Editorial
Elderly: Stay in the Hospital or Go Home
Ayşe Karci*
Department of Anesthesiology and Reanimation, Dokuz Eylül University Medical School, Turkey
*Corresponding author: Ayşe Karci, Department of Anesthesiology and Reanimation, Dokuz Eylül University Medical School, Turkey
Published: 27 Sep, 2017
Cite this article as: Karci A. Elderly: Stay in the Hospital or
Go Home. Clin Surg. 2017; 2: 1634.
Editorial
Elderly patients are uniquely vulnerable and particularly sensitive to the stresses of
hospitalization and surgery/ anesthesia in ways that are only partially understood. Clearly,
there are two major challenges confronting anesthesiologists today: the nuances of gerontologic
anesthesia and the safety of day-case surgery. Even “normal” aging results in alterations in cardiac,
respiratory, neurologic, and renal physiology that are linked to reduced functional reserve and
ability to compensate for physiologic stress. Moreover, the consumption of multiple medications
so typical of the elderly can alter homeostatic mechanisms. Clearly, the goal of the preoperative
evaluation should be the identification of major predictors of cardiac risk in patients who have
a prohibitive rate of perioperative morbidity and mortality, and are inappropriate candidates for
elective outpatient surgery. Routine screening in a general population of elderly patients does not
significantly augment information obtained from the patient’s history. Additionally positive results
on screening tests have modest impact on patient care. So, for preoperative cardiac evaluation,
the patient’s activity level, expressed in metabolic units, is accepted as the primary determinant
of the necessity for further evaluation, along with the results obtained from history and physical
examination. A preoperative assessment of comorbid conditions should be undertaken to detect
hypertension, dysrhythmias, previous MI, cerebrovascular disease, and biventricular failure. In
patients with intermediate clinical predictors, the invasiveness of the surgery and the functional
status of the patient will have major roles in determining the nature and extent of preoperative
testing or intervention. No preoperative cardiovascular testing should be performed if the results
will not change perioperative management.
Since subtle forms of cognitive impairment can predispose to worsened cognitive outcome
postoperatively, a multidimensional approach should include screening for mental status,
depression, and alcohol abuse. It should be appreciated that the elderly patient is at much greater
risk for long-term functional compromise after the stress of surgery. Appropriate preoperative
optimization may well pay dividends in terms of improving functional status after discharge.
Many anesthesiologists question whether OSA patients are appropriate candidates for ambulatory
surgery. Recently, members of the ASA Task Force on Perioperative Management of Patients
with Obstructive Sleep Apnea implied that OSA patients can be safely managed on an outpatient
basis, as well as the appropriate time for their discharge time from the surgical facility. However,
those individuals with multiple risk factors, most probably will benefit from a more conservative
approach that includes postoperative admission and careful monitoring. It is important not to be
lulled into a false sense of security simply because general anesthesia is not involved. Efforts to
identify the “best” intraoperative anesthetic agent or technique or approach for the elderly continue,
but it seems that no anesthetic agent or technique is unequivocally superior for all conditions or
circumstances. Therefore, clinicians should strive to maintain homeostasis, to avoid drug cocktailsespecially
long-acting benzodiazepines and anticholinergics-to administer short-acting drugs,
maintain normothermia and euvolemia, and provide adequate postoperative analgesia. Because of
pulmonary changes, especially when general anesthesia is preferred, it is imperative to appreciate
that desaturation occurs faster in older adults and also they are more vulnerable to desaturationrelated
cardiac events. Advanced age is clearly associated with a reduction in median effective dose
requirements for all agents that act within the central nervous system. This reduction in anesthetic
requirement is agent-independent and probably reflects fundamental neurophysiological changes
in the brain, such as reduced neuron density or altered concentrations of neurotransmitters. Use
of bispectral index (BIS) monitoring, can provide more rapid emergence in geriatric patients
and keeping the BIS level close to 60 rather than in the 40 range has been recommended. Indeed,
neuraxial, plexus, or nerve blocks in the elderly may be associated with an increased risk of
persistent numbness, nerve palsies, and other neurologic complications. Monitored anesthesia
care with intravenous sedation has become really important in the ambulatory venue and many
procedures can be performed with local anesthesia plus sedation. These changes have been in the favor of increasing number of geriatric patients with coexisting
medical conditions that benefit from minimally invasive surgical and
anesthetic techniques. The implications of cognitive decline in elderly
are devastating because affected individuals often become dependent
and withdraw from society. It has been postulated that pain, sleep
deprivation, sensory deprivation or overload, and an unfamiliar
environment may contribute to delirium. To overcome the problem
early mobilization and appropriate environmental stimuli are
encouraged. Because ambulatory patients return home to a familiar
environment postoperatively where appropriate stimuli and support
are available, one suspects that the incidence of delirium may be less in
outpatients than in their hospitalized counterparts. Typically it should
be remembered that, pain and post-operative nausea and vomiting are
two of the most common reasons for unanticipated admission after
planned outpatient surgery. It is imperative that elderly outpatients be
discharged from an outpatient surgery facility only if accompanied by
an escort, and a competent individual should remain with the patient
for at least 24 h postoperatively. Geriatric patients are at higher risk
for drowsiness, confusion, falls, urinary retention, and adverse drug
interactions than their younger counterparts. Clinicians should
provide the patient and his or her caregiver with clear, written postoperative
instructions about administration of medications, activities
to be avoided, and the phone number to be called should problems or
questions arise. When possible, a case might be made for encouraging
ambulatory surgery because of its typically brief duration, relatively
noninvasive approach, and its ability to allow elderly patients to
recover in their familiar, supportive home environment.