It’s a strange irony that population ageing is both one of the biggest success stories of public health policies and one of its biggest challenges. It’s a well-publicised fact that the proportion of the world’s population aged over 60 years is expected to double from 12% today to 22% in 2050. Even looking at the comparatively recent past, based on global averages a child born in 1990 could expect to live to around 66 years old, whilst a child born in 2012 is expected to live to 73.1

 

The trouble is, older people today are not generally in better health than their parents were at the same age. According to the World Health Organization there has only been a very slight decline over 30 years in the proportion of older people needing help with basic activities, and ageing is still characterized by multiple chronic conditions and geriatric syndromes. Heart disease, stroke and chronic lung disease are the leading causes of death, while common causes of disability include sensory impairment, back and neck pain, chronic obstructive pulmonary disease, depressive disorders, falls, diabetes, dementia and osteoarthritis.2

 

What is risk?

Given the high prevalence of multiple chronic conditions among the elderly, it’s little surprise that age has a strong correlation with surgical risk. However, in the surgical setting the identification of ‘high risk’ patient groups can be problematic, and is not consistent internationally or even intra-nationally. In assessing the risks of surgical complications, morbidity and mortality, surgeons take into account a wide array of factors, including (but not limited to) age, severity of condition and the presence co-morbidities, as well as factoring in the inherent risk of the surgery itself.3 The age of the patient, while it may impact on a number of medical risk criteria, is therefore not a precise measure of risk.

 

Nevertheless, it is fair to say that older patients have a statistically higher chance of post-surgical complications than their younger counterparts. One observational study undertaken across three teaching hospitals in Melbourne, Australia in 2004, found that patients aged over 70 had higher rates of postoperative complications and a higher 30-day mortality rate, and that patient factors were in fact stronger predictors of mortality than the type of surgery.

 

The research4 showed that 6% of patients aged over 70 had died within 30 days of surgery, while 19% had developed complications after five days, 12% of which subsequently died by day 30. The type of surgery was found to be a weaker predictor of mortality than patient factors. Older age was a key factor in predictor of 30-day mortality: by the age of 80 years the risk of death doubled from that of 70, and it doubled again between the ages of 80 and 90.

 

Other key pre-operative factors included the severity of systemic disease (as measured by ASA level) and the level of plasma albumin (which measures chronic disease and malnutrition). The leading indicators of post-operative death were ICU admission (especially unplanned), sepsis and renal impairment. Overall, patients aged over 70 experienced 31 complications per 100 compared with 23 in 100 across all age groups.

 

Integrated services

The authors of the study note that these findings are comparable with similar studies in North America and Europe, and point to a need internationally to optimise the health of elderly patients prior to surgery. Whilst particularly crucial to elderly patients, this emphasis on ‘prehabilitation’ is a growing concern for patients of all ages, with studies suggesting that weight loss, exercise, smoking cessation and detailed consultation can have a tangible impact on patient outcomes and recovery.

 

In the hospital setting, the authors of the Melbourne study make a series of recommendations to improve the prospects of elderly surgical patients, including:

 

• Co-management of older surgical patients by doctors specialising in hospital medicine (hospitalists), who ideally have skills in resuscitation, acute pain management, and general medicine
• Nurse-led critical care outreach, with a critical-care trained nurse reviewing high-risk patients on general wards
• The ICU-based, doctor-led, medical emergency team (MET) can be used to resuscitate surgical patients showing early signs of physiological instability

 

Through a combination of prehabilitation, detailed risk assessment, integrated care and age-appropriate consultation with the patient, it’s thought that the hospital setting could reduce the risks of surgical complications among the elderly. However, many experts claim that in order to meet the needs of a changing demographic a wholesale change is needed in our approach to health and social care. A move towards integrated, personalised, wraparound care would provide the best opportunity for early interventions, diagnosing, treating and managing myriad health problems to maintain a better overall quality of life for the patient.

 

A research paper5 appearing in the Journal of the American Geriatrics Society claims to be the first empirical study of post-surgical cancer patients to link a specialized home care package with improved survival rates. The study involved 375 post-operative patients aged 60–92 discharged from the Comprehensive Cancer Center in Pennsylvania. Researchers placed 190 of these patients in an intervention group, which received specialized home care by advanced practice nurses (APNs) providing four weeks of clinical assessment, monitoring, teaching and skills for the patients and their families. The researchers measured survival as well as predictors of survival such as depressive symptoms, symptom distress, function status, comorbidities, length of hospital stay, age of patient and stage of disease. Overall, the intervention group experienced improved survival, particularly in the case of patients with later stage cancer, where survival at 44 months was 67% compared to 40% in the control group.

 

Whilst the provision of truly integrated healthcare would represent a considerable investment of resources and a radical rethink, the evidence increasingly suggests that it would not only positively impact on the health of elderly patients, but in doing so also reduce the burden on acute health services, making it a win-win for 21st century medicine.

Studies suggest that older patients have higher rates of in-hospital mortality and morbidity. Is this borne out by your experience, and if so, what are the main risks?

 

First of all, it’s worth bearing in mind that the concept of ‘old age’ is itself ambiguous. Where we might once have considered a person to be ‘old’ at 60, with today’s increased life expectancy we’re really talking about patients over 70. Then we will see patients aged 70 who are regularly playing tennis and expect to maintain their active lifestyle, and patients who at the same age expect only to have less pain and a better quality of life. Each patient has to be assessed on an individual basis according to their health status and their expectations.

 

There’s no uniform criteria to measure the impact of old age on surgical risk, because there are a great deal of variables to consider. However, it’s certainly the case that age impacts on surgical results. Generally speaking, elderly patients are more likely to have co-morbidities and poorer bone quality, and with that comes a higher risk of complications and longer recovery times.

 

How do medical teams minimize those risks for older patients?

 

We must do everything we can to avoid surgical complications, because older people are far less tolerant and resilient than younger people, who tend to bounce back more quickly. After the preoperative assessment, it is critical that the patient is in the best medical condition. Nutrition, adequate management of comorbidities and preoperative measures to lower the risk of infection are all relevant issues that need to be taken care of.

 

It’s important after surgery to encourage our patients to get out of bed earlier, and start physiotherapy as soon as possible. Older people are also more likely to be on existing medication for co-morbidities so we have to get their medications right, according to the post operative requirements . In every area, older patients need more support: they will see more consultants, require more medication and stay in hospital longer. That has to be accepted, and is part of providing the best care.

 

In terms of communication, how do you ensure that older patients understand the risks of surgery and the support they will require to recover?

 

We involve the family of the patient in the pre-surgical consultation, because they will need more support to recover at home. It’s important to ensure that the patient will have everything they need not just medically, but in terms of accessing the right diet and being able to get up and move around. In any surgery it’s important to communicate clearly with the patient to ensure they fully understand the risks. Illnesses such as dementia are a contra-indication to surgery, so it’s not likely that we would be in a position of trying to explain surgical procedures to patients with advanced cognitive problems.

 

Are there any national guidelines available to standardize the care of elderly patients?

 

I’m not aware of any national policies or guidelines – generally it’s up to each individual institution to develop their practice as they see fit. Unfortunately that will vary from country to country, and across the public and private sector. I work in a private institution in Buenos Aires, the capital city of Argentina, so our approach to patient care might be radically different to that of a hospital in another state. All of our patients have private health insurance, compared with around 30% in the country as a whole. I suspect our approach will be closer to what can be seen in other countries with well-established private insurance. We run a ‘Social Assistance’ department which provides co-ordinated care packages, combining services such as physiotherapy, surgical follow-up and home support. I expect that for many countries these after-care services are a lifeline for isolated elderly people, but in Argentina there’s a family culture for elderly parents to live with their children, so the vast majority of patients will have a support network at home to tend to their recovery.

 

 

 

 

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Advancing care for advanced age

 

Dr Marcelo Gruenberg of Hospital Italiano de Buenos Aires discusses the potential complications of caring for elderly patients