Gabriel M. Gurman, MD
Once upon a time, when I started my residency in anaesthesia, one of the absolute contraindications for surgery was the very old patient. Nobody wanted to touch a very old patient with significant comorbidities, except in case of emergency. The postoperative morbidity and mortality were high enough to justify this “policy”, and the medical personnel lived with the impression that this situation was accepted by the general public. I do not remember any revolt against refusing a case, neither from the patient nor from family, because everybody understood that he/she was “too sick” to be put on the operating table.
More than half a century ago, the general opinion was that “surgery in the elderly should be confined to unequivocally necessary cases”(Bedford et al) (1).
Today we are facing a completely different concept. I am taking the liberty to make a statement – today, there is no absolute contraindication to any surgical procedure because of the medical condition of the patient, old age included.
Already thirty years after Bedford’s paper, the trend became completely different, and a paper in a very esteemed journal declared: “age alone should not be bar to surgery and anaesthesia” (2).
The Guinness World Record for the oldest patient to have surgery was published in the year of 2000. The patient, a 113-years old lady, was operated on for repair of right femoral shaft fracture, under general anaesthesia. She was discharged home at the 23rd postoperative day and lived an additional nine months, to celebrate her 114th birthday!
Anaesthesiology has progressed in such a way that today we possess the expertise and the means, first to correctly assess every patient’s medical condition, and then to select the most appropriate anaesthesia technique, which would best keep the his/her homeostasis and reduce the rate of postoperative complications.
Thus, today, old age does not represent an obstacle anymore in solving the surgical problems of the patient. However, at the same time, in many cases, the old patient raises many questions which need to be solved before surgery and anaesthesia.
In some emergency cases, if possible, the surgical act is postponed for just a couple of hours, during which efforts are made to improve the patient’s condition and bring that patient to the operating table at a higher level of homeostatic stability.
In case of elective surgery for a very sick, old patient, the surgical team’s decision to postpone the operation is easier, but sometimes, like in the case cancer, surgery is needed as soon as possible, and the anaesthesiologist is obliged to find the quickest way to prepare the patient.
Today anaesthetising an old patient is everybody’s “daily bread”. More and more patients live after the retirement age and are in need for a surgical procedure. As one of our peers wrote many years ago (today we live longer, but a greater proportion of our life is spent in ill health (3). Life expectancy is continuously increasing, in some countries reaching the age of 85. Today, people aged 65 or older exceed 30% of the population in Japan and Western Europe, and 20% in the USA. The total global population older than 65 years today stands at more than 700 million.
In the developed world the annual rate of surgery for people older than 75 is around 30%, in comparison with the group aged 35-44, for which the rate of surgery is only 9%. Almost 50% of the surgical procedures performed on old patients are done on an emergency basis.
Is my patient really old?
This is a good question, because the definition of the old age varies from one source to another. The explanation is clear, if one takes into consideration that the definition according to which old age refers to ages nearing or surpassing the life expectancy of human beings. But life expectancy largely varies from one country to another.
A much more accepted definition is that one which divides the old people into three categories: young old (65-74), old -old (75-84) and very old (>85)
Does the old age definition have any clinical, practical importance?
For some clinicians, the answer is yes, and for them people older than 80 are automatically part of American Society of Anaesthesiology (ASA) physical status class III or IV groups (4).
But the truth is that age per se not as important as the patient co-morbidity.
Moor and Stiff wrote in 1998: “ …age does not appear to significantly affect perioperative mortality. Rather, it is high incidence of coexisting medical conditions and the complexity of surgery in this age group that cause elderly patients to have a greater risk of perioperative morbidity and mortality (5).”
If so, the anaesthesiologist is supposed to be aware of the variability in the health condition of the old age, and not to accept the concept that the old patient is always, by definition, inpermanent danger of developing intra- and postoperative complications.
The physiological senescence.
We are speaking here about a special category of patients, that one which can be defined as “old and healthy”. The truth is that this term does not exactly reflects the reality. Age has a continuous influence on the human being health. Body organs, especially the vital ones, but not only, are influenced by the long-term functionality, under different factors and conditions. During life, the body suffers a lot of changes, some of them having a practical importance for the anaesthesiologist.
Here is a short list: delayed gastric emptying, impaired hepatic metabolism, chronic anaemia, reduction in the number of nephrons, bone fragility and osteoporosis, hypothyroidism (as an explanation of reduced basic metabolic rate), problematic memory, visual and hearing impairment.Does it mean that this kind of patient could be considered sick?
The logical approach in this case would mean special care regarding the anaesthetic dosage, positioning on the operating table and prevention-in time- of any complication or adverse event which could affect the already impaired functionality.
Some studies tried to investigate the influence of anaesthesia on the cognitive function in the case of an old patient, and specifically on the development of Alzheimer’s disease. The last paper on this topic (6) concluded that this possible relation remains to be clarified. Further studies, including large cohorts of patients, are necessary. This aspect is too important to be neglected. It can affect any patient who is considered “old”, even if he/she could be included in the category of “old and healthy”.
The pathological senescence.
Apparently, this is a clear category of sick patients, suffering from various diseases which usually accompany old age, mainly cardiovascular, pulmonary, as well as depression and serious impairment of the cognitive function.But this kind of thinking is too superficial.
There are many old and sick patients, whom chronic diseases are kept in a stable condition, due to proper medication and correct daily activity. The so called “metabolic syndrome”, which includes diabetes, hypertension, hypercholesterolaemia, could be successfully treated, if not cured.
If the patient takes care of him/herself, keeps a proper diet, performs regular physical activity, does not smoke and avoids excess alcohol consumption, there is a good chance that his/her medical condition would be kept stable.Yes, this patient needs a special attention, but his/her chance to recover, even from an extended surgical procedure, is to be expected.
Finally, one cannot forget that group of patients who are candidates for a surgical intervention and suffer from a variety of clinical conditions, which are still compatible with life, but for which homeostasis is difficult to keep in normal ranges, even in the absence of surgery and anaesthesia. This is the really a category of patients in jeopardy, most of them belonging to ASA IV category.
This paper’s aim is farfrom offering the reader the “cookbook” of taking care of the old patient. The experienced anesthesiologist would know how to deal with the old and sick patient. The statistics of the last years show that more and more old and sick patients survived surgical interventions and the postoperative period without any difficulty.
But some advice is needed in order to complete the whole scenario.
The literature recommends the following measures, among others, to be taken in case of every old, sick or not, patient:
Be prepared for haemodynamic instability
- Plan post-operative analgesia
- Monitor subclinical events
- Allow time for drug response, recovery, tracheal extubation
- Factor into every case the risk and benefit of every decision
I would like to end these notes with two quotations.
The first one belongs to the late Golda Meir, the legendary Israeli prime minister: “Old age is like a plane flying through a storm. Once you’re aboard, there’s nothing you can do”.
But this one, coming from Alan Bleasdale, the well-known British screenwriter, is much more optimistic: “To resist the frigidity of old age, one must combine the body, the mind, and the heart. And to keep these in parallel vigor one must exercise, study, and love”.
1.Bedford PD, Lancet 1955; II:257
2.Edwards AE, Anaesthesia 1996;51:3
3.Barsky AJ, New Engl J Med 1988;318:414
4.Roy R, in “Clinical Anesthesia Practice. Eds Kirbi RR et al. 2nded 2002 pp 345
5.Moore LE and Stiff JL. In : Principles and practice of anesthesiology. Eds: Longnecker DA, Tinker JH, Morgan GE. 2nded. 1998, pp 475.
6.Marques AFVDSF, Lapa TASC. Rev Bras Anestesiol 2018;68:174