Changing Ideas on Surgery for the Elderly
Nowadays, the punchline doesn't carry the same comical weight as it
would have 20 years ago. And not only are people living longer, but
they are being operated on at increasingly later stages in life. Not
only are these surgeries less risky, there is a greater expectation by
physicians and patients that the elderly still have many years of
productive and fulfilling life ahead of them.
The numbers are staggering. Currently, one out of eight
Americans is older than 65; by 2050, one in five will be older than 65.
The fastest growing segment of this population is those over 85. Twenty
years ago, 19 percent of those operated on were over 65; by 1996, that
figure had climbed to 36 percent. In short, a 65-year-old man today can
expect to live another 16 years, a woman 20 additional years.
These trends have caused a subtle shift in decision-making
about surgery. No longer are they based solely on the risk of surgery
itself, but on optimal disease management and the preservation of the
quality of life. One of the issues facing physicians, elderly patients
and their families is the effects of surgery on those mental functions
‚ memory, cognition and intellect that make us who we are.
Are the elderly at greater risk for impairment of mental
functioning after surgery, and if so, why? How can it be prevented? To
try to answer these questions, a group of international experts
convened at Duke last week for the second Duke Conference on Surgery
and the Elderly.
"This topic is so vitally important," Dr. Robert Anderson,
chairman of surgery at Duke, told the assembled group of 40-plus
physicians. "As cardiac surgeons, we operate on elderly patients all
the time. We can keep the heart muscle viable, but what we worry about
the most is cerebral preservation. It's a difficult problem, and one
that needs more investigation."
Already, research led by Duke cardiac anesthesiologist Dr. Mark
Newman has shown that a significant number ‚ 42 percent ‚ of patients
who received coronary bypass surgery had measurable cognitive decline
five years after surgery.
"To help us understand these issues we need better animal
models for pre-clinical studies," Newman said. "We also need to be able
to identify high-risk patients and to organize large multi-center
trials to test new brain-protection ideas."
In other surgical areas, the data aren't as clear. In hip
fracture patients, for example, Dr. Kenneth Koval, orthopedic surgeon
at the Hospital for Joint Diseases at New York University, reported
that 5 percent of his patients suffered cognitive impairments after
It doesn't appear that the type of anesthesia used has an
impact on cognitive decline. After an exhaustive review of the studies
to date, Dr. Pamela Williams-Russo from Cornell could not find a
difference in outcomes between general and regional anesthesia.
"Aging is a rampant global issue," said Dr. Joseph Ouslander,
president of the American Geriatric Society. "We will be taking care of
older and older patients, and they are different."
While all agree that more research is needed, there were certain trends that emerged:
… The older the patient, the higher the risk for cognitive impairment.
… The temperature of the patient during surgery seems to play a role.
… Genetics, through the role of the APOE variant, may be important.
… Education seems to protect against impairment.