Chance favours the prepared: surgery in older patients
David Cohen is a consultant geriatrician at Northwick Park Hospital and a spokesperson of the British Geriatrics Society.
The Duke of Edinburgh’s recent admission to hospital raised the question of surgery in older people. Surgery and an anaesthetic are a major stress on anybody and older people are particularly susceptible. This not only applies to people who are frail and have other illnesses but also to people who appear very fit. Obviously, in an emergency, there may be no choice other than to go ahead with surgery but in non-urgent situations it is important to take particular precautions in later life. Anyone contemplating surgery should make sure that they have a good general medical history and examination well before the operation. Problems that may affect recovery should be carefully sought and investigated so that there are no surprises.
It is particularly important to identify people who have memory or thinking problems such as early dementia because, to recover well from elective surgery, cooperation with the treating doctors, nurses and physiotherapists is vital. People with dementia often have great difficulties understanding this. They are also more likely to become confused around the time of an operation. This is called delirium and significantly increases the risk of other complications such as falls, constipation and infections. Sometimes it may be better to consider that surgery should not be carried out: accepting the existing condition may be better than the potential complications of an operation.
The surgery itself and any anaesthetic should be carefully planned. There is now very good evidence for the use of ‘enhanced recovery’. The patient attends a special meeting with the surgeon and anaesthetist before surgery when all their other illnesses are carefully analysed. A detailed plan for what will happen around the time of surgery is made so that people can prepare themselves properly. Before planned surgery, patients should try to get as fit as they possibly can, both by taking regular exercise and by stopping any cigarettes, alcohol or unnecessary drugs.
Hospitals using enhanced recovery techniques will shorten the time people have to fast before the anaesthetic, give a special nourishing drink just before surgery and avoid as many of the tubes, drips and catheters often used, unless they are absolutely necessary.
Post-operatively all unnecessary tubes, monitors and precautions will be removed quickly so that patients can get up and walk about. Bed rest can be a bad thing for older people at this time and it is important for them to get out of bed, walk as soon as possible and maintain muscle tone, strength and balance. This lowers the chance of chest and urine infections, leg and lung clots and constipation. Unfortunately many hospitals are still not practising these techniques so patients and relatives should take it upon themselves to try to follow this regime as much as possible. Many surgical complications could be avoided if patients got up and moving more quickly than they do at present.
In frail patients where surgery cannot be avoided it is important to involve specialists for older people such as geriatricians and psycho geriatricians, well before surgery so that plans can be made to minimise and deal with any complications. They will be expert at identifying people who have frailties that are not obvious to most surgeons and will have a much better idea of who will do well and for whom surgery is simply too great a risk.
If you’re interested in improving pre- and peri-operative assessment and management of older patients, you can learn more about this from our POPS special interest group.