discussed later in this chapter.While frailty is often defined as a geriatric syndrome, it is also plausible that other geriatric syndromes (i.e., urinary incontinence, falls, pressure ulcers, delirium, and functional decline) may demonstrate shared risk factors that lead to frailty. In turn, frailty may also cause more risk factors and more geriat-ric syndromes.16 Regardless of the association and directionality between frailty and other geriatric syndromes, identification of each is essential in the preoperative setting in order


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Surgery_Schwartz. more geriat-ric syndromes.16 Regardless of the association and directionality between frailty and other geriatric syndromes, identification of each is essential in the preoperative setting in order to help risk stratify and potentially to mitigate risk for patients considering surgical intervention.FallsOlder adults are at markedly increased risk of falls, and one in three adults age 65 and older report falling in the last year. The incidence of falls increases with age, and close to 60% of individuals who have fallen in the last year will fall again within the following year. Falls are associated with subsequent declines in functional status, greater likelihood of nursing home placement, increased use of medical services, and development of a fear of falling. Approx-imately half of older individuals who fall are unable to get up, resulting in a “long lie,” which is further associated with lasting functional declines.17 In fact, falls can be so detrimental to older individuals that


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Surgery_Schwartz. individuals who fall are unable to get up, resulting in a “long lie,” which is further associated with lasting functional declines.17 In fact, falls can be so detrimental to older individuals that the Joint Commission (United States) established fall prevention as one of its national safety goals in 2015.18Causes of falls can be multifactorial, as with other geri-atric syndromes. Factors include age-related declines, chronic disease, medications, environmental factors, changing positions, routine activities, risk-taking behaviors, acute illness, or situ-ational hazards such as the unfamiliar setting of hospitals and long-term care facilities.17It has been shown that preoperative falls are associated with poor postoperative outcomes among patients undergoing elective surgery. One study looking at 7982 such patients found that a preoperative history of one, two, or three or more falls predicted postoperative falls at 30 days (adjusted OR 2.3, 3.6, 5.5, respectively) and 1 year (adjusted


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Surgery_Schwartz. at 7982 such patients found that a preoperative history of one, two, or three or more falls predicted postoperative falls at 30 days (adjusted OR 2.3, 3.6, 5.5, respectively) and 1 year (adjusted OR 2.3, 3.4, 6.9, respec-tively), in addition to predicting a decline in functional status at 30 days (adjusted OR 1.2, 2.4, 2.4, respectively) and 1 year (adjusted OR 1.3, 1.5, 3.2, respectively) and in-hospital compli-cations (adjusted OR 1.2, 1.3, 2.0, respectively).18 Furthermore, preoperative falls are a major predictor of poor postoperative outcomes and may be a valuable preoperative assessment tool as part of routine preoperative care.DeliriumDelirium is a disorder of attention and awareness that develops acutely and tends to fluctuate, as defined by the new Diagnos-tic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) criteria. Delirium is so common among older adults that up to one third of patients age 70 and older admitted to the hospital experiences delirium, half


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Surgery_Schwartz. of Mental Disorders, Fifth Edition (DSM-5) criteria. Delirium is so common among older adults that up to one third of patients age 70 and older admitted to the hospital experiences delirium, half of which have delirium on admission and the other half of which develop delirium dur-ing the hospitalization itself.19 Rates of delirium among older patients undergoing surgery ranges from 4% to 5% in cataract and urologic procedures to 50% to 60% in infrarenal AAA repair or hip fracture surgery.20 Patients who develop postopera-tive delirium have a twoto threefold increased risk of mortality within the first year after surgery.21Preoperative assessment should focus on the identifi-cation of risk factors for delirium including age 70 years or older, cognitive impairment, limited physical function, history of alcohol abuse, abnormal serum sodium, potassium or glu-cose, intrathoracic surgery, and AAA surgery. Preoperative assessment and documentation of mental status is imperative in order to


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Surgery_Schwartz. history of alcohol abuse, abnormal serum sodium, potassium or glu-cose, intrathoracic surgery, and AAA surgery. Preoperative assessment and documentation of mental status is imperative in order to establish a baseline for postoperative comparison. Intraoperative blood loss is another risk factor for postopera-tive delirium, and patients with a postoperative hematocrit less than 30% are at increased risk, irrespective of baseline risk fac-tors. Postoperatively, undertreatment of pain is an important risk factor for delirium. Management of fluid, electrolyte and metabolic abnormalities, optimization of blood loss replace-ment, maintenance of circadian rhythms, and cautious prescrip-tion of medication and pain management are among the most important methods by which to minimize the risk of postop-erative delirium among surgical patients.20 Furthermore, many commonly used medications may induce delirium and should be avoided. They include drugs with anticholinergic properties,


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Surgery_Schwartz. risk of postop-erative delirium among surgical patients.20 Furthermore, many commonly used medications may induce delirium and should be avoided. They include drugs with anticholinergic properties, corticosteroids, merperidine, and sedative hypnotics. Finally, postoperative care bundles have been shown to successfully reduce the incidence of delirium. These strategies include sensory enhancement (glasses, hearing aids), early mobility, cognitive orientation and therapeutic activities, and sleep proto-cols. Treatment of postoperative delirium should focus on treat-able etiologies (Fig. 47-1), and pharmacologic treatment should be reserved for patients who are at risk of harming themselves or others.PREOPERATIVE ASSESSMENTPreoperative assessment in older adults is more complex than in younger individuals, as there are many unique characteris-tics that require consideration. The purpose of the assessment Brunicardi_Ch47_p2045-p2060.indd 204728/02/19 2:08 PM 2048SPECIFIC


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Surgery_Schwartz. than in younger individuals, as there are many unique characteris-tics that require consideration. The purpose of the assessment Brunicardi_Ch47_p2045-p2060.indd 204728/02/19 2:08 PM 2048SPECIFIC CONSIDERATIONSPART IIFigure 47-1. Useful algorithm to determine preoperative management of the acutely delirious patient.is not to “clear” the patient for surgery but rather to minimize risks and optimize good outcomes. The ACS NSQIP and the American Geriatrics Society (AGS) published best practice guidelines to help optimize this process. Preoperative planning should be pro-active, commencing at the time of surgical decision-making, if not sooner. To this end, the ACS NSQIP/AGS produced best practice guidelines and a preoperative management checklist to provide a framework for thinking about critical issues in this patient population (Table 47-2).22 In addition to these issues, they emphasize the importance of planning analgesia strategies, making efforts to minimize opioid use and to


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Surgery_Schwartz. critical issues in this patient population (Table 47-2).22 In addition to these issues, they emphasize the importance of planning analgesia strategies, making efforts to minimize opioid use and to prevent functional and cognitive decline, obtaining multidisciplinary consultation early and early involvement of allied health staff (i.e., physical or occupational therapy), and anticipating home health needs that may be required at discharge.23Best Practices: Preoperative AssessmentFunctional Assessment. As previously discussed, poor phys-ical function prior to surgery is associated with higher risk of major postoperative complications, increased need for intensive WORKUPPhysical exam• Check surgical wound• Check for tubes/lines/drains• Urinalysis• CBC, BMP• May consider: TSH, NH3, LFT, EtoH/tox• Blood/sputum/urine cultures-Vital signs, pulse ox, pain assessmentMedication reviewLaboratory evaluation:---Chest XRSubstance abuse history--PHARMACOLOGIC MANAGEMENT:ONLY FOR AGITATED DELIRIUM


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Surgery_Schwartz. Blood/sputum/urine cultures-Vital signs, pulse ox, pain assessmentMedication reviewLaboratory evaluation:---Chest XRSubstance abuse history--PHARMACOLOGIC MANAGEMENT:ONLY FOR AGITATED DELIRIUM AND PATIENT SAFETYAgent of choice: Low dose Haloperidol0.5 mg PO: 1–2 hours for effect, may redose in 60 m0.5 mg IM/IV: 20–40 min to take effect, may redosein 30 mMost patients respond to total of 1–2 mgCheck 12 lead EKG, hold if QTc >500----Use benzos only if there is a concern for withdrawalDIFFERENTIAL DIAGNOSIS DRUG!!! Electrolytes, environment change Lack of drugs (withdrawal), lack of sleep Infection, idiopathic Restraints, reduced sensory input (vision/hearing) Intracranial (CVA, bleed, post-ictal, meningitis) Urinary retention, or fecal impaction Metabolic, includes PE/MI, uremia, ammonia, thyroidDELIRIUMAlways check the medication list – there is acumulative effect burden, any new medicationor recent dose change is suspectAlgorithm for the acutelydelirious patient.For prevention in at


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Surgery_Schwartz. thyroidDELIRIUMAlways check the medication list – there is acumulative effect burden, any new medicationor recent dose change is suspectAlgorithm for the acutelydelirious patient.For prevention in at risk patientsplease refer to opposite side.Why are they delirious?Common Delirium Inducing MedicationsRisk FactorsPrecipitating Factors, in aaddition to SURGERYPhysical restraintsMalnutrition3 medication classes addedBladder catheterUncontrolled pain-----PREVENTION/CONSERVATIVE MANAGEMENTSensory enhancement: Hearing aids, glasses at bedsideMobilizationCognitive orientation and stimulationSleep enhancementMedication reviewNormalize environment• Get rid of tethers• Keep room calm and quiet• Encourage family/caregiver involvement------Address/remove precipitating factors or agentsIf MB consider hospitalist consult--Are they a danger tothemselves or others?Age >65Cognitive impairmentComorbidity burdenPoor functional statusHearing/vision impairmentDepression------Anticholinergics: Tricyclics,


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Surgery_Schwartz. hospitalist consult--Are they a danger tothemselves or others?Age >65Cognitive impairmentComorbidity burdenPoor functional statusHearing/vision impairmentDepression------Anticholinergics: Tricyclics, antihistamines,H2-blockers, antimuscarinics, antispasmodics,promethazine, olanzapine, paroxetineCorticosteroids: methylprednisone, prednisoneMeperidineSedative hypnotics: benzos, zolpidem----Nu-DESC Screen: ScoreEach item scored 0–2• Disorientation• Inappropriate behavior• Inappropriate communication• Illusions/hallucinations• Psychomotor retardationIs your patient acutely delirious?Yes?Differential and workupBrunicardi_Ch47_p2045-p2060.indd 204828/02/19 2:08 PM 2049SURGICAL CONSIDERATIONS IN OLDER ADULTSCHAPTER 47Table 47-2Immediate preoperative management checklist from the ACS NSQIP/AGS1. Confirm and document patient goals and treatment preferences, including advance directives2. Confirm and document patient’s health care proxy or surrogate decision-maker3. In patients with


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Surgery_Schwartz. and document patient goals and treatment preferences, including advance directives2. Confirm and document patient’s health care proxy or surrogate decision-maker3. In patients with existing advance directives, discuss new risks associated with the surgical procedure and an approach for potentially life-threatening problems consistent with the patient’s values and preferences4. Consider shortened fluid fast (clear liquids up to two hours before anesthesia)5. Adhere to existing best practices regarding antibiotic and venous thromboembolism prophylaxis6. Ensure nonessential medications have been stopped and essential medications have been takenAdapted with permission from Mohanty S, Rosenthal RA, Russell MM, et al: Optimal Perioperative Management of the Geriatric Patient: A Best Practices Guideline from the American College of Surgeons NSQIP and the American Geriatrics Society, J Am Coll Surg. 2016 May;222(5):930-947.rehabilitation services, increased rates of discharge to a skilled or


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Surgery_Schwartz. from the American College of Surgeons NSQIP and the American Geriatrics Society, J Am Coll Surg. 2016 May;222(5):930-947.rehabilitation services, increased rates of discharge to a skilled or assisted nursing facility, and higher mortality.24-26 Assessment of physical function and performance status in the preoperative setting are recommended by the ACS NSQIP/AGS best practice guidelines.22 There are several methods by which to measure physical function. Overall functional status may be ascertained by assessing the ability of an individual to perform activities of daily living (ADLs) and instrumental ADLs. ADLs include dressing, bathing, toileting, transferring, continence, and eating independently.25 Instrumental ADLs measure an individual’s ability to live independently and include the ability to perform the following tasks: shopping, laundry, mode of transportation, ability to handle finances, responsibility for won medications, food preparation, and housekeeping.27In addition to


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Surgery_Schwartz. ability to perform the following tasks: shopping, laundry, mode of transportation, ability to handle finances, responsibility for won medications, food preparation, and housekeeping.27In addition to assessment of ADLs and instrumental ADLs, the surgeon should also assess for deficits in vision, hearing, and swallowing, inquire about history of falls in the past year, evaluate for limitations in gait and mobility, and determine risk for falls, which can be performed via the timed up and go test (TUGT). This test measures gait and mobility impairment and is associated with increased risk for falls in ambulatory individu-als. All that is required to perform this test are a chair, a mark 10 feet in front of the chair, and a stopwatch. Individuals are instructed to do the following while being timed:1. Stand up from the chair (without using arm rests, if possible)2. Walk to the mark (10 feet in front of them)3. Turn4. Walk back to the chair5. Sit down in the chairA time of ≥15 seconds


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Surgery_Schwartz. timed:1. Stand up from the chair (without using arm rests, if possible)2. Walk to the mark (10 feet in front of them)3. Turn4. Walk back to the chair5. Sit down in the chairA time of ≥15 seconds indicates high risk of falls and should prompt referral to physical therapy for further assessment.In a prospective cohort of individuals age 65 and older undergoing surgery, the TUGT times were stratified into three groups that strongly correlated with varying risk for postop-erative complications and 1-year mortality. These groups were “slow” (≥15 seconds), “intermediate” (11–14 seconds), and “fast” (≤10 seconds). Postoperative complications and 1-year mortality in the slow group were significantly higher com-pared to those in the fast group, 52% to 77% versus 11% to 13% for complications, and 31% compared to 3% for mortality, respectively.9Frailty AssessmentAs stated earlier, frailty is an important consideration in preop-erative planning for older individuals. Measurement of frailty can


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Surgery_Schwartz. 31% compared to 3% for mortality, respectively.9Frailty AssessmentAs stated earlier, frailty is an important consideration in preop-erative planning for older individuals. Measurement of frailty can take several forms. One method is to apply the operational definition put forth by Fried (see Table 47-1), which has been applied to surgical patients and shown to be an independent pre-dictor of postoperative adverse events, increased length of stay, and higher likelihood of discharge to a skilled or assisted living facility.5The frailty phenotype, however, may be cumbersome to apply in the busy clinical setting. To this end, Robinson proposed alternative definitions and methods for frailty mea-surement. One such method includes the following criteria: cog-nitive impairment (Mini-Cog score of ≤3), poor nutrition (serum albumin ≤3), history of falls (≥1 fall in the past 6 months), and low hematocrit (<35%).26 A second definition includes func-tional impairment (TUGT ≥15 seconds and


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Surgery_Schwartz. of ≤3), poor nutrition (serum albumin ≤3), history of falls (≥1 fall in the past 6 months), and low hematocrit (<35%).26 A second definition includes func-tional impairment (TUGT ≥15 seconds and dependence in any ADL) and comorbidity (Charlson index score ≥3).28Cognitive and Behavioral AssessmentPreoperative cognitive impairment is strongly linked to postop-erative delirium, worse surgical outcomes, longer hospital stays, increased risk of functional decline, and even mor-tality. History and cognitive assessment are important to con-sider early on in all surgical candidates age 65 years and older in the preoperative setting. The Mini-Cog, consisting of the three-item recall and clock draw tests, can be used to complete this assessment (Table 47-3). If possible, someone who knows the patient well (such as a spouse or family member) should be interviewed about the presence and evolution of any cognitive decline in the patient. If decline is present, the patient should be referred to a


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Surgery_Schwartz. well (such as a spouse or family member) should be interviewed about the presence and evolution of any cognitive decline in the patient. If decline is present, the patient should be referred to a primary care physician, geriatrician, or mental health specialist for further evaluation. Documentation of pre-operative cognitive status will further assist in the identification of any postoperative cognitive dysfunction.22 Risk factors for postoperative delirium should also be assessed in the preopera-tive period and are detailed in Table 47-4.In addition to measuring cognitive status, assessing the patient’s decision-making capacity is also important to deter-mine the patient’s ability to provide informed surgical consent. It is helpful to ask the patient to describe, in his/her own words, the important features of the discussion, the condition and indi-cations for surgery, and the risks, benefits, and alternatives to surgery. There are four legally-relevant criteria for decision-making


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Surgery_Schwartz. important features of the discussion, the condition and indi-cations for surgery, and the risks, benefits, and alternatives to surgery. There are four legally-relevant criteria for decision-making capacity22:1. The patient can clearly indicate his/her treatment choice.2. The patient understands the relevant information communi-cated by the physician.3. The patient acknowledges his/her medical condition, treat-ment options, and likely outcomes.4. The patient can engage in a rational discussion about the treatment options.Depression should also be screened for in the preoperative setting, as up to 11% of the population age 71 years and older in the United States suffer from this condition.29 Risk factors 2Brunicardi_Ch47_p2045-p2060.indd 204928/02/19 2:08 PM 2050SPECIFIC CONSIDERATIONSPART IITable 47-4Risk factors for postoperative deliriumCognitive and behavioral disorders:• Cognitive impairment and dementia• Untreated or inadequately controlled pain• Depression• Alcohol use• Sleep


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Surgery_Schwartz. 47-4Risk factors for postoperative deliriumCognitive and behavioral disorders:• Cognitive impairment and dementia• Untreated or inadequately controlled pain• Depression• Alcohol use• Sleep deprivationDisease or illness related:• Severe illness or comorbidities• Renal insufficiency• Anemia• HypoxiaMetabolic:• Poor nutrition• Dehydration• Electrolyte abnormalitiesFunctional impairments:• Poor functional status• Immobilization• Hearing or vision impairmentOther:• Older age ≥70 years• Polypharmacy and use of psychotropic medications (benzodiazepines, anticholinergics, and antihistamines)• Risk of urinary retention or constipation, presence of urinary catheterReproduced with permission from Chow WB, Rosenthal RA, Merkow RP, 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 Oct;215(4):453-466.Table


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Surgery_Schwartz. 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 Oct;215(4):453-466.Table 47-3Cognitive assessment: three-item recall and clock draw1. Get the patient’s attention and say: “I am going to say three words that I want you to remember now and later. These words are banana, sunrise, chair. Please say them for me now.” Give the patient three tries to repeat the words. If unable after three tries, go to next item.2. Say all of the following phrases in the order indicated: “Please draw a clock in the space below. Start by drawing a large circle. Put all the numbers in the circle and set the hands to show 11:10 (10 past 11).” If the subject has not finished clock drawing in 3 minutes, discontinue and ask for recall items.3. Say: “What were the three words I asked you to remember?”Scoring:• 3 item recall (0-3 points): 1 point for each correct word• Clock draw (0-2


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Surgery_Schwartz. in 3 minutes, discontinue and ask for recall items.3. Say: “What were the three words I asked you to remember?”Scoring:• 3 item recall (0-3 points): 1 point for each correct word• Clock draw (0-2 points): 0 points for abnormal clock; 2 points for normal clock A normal clock has all of the following elements: 1. All numbers 1-12, each only once, are present in the correct order and direction (clockwise) inside the circle. 2. Two hands are present, one pointing to 11 and one pointing to 2. 3. Any clock missing any of these elements is scored abnormal. refusal to draw a clock is scored abnormalTotal score of 0, 1, or 2 suggests possible impairmentTotal score of 3, 4, or 5 suggests no impairmentReproduced with permission from Borson S, Scanlan J, Brush M, et al. The mini-cog: a cognitive ‘vital signs’ measure for dementia screening in multi-lingual elderly, Int J Geriatr Psychiatry. 2000 Nov;15(11):1021-1027.for depression in older adults include female gender, disability,


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Surgery_Schwartz. cognitive ‘vital signs’ measure for dementia screening in multi-lingual elderly, Int J Geriatr Psychiatry. 2000 Nov;15(11):1021-1027.for depression in older adults include female gender, disability, bereavement, and sleep disturbance. Poor health status, cogni-tive impairment, living alone, and new medical illness may also contribute to depression.30The Patient Health Questionnaire-2 (PHQ-2) can be used to screen for depression via the following two questions31:1. In the past 12 months, have you ever had a time when you felt sad, blue, depressed, or down for most of the time for at least two weeks?2. In the past 12 months, have you ever had a time, lasting at least two weeks, when you didn’t care about the tings things that you usually care about or when you didn’t enjoy the things that you usually enjoy?If a patient answers yes to either question, further revalu-ation with a primary care physician, geriatrician, or psychiatrist is recommended.Screening for alcohol and substance abuse


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Surgery_Schwartz. usually enjoy?If a patient answers yes to either question, further revalu-ation with a primary care physician, geriatrician, or psychiatrist is recommended.Screening for alcohol and substance abuse is also recom-mended, as alcohol use is common among older adults. Up to 13% of men and 8% of women ≥65 years consume at least 2 drinks per day and 14.5% of men and 3.3% of women con-sume 5 or more drinks per day.32 Alcohol and substance abuse are associated with increased rates of postoperative mortality and complications including pneumonia, sepsis, wound infec-tion and disruption, and prolonged length of stay.33,34 The ACS NSQIP/AGS recommend screening for alcohol and substance abuse among older individuals with the modified CAGE ques-tionnaire in combination with prescribing daily multivitamins. including folic acid and high dose (100 mg) oral or parenteral thiamine to patients who drink alcohol.22,35Medical AssessmentA thorough medical assessment should be performed in all older


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Surgery_Schwartz. including folic acid and high dose (100 mg) oral or parenteral thiamine to patients who drink alcohol.22,35Medical AssessmentA thorough medical assessment should be performed in all older operative candidates and should include a cardiac evaluation, pulmonary evaluation, nutritional assessment, and medication evaluation and management where appropriate.Cardiac adverse events are the most common cause of serious perioperative morbidity and mortality among patients undergoing noncardiac operations and occur more commonly in older adults.36,37 For these reasons, cardiac evalu-ation may be helpful to identify older patients with higher risk for cardiac complications who may be candidates for periopera-tive optimization. This evaluation should follow the American College of Cardiology and the American Heart Association (ACC/AHA) algorithm for cardiac evaluation and care. This is a step-wise approach that incorporates the following factors: (a) urgency of surgery (whether the procedure is


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Surgery_Schwartz. American Heart Association (ACC/AHA) algorithm for cardiac evaluation and care. This is a step-wise approach that incorporates the following factors: (a) urgency of surgery (whether the procedure is an emergency); the (b) presence of active major cardiac risk factors (i.e., unsta-ble coronary syndromes, decompensated heart failure, signifi-cant arrhythmias or severe valvular disease) that would necessitate referral to a cardiologist; (c) if risk factors for stable coronary artery disease are present, then calculation of risk for major adverse cardiac events using the ACS NSQIP calculator 3Brunicardi_Ch47_p2045-p2060.indd 205028/02/19 2:08 PM 2051SURGICAL CONSIDERATIONS IN OLDER ADULTSCHAPTER 47is recommended; (d) if the patient is at low risk for major car-diac events (<1%) then no further testing is needed; (e) if the patient is at elevated risk of major cardiac events, then determi-nation of functional capacity with an objective measure or scale may be helpful; (f) if functional


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Surgery_Schwartz. testing is needed; (e) if the patient is at elevated risk of major cardiac events, then determi-nation of functional capacity with an objective measure or scale may be helpful; (f) if functional capacity is poor, then additional testing such as pharmacological stress testing, may be helpful; and finally (g) if testing does not impact care, then one should proceed to surgery or consider alternative treatment strategies.38 Routine electrocardiograms are not indicated in older patients undergoing low-risk surgery in the absence of other risk factors.39-41The combined effect of depletion of intravascular volume, age-related impairment of response to catecholamines, and increased myocardial relaxation time adversely affects the cardiac function of an older adult patient under stress in the perioperative period. Aging has been demonstrated to cause a decrease in cardiac output by approximately 1% per year. Older individuals fail to augment heart rate to the same extent as younger


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Surgery_Schwartz. in the perioperative period. Aging has been demonstrated to cause a decrease in cardiac output by approximately 1% per year. Older individuals fail to augment heart rate to the same extent as younger individuals. More importantly, the ability to increase cardiac output with aging is dependent on ventricular dilatation, which is determined by preload. Therefore, careful attention must be paid to volume status in the perioperative period. Over one half of all postoperative deaths in older adult patients and 11% of postoperative complications are a result of impaired car-diac function under physiologic stress. Incomplete emptying of the ventricle at end systole and subsequent reduction in ejection fraction is characteristic of the aging heart. Reduced distensibil-ity, in addition to acute stressors, leads to impaired coronary perfusion and cardiac ischemia.An important predictor of surgical outcomes and cardiac complications in the older adult is congestive heart failure (CHF). CHF is


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Surgery_Schwartz. stressors, leads to impaired coronary perfusion and cardiac ischemia.An important predictor of surgical outcomes and cardiac complications in the older adult is congestive heart failure (CHF). CHF is present in approximately 10% of patients older than 65 years and is the leading cause of postoperative morbid-ity and mortality. This prevalence will likely increase as per-cutaneous interventions and medical therapy prolongs survival from myocardial ischemia and acute myocardial infarction. Therefore, identifying correctable and uncorrectable cardiovas-cular disease is critical before elective surgical interventions.Common pulmonary postoperative complications in older adults include atelectasis, pneumonia, and prolonged mechanical ventilation.42 These complications can contribute significantly to overall morbidity and mortality among older adults, affecting up to 15% of individuals ≥70 years in the postoperative setting.22,43 Risk factors for postoperative pulmonary complications


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Surgery_Schwartz. to overall morbidity and mortality among older adults, affecting up to 15% of individuals ≥70 years in the postoperative setting.22,43 Risk factors for postoperative pulmonary complications include both patient and procedure-related factors. Patient-related fac-tors include age >60, chronic obstructive pulmonary disease (COPD), American Society of Anesthesiologists (ASA) class II or greater, functional dependence, congestive heart failure, obstructive sleep apnea, pulmonary hypertension, current ciga-rette use, impaired sensorium, preoperative sepsis, weight loss >10% in 6 months, serum albumin <3.5 mg/dL, and blood urea nitrogen (BUN) ≥7.5 mmol/L (≥1.5 mg/dL). Surgical related fac-tors include prolonged operation of greater than 3 hours, surgi-cal site, emergency operation, general anesthesia, perioperative transfusion, and residual neuromuscular blockade after an opera-tion. Of note, obesity, well-controlled asthma, and diabetes are not risk factors for postoperative pulmonary


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Surgery_Schwartz. anesthesia, perioperative transfusion, and residual neuromuscular blockade after an opera-tion. Of note, obesity, well-controlled asthma, and diabetes are not risk factors for postoperative pulmonary complications. It is recommended that patients with COPD and asthma that is not well controlled undergo preoperative optimization of pulmonary function and other general recommendations include smoking cessation, preoperative intensive inspiratory muscle training, and selective chest radiograph and pulmonary function testing.22In general, the use of routine preoperative screening com-bined with the high cost of unnecessary testing dispute the use of a routine battery of preoperative screening tests in all patients. Instead, it is preferable to perform selected tests in high-risk patients based on history, physical exam, known comorbidities, and the type of procedure being planned.22Nutritional AssessmentNutritional status should also be performed in older adults prior to surgery, as poor


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Surgery_Schwartz. on history, physical exam, known comorbidities, and the type of procedure being planned.22Nutritional AssessmentNutritional status should also be performed in older adults prior to surgery, as poor nutrition is potentially modifiable and related to increased risk of postoperative complications. The most com-mon adverse events related to poor nutritional status are infec-tious complications (i.e., surgical site infections, pneumonia, urinary tract infections), wound complications (i.e., dehiscence and anastomotic leaks), and increased length of stay. The ACS NSQIP/AGS best practice guidelines recommend the following to screen for poor nutritional status:1. Document height and weight and calculate body mass index (BMI). A BMI <18.5 kg/m2 places an individual at risk and should prompt referral for full nutritional assessment.2. Measure baseline serum albumin and prealbumin levels. Serum albumin <3.0 g/dL (with no evidence of hepatic or renal dysfunction) should prompt referral for full


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Surgery_Schwartz. for full nutritional assessment.2. Measure baseline serum albumin and prealbumin levels. Serum albumin <3.0 g/dL (with no evidence of hepatic or renal dysfunction) should prompt referral for full nutritional assessment.3. Inquire about unintentional weight loss in the last year. Unintentional weight loss >10% to 15% in the past 6 months is associated with severe nutritional risk and should prompt assessment by a dietician.22The American Society for Parenteral and Enteral Nutrition (ASPEN) argues that measurement of serum albumin and pre-albumin reflect the severity of the inflammatory response rather than true poor nutritional status. Instead, they favor a more indi-vidualized approach whereby the presence of any of the follow-ing six factors would classify an individual with malnutrition:1. Insufficient energy intake. Severe malnutrition in the context of chronic illness is defined as <75% of estimated energy requirement for ≥1 month.2. Weight loss. Severe malnutrition in the context


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Surgery_Schwartz. energy intake. Severe malnutrition in the context of chronic illness is defined as <75% of estimated energy requirement for ≥1 month.2. Weight loss. Severe malnutrition in the context of chronic illness is defined as >5% weight loss in 1 month, >7.5% weight loss in 3 months, >10% weight loss in 6 months, and >20% weight loss in 1 year.3. Loss of muscle mass. Severe malnutrition is defined as severe muscle wasting of the temples, clavicles, shoulders, interosseous muscles, scapula, thigh, and calf.4. Loss of subcutaneous fat. Severe malnutrition is defined as loss of subcutaneous fat (e.g., orbital, triceps, fat overlying the ribs).5. Localized or generalized fluid accumulation that may sometimes mask weight loss. This can be demonstrated by fluid accumulation evident on exam (e.g., extremities, vulvar/scrotal edema, or ascites).6. Diminished functional status as measured by hand grip strength. Measurements for grip strength are based on nor-mative standards supplied by the


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Surgery_Schwartz. extremities, vulvar/scrotal edema, or ascites).6. Diminished functional status as measured by hand grip strength. Measurements for grip strength are based on nor-mative standards supplied by the manufacturer of the mea-surement device.44Regardless of the method used to measure nutritional sta-tus, attention to the diagnosis and management of malnutrition in the perioperative setting is imperative to optimize postopera-tive outcomes.4Brunicardi_Ch47_p2045-p2060.indd 205128/02/19 2:08 PM 2052SPECIFIC CONSIDERATIONSPART IIPsychosocial ConsiderationsAnxiety, depression, substance abuse, and social isolation are common, underdiagnosed conditions in older adults. Careful screening can identify these potential barriers to recovery, safe discharge after surgery, and maintenance of independence.Medication ReviewCareful review and documentation of the patient’s complete med-ication history is important in the preoperative setting. The review should include the use of nonprescription agents,


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Surgery_Schwartz. ReviewCareful review and documentation of the patient’s complete med-ication history is important in the preoperative setting. The review should include the use of nonprescription agents, including over-the-counter, nonsteroidal anti-inflammatory drugs (NSAIDs), vitamins, eye drops, topical agents, and herbal products.Additionally, it is important to discontinue medications that should be avoided prior to surgery in order to minimize potential adverse events and interactions. These include dis-continuation of all nonessential medications that are associated with increased surgical risk and medications with potential for drug interactions with anesthesia. Herbal medication should be stopped at least 7 days prior to surgery, and the Beers criteria should be reviewed. Medications with potential for withdrawal (e.g., selective serotonin reuptake inhibitor [SSRIs], tricyclic antidepressants, benzodiazepines, antipsychotics, monoamine oxidase inhibitors [MAOIs], β-blockers, clonidine,


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Surgery_Schwartz. for withdrawal (e.g., selective serotonin reuptake inhibitor [SSRIs], tricyclic antidepressants, benzodiazepines, antipsychotics, monoamine oxidase inhibitors [MAOIs], β-blockers, clonidine, statins, and corticosteroids) in addition to angiotensin-converting enzyme inhibitors and angiotensin II receptor blockers should be con-tinued unless hypertension is well controlled. Medications that are associated with increased risk for postoperative delirium should also be avoided and replaced with safer medications. For example, benzodiazepines should be stopped or reduced, where possible. Pain should be adequately controlled and meperi-dine should be avoided for pain management. Caution should be used when prescribing antihistamine H1 antagonists (such as diphenhydramine/Benadryl) and medications with antihista-mine effects. Of note, there is no increased risk associated with neuroleptics (antipsychotics) and digoxin and no conclusive evi-dence against using H2 agonists, tricyclic


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Surgery_Schwartz. medications with antihista-mine effects. Of note, there is no increased risk associated with neuroleptics (antipsychotics) and digoxin and no conclusive evi-dence against using H2 agonists, tricyclic antidepressants, anti-Parkinson medications, steroids, NSAIDs, and antimuscarinics in the perioperative setting.Certain medications, such as β-blockers or statins, may be beneficial to start preoperatively in order to reduce risk of perioperative adverse events such as cardiac complications and stroke. There are ACC/AHA guidelines to support the use of perioperative β-blockers in patients who are already taking them, particularly those with independent cardiac indications such as arrhythmia or history of myocardial infarction and in patients who are undergoing intermediate risk or vascular surgery with no known coronary artery disease or with multiple clinical risk factors for ischemic heart disease. Statins should be started as soon as possible prior to surgery in patients who have known


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Surgery_Schwartz. with no known coronary artery disease or with multiple clinical risk factors for ischemic heart disease. Statins should be started as soon as possible prior to surgery in patients who have known vascular disease, elevated low-density lipoprotein cholesterol, or ischemia on thallium testing. They may also be considered in patients undergoing vascular and intermediate-risk surgery.Additionally, medications doses should be adjusted based on renal function. Older patients are at greater risk for renal impairment and chronic kidney disease; furthermore, adjustment of medications that are renally cleared is an important consider-ation. Glomerular filtration rate (GFR), rather than creatinine, is the best overall measure of renal function due to the fact that the ratio of GFR to creatinine decreases with increasing age.22Finally, medication use is very common among the older population, and older individuals should be monitored for polypharmacy and potential adverse interactions. This is of


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Surgery_Schwartz. with increasing age.22Finally, medication use is very common among the older population, and older individuals should be monitored for polypharmacy and potential adverse interactions. This is of real concern since 40% of individuals age 65 years and older are taking five or more medications prescribed by more than one doctor.45 Additionally, 68% of older adults use over-the-counter medications, dietary supplements, or both concurrently with prescription medications.46 Of note, polypharmacy has been associated with increased risk of cognitive impairment, morbidity, and mortality, and the risk of adverse drug reactions increases with a greater number of medications.45,47Patient CounselingDetermination of the patient’s preferences and expectations prior to surgery is an essential component to preoperative assessment and decision making. One study demonstrated that agreement between patients and their surrogates (primary care providers and close family members) was poor, despite patients


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Surgery_Schwartz. preoperative assessment and decision making. One study demonstrated that agreement between patients and their surrogates (primary care providers and close family members) was poor, despite patients predicting that their physicians (90%) and family members (87%) would accurately represent their wishes. Instead, they found that per-cent of agreement ranged from 59% to 88%, suggesting that sub-stituted judgement may not be a good proxy for an individual patient’s wishes.48 Another study looked at older patients with limited life expectancy due to cancer, congestive heart failure, or chronic obstructive pulmonary disease and found that 99% of patients would undergo a low-burden treatment to restore current health (with the alternative being death), but that 74% and 89% would forgo treatment if it resulted in severe functional or cognitive impairment, respectively.49 Furthermore, it is imperative that the surgeon have a substantive discussion with the patient prior to sur-gery to determine


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Surgery_Schwartz. it resulted in severe functional or cognitive impairment, respectively.49 Furthermore, it is imperative that the surgeon have a substantive discussion with the patient prior to sur-gery to determine their preferences and expectations and that fam-ily members and potential decision-making surrogates be involved. The ACS NSQIP/AGS Guidelines recommend that the following four points be included in these conversations:1. Ensure that the patient has an advance directive and desig-nated health care proxy.2. Discuss treatment goals and plans with the patient to ensure that the physician understands the patient’s preferences and expectations. This should be documented in the medical record.3. The surgeon should describe the expected postoperative course and possible complications, including the potential for functional decline and need for rehabilitation or nursing home care, if relevant.4. The physician should determine the patient’s family and social support systems. If support is


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Surgery_Schwartz. the potential for functional decline and need for rehabilitation or nursing home care, if relevant.4. The physician should determine the patient’s family and social support systems. If support is insufficient, then a referral to a social worker should be considered.22The American College of Surgeons has created a checklist for the optimal preoperative assessment of the geriatric surgical patient (see Table 47-2).PREOPERATIVE PREPARATIONIn the immediate preoperative period, careful planning is essen-tial to optimize the care of the frail older patient.Patient Goals, Preferences, and Advance DirectivesIt is important that surgeons have a good understanding of patients’ goals and wishes surrounding their medical care, par-ticularly towards the end of life. This should be established in the clinic setting prior to surgery and should be confirmed Brunicardi_Ch47_p2045-p2060.indd 205228/02/19 2:08 PM 2053SURGICAL CONSIDERATIONS IN OLDER ADULTSCHAPTER 47and documented throughout the


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Surgery_Schwartz. clinic setting prior to surgery and should be confirmed Brunicardi_Ch47_p2045-p2060.indd 205228/02/19 2:08 PM 2053SURGICAL CONSIDERATIONS IN OLDER ADULTSCHAPTER 47and documented throughout the process. Additionally, patients should be encouraged to designate a health care proxy to help with this process, should they be unable to make their own med-ical decisions. The healthcare team should also consider early palliative care consultation in individuals with poor prognoses who are electing to undergo surgery, particularly if they have a life expectancy of less than 6 months.Preoperative FastingHistorically, preoperative fasting began at midnight the night before elective surgery, whereby, patients were not permitted to have any oral intake of either liquids or solids. However, more recent literature suggests that there may be no clear benefit to extended periods of fasting greater than 6 hours.50 Based on the American Society of Anesthesiologists 2011 practice guidelines for all


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Surgery_Schwartz. literature suggests that there may be no clear benefit to extended periods of fasting greater than 6 hours.50 Based on the American Society of Anesthesiologists 2011 practice guidelines for all adults, fasting should take the form of stopping clear liq-uids at least 2 hours before elective procedures, stopping light food intake and/or nonhuman milk 6 hours before elective pro-cedures and stopping fried, fatty foods and meat at least 8 hours before elective procedures. Of note, patients with comorbidities or diseases that can affect gastric emptying (i.e., diabetes, hiatal hernia) may require additional periods of fasting.Antibiotic Prophylaxis and Venous Thromboembolism PreventionAntibiotic prophylaxis for older adults should comply with standard guidelines put forth by The Society for Healthcare Epidemiology of America/Surgical Infection Society/American Society of Health-System Pharmacists/Infectious Disease Society. Older adults who receive appropriate preoperative antibiotics


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Surgery_Schwartz. Healthcare Epidemiology of America/Surgical Infection Society/American Society of Health-System Pharmacists/Infectious Disease Society. Older adults who receive appropriate preoperative antibiotics demonstrate a mortality benefit at 60 days.51,52 Appropriate antibiotics should be administered within 60 minutes prior to surgical incision.Older adults are at higher risk for venous thromboem-bolism (VTE), making VTE risk stratification among this population essential. Older individuals undergoing orthopedic procedures (i.e., total hip or knee arthroplasty) or who have suffered a hip fracture should be treated with low molecular weight heparin (LMWH) (starting either 13 hours or more pre-operatively or 12 hours or more postoperatively) for a minimum of 10 to 14 days and up to 35 days. Older adults undergoing nonorthopedic surgery (i.e., general, abdominopelvic, bariatric, vascular plastic/reconstructive, and thoracic surgery) should have LMWH or low-dose unfractionated heparin (LDUH) and


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Surgery_Schwartz. undergoing nonorthopedic surgery (i.e., general, abdominopelvic, bariatric, vascular plastic/reconstructive, and thoracic surgery) should have LMWH or low-dose unfractionated heparin (LDUH) and mechanical prophylaxis with intermittent pneumatic compres-sion (IPC). Older adults undergoing craniotomy/spinal surgery or cardiac surgery should have IPC. Finally, older individuals who experienced major trauma and spinal cord injury should use LDUH/LMWH and IPC if not contraindicated.23Surgical PrehabilitationOne purpose of the preoperative assessment is to identify potentially modifiable risk factors in order to optimize surgi-cal outcomes. Several prehabilitation programs have emerged in order to help meet this need and have demonstrated prom-ising results. One of the first of such programs was referred to as the Proactive Care of Older People undergoing surgery (POPS) study in the United Kingdom’s National Health Service (NHS). This project was designed to decrease complications leading


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Surgery_Schwartz. referred to as the Proactive Care of Older People undergoing surgery (POPS) study in the United Kingdom’s National Health Service (NHS). This project was designed to decrease complications leading to increased hospital length of stay among at-risk older adults undergoing elective surgery. The authors performed a structured geriatric team intervention to identify at-risk patients and to then facilitate coordinated multidisciplinary care in the form of daily inpatient rounds, weekly multidisciplinary meet-ings, and biweekly ward rounds led by a POPS consultant/clini-cal nurse specialist. Outcomes in surgical patients undergoing the POPS intervention were compared to those among patients not undergoing the intervention. The POPS group had fewer postoperative complications, including lower rates of pneumo-nia (4% vs. 20%, P = 0.008) and delirium (4% vs. 19%, P = 0.028), better pain control (2% vs. 30%, P <0.001), lower rates of delayed mobilization (9% vs. 28%, P = 0.-12) and lower rates


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Surgery_Schwartz. of pneumo-nia (4% vs. 20%, P = 0.008) and delirium (4% vs. 19%, P = 0.028), better pain control (2% vs. 30%, P <0.001), lower rates of delayed mobilization (9% vs. 28%, P = 0.-12) and lower rates of inappropriate catheter use (7% vs. 37%, P = 0.046). They also demonstrated a reduction in hospital length of stay by 4.5 days.53The Michigan Surgical Home and Optimization Program (MSHOP) is another example of a successful prehabilitation program. This is a structured, home-based preoperative train-ing program that targets physical, nutritional, and psychological interventions. The intervention included the following four com-ponents: (a) a home-based walking program with daily remind-ers and feedback; (b) incentive spirometry instructions starting one week prior to surgery; (c) education on nutrition, stress management, and care planning; and (d) resources for smoking cessation, when appropriate. Eighty-two percent of individu-als enrolled in the study were actively engaged in the


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Surgery_Schwartz. on nutrition, stress management, and care planning; and (d) resources for smoking cessation, when appropriate. Eighty-two percent of individu-als enrolled in the study were actively engaged in the program. Compared to individuals who did not undergo the intervention, patients enrolled in the trial demonstrated a 31% reduction in hospital length of stay and a 28% reduction in cost.64 Collec-tively, the POPS study and the MSHOP studies are illustrative of the notion that attention to preand perioperative assessment in the older population result in improved postoperative out-comes that benefit the patient, hospital, and health care system.Palliative Care Services for Older Surgical PatientsAmong seriously ill individuals, palliative care services have the potential to increase quality of life, improve symptoms and patient satisfaction, and reduce caregiver burden.55-57 The role of palliative care in older surgical patients is not as well under-stood, and it is not widely understood in


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Surgery_Schwartz. improve symptoms and patient satisfaction, and reduce caregiver burden.55-57 The role of palliative care in older surgical patients is not as well under-stood, and it is not widely understood in the surgical population.58 Over a decade ago, the American College of Surgeons Pallia-tive Care Workgroup identified core competencies of surgical palliative care.59 The two key elements of palliative care—pain management and communication skills—are essential. For sur-geons who frequently care for individuals at high risk of mor-bidity and mortality, there are six additional core competency domains: patient care, medical knowledge, practice-based learn-ing, interpersonal skills, communication skills, and profession-alism (Table 47-5).Emerging data suggests that surgical patients benefit from the addition of palliative care principles and services. An interventional trial evaluating a decision-making interven-tion considering procedures that included information about health status and


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Surgery_Schwartz. the addition of palliative care principles and services. An interventional trial evaluating a decision-making interven-tion considering procedures that included information about health status and prognosis increased the likelihood of choosing less aggressive treatment options among patients with frailty (OR 3.41, 95% CI 1.39–8.39) or dementia (OR 1.66, 95% CI 1.06–2.64).60 In a study of preoperative care consultation in frail older adults, Ernst et al found that preoperative palliative care consultations were associated with reduced mortality.61 Several studies have found that postoperative palliative care improves symptoms, including uncertainly, symptom distress, and depres-sion, and improves quality of life.62-63Brunicardi_Ch47_p2045-p2060.indd 205328/02/19 2:08 PM 2054SPECIFIC CONSIDERATIONSPART IITable 47-5Core Competencies in surgical palliative careDOMAINCOMPETENCYPatient Care Possess the capacity to guide the transition from curative and palliative goals of treatment


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Surgery_Schwartz. 47-5Core Competencies in surgical palliative careDOMAINCOMPETENCYPatient Care Possess the capacity to guide the transition from curative and palliative goals of treatment to palliative goals alone based on patient information and preferences, scientific and outcomes evidence, and sound clinical judgmentPerform an assessment and gather essential clinical information about symptoms, pain, and sufferingPerform palliative procedures competently and with sound judgment to meet patient goals of care at the end of lifeProvide management of pain and other symptoms to alleviate sufferingCommunicate effectively and compassionately bad news and poor prognosesConduct a patient and family meeting regarding advance directives and end-of-life decisionsExercise sound clinical judgment and skill in the withdrawal and withholding of life supportMedical knowledge Acute and chronic pain managementNon-pain symptom managementEthical and legal basis for advance directives, informed consent,


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Surgery_Schwartz. in the withdrawal and withholding of life supportMedical knowledge Acute and chronic pain managementNon-pain symptom managementEthical and legal basis for advance directives, informed consent, withdrawal and withholding of life support, and futilityGrief and bereavement in surgical illnessQuality of life outcomes and prognosticationRole of spirituality at the end of lifeInterpersonal and communication skillsSurgeons must be competent and compassionate communicators with patients, families, and other health care providers. They should be effective in communicating bad news and prognosis and in redefining hope in the context of cultural diversity. The interdisciplinary nature of palliative care requires that the surgeon is skilled as both a leader and a member of an interdisciplinary team and maintains collegial relationships with other health care providers.ProfessionalismSurgeons must maintain professional commitment to ethical and empathic care, which is patient focused, with


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Surgery_Schwartz. team and maintains collegial relationships with other health care providers.ProfessionalismSurgeons must maintain professional commitment to ethical and empathic care, which is patient focused, with equal attention to relief of suffering along with curative therapy. Respect and compassion for cultural diversity, gender, and disability is particularly important around rituals and bereavement at the end of life. Maintenance of ethical standards in the withholding and withdrawal of life support is essential.Systems-based practiceSurgeons must be aware and informed of the multiple components of the health care system that provide palliative and end-of-life care. Surgeons should be knowledgeable and willing to refer patients to hospice, palliative care consultation, pain management, pastoral care, social services, etc., and to understand resource utilization and reimbursement issues involved.Data from Mohanty S, Rosenthal RA, Russell MM, et al: Optimal Perioperative Management of the


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Surgery_Schwartz. care, social services, etc., and to understand resource utilization and reimbursement issues involved.Data from Mohanty S, Rosenthal RA, Russell MM, et al: Optimal Perioperative Management of the Geriatric Patient: A Best Practices Guideline from the American College of Surgeons NSQIP and the American Geriatrics Society, J Am Coll Surg. 2016 May;222(5):930-947.SPECIAL CONSIDERATIONSFunctional RecoveryIn the past decade, there has been increasing attention to the examination of functional outcomes after major surgery in the geriatric population. In a large prospective cohort study of patients age 60 years and older undergoing abdominal surgery, Lawrence et al found that older adults required several months to fully return to basic activities of daily living (ADLs) and up to 6 months to become independent in more complex instrumental activities of daily living (IADLs).65 Older adults are frequently discharged to postacute facilities even when they are functional dependent at baseline


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Surgery_Schwartz. independent in more complex instrumental activities of daily living (IADLs).65 Older adults are frequently discharged to postacute facilities even when they are functional dependent at baseline and have an uncomplicated postoperative course.66Among frail older adults, functional decline after surgery is often substantial and sustained. Studies examining functional outcomes after surgery among nursing home residents have demonstrated that the majority of nursing home residents who undergo surgery do not return to baseline levels of function post-operatively.67-68 Among residents who underwent colectomy for cancer, 53% were dead after 1 year and over half of 1-year survi-vors experienced functional decline.68 For residents who undergo lower extremity bypass, half die within a year of surgery.67 At 1 year, 13% of the initial vascular surgery cohort was ambulatory, and 18% had maintained or improved their baseline functional status—calling into question the efficacy of this procedure in


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Surgery_Schwartz. At 1 year, 13% of the initial vascular surgery cohort was ambulatory, and 18% had maintained or improved their baseline functional status—calling into question the efficacy of this procedure in the nursing home. A study of hip fracture repair in nursing home resi-dents found that over a third of residents died and over half of resi-dents had died or experienced functional decline within 180 days after fracture. Residents with multiple comorbidities and advanced cognitive impairment and those who did not undergo surgical cor-rection of the fracture experienced the worst outcomes.5Brunicardi_Ch47_p2045-p2060.indd 205428/02/19 2:08 PM 2055SURGICAL CONSIDERATIONS IN OLDER ADULTSCHAPTER 47Cancer SurgeryApproximately 50% of cancer diagnoses are currently made in patients age 70 years or older.69 It is predicted that the increase in the older adult population will account for up to a 50% increase in the number of patients undergoing oncologic procedures by the year 2020. The increased


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Surgery_Schwartz. It is predicted that the increase in the older adult population will account for up to a 50% increase in the number of patients undergoing oncologic procedures by the year 2020. The increased life expectancy of the geriatric patient coupled with the increasing incidence of cancer with advancing age will lead to an increased prevalence of malignant disease requiring surgical intervention. This is an area of great interest given that randomized clinical trials to determine the out-comes of older adult patients undergoing curative resections, as well as neoadjuvant and adjuvant therapy, are lacking. In addi-tion, older adult patients are rarely included in clinical trials; therefore, treatment decisions are often based on individual sur-geon experience and nongeriatric data, and they may be flawed by inherent biases regarding the outcome of complete oncologic resections in older adult patients. Surgeons may also be reluctant to expose older patients to the toxic effects of chemotherapy


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Surgery_Schwartz. flawed by inherent biases regarding the outcome of complete oncologic resections in older adult patients. Surgeons may also be reluctant to expose older patients to the toxic effects of chemotherapy and radiation without proven efficacy in this geriatric population. This highlights the need for research targeting the specific needs of older adult patients with malignancy to aid in the development of specific treatment guidelines for various cancers within this age cohort.Numerous studies have documented increased risk of post-operative morbidity and mortality in older adults with cancer. Evaluation of a national surgical registry found that older adults undergoing major gastrointestinal surgery have substan-tially higher risks of complications and death than individuals younger than 65 years.70 The impact of age on risk was present across all operations but had most impact in liver and rectal surgery. Surgeons are challenged to decide whether major sur-gery is justified in older adult


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Surgery_Schwartz. The impact of age on risk was present across all operations but had most impact in liver and rectal surgery. Surgeons are challenged to decide whether major sur-gery is justified in older adult patients, especially those with limited life expectancy. Effectiveness of oncologic surgery in older adult patients depends on whether a cure can be achieved safely without compromise to functional status or quality of life. Postoperative life expectancy should be improved by surgery, or, at the very least, not diminished.Emergency SurgeryEmergent surgery caries exceptionally high risk for older adult patients. In an analysis of patients age 90 years and older, 90-day mortality after emergency gastrointestinal procedures was 54%.71 In a large cohort of patients undergoing endovas-cular repair for ruptured aortic aneurysm, 30-day mortality was 35% after primary aortic repair and 52% after open conversion of endovascular aortic repair.72Frail institutionalized elders are at substantial risk for


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Surgery_Schwartz. ruptured aortic aneurysm, 30-day mortality was 35% after primary aortic repair and 52% after open conversion of endovascular aortic repair.72Frail institutionalized elders are at substantial risk for poor surgical outcomes after emergent surgery. In an analysis of over 70,000 nursing home residents who underwent emer-gent abdominal operations (surgery for bleeding ulcer, chole-cystectomy, appendectomy, and colectomy), operative mortality was twoto threefold higher than among matched community-dwelling elders.73 In addition, invasive life-sustaining interven-tions after surgery were significantly higher in the nursing home population than among noninstitutionalized Medicare enrollees, ranging from 18% vs. 5%, respectively, after cholecystectomy to 55% vs. 43%, respectively, after ulcer surgery. The combined effects of poor nutrition, decreased cogni-tion, and immune impairments due to nutritional or phar-macologic factors create a treacherous circumstance for older adult patients with


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Surgery_Schwartz. The combined effects of poor nutrition, decreased cogni-tion, and immune impairments due to nutritional or phar-macologic factors create a treacherous circumstance for older adult patients with poorly defined symptoms or who pres-ent with more advanced disease. In acute abdominal conditions, such as acute appendicitis and acute cholecystitis, one-third of older adult patients will lack an elevated white blood cell count, one-third will lack fever, and one-third will lack physical find-ings of localized peritonitis.74 These deficits contribute to a threefold higher rate of perforated appendicitis and of gangrene of the gallbladder in older adult patients compared to young patients. An “unimpressive” physical exam in an older adult patient with acute onset of abdominal symptoms should never be taken as a sign of the absence of surgical disease.Cardiovascular SurgeryWith advances in cardiopulmonary bypass technique, myocar-dial protection, and improved perioperative care, coronary artery


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Surgery_Schwartz. be taken as a sign of the absence of surgical disease.Cardiovascular SurgeryWith advances in cardiopulmonary bypass technique, myocar-dial protection, and improved perioperative care, coronary artery bypass grafting (CABG) and valve replacement operations have become safer in older patients. When considering cardiovascular surgery in elders, it is essential to consider that advanced age is not the strongest predictor of poorer outcomes or increased mor-tality compared in older patients. It has been demonstrated that emergency operations, preoperative New York Heart Association (NYHA) functional class 3 or greater, and chronic renal failure are the strongest independent predictors of increased operative mortality.75 In one study, preoperative renal dysfunction, cere-brovascular disease, valve surgery, and catastrophic state were independent predictors of increased mortality in older adult patients.76 Older adult patients with non–dialysis-dependent renal dysfunction had a 60% chance of


Surgery_Schwartz

Surgery_Schwartz. surgery, and catastrophic state were independent predictors of increased mortality in older adult patients.76 Older adult patients with non–dialysis-dependent renal dysfunction had a 60% chance of death during a 5-year follow-up period compared to 25% in older adult patients with-out a history of renal dysfunction. Similarly, the presence of cerebrovascular disease resulted in a two-fold increase in mor-tality among older adult patients.76 Even patients who were 80 years of age or more did not have any significant increase in surgical risk and within this population, and the 4-year actuarial survival was 70.5% with an event-free survival of 60.6%.There has been an increase in definitive operative interven-tion to older patients with operable coronary artery disease. The Society of Thoracic Surgeons reports that perioperative mortality rates range from 1.6% in patients 51 to 60 years of age to 7.7% in those 81 to 90 years of age.77 Older patients are more likely to have significant


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Surgery_Schwartz. Surgeons reports that perioperative mortality rates range from 1.6% in patients 51 to 60 years of age to 7.7% in those 81 to 90 years of age.77 Older patients are more likely to have significant three-vessel disease accompanied by poor ejec-tion fraction, left ventricular hypertrophy, significant valvular disease, and previous history of myocardial infarction than are younger patients.77 Older patients also are more likely to be clas-sified as NYHA functional class 3 or higher and are more likely to present on an emergent basis, in part because of reluctance to provide elective surgical intervention because of presumptive poorer outcome. Despite the increased risk of morbidity and mortality compared to younger patients, older adult patients, including those >80 years old, can undergo CABG with accept-able mortality risk. The overall mortality rate is approximately 7% to 12% for older adult patients, including those in whom CABG is performed under emergency conditions. The mortality


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Surgery_Schwartz. with accept-able mortality risk. The overall mortality rate is approximately 7% to 12% for older adult patients, including those in whom CABG is performed under emergency conditions. The mortality rate decreases to approximately 2.8% when CABG is performed electively with careful preoperative evaluation.78Valve ReplacementAs the population ages, the incidence of senile calcific aortic stenosis and referral for aortic valve replacement are increas-ing. The operative mortality from aortic valve replacement is estimated to be between 3% and 10%, with an average of approximately 7.7%.76 If aortic stenosis is allowed to progress without operative intervention, CHF will ensue. The average survival of these patients is approximately 1.5 to 2 years. If a patient is deemed fit for operative intervention, age should not 6Brunicardi_Ch47_p2045-p2060.indd 205528/02/19 2:08 PM 2056SPECIFIC CONSIDERATIONSPART IIbe a deterrent, especially considering the potential to increase life expectancy. It