Perioperative care in older adults.

Abstract

1 Background Over the last 20 years, the number of older adults requir- ing surgical interventions has substantially increased and will continue to escalate as the population ages. Periopera- tive management of older patients poses challenges not en- countered in younger individuals. People over 70 years of age are more likely to have multiple comorbidities, physical and cognitive impairments, and reduced cardiac, pulmonary, and renal reserve. These factors predispose older patients to increased risk for perioperative complications and pro- longed length of hospital stay, which in turn increase risk for iatrogenesis, nosocomial infections, and perioperative mortality. Current recommendations for perioperative assessment and management for older patients are derived from data collected in predominantly younger cohorts. Given the pau- city of evidence-based guidelines for this patient population, it is vital to understand the pathophysiologic changes that occur in the older patient in order to reduce their periopera- tive risk. The objectives of this review are to briefly summarize age-related effects on organ system reserve, identify comor- bidities and geriatric conditions that pose increased risk for perioperative complications, and increase awareness of the essentials of perioperative evaluation and therapy in the older surgical patient. The overall goals are to ensure ap- propriate perioperative assessment and medical manage- ment and to minimize the risk of complications in older patients undergoing surgical procedures. ogic reserve of all organ systems, even in the absence of any underlying pathology, and these changes predispose to the development of perioperative adverse events. In addition, older patients often have multiple comorbidities requiring complex medical regimens that may further complicate pe- rioperative management. In this context, age-related changes in gastrointestinal physiology, kidney function, body com- position (such as reduction in muscle mass and intravascular volume) and metabolism lead to alterations in the pharma- codynamics and pharmacokinetics of most drugs. As a re- sult, older patients are often more sensitive to anesthetic and analgesic agents administered during the perioperative period. Other age-related physiologic alterations increase the li- kelihood of postoperative cardiac (e.g., atrial fibrillation, heart failure) and non-cardiac (e.g., delirium, pneumonia) complications. For these reasons, older patients undergoing major surgery require a comprehensive preoperative evalua- tion that should include assessment of functional status, cognition, and frailty. Combining these factors with conven- tional perioperative risk assessments facilitates the identifi- cation of older patients at risk for specific postoperative complications, and may enable implementation of manage- ment strategies designed to reduce perioperative risk and minimize delays in recovery.