Older than old, sicker than sick

Older than old, sicker than sick

  • Issue 68

Gabriel M. Gurman
Chief Editor

The ESA Focus Meeting on Perioperative Medicine: The Ageing Patient, in November 2016 in Lisbon was a real success.

For the first time a full scientific event was dedicated to the older patient, and the various presentations referred not only to his/her medical condition, but also to the psychological aspects of older age and its specific problems pertinent to the anaesthesiologist. The subject of older age is one that has to represent a continuous interest for our profession, even if for the simple reason that in the last decades we have witnessed a continuous increase in the percentage of the geriatric population.

Some data show that the population aged 60 years and over has tripled since 1950, reaching 600 million in 2000 and more than 700 million by the end of the first decade of the current century. It seems that in less than 30 years the older population of the entire globe will surpass 2 billion. This very clear trend is also accompanied by a continuous decrease in fertility. The final result is that in some European countries the percentage of citizens older than 65 is already above 20%.

But the permanent increase in life expectancy in Europe comes too often with a lot of problems and the older patient’s health condition is a primordial worry for everyone involved in healthcare. Statistical data show that people above the age of 80 represent 8% of all surgical patients, and in this demographic group around 50% of all surgical procedures are performed on an emergency basis. More than this, almost 10% in this group belong to ASA 4 and 5. Some 30 years ago a paper in a very esteemed journal (N Engl J Med 1988;318:415) mentioned the fact that ‘Today we live longer, but a greater proportion of our life is spent in ill health’.

The older patient comes with a very problematic co-morbidity. Chronic vital organ deficiencies are almost a rule. The physiological reserves of the older man or woman are limited, and his/her ability to adapt to acute situations is questionable. The polypharmacy is another serious aspect of older age, influencing the anaesthetic regimen and the rate of adverse reactions to drugs. At the same time, the number of surgical procedures and admittances to acute care areas is constantly increasing. The older patient develops more postoperative complications and their gravity is much more evident than in younger groups of surgical patients.

This situation is permanently dynamic, while society’s efforts to cope with the reality are, in many places of our continent, far from being satisfactory. The financial burden of healthcare creates an atmosphere in which, sometimes, the main scope of the medical administration is to save money, to reduce costs by decreasing the length of stay, not only in the ward, but also in the critical care and high-dependency units. In this context, the ethical problems are raised by the surgical treatment of the elderly that sometimes cuts corners, with a tendency to consider the patient ‘too old’ to be taken care of.

These are the reasons why the average European anaesthesiologist is faced every day with a long list of ethical, financial, and logistic problems related to the absolute need to assess the older patient’s condition and also to evaluate his/her potential danger for complications. Since today there is no absolute contraindication for surgery, interventions in the elderly represent a real challenge for the surgical team, the anaesthesiologist included.

Actually, the main core of the Lisbon meeting was directed to this daily task.

The good news emerging from that meeting is that we are better prepared to deal with the older patient and his/her special problems. The pre-anaesthetic outpatient clinics assess and prepare the patient for the elective surgical interventions. Guidelines and protocols help the practitioner to make better use of equipment and drugs by taking into consideration even the remote possibilities for secondary effects. One example is the increased use of central nervous system monitoring (like BIS) in order to optimize drug administration and prevent too deep or too superficial anaesthesia.

The postoperative cognitive dysfunction of the older patient occupied an important place in the scientific program of the Lisbon meeting. Things that were partially known became clear and definite: the older patient is more prone to develop serious postoperative psychological complications, and this reality is responsible for a longer stay in the hospital and even for higher surgical mortality. A better understanding of the pathophysiology of this entity could reduce the percentage of postoperative delirium and improve the patient outcome.

But at the same time there are other aspects of our daily activity that need to be given proper interest and solutions.

One of them is the older patient candidate for emergency surgery. In this situation, in many cases, the older patient reaches the operating room with no real possibility either to assess his/her condition or to take elementary measures to improve it (such as hydration or diuretics or blood transfusion). In this case the surgical risk is substantially increased and it imposes a correct and rapid clinical judgment in order to limit the extension of the surgical procedure to a minimum.

Nowadays the system of ‘same day surgery’ is extended to most of our hospitals. This administrative arrangement has a real impact on the anaesthesiologist’s activity, first because he/she cannot change anything in the patient’s usual medication nor ask for supplementary tests. Even if the elderly patient was examined days/weeks before surgery in the context of the outpatient clinic, his/her condition could change from one day to another. It is the anaesthesiologist’s task to find a solution for assuring patient safety during and after surgery, even in this not too ideal situation.

Finally, a word about a very interesting panel, this time on ourselves! The scientific committee of the Lisbon meeting organized an intense discussion about the anaesthesiologist before retirement with the participation of the invited experts as well as the audience.

This topic is not at all simple or banal! On one side we all grow older and hope that one day we will retire in good health. But in many countries the current legislation obliges the physician to retire at a certain age, no matter his/her abilities to go on working. This reality creates a serious psychological problem for most of those who, still, feel fit enough to continue to practice, probably fewer hours per day or fewer days per week. Retirement also needs a preparation process that would help the physician to cope with the coming new situation and find alternatives for filling up the new leisure time.

At the same time, as I had the opportunity to mention in one of my previous editorials, most of our countries suffer from a perennial anaesthesia manpower shortage. The discussions in the framework of the Lisbon panel referred to this paradox, which has as a result a too early retirement of a professional who still could be useful to the system and aggravation of the lack of manpower in our specialty.

Meanwhile, we are working and taking care of our patients, and have almost no time to think about the future to come. If so, one has to take seriously into consideration the famous sentence belonging to George Bernard Shaw: ’You don’t stop laughing when you grow old, you grow old when you stop laughing.’ We have to keep our mood high, not only for our patients but also for ourselves.