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The current annual rate for surgery on people over age 65 is 15 percent and rising. Twenty percent of all open-heart procedures are on people over the age of 70. Improved evaluation and management techniques for older people undergoing surgery are being introduced. In the following pages we will discuss the key issues concerning surgery: determining whether the operation is necessary, agreeing to the surgeons, minimizing your risks, and trying to reduce complications. (More detailed discussion of specific conditions mentioned here can be found in Part IV.)
You should be aware of your responsibility in selecting a surgeon. Sometimes your personal physician helps by recommending the surgeon, but you are ultimately in charge of this decision. Approximately one-quarter to one-third of all surgical procedures currently performed in the United States are unnecessary. You should always obtain a second opinion before deciding to have any kind of elective surgery. If your physician recommends surgery, find out as much as possible about what will happen during surgery. Also, determine the surgeon's experience in performing the operation, and what the surgeon considers acceptable as quality of life for a person before and after the surgery. If you want to know who will perform the anesthesia during the surgery, ask the surgeon. What matters most concerning an anesthesiologist is that the surgeon feels comfortable with the anesthesiologist's work, reputation, and expertise. Also, you should not assume that the surgeon you have chosen will be the person who actually performs the operation. Ask the surgeon who will perform the operation. Some hospitals are teaching hospitals, and the actual surgical procedure may be done by a surgical resident who is learning the technique. You have every right to know who will be performing the surgery on you.
Although the risk associated with many operations increases as we age, the overall risk for older people has been steadily declining over the past 30 years. In fact, elective surgery on people who are over 80 years old is safer in the 1990s than the same procedures were when performed on younger people in the 1960s. Coexisting medical diseases and the urgency of the procedure are more important factors than age in predicting possible complications. Moreover, people over the age of 80 can undergo major surgery without excessive mortality.
Complications involving the heart are the most life-threatening. In surgical cases involving elderly individuals, mortalities due to heart disease are about 3 to 5 percent. The average risk of a heart attack after surgery is 1 to 4 percent and that of congestive heart failure is between 4 and 10 percent.
Complications involving the lungs, the most common cause of postoperative complications in the older age group, affect 15 to 45 percent of older people who undergo surgery. Pneumonia is more than twice as common as other respiratory causes of death. Cancer is the next most common condition that is associated with postoperative death in older people. Kidney failure, stroke, and bleeding are less common causes.
Three issues are most often considered in the evaluation for surgery: What medical conditions could adversely affect the surgical risk? What is the overall level of risk associated with the conditions identified? How should these conditions be managed to control the risk?
Because problems with your heart and lungs comprise the majority of serious postoperative complications, the assessment of your surgical risk involves determining your cardiovascular risk and your pulmonary risk. Reduced blood flow to your heart, heart attacks, congestive heart failure, and disturbances of the heart rhythms are serious problems. Interestingly, stable angina pectoris, compensated congestive heart failure, and well-controlled high blood pressure do not seem to contribute to your risk of cardiac complications.
Assessing your heart function is particularly important, since the effects of age are first seen as a reduction in heart function with physical stress. The preoperative assessment often includes an electrocardiogram if major surgery is expected. If you have a known heart disease or if multiple risk factors are present, you may be asked to take a stress test of your heart. If you cannot complete the stress test or raise the heart rate above 100 beats per minute, you may be vulnerable to increased risk after surgery.
In order to avoid the risk of postoperative lung complications, most notably pneumonia, you must be able to generate enough airflow to expel the mucus that can accumulate in your lungs during surgery. The progressive, age-associated loss of lung function and common nonlung conditions such as obesity, malnutrition, skeletal abnormalities, and general muscular weakness may place you at risk for these lung complications after surgery.
Cigarette smoking is a major risk factor for complications after surgery. Smokers are most likely to have significant lung disease, increased amounts of airway secretions, bacterial contamination of the airways, and diminished ability to clear up secretions. All smokers should stop smoking eight weeks prior to surgery. (If you smoke, stop smoking now.)
Detectable clots (thromboses) in the deep veins of the leg develop in about half of all elderly surgical patients. Orthopedic surgery (especially hip surgery) and surgery in people with cancer also produce an increased risk of clots in the large veins in the leg. Additional risk factors include obesity, heart disease, a history of prior blood clots, and immobility. Other factors that cause concern include additional chronic diseases, malnutrition, a diminished will to live, kidney disease, dementing illness, and active infection.
Your risk of a heart attack extends through the first week after surgery, with the greatest risk on the fourth postoperative day; in over half of these heart attacks there is no chest pain, so many physicians perform an electrocardiogram on the day of surgery and on the first two or three postoperative days. Others suggest continual monitoring of the heart during this time. Nonetheless, you should have at least one electrocardiogram after surgery.
Congestive heart failure after surgery is most likely to occur in people with heart failure before surgery, although half of the people who develop heart failure after surgery have had no prior evidence of it. Other reported risk factors for heart failure after surgery are an abnormal preoperative electrocardiogram, surgery in the chest or abdomen, and advanced age.
Collapse of the small airways in the lungs and increased secretions in the lungs are responsible for pneumonia after surgery. The development of airway collapse is associated with lying on the back, incisions near the diaphragm, obesity, pain on breathing, sedation, and an excess of sticky secretions that cause plugging. Before surgery, stopping smoking for eight weeks or more and the treatment of lung disease may significantly reduce your risk of having pneumonia after an operation.
You may receive heparin, a blood thinner sometimes given to prevent blood clots from forming in the deep veins in the legs. Heparin is often given as an injection twice a day. If you are undergoing hip surgery or surgery for cancer, the anticoagulant warfarin is often given instead because heparin does not seem to be adequate.
If you have diabetes, you should receive glucose and insulin before and after surgery. You should also avoid having low blood sugar by discontinuing oral medications used to lower blood sugar one or two days before surgery.
The death rates after surgery in people with dementia may be as high as 20 percent one month after the operation and 50 percent at six months. In addition, delirium after surgery is much more commonly seen in people who have dementia before surgery. Depression, which is common in older people, may limit their interest in recovery. Depression should be treated prior to having any elective surgical procedures.
The overall likelihood of delirium in older people who have general surgery is between 10 and 15 percent. The factors that would precipitate delirium include medications, infection, low oxygen, heart problems, changes in body chemistry such as low sodium in the blood or a low blood sugar, fecal impaction, and urinary retention. Sleep deprivation, sensory deprivation, immobility, and being in an unusual place are also contributing factors. Because of this, the first priority in the management of a person with delirium after surgery is to recognize and correct any of these factors. Obviously, you will not be able to recognize delirium in yourself, so close observation and orientation by family members, hospital staff, or paid sitters may help reduce your risk of injury until you recover.
We have seen in this chapter that surgery presents you with a number of responsibilities: agreeing to a surgeon, determining the necessity of the operation (since one in three operations performed is not necessary), finding out who will actually perform the operation, minimizing your risks, and trying to reduce complications. Heart and lung complications and blood clots cause the most serious problems; delirium after surgery is common, and you must be prepared for postoperative confusion.