Considerations for Geriatric Patients Undergoing Colorectal Surgery
As the population ages, the number of elders undergoing surgery increases dramatically. Historically, surgical outcomes were thought to be notoriously high, however, recent data suggest otherwise in selectively fit individuals. The difficulty in caring fo
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Key Concepts • The geriatric population is diverse, with varying levels of health status including physiologic reserve and cognitive function. As such, chronological age is a poor marker of functional, physical, and cognitive decline in the elderly. • Fit elderly patients, those without significant comorbidities or cognitive decline, can be managed similar to that of younger patients. Frail patients are associated with higher morbidity and mortality in both elective and emergent operations. • Elderly patients undergoing emergent procedures are at high risk (17–31 %) for post-operative mortality. • Minimally invasive surgery is safe and appropriate in the elderly population, allowing them to benefit from decreased post-operative morbidity, faster return of bowel function, decreased length of stay, and less pain. • While some assessment models identify age as an independent risk factor for adverse outcomes, a focus on chronologic age substantially limits effective management of the geriatric patient. • Frailty is used to represent a global limited reserve in the elder population. As such, abnormalities in frailty domains are a potentially useful tool for predicting poor outcomes.
Introduction Today’s elderly population is steadily growing, due in part to improvements in general medical care, enhanced screening protocols, and advances in anesthesia. In fact, the average life expectancy for a 75-year-old man and woman is now 10.7 and 12.8 years, respectively [1]. Life expectancy is further predicated on level of fitness (Figure 65-1). Recent projections suggest over half of all current operations in the USA are performed on patients older than 65 years of age, with estimates of surgical volume increasing from 14 to 47 % between 2000 and 2020, due to more elderly patients [2].
This steadily increasing volume of elderly patients underscores the importance of defining, and applying appropriate treatment in this population. Unfortunately, considerable evidence suggests elderly patients with cancer are less likely to be offered standard of care treatment. This is particularly evident in clinical cancer trials, where elders comprise only 25 % of participants [3]. Exclusion of older patients is not limited to clinical trials, but also extends to chemotherapy, radiation therapy, and surgical intervention [4, 5]. For decades, advanced chronological age has been considered the main factor for determining surgical intervention in older patients. Non-operative bias stems from outdated reports demonstrating higher risk of mortality and morbidity. Recent, but inconsistent, data suggests elective surgery may be safe in the elderly with mortality rates as low as 4.7 % [6–10]. However, post-operative mortality and morbidity in the older population remain variable, with post-operative morbidity reported as high as 60 % [6, 9, 10]. The discrepancy in data may reflect the absence of a consistent definition of “elderly” in the literature, as well as incomplete information concerning common risk factors unique to the elder population. Several s
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