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214 M.R. Katlic
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CASE STUDIES
Case 1
A 100-year-old woman fractured her right hip in a
nursing-home fall. She had a history of myocardial
infarction, congestive heart failure, aortic stenosis,
arthritis, and hiatus hernia. She had previously undergone cataract surgery, cystocele repair, and open
reduction/internal fixation of a left hip fracture. Open
reduction/internal fixation of her new fracture was
performed under general anesthesia. During her second
postoperative week she developed acute gangrenous
cholecystitis, requiring emergency cholecystectomy.
This episode was complicated by left lower lobe pneumonia, which resulted in antibiotic treatment, and by a
localized intra-abdominal abscess, which was successfully treated with percutaneous drainage and antibiotics. Six weeks after admission she returned to her
nursing home. Protruding Enders rod pins in her right
leg led to pin removal under local anesthesia 8 months
later. At 101 years of age, she underwent elective
endoscopic resection of a rectal villous adenoma containing carcinoma in situ. Postoperative bleeding from
the resection site mandated suture ligation under general anesthesia. She returned to her nursing home,
where she lived two years. She died two weeks before
her 103rd birthday.
Case 2
A 100-year-old retired laborer was ambulatory at his
nursing home until his toes became painful. He had a
history of hypertension, chronic lung disease, and severe
peripheral vascular disease and had undergone prostatectomy. On examination, he had a gangrenous right foot
with Proteus cellulitis extending to the calf and an
absence of leg pulses below the femoral arteries. He
underwent amputation of the right leg above the knee
while under general anesthesia (spinal anesthesia was
aborted because of the patient’s agitation) and was discharged 11 days later. He had one later 4-day admission
for bronchitis and died at age 101 years of “old age.”
Case 3
A 101-year-old woman was ambulatory and independent
at home, but suffered from a large right inguinal hernia.
Her past history included congestive heart failure, atrial
fibrillation, adult-onset diabetes mellitus, blindness, and
a resected basal-cell carcinoma of the face. Elective right
inguinal herniorrhaphy was completed under local anesthesia in the outpatient surgical unit. Postoperatively,
stating that she would “rather wear out than rust out,” she
took a 3-month cruise around the world and later lectured
at a local college geriatric course. On the penultimate
day of her life she completed a political poll. She died of
congestive heart failure at age 102.
Discussion
Centenarians recover surprisingly well from surgery, leading
one to speculate that the 100-year-old patient who has not
already succumbed to a myocardial infarction or pulmonary
embolus is less likely to do so, even in the perioperative
milieu. The Mayo Clinic study of surgery in nonagenarians
supports this finding, as neither pneumonia nor atherosclerosis with myocardial infarction was a major cause of postoperative death [
Certainly all that has been learned about surgery in the
elderly should be applied to the centenarian. Clinical presentation of surgical problems may be subtle, preoperative preparation is essential, and scrupulous attention to detail
intraoperatively and perioperatively yields great benefit.
Virtually all studies of surgery in the elderly have also shown
an up to threefold greater risk for emergency surgery than
elective surgery. The worst complications in the author’s
15].
series, pneumonia and intraabdominal abscess, did occur
after emergency surgery, but the patients generally tolerated
even urgent operations well.
Centenarians may be considered a natural model of successful aging. What is it about the 100-year-old that allowed
him or her to enter this select age group?
Physiologic Changes in Centenarians
The oldest-old manifest low frequencies of the E4 form of
gene coding for apolipoprotein E, a protein linked to an
increased risk of acquiring Alzheimer’s disease. Among
healthy subjects age 90–103 years, 14% had at least one E4
gene, in contrast to 25% of subjects younger than age 65
[10]. It may be that many of those with E4 suffer early
Alzheimer’s disease and do not survive to become centenarians. This cohort effect may explain some of the other
21517 Surgery in Centenarians
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physiologic and pathologic changes in centenarians described
below. Silver found that dementia is not inevitable with aging
and that dementia in centenarians is often not attributable to
Alzheimer’s disease [34–36].
Morphologic changes occur in the brain with age –
decreased brain weight, atrophy of the cerebral hemispheres,
fall in the number of Purkinje cells in the cerebellum – but
healthy aged subjects show little difference from young
adults with respect to cerebral blood flow and oxygen uptake
[37]. Hubbard et al. studied electroencephalograms in centenarians and found slowing of the posterior dominant rhythm,
but there was no evidence of a progressive decrease in frequency between the ages of 80–100 years [38]. Wellpreserved mucociliary clearance in the lung of a centenarian
was documented by Pavia and Thomson despite 80 years of
smoking history [39].
An even more paradoxical finding was described by Mari’s
group [40]. They found that a high proportion of 25 healthy
centenarians had laboratory evidence of activation of the
coagulation system, shown by high levels of enzymes, activation peptides, and enzyme-inhibitor complexes. Levels of factor X activation peptide were equal to those found in patients
with disseminated intravascular coagulation. Even procoagulant proteins such as fibrinogen and factor VIII – predictors of
cardiovascular disease in young adults – were elevated in
centenarians; yet these individuals had no current or past
thrombotic events. The authors concluded that significant
alterations of these markers are still compatible with health
and long life. A more recent study by this group found that
the 4G allele and 4G/4G genotype associated with elevated
levels of plasminogen activator inhibitor 1 (PAI-1), which
predicts recurrence of myocardial infarction in young men,
were even more frequent in centenarians than young adults.
The homozygous genotype for the deletion of polymorphism of the angiotensin converting enzymes, which predisposes to coronary artery disease, is also paradoxically more
frequent in centenarians than in adults of age 20–70 years
[41]. Mannucci et al. speculated that occult factors compensate for these putatively unfavorable genotypes in centenarians (e.g., linkage dysequilibrium with a locus counteracting
the bad effect of elevated PAI-1 levels offsets the risk of
hypofibrinolysis). It may be that if an elderly person has
already escaped thrombotic disease, it is advantageous to
have decreased fibrinolysis [42]. A different genetic finding
in centenarians – decreased frequency of the E4 allele of the
gene, which encodes apolipoprotein E – would go along with
decreased risk of ischemic heart disease [41].
Laboratory values in healthy centenarians may differ even
from those of younger elderly adults: widening of the range
for sodium levels to 132–146 mmol/L, slightly higher potassium and chloride, decreased total calcium, slight increase in
ionized calcium, increased blood glucose, increased alkaline
phosphatase and lactate dehydrogenase, slightly decreased
bilirubin and total protein, increased amylase likely due to
decreased renal function, increased serum urea nitrogen and
slightly increased creatinine, increased urinary albumin, elevated urate, decreased albumin, elevated carcinoembryonic
antigen, decreased cholesterol and triglycerides, decreased
vitamin B12, decreased zinc, slightly decreased thyroxine,
increased prolactin, no change in corticotropin, decreased testosterone and estradiol, marked decrease in dehydroepiandrosterone, decreased progesterone, unchanged cortisol, slightly
higher gastrin, lower erythrocyte, leukocyte, and platelet
counts, slight decreases in hemoglobin, hematocrit, and iron
[43]. Higher functioning centenarians appear to have higher
levels of serum albumin [44]. Discussion of possible mechanisms for these findings is beyond the scope of this chapter.
Franceschi asserted that a complex remodeling of the
immune system occurs in healthy centenarians in contrast to
the presumed progressive deterioration (especially with the
T-cell branch) [45, 46]. Peripheral blood T cells and major
T cell subsets are only slightly decreased despite age-related
thymic involution. B lymphocytes are deceased despite data
that several immunoglobulin classes are elevated in the
serum. Interestingly, peripheral blood lymphocytes in centenarians appear resistant to the oxidative stress that causes
irreversible cell damage in younger individuals; such stress
may retard entrance into the cell cycle rather than cause permanent damage [47].
Centenarians are more likely to have low body weight
[48, 49], possibly due to loss of muscle and fat [50]; a number
of investigators have reported short stature even when the
effects of aging are considered. Decreased bone mass,
however, is not universally present [51]. Both male and
female centenarians are more likely to have feminine or
androgynous personality traits, rather than masculine ones
and are more likely to have a type B behavior pattern (easygoing) [52].
Pathology in Centenarians
Although atherosclerosis has been found in coronary, cerebral, femoral, and abdominal aortas of centenarians [53], the
ascending aorta may be spared [48, 54]. Myocardial fibrosis
is located chiefly in the left ventricle and septum, and cardiac
amyloid deposition is characteristic [53]. Coronary disease
at autopsy is common [55, 56], though perhaps less so in
Japanese centenarians [57]. Pneumonia was found in 15 of
23 patients in Ishii and Sternby’s series and was also the
most common cause of death [53]. Alveolar ectasia and
decreased elastic fiber were also seen in the lungs.
Interestingly, recent or old thromboembolism in the pulmonary arterial tree was common at autopsy despite the absence
of clinical pulmonary emboli during life [53].
216 M.R. Katlic
100
Cancer Mortality
Non-Cancer Mortality
80
60
40
20
0
02468
Age at Death (years)
Mortality Rate (per 100 dogs)
10 12 14 16
60
50
40
30
% Siblings Living to Age 90 Years
20
10
n = 11/46
n = 2/17
Male Siblings (p =0.29)Female Siblings (p =0.003)Total Siblings (p =0.001)
n = 3/22
n = 5/39
n = 55/136
n = 44/90
Centenarian Siblings
Control Family Siblings
0
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In the kidney, chronic pyelonephritis and atherosclerosis
are usually pronounced; and the testes, ovaries, and uterus
show atrophic changes [58]. In the gastrointestinal tract, the
liver also shows atrophy and colonic diverticula are common.
Gallstones are common (13/23 patients), and peptic ulcer is
rare [58]. Osteoporosis is common [59], but not universal
[51]. Similarly, in the brain, changes of Alzheimer’s disease
are common but not universal; when present these may not
correlate with clinical neurologic findings [60, 61].
Cancer as a cause of death was unusual in Ishii and
Sternby’s autopsy series [59]; it represented 7.1% of Stanta’s
99 autopsies in centenarians [62], and 31% of Klatt and
Meyer’s 32 patients [54]. The 7.1% rate in Stanta’s series
was significantly different (p < 0.001) from that in age groups
75–90 years (25%) and 95–99 years (9.5%). Metastases in
this series were found in 23.5% of the centenarians with cancer and 63.2% of those 75–90 years old; local infiltration did
not differ among groups. Many of the cancers in centenarians
(70%) were undiagnosed during life, a fact that may explain
the exceptionally low incidence of cancer (4%) as a cause of
death in epidemiologic studies [63]. Of all the types of cancer, only the prevalence of gallbladder adenocarcinoma was
increased in Stanta’s series [62]. Germ-line polymorphisms
may play a role in the decreased susceptibility of centenarians to cancer [64]. In exploring an animal model of extreme
Fi g u r e 17.3 Comparison of age-specific cancer and noncancer mortality
for 345 Rottweiler dogs. Age-specific cancer and noncancer mortality
rates were calculated at 2-year intervals from 0 to 14 years of age and
expressed as the number of cancer or noncancer deaths per 100 dogs that
entered the interval. (Reprinted with permission from Cooley [65]).
longevity, Cooley found that only 19% of extreme aged dogs
died of cancer versus 82% of dogs with usual longevity
(p < 0.0001) [65] (Fig. 17.3). In summary, cancer in the oldest-old is less frequent and less aggressive.
Centenarians, like younger individuals, die of specific
organ failure, not “old age” [66]. Berzlanovich [67] reviewed
autopsy records of forty Austrian centenarians, 60% of whom
had been described as healthy before death; all had a specific
cause of death, including cardiovascular in 68%, respiratory
25%, gastrointestinal 5%, and cerebrovascular 2%.
Determinants of Extreme Longevity
Despite our fascination with centenarians, little is known
about the influences – genetic, environmental, and medical –
on their longevity. Vaupel’s group, in extensive studies of
nearly 3,000 Danish twin pairs born during 1870–1900 estimated the heritability of longevity to be 0.26 for men and
0.23 for women; the sex difference resulted from the greater
impact of unshared environmental factors in the women [68].
Other family studies have shown weak correlations for
life-span between parents and offspring (0.01–0.05) and
somewhat higher correlations between siblings (0.15–0.35)
[69, 70] (Fig. 17.4) suggesting either that the genetic factors
are nonadditive (genetic intralocus interaction) or there is a
higher degree of shared environmental influences among sib-
Fi g u r e 17.4 Percentage of siblings of centenarians and controls who
reached age 90 years, when controlling for extrinsic or unknown causes
of mortality. (Reprinted with permission from Willcox [70]).
lings than parents. The offspring of centenarians nevertheless
manifest less cardiovascular disease than the general population at similar age [71–73], and, in one study, less cancerspecific mortality [73].
Several specific genetic factors have been associated with
extremely long life [74]. In a study of Japanese centenarians,
Takata et al. [75]. showed a significantly lower frequency of
HLA-DRw9 and a higher frequency of HLA-DR1 among
centenarians compared to younger adults; these antigens are
negatively associated with autoimmune diseases in Japan,
16000
Telomere Lengths - 'Healthy' vs. 'Unhealthy'
Mean telomere length (bp)
14000
12000
10000
8000
6000
4000
2000
0
Healthy Unhealthy
Genetics: genes coding for
Human leukocyte antigens HLA-DR
Apolipoprotein E
Angiotensin-converting enzyme (ACE)
Environment
Year of birth
Smoking
Alcohol
Diet
Locale cf. Sardinia, Okinawa
Medicine
Dehydroepiandrosterone (DHEA)
Other
Long-lived sibling
Long-lived parent
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suggesting mediation of the genetic influence through a lower
incidence of disease. The low prevalence of the E4 allele of
apolipoprotein E (APOE) and increased prevalence of the DD
genotype for angiotensin-converting enzyme (ACE) have
been mentioned above [42]; neither of these, however, was
associated with longevity in a Korean study [76]. Puca
reported evidence for a specific locus (D451564) on chromosome 4 associated with longevity in a sibling pair linkage
study [77]. The role of inherited and somatic mutations of
mitochondrial DNA (mtDNA) in centenarians remains unclear
[78]. Short chromosomal telomeres have been associated with
increased mortality in persons over the age of 60 [79], but this
has not held true for the oldest old [80, 81]; nevertheless,
Terry [82] found that healthy centenarians have significantly
longer telomeres than unhealthy centenarians (Fig. 17.5).
The mediation of genetic influences on longevity via
genetic influences on smoking and body mass index – two
factors associated with longevity in epidemiologic studies –
was disproved by Herschind [83]. Even smoking status has
shown no definite association with extreme longevity, nor
has alcohol consumption, diet, or exercise [84]. Such “lifestyle” factors may, however, influence one’s functional status at the age of 100 [44]. Environmental factors such as
socioeconomic status and early life nutrition appear to have
little influence [85]. Although no “fountain of youth” medicine has been discovered, the inverse correlation of blood
levels of dehydroepiandrosterone (DHEA) with mortality
has prompted ongoing clinical trials of its administration [86],
21717 Surgery in Centenarians
T
a b l e 17.2 Posulated Determinants of extreme life-span in the
industrialized world
not all of them salutary [87]. Some environments, e.g., Sardinia
and Okinawa, appear to be conducive to extreme longevity
as do personal factors such as activity, discipline, altruism,
spiritual faith [88], musical instruments, and humor. In a
study of 483 Italian centenarians, 88.6% had never smoked
cigarettes [89]. Centenarians themselves attribute their longevity to God, singing, pickled herring, shochu (sugar cane
liquor), honey, port, abstinence, boiled onions, whiskey, red
wine, fish, luck, chocolates, olive oil, weakness for women
(or men), and more.
In summary, it is likely that a large number of factors
interact to determine longevity, three-fourths of them being
environmental (Table 17.2). The involvement of a number of
genes, each contributing a little, might influence longevity
directly or, more likely, through determining susceptibility to
disease at different ages.
Fi g u r e 17.5 Mean telomere length measured in base pairs (bp) in 19
healthy versus 19 unhealthy centenarians. Bars: interquartile ranges
(Q75% to Q25%) of telomere length. Diamonds: mean; horizontal line
within bars: median telomere lengths; Vertical lines: overall range of
telomere lengths. (Reprinted with permission from Terry [82]).
Selective Survival Hypothesis
A 100-year-old is as likely to survive surgery as are his sons
and daughters, and one may speculate that he is even more
likely to do so. The man or woman who has endured ten de-
cades of life’s labors enters a select group whose physiologi-
cal resilience is greater than that of many who are chrono-
logically younger. – M.R. Katlic, 1985 [33]
This selective survival concept was discussed by Thomas
Perls, principal investigator with the New England Centenarian
Study [10]. Perls postulated, supported by his research and
that of others, that certain individuals are resistant to the diseases that cripple and kill most people before age 90. These
individuals – although 95% have some form of chronic disease [90], including cardiovascular disease [91] – not only
218 M.R. Katlic
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live longer lives, they also live relatively free of debilitating
infirmities.
Mortality rates for centenarians, for example, are lower
than would be anticipated by extrapolating the death rates of
younger adults. Mortality can be reasonably predicted up to
approximately age 80, but the linear decline in health not
only slows at advanced age, but varies more among individuals, thus selecting the most fit [92]. Selection is more
than sufficient to overcome the effects of aging and is greater
in men, probably because of their higher mortality at younger
ages [93, 94]. This “gender crossover” resulting from the
selection of fit men can be seen as early as age 80, but is
more evident in centenarians: men make up 20% of 100-yearolds and 40% of 105-year-olds. Female-to-male ratios, however, may range from 2:1 to 7:1 in different provinces within
the same country [95]. Age 95–97 years appears to be the
age at which a person’s chance of dying increases in a linear
rather than an exponential manner with time (Fig. 17.6)
[10]. Carey [96] found the same phenomenon in medflies.
Fi g u r e 17.7 High threshold for acquiring disease and slow aging
process may promote survival because of the good health of centenarians. (From Perls [10]. Copyright© 1995 by Scientific American, Inc.
All rights reserved).
Whether due to compositional change in the cohort (selec-
tion of the fittest) or better intrinsic cellular defense mechanisms (see peripheral blood lymphocyte data above), the
very old have a higher threshold for acquiring disease and a
decreased mortality rate, allowing them not only to survive,
but to do so in relatively good health (Fig. 17.7). In 1990, the
Medicare costs for those who died at age 70 was $6475 during each of the last 5 years of life compared to $1,800 per
year for those who died at age 100 [97]. In 1995 medical
expenses for the last 2 years of life average $22,600 for
people who died at age 70 and $8,300 for those who died
after age 100 [6].
Perls’ group has described three morbidity profiles for
centenarians [98]. Survivors had an age-associated illness
prior to age 80 years (24% of men and 43% of women);
Delayers experienced an age-associated illness after 80 years
(44% of men and 42% of women); Escapers reached age 100
without a diagnosis of common age-associated illness (32%
of men and 15% of women). With respect to the most lethal
diseases – heart disease, cancer, and stroke – 87% of male
centenarians and 83% of female centenarians either delayed
or escaped. Motta [99], who studied 602 Italian centenarians,
writes that even those who are free of disease, autonomous,
and bright should not be considered prototypes of “successful aging”, as they have not maintained any social or productive activities. Most consider centenarians to be models of
healthy aging from which we can learn, in order to improve
the health of all elderly [100].
Fi g u r e 17.6 Observed mortality rate slows after age 97 years compared
to the expected mortality rate. (From Perls [10]. Copyright© 1995 by
Scientific American, Inc. All rights reserved).
Supercentenarians
Supercentenarians, those aged 110 years or more, likely
number less than 500 worldwide; most are women [101].
Schoenhofen [102] studied 32 such individuals, 84% of them
women. Cardiovascular disease and stroke were rare,
Parkinson’s disease absent, and cancer successfully treated
in 25%; 41% were independent or required minimal assistance. The parents and siblings of supercentenarians also
manifest a survival advantage [103].
21917 Surgery in Centenarians
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Conclusions
All that has been learned about surgery in the elderly should
be applied to the centenarian: clinical presentation of surgical problems may be subtle, preoperative preparation is
essential, emergency surgery carries high risk compared to
elective operation, and scrupulous attention to detail intraoperatively and perioperatively yields great benefit. It is not
unreasonable to speculate that the 100-year-old who has not
already succumbed to a myocardial infarction or pulmonary
embolus is unlikely to do so, even during the perioperative
period. Survival to the centenary indicates that one has been
tested by life and has been found exceptionally fit. Elective
surgery should not be deferred nor emergency surgery denied
the centenarian on the basis of chronologic age.
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https://t.me/med1917
Chapter 18
https://t.me/med1917
The Effect of Advancing Age on Physician Performance
Jennifer F. Waljee and Lazar J. Greenfield
Introduction
Regardless of profession, aging is ubiquitous and profoundly
influences performance throughout one’s career. Often,
advanced age is considered to bring wisdom and knowledge
through longitudinal experience. A common quote is frequently heard in the hallways of hospitals on rounds and at
morbidity–mortality teaching conferences: “Good judgment
comes from experience, and often experience comes from
bad judgment.”
However, there is considerable evidence to suggest that
advanced age is associated with a decline in an individual’s
performance. One of the earliest examples of such research
that has changed public policy is the ability to operate a
motor vehicle. Prior research indicates that older adults have
less visual field acuity and visuospatial attention compared
with younger individuals, which has been correlated with a
decreased ability to operate a motor vehicle [1]. Age-related
factors associated with motor vehicle collisions include
decreased attention, reaction time, memory, executive function, mental status, visual function, and physical function.
Such individuals frequently lack insight into their cognitive,
sensory, and physical limitations [2].
In recent years, there has been increasing interest in the
effects of age on physician performance and healthcare
quality. While not only a sensitive and controversial topic,
understanding the effects of the aging process on medical
practitioners is important for the assessment of competence and the mechanisms and timing for retirement. This
review will examine recent data regarding the effects of
age on physician performance and consider the implications for physicians in practice and for those who develop
healthcare policy.
J.F. Waljee (*)
Plastic and Reconstructive Surgery, Department of Surgery,
University of Michigan Medical Center, Ann Arbor, MI, USA
e-mail: filip@med.umich.edu
The Physiology of Aging in Relation
to Performance
The physiologic effects of aging are complex and multifactorial. Previous studies have demonstrated that advancing age is
correlated with a decline in motor skills (both gross and fine),
decreased visual acuity, and impaired cognitive functioning.
However, in practice, it is difficult to assess any individual factor
in isolation, as they work in concert to enable an individual to
complete a task. For example, over time, older individuals are
not only less adept at learning a new motor skill by practice, but
also less able to integrate these with cognition and to coordinate
movement sequences. Older individuals also have slowed cognitive and motor responses to stimuli compared with younger
individuals. Similarly, individuals who err in cognitive tasks
are more likely to err in concurrent motor tasks as well [3].
Several aspects of cognition have been shown to decline
with age. For example, older individuals are less able to learn
new tasks through repeated training and subsequently to execute complex tasks. Additionally, age-related declines exist
in several aspects of attentive skills, such as sustained attention, selective attention, and inhibition tasks [4, 5]. Previous
studies have documented age differences with respect to
memory retrieval, but not necessarily memory encoding or
motor memory [3]. For example, new motor memories can
be retained for at least 2 years without rehearsal in individuals up to 95 years in age [
Of interest to surgeons and those physicians in procedural
subspecialties, hand dexterity and visual acuity are significantly influenced by the aging process [7, 8]. Older adults
have more difficulty maintaining and varying manual force
compared with younger individuals. Changes in ocular optics
and neural pathways with age result in decreased visual perception, and an individual’s ability to discriminate color, contrast, and motion. Older individuals may also have slower
visual processing speeds compared with their younger counterparts [9, 10]. Recent encouraging studies indicate that some
age-related declines in visual acuity and hand functioning can
be prevented with more extended practice which may allow
the development of training protocols to prevent age-related
decline in skills for practicing physicians [11, 12].
6].
R.A. Rosenthal et al. (eds.), Principles and Practice of Geriatric Surgery,
DOI 10.1007/978-1-4419-6999-6_18, © Springer Science+Business Media, LLC 2011
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