Surgery and the elderly

@varelalaf

More and more elderly people are being seen in the operating room, especially for large joint replacement interventions, for colorectal cancer resections or for vascular pathologies, to cite the most frequent casuistry. Many of these actions are aggressive and generate risks of postoperative complications, which often require catheters, serum, transfusions, intubations, etc. Therefore, a lot of clinical circumstances are generated that induce immobilization, a situation that adds a new chain of risks, especially thromboembolism, bedsores, infections, disorientation, delusions, malnutrition and dehydration.

Fragility, the key to results

A US multivariate analysis, based on a database of almost half a million elderly people operated on from various types of interventions (all of them of high complexity), has shown that the degree of fragility before the intervention is associated with complications and mortality. This relationship, on the other hand, has been subsequently confirmed in a systematic review. For this reason, several researchers have been quick to support an obvious issue: if the fragility of the people to be operated is detected in a preventive manner and an individualized plan is operated in a multidisciplinary team environment throughout the surgical process, this fact reduces complications and mortality by itself.

Despite the evidence of the association between frailty and surgical results, it seems that many surgeons are determined to ignore it. In a survey carried out by the European Society of Oncological Surgery (2016) answered by 251 surgeons, almost all (> 90%) believe that the age of the patients isn't a limitation for surgery, which would be an interesting criterion, if not for more than half of these surgeons don't see the assessment of frailty as mandatory, since they think that with the ASA test of anaesthetists and with some complimentary assessment of nutritional and functional status is enough.

The comprehensive geriatric evaluation, beyond fragility

The next question that arises is concerning the elderly who are operated on is whether the indication of the intervention is adjusted to their way of being and living, and therefore two key instruments for a valuable surgical practice emerge: integral geriatric evaluation that goes beyond the detection of fragility, since in addition to clinical, mental and functional issues, it analyzes the family, social and quality of life environment, and what is even more important, the shared decisions for which it is necessary to create an environment that favours people to reflect on consent without haste, with respectful support to end up deciding according to their beliefs and values.

Detecting frailty to better prepare older people for surgery is a challenge for which it seems that there is still a long way to go, but the most valuable advance for surgeons who operate in the elderly is to learn to put the decision in a personal and social context of each patient, and therefore we need professional work with a broader view.


Jordi Varela
Editor