The super-elderly – Outcome and Perioperative Management

The super-elderly – Outcome and Perioperative Management

Session took place on Sunday 3 June

The super-elderly, generally defined as patients aged 85 years or older, are a growing sector in society. In this session, Idit Matot (Professor & Chair, Division of Anaesthesia & Intensive Care & Pain, Tel Aviv Medical Center, Israel) set out the issues around outcome and perioperative management of this increasingly important group.

The EU-28 population pyramids show the distribution of the population by sex and age groups. Nowadays, because of the high fertility rates in the 1960s, the pyramid looks like a rhomboid, meaning narrow at the bottom at younger age and in the upper part, the super-elderly with a bulge in the middle (more people aged 40-60 years). This, however, is going to change because of low fertility rate and increased longevity, and the pyramid is predicted to take the shape of a block, with the super-elderly growing from 5% of the population to 12% in 50 years!

“This super-elderly group needs operations, and currently, 30% of surgical load and procedures under anaesthesia are in the elderly, and about a third of these in the super-elderly,” explains Professor Matot. “Keeping that in mind, we should learn more about this patient group and invest more in research, so we can wisely treat this unique population.”

She stressed that not all elderly patients in need of surgery should actually be operated on. Recent studies, mostly from the surgical literature, show that about a third of the super-elderly undergo an operation in the last year of their life, 18% in the last month and 8% in the last week.  “It is not only that they don’t really benefit from surgery, but also that many become significantly disabled, some remain on mechanical ventilation, with tracheostomy, in diapers and with severe cognitive decline,” explained Professor Matot. “We need to discuss these aspects with the patient and the family to clarify these issues and set expectations.”

Almost half of the super-elderly following surgery will have significant ongoing care needs after discharge, for example, going on to a nursing home or some other facility. Care needs can intensify if a complication develops following surgery: in these cases, 90% of the super-elderly will require heavy support. “Thus, it is essential that we re-think surgery, when treatment burdens outweigh benefits,” said Professor Matot.

She added that, because super-elderly patients have no physiologic reserves, any complication will significantly increase mortality. The most common complications in this age group are delirium, renal (acute kidney injury) and cardiovascular. The significance of each and measurements to avoid complications were discussed in the talk, with special focus on the importance of avoiding intra-operative hypotension. Also, in very high-risk elderly patients, Professor Matot reminded the audience of the benefits of a possible anaesthetic technique that has been neglected in recent years: continuous spinal anaesthesia.

She also discussed an ongoing feasibility study, running in her department, which is “escorting the elderly to the operating room”. Just like parents escorting their child into the OR, or partners present during Caesarean section / labour with their wife, some elderly and families feel that the presence of a relative in the OR till induction of anaesthesia will help reduce anxiety, improve communication with the staff (as these patients usually don’t hear well or see well) and maybe help reduce delirium.

Professor Matot concluded: “The super-elderly population is growing and has special needs. My talk analysed specific aspects related to this patient population and I hope that it will trigger more anaesthesiologists to specialise in this challenging field of super-elderly perioperative management.”