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3 Principles ofGeriatric Surgery
35
areas with little fat and muscle over bony prominences: the sacrum, lower back,
heels, greater trochanters, ankles, and ischial tuberosities. Pressure sores can
become infected, leading to secondary sepsis and death.
Cardiovascular deconditioning with prolonged bed rest includes increased resting heart rate and decreased ejection fraction and stroke volume. The shorter diastolic lling period reduces coronary blood ow and oxygen delivery to cardiac
muscle, leading to a decline in cardiovascular function that appears to stabilize over
time. A typical complication is orthostatic hypotension, which increases the risk of
syncopal episodes and cerebral hypoperfusion on assumption of upright posture.
This occurs within 2–3weeks of bed rest due to an excessive pooling of blood in the
lower extremities and a decrease in circulating blood volume [15]. Another potential complication is venous thrombosis. Venous thromboembolism is due primarily
to venous stasis and to a lesser degree to increased blood coagulability. Stasis occurs
in the legs owing to decreased contraction of the gastrocnemius and soleus muscles.
Most deep venous thrombi occur in the calf muscles and originate mainly in the
soleus sinus. Length of bed rest is directly related to the frequency of deep venous
thrombosis. Patients with venous thrombosis have a 50% higher likelihood of developing pulmonary emboli; the mortality rate is about 20–35%.
Reduction of rib cage expansion and displacement of the diaphragm cephalad
due to the pressure from the bed are predisposing factors to hypoventilation of the
dependent areas of the lungs. Failure to fully expand the chest wall results in a
25–50% decrease in respiratory capacity [16]. In the horizontal position, lung perfusion is altered, leading to changes in the ventilation/perfusion ratio, and results in
respiratory insufciency and hypoxemia. In addition, the mucociliary clearance and
the cough reex are impaired, increasing the risk of infection of the lung
parenchyma.
Irrespective of the patient’s emotional state, anorexia and constipation are common complications of immobilization. Uncomfortable bed position and feelings of
embarrassment can inhibit the defecation reex, resulting in the buildup of stool in
the colon and dehydration. Stool retention and impaction stretch the rectum and
colon. Over time, the stretch receptors in the rectum are inhibited, with loss of the
urge to defecate. In paradoxical diarrhea, liquid stool ows around a hard, impacted
fecal mass inside the rectum. The continued presence of the fecal mass irritates the
rectal mucosa, leading to the overproduction of mucus and the formation and leakage
of watery stool. Fecal impaction can also put pressure on the bladder neck, creating
an obstacle to urination already impaired by prostate hypertrophy in older men.
The best method to manage the immobilization syndrome is to prevent it by not
immobilizing the patient in the rst place. Very few situations require complete bed
rest beyond a couple of days. Patients should be kept in a sitting or semi-sitting position to facilitate respiratory and cardiovascular function. Patients should also be
encouraged to get up and walk at least two to three times over the course of a day to
use the bathroom or around mealtimes, for example. In this way, intestinal and urinary problems and orthostatic hypotension can be avoided. For patients who must
not or cannot get out of bed, mobilization exercises of the lower extremities can
enhance cardiovascular function and prevent deterioration of musculoskeletal
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M. Nano and M. Solej
function. Patients should also be taught how to perform breathing exercises. For
patients unable to do active exercises in bed, passive mobilization exercises with
frequent position changes should be performed to prevent contracture, ankylosis,
and pressure sores.
3.3 Malnutrition
Malnutrition is one of the leading causes of postoperative complications and mortality in elderly surgical patients, particularly among the institutionalized elderly.
Malnutrition places the older patient at higher risk for delayed surgical wound healing, development of surgical wound complications, and onset and worsening of
pressure sores. These problems stem from social issues (extrinsic factors) and from
age-related changes in the gastrointestinal tract (intrinsic factors). The combination
of both sets of factors makes malnutrition in the elderly often difcult and complex
to correct.
Extrinsic factors associated with malnutrition include decreased physical ability,
social isolation (widowers are at increased risk of dietary deciency) [17], poor
nutritional knowledge, economic hardship, alcoholism, monotonous diet, lack of
exposure to sunlight, refusal to change eating habits, indiscriminate use of medications, and preference for foods that hold a symbolic meaning or for gratifying foods
to compensate for frustration.
Though age-related changes in the gastrointestinal tract vary considerably from
person to person, they typically lead to altered function of affected areas. For example, inadequate mastication may result from masticatory muscle fatigue and poor
dentition (often due to nancial constraints that preclude oral restoration). The
senses of smell and of taste, in particular due to loss of gustatory papillae, are diminished. The taste sensation most often affected is salty, followed by bitter, whereas
the threshold perception of sweet is usually preserved [18]. This, along with economic and psychological factors, explains the predilection for sweet foods among
the elderly despite reduced glucose tolerance. Muscle incoordination, even when
cerebrovascular disease is absent, results in altered deglutition [
muscular structure and function within the esophagus of adults over 80years of age,
as described under the term “presbyesophagus” [20], include reduced speed of
propagation of the peristaltic wave, particularly to the upper third and the lower
third segments and incoordination between opening and closing of the lower esophageal sphincter and propagation of the peristaltic wave. In addition, the production
of hydrochloric acid, pepsin, and intrinsic factor is decreased, with malabsorption of
iron and vitamin B
. In the liver, the production of hepatic enzymes and albumin is
12
diminished, and drug metabolism is altered. While the overall morphology of the
small intestinal mucosa remains largely unchanged, the relatively poorly differentiated, immature enterocytes present are functionally incapable of normal absorption
[21]. Active transport mechanisms are impaired, and lactase production is decreased
(resulting in lactose malabsorption). Also correlated with advanced age are zinc
malabsorption (an essential element for numerous metabolic, enzymatic, and
19]. Changes in
3 Principles ofGeriatric Surgery
37
immune functions) and deciency of vitamins A, D, E, and K (typically associated
with laxative overuse).
Small intestinal bacterial overgrowth syndrome (SIBO) is the most common
cause of malabsorption in older adults. It is caused by the presence of excessive
bacteria in the small intestine and is implicated as the cause of megaloblastic anemia. SIBO is caused by the decreased production of gastric juices and local secretion of immunoglobulins by the gastrointestinal tract. The colon is characterized by
a marked reduction in peristalsis and thinning of the colon wall due to loss of muscle bers. In patients who use excessive amounts of laxatives, the mucosa appears
brown to black in color (melanosis), the rectal wall gradually loses elasticity, and
the mucosa becomes less sensitive.
Extrinsic and intrinsic factors can combine to put the older patient at risk for
nutritional deciencies that complicate the postoperative course. Often, however,
nutritional deciencies are not related to age but rather to reduced food intake.
History taking should investigate for social factors that can potentially affect dietary
habits. Involuntary weight loss of 4–5% over the past year is associated with a signicant increase in morbidity and mortality. Beyond social and psychological factors, weight loss may be a sign of undiagnosed illness (neoplasia, hyperthyroidism,
malabsorption, and, more rarely, cardiorespiratory and renal diseases) [22].
Correction of nutritional status should be achieved with enteral nutrition therapy
to promote epithelial maintenance and function, as well as mucosal immune function. Enteral nutrition therapy should be supplemented with dietary integrators to
correct specic deciencies [17]. Parenteral nutrition therapy administered via a
peripheral line or central access should be reserved for patients who cannot or must
not or do not want oral administration or in situations in which the time for renutrition is short (preoperative period). It should be remembered, however, that parenteral nutrition is not devoid of complications (patient positioning and management
of infections). During the postoperative period (but also during the preoperative
period if there is sufcient time), the return to oral intake should not coincide with
complete discontinuation of parenteral nutrition therapy. Both types of nutrition
therapy should be continued for several days to ensure adequate caloric intake.
Continuation of parenteral hydration may be indicated, as often occurs in patients
who do not have adequate oral uid intake.
1
Where geriatric medicine and surgery differ from other branches of medicine,
the extent to which a patient’s medical history, epidemiology of diseases, presence
of coexisting conditions, need for functional assessment, decompensation cascade,
drug therapy, and real-life circumstances all come into play in the delivery of care.
One of the principal challenges of clinical geriatrics is early diagnosis owing to the
difculty in obtaining a history and the problems with interpreting symptoms [23].
1
The authors wish to thank Dr. Marco Tinivella, Head of Dietary and Clinical Nutrition Service,
San Luigi Gonzaga Hospital, for critical review of this section.
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M. Nano and M. Solej
History taking in the elderly takes extra effort: they are not in a hurry, they have their
own pace for telling their story, and they need time to tell it. Since reaction times are
slower, quick answers should not be expected. The patient’s age is often far older
than that of the physician, creating a generational divide in life rhythm. Questions
may not always be correctly or completely understood. An ill older adult is particularly vulnerable to the burden of illness, distressed by anxiety and physical pain, and
distracted by these complicating factors. Often, hearing is impaired, a condition the
patient may be reluctant to disclose. Symptoms may go unmentioned because it is
thought to be merely typical of growing old. Moreover, associating certain diseases
with age-related changes is deeply ingrained in medical culture. Members of the
care team need to distinguish previous physiological alterations from specic diseases: aging of the arterial wall is not the same as arteriosclerosis, nor is cerebral
aging indicative of dementia or joint senescence a sure sign of osteosclerosis. Also
important in this context is the difference between normality and normal.
Interpreting symptoms is challenging, particularly so in older adults. A helpful
mnemonic is the triad: altered signs and symptoms, masked signs and symptoms,
and variable signs and symptoms.
– Altered signs and symptoms. Pain symptoms may be attenuated or absent (silent
suffering of organ systems). Because signs of peritonism may be vague, and hyper-
thermia and leukocytosis limited to the acute event (e.g., diverticular perforation),
the event may go unrecognized, resulting in delayed diagnosis and hospitalization
for an advanced stage of generalized peritonitis. There are other associated dis-
eases which, if complicated, can mimic a surgical disease. For example, metabolic
acidosis in a diabetic patient can resemble acute surgical abdomen manifesting
with abdominal pain, rebound tenderness (positive Blumberg sign), vomiting,
fever, cutaneous hyperesthesia, and leukocytosis. Establishing the differential
diagnosis between diabetic ketoacidosis-induced false acute abdomen and true
acute surgical abdomen is complicated by ketoacidosis. A useful clue in the diag-
nosis of the former is that pain is preceded by nausea, vomiting, and polydipsia.
– Masked signs and symptoms. The presence of coexisting conditions further com-
plicates interpreting symptoms. In addition, an acute event may precipitate a
coexisting illness, distracting attention away from the acute event and delaying
diagnosis. For example, in a patient with heart disease, an initially oligosymp-
tomatic peritonitis may be the cause of an episode of congestive heart failure,
drawing clinical attention only to the acute event.
– Variable signs and symptoms. There are certain diseases that can manifest very
differently from those typically seen in younger patients. Hyperthyroidism can
manifest with the classic symptoms of hypothyroidism (apathetic hyperthyroid-
ism), making it difcult to establish the clinical diagnosis in relation to senile
involutional cerebropathy.
Collectively, these risk factors place the elderly in a precarious situation of distress.
Distressing symptoms are associated with psychophysical and emotional decline and
3 Principles ofGeriatric Surgery
39
frailty, one of the hallmark characteristics of high-risk elderly surgical patients.
Closely linked to frailty is delirium, usually but not always occurring during the postoperative period, which signicantly diminishes the quality of life of older adults.
3.4 Frailty
The term “frailty” in reference to the elderly was coined in 1973 when the US
Congress created the Federal Council on the Aging (FCA) with a mandate to inform
policies and program interventions addressing the special needs of older Americans
and armed forces veterans. In 1974, the FCA created the Task Force on the Frail
Elderly, with the Reverend Monsignor Charles Fahey of the Roman Catholic
Diocese of Syracuse, NewYork, appointed as chairman. Under his chairmanship,
the Task Force was responsible for dening the concept of the frail elderly to
describe a range of conditions in older people, including general debility, cognitive
impairment, and living in a structurally and socially marginalized environment [24].
Frailty encompasses socioeconomic, psychological, health-care, and biological
aspects, any one of which may predominate in an individual older person, though
there is a common denominator. Well-being means not only the absence of disease.
Indeed, an older person may feel unwell even when no organic illness is present.
The geriatric patient represents a new concept of health composed of various different components, the principal ones being absence of disease, residual functioning,
affective and cognitive capacities, and social resources. Largely ignored by conventional medicine, the frail elderly are considered scientically uninteresting, ungratifying professionally, unhealable, troublesome to manage, costly, and difcult to
discharge [25]. The prevention, identication, and treatment of frailty are the core
concern and main challenge in modern geriatric medicine [26, 27].
The general prole of the frail elderly patient is characterized by advanced or very
advanced age, multiple chronic illnesses, disability, socioeconomic problems, loneliness and poverty, and precarious homeostasis due to multisystem failure that trigger
the so-called failure cascade associated with elevated mortality. Added to these conditions are biological and biochemical abnormalities of uncertain origin that are the
hallmarks of frailty: elevated C-reactive protein (CRP), interleukin-6 (IL-6), tumor
necrosis factor-α (TNF-α), D-dimer, osteopenia, sarcopenia, anemia, insulin resistance, and decreased iron, vitamin B12, folate, and albumin levels [28–30].
In 1976, Bernard Isaac described the four giants of geriatrics—incontinence,
immobility, instability (falls), and intellectual impairment—from which ve geriatric syndromes were subsequently derived: pressure ulcers, incontinence, falls, functional decline, and delirium [31–33]. The frail elderly patient is categorized as such
when three of these ve syndromes are present.
Frailty is a dynamic condition that can be measured. The two major models for
the assessment of frailty are the frailty phenotype devised by Fried and coworkers
[27] and the fragility index proposed by Rockwood and colleagues [34]. The frailty
phenotype (FP) is based on the assessment of ve parameters [29]:
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1. Unintentional weight loss over the past year (10lbs or 4.5kg)
2. Self-reported exhaustion on at least 3days/week
3. Reduced muscle strength as evaluated by handgrip (less than 13lbs or 5.85kg
for men and 7.5lbs or 3.37kg for women)
4. Reduced physical activity as measured with the Physical Activity Scale for the
Elderly (PASE)
5. Reduced gait speed over a known distance (more than 7s to cover 4.57m)
If three of these ve features are present, the patient is deemed as frail; if one to
two are present, the patient is categorized as pre-frail; if none are present, the patient
is considered robust.
The frailty index (FI) conceptualizes frailty as a syndrome characterized by the
loss of physiological reserve due to the accumulation of decits, resulting in vulnerability to stress. The index is derived from the Canadian Study of Health and Aging
(CSHA) and comprises 70 items. It is calculated by dividing the number of decits
in a patient by the number of decits measured [35–38]. The index is composed of
four scores: 0 (no positive items), 0.33 (1/4 positive items), 0.67 (3/4 positive items),
and 1 (all positive items—indicating maximum severity of frailty).
However, neither of these assessment tools takes into account many of the other
important factors that contribute to frailty, such as living alone, social engagement,
empowerment/life control, and socioeconomic status. The best instrument for
assessing frailty is the comprehensive geriatric assessment (CGA) dened as a multidimensional diagnostic process intended to determine an older person’s medical,
psychosocial, and functional limitations. Among the many assessment scales
described in the literature, the most widely used are the Clinical Frailty Scale (CFS),
the Growing Frailty Indicator (GFI), the Tilburg Frail Indicator (TFI), and the
Edmonton Frailty Scale (EFS) [39].
Since more and more older patients with comorbidities undergo surgery [40],
surgeons have begun to use frailty as a predictive tool to identify those at risk
for poor outcomes [
32, 33, 36]. In patients over age 75years, frailty is associ-
ated with increased postoperative mortality, postoperative complications, prolonged hospital stay, discharge to residential care, unplanned 3-month
readmission, increased 3-month mortality, and a three- to eightfold higher incidence of postoperative delirium in elective and emergency abdominal surgery
[31, 41–43]. The CGA has been shown to predict postoperative complications in
frail elderly patients better than chronological age predicts postoperative mortality [44]. Unfortunately, none of these three tools (CGA, FI, FP) has been
adopted in routine preoperative assessment. The CGA is the most comprehensive, while the FP is the simplest. Although the FP measures only physical performance, it may provide a valid clinical tool and starting point for the assessment
of frailty in surgical patients [45].
3 Principles ofGeriatric Surgery
41
3.5 Delirium
Delirium is an acute, uctuating disturbance characterized by a reduced ability to
focus, maintain, or shift attention; it is accompanied by changes in cognition and
perceptual disturbances secondary to a general medical condition. In the surgical
setting, emergency admission for an acute condition may precipitate preoperative
delirium. There are no prevalence data for preoperative delirium; however, depending on patient age and risk category, its occurrence is estimated to range between 9
and 87%, with older patients undergoing cardiac surgery at greater risk (80%) than
those receiving an orthopedic procedure (up to 40%) [46].
Postoperative delirium is closely correlated with frailty. An episode of postoperative delirium in a previously non-frail elderly patient may herald the onset of frailty.
It is associated with a variety of poor outcomes, including functional decline, prolonged hospital stay, higher heathcare costs, risk of falling, pressure ulcers, transfer
to a nursing home (institutionalization), and an increase in postoperative mortality
from 4 to 20% [47]. Moreover, it may be an early signal of postoperative complications such as atrial brillation, myocardial infarction, respiratory difculty, urinary
tract infection, and line infection [48]. Risk factors include preexisting dementia,
older age, functional impairments, multiple comorbidities, poor vision or hearing,
ongoing infections, self-reported alcohol abuse, and psychopathological symptoms.
The acronym VINDICATE was created as a mnemonic denoting the causes of
postoperative delirium: vascular infections, nutrition, drugs, injury, cardiac, autoimmune, tumors, and endocrine) [49]. While autoimmune and endocrine causes are
rarely encountered in elderly patients, preexisting dementia appears to be the strongest predictor for the development of postoperative delirium [50], and male sex is
reportedly a signicant predictor though its association with postoperative delirium
is unclear [51]. Commonly used medications may also precipitate an episode. The
Beers criteria, developed in 1997 and updated in 2003, for inappropriate medication
use in the elderly list antihistamines, benzodiazepine, muscle relaxants, meperidine,
cimetidine, corticosteroids, belladonna, warfarin, and antiparkinson agents [52].
Postoperative delirium does not manifest immediately after surgery when the
patient is lucid; instead, it may develop in 1–3days following the lucid interval [53].
In addition to preoperative risk factors, there are several postoperative factors that
may predispose to the development of delirium, including incomplete pain control,
electrolyte abnormalities, presence of a bladder catheter, immobility, and sleep
deprivation. Postoperative delirium is also correlated with frailty, duration of the
operation, and blood loss. Though less often and less severe, delirium can develop
after administration of local and locoregional anesthesia.
Delirium is usually transient and self-limiting, though it can persist through hospital discharge in up to 50% of cases [54]. Its etiology is not yet fully understood
and is probably multifactorial. Central cholinergic deciency is the leading hypothesized mechanism. Three subtypes are distinguished: hyperactive delirium characterized by agitation and hallucination; hypoactive delirium with decreased activity,
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decreased speech, and reduced awareness, which may be overlooked in patients
who are withdrawn or calm; and mixed hyper-hypoactive delirium. Hypoactive
delirium is associated with higher mortality. Diagnosis is often challenging and
goes unrecognized in nearly 50% of cases [50].
According to the Diagnostic and Statistical Manual of Mental Disorders, Fourth
Edition (DSM-IV), four of the following criteria are needed to establish a diagnosis
of postoperative delirium [55]:
1. Disturbance of consciousness, i.e., reduced clarity of awareness of the environ-
ment, with reduced ability to focus, sustain, or shift attention.
2. A change in cognition (such as memory decit, disorientation, language distur-
bance) or the development of a perceptual disturbance that is not better accounted
for by a preexisting, established, or evolving dementia.
3. The disturbance develops over a short period of time (usually hours to days) and
tends to uctuate during the course of the day.
4. There is evidence from the history, physical examination, and laboratory nd-
ings that the disturbance is caused by the direct physiological consequences of a
general medical condition, developed during substance intoxication or during or
shortly after a withdrawal syndrome.
Inattention is the cardinal symptom in the aged patient [56]. There are no specic
tests for the diagnosis. As seen in frailty, inammation markers are often elevated,
though it is unclear whether the alterations are the cause or the effect of delirium
[53]. Imaging studies may be useful to exclude other causes. Chest radiography,
magnetic resonance imaging of the head, or abdominal computed tomography
should be ordered when there is clinical suspicion of specic pathologies such as
infection or stroke.
Treatment is based on a multicomponent approach. Pharmacological treatment is
not recommended as a rst-line therapy. The American Geriatrics Society has developed a core set of strategies for the prevention and treatment of postoperative delirium [
56].
Behavioral and Nonpharmacologic Strategies for Prevention/Treatment of
Delirium
1. Sensory enhancement (ensuring glasses, hearing aids, or listening ampliers)
2. Mobility enhancement (ambulating at least twice per day if possible)
3. Cognitive orientation and therapeutic activities (tailored to the individual)
4. Pain control with scheduled acetaminophen if appropriate
5. Cognitive stimulation (if possible, tailored to the individual’s interests and
mental status)
6. Simple communication standards and approaches to prevent the escalation of
behaviors
7. Nutritional and uid repletion enhancement
8. Sleep enhancement (daytime sleep hygiene, relaxation, nonpharmacologic
sleep protocol, and nighttime routine)
3 Principles ofGeriatric Surgery
43
9. Medication review and appropriate medication management
10. Daily rounding by an interdisciplinary team to reinforce the interventions
Strategies should usually include these core elements, but this list is not all
inclusive.
The drug of choice is haloperidol, which may induce extrapyramidal side effects.
Low-dose benzodiazepine should be reserved for patients with a previous or current
history of alcohol abuse or have consumed alcohol during the preoperative period
and are experiencing symptoms of alcohol or benzodiazepine withdrawal.
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