101
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Demeure MJ, Fain MJ. The Elderly Surgical Patient and Postoperative Delirium. J Am Coll Surg 2006; 203:752-7. [PMID: 17084339 DOI: 10.1016/j.jamcollsurg.2006.07.032] [Citation(s) in RCA: 78] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2006] [Revised: 07/25/2006] [Accepted: 07/26/2006] [Indexed: 12/28/2022]
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102
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Abstract
Many diseases of the biliary tract and pancreas preferentially effect the elderly. Recent innovations in the evaluation and management of these disorders have directly impacted the lives of many seniors. Improved outcomes of pancreatic surgery is a good example of a positive impact in quality of life, especially when these surgeries are performed in centers of excellence. Evaluation and treatment strategies are presented for complicated calculous biliary disease, pancreatic carcinoma, and pancreatic cystic neoplasms.
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Affiliation(s)
- R Matthew Walsh
- Department of General Surgery, The Cleveland Clinic, 9500 Euclid Avenue, Cleveland, OH 44195, USA.
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103
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Stehle JR, Weeks ME, Lin K, Willingham MC, Hicks AM, Timms JF, Cui Z. Mass spectrometry identification of circulating alpha-1-B glycoprotein, increased in aged female C57BL/6 mice. Biochim Biophys Acta Gen Subj 2006; 1770:79-86. [PMID: 16945486 DOI: 10.1016/j.bbagen.2006.06.020] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2006] [Revised: 06/12/2006] [Accepted: 06/13/2006] [Indexed: 11/27/2022]
Abstract
In this study, we surveyed the profiles of mouse circulating proteins by 2-dimensional SDS-PAGE in different strains, sexes and ages. Among visible protein spots on 2-D gels with silver-staining, we identified a unique set of 7 seemingly-related proteins whose levels were consistently elevated in older C57BL/6 female mice. This set of 7 proteins was absent in C57BL/6 males or in BALB/c mice of either sex of any age. When C57BL/6 female mice were crossed with BALB/c males, the age-related increase of these proteins became sporadic and not linear in the F1 offspring. All 7 spots of this protein group were picked and subjected to identification by mass spectrometric analysis after tryptic digestion. The results showed that all 7 spots were different isoforms of alpha(1)B-glycoprotein with different degrees of post-translational modifications, such as phosphorylation. These results suggest that alpha(1)B-glycoprotein changes in mice in a sex and age dependent manner.
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Affiliation(s)
- John R Stehle
- Department of Pathology, Wake Forest University School of Medicine, Winston-Salem, NC 27157, USA
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104
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Abstract
The aging population is currently one of the main issues facing international health care systems. It is a recognized fact that with advancing age, the likelihood of developing health problems and chronic disease will increase and the demand for health care resources will escalate. This will impact hospitals and long-term care facilities. Our young nurses of the future will be faced with the challenging task of caring for this elderly population. A review of the literature revealed that nursing students have a negative attitude toward the elderly. This may be affected by personal beliefs, values, culture, experience, or observations. Their perceived attitudes toward the gerontology field will make it difficult to recruit the nurses required in this area. This article will explore these issues and examine the role of all health care professionals to help change their attitudes and develop a more positive relationship to meet the needs of this unique population.
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Affiliation(s)
- Marge Lovell
- Vascular Surgery Department, University of Western Ontario, London Health Sciences Centre, London, Ontario, Canada
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105
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Razzaque MS, Sitara D, Taguchi T, St-Arnaud R, Lanske B. Premature aging-like phenotype in fibroblast growth factor 23 null mice is a vitamin D-mediated process. FASEB J 2006; 20:720-2. [PMID: 16436465 PMCID: PMC2899884 DOI: 10.1096/fj.05-5432fje] [Citation(s) in RCA: 251] [Impact Index Per Article: 13.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
Fibroblast growth factor 23 null mice (Fgf-23-/-) have a short lifespan and show numerous biochemical and morphological features consistent with premature aging-like phenotypes, including kyphosis, severe muscle wasting, hypogonadism, osteopenia, emphysema, uncoordinated movement, T cell dysregulation, and atrophy of the intestinal villi, skin, thymus, and spleen. Furthermore, increased vitamin D activities in homozygous mutants are associated with severe atherosclerosis and widespread soft tissue calcifications; ablation of vitamin D activity from Fgf-23-/- mice, by genetically deleting the 1alpha(OH)ase gene, eliminates atherosclerosis and ectopic calcifications and significantly rescues premature aging-like features of Fgf-23-/- mice, resulting in prolonged survival of Fgf-23-/-/1alpha(OH)ase-/- double mutants. Our results indicate a novel role of Fgf-23 in developing premature aging-like features through regulating vitamin D homeostasis. Finally, our data support a new model of interactions among Fgf-23, vitamin D, and klotho, a gene described as being associated with premature aging process.
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Affiliation(s)
- Mohammed S. Razzaque
- Department of Developmental Biology, Harvard School of Dental Medicine, Boston, Massachusetts
| | - Despina Sitara
- Department of Developmental Biology, Harvard School of Dental Medicine, Boston, Massachusetts
| | - Takashi Taguchi
- Department of Pathology, Nagasaki University Graduate School of Biomedical Sciences, Nagasaki, Japan
| | | | - Beate Lanske
- Department of Developmental Biology, Harvard School of Dental Medicine, Boston, Massachusetts
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106
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Macrì A, Scuderi G, Saladino E, Trimarchi G, Terranova M, Versaci A, Famulari C. Acute gallstone cholecystitis in the elderly: treatment with emergency ultrasonographic percutaneous cholecystostomy and interval laparoscopic cholecystectomy. Surg Endosc 2005; 20:88-91. [PMID: 16333552 DOI: 10.1007/s00464-005-0178-6] [Citation(s) in RCA: 44] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2005] [Accepted: 09/04/2005] [Indexed: 01/06/2023]
Abstract
BACKGROUND The treatment of acute cholecystitis in the elderly is still a subject of debate, particularly with reference to the timing of surgery and the role of laparoscopy. PATIENTS From January 1994 to June 2002 we observed 27 patients aged over 70 years with acute calcolous cholecystitis. The patients were submitted to ultrasonographic percutaneous cholecystostomy within 12 h of the acute attack. For two patients (7.4%) at high operative risk, we chose a conservative treatment. Twenty-five patients (92.6%) were submitted, in 15 cases (60%) within 5 days and in 10 patients (40%) within 8 days, to a laparoscopic cholecystectomy. Statistical significance was accepted when the value of p was less than 0.05. RESULTS Ultrasonographic percutaneous cholecystostomy was performed successfully in all patients, without major morbidity or mortality, and complete resolution of clinical symptoms was obtained within 48 h. The conversion rate of laparoscopy was 20% (13.3% in patients submitted to surgery within 5 days and 30% in the group submitted within 8 days--p > 0.05). The postoperative morbidity rate was 24%; it was higher (40% versus 15%) in patients converted to laparotomy (p > 0.05); mortality was 4%. The period of hospitalization was 11 days in patients operated laparoscopically and 21 days in those converted to open cholecystectomy (p < 0.001). CONCLUSIONS The more rational treatment of acute calcolous cholecystitis in elderly patients is represented by ultrasonographic percutaneous cholecystostomy followed, within 5 days, by laparoscopic cholecystectomy using an abdominal insufflation maximum to 12 mmHg and a limited 10-15 degrees head-up tilt.
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Affiliation(s)
- A Macrì
- Emergency Surgery Unit, University of Messina, Messina 98125, Italy.
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107
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Alliot C. CHOP Versus CHOP Plus Granulocyte Colony-Stimulating Factor in Elderly Patients With Aggressive Non-Hodgkin's Lymphoma. J Clin Oncol 2005; 23:4797-9; author reply 4799-800. [PMID: 16034060 DOI: 10.1200/jco.2005.01.3920] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
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108
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Bhattacharya D, Ammori BJ. Contemporary minimally invasive approaches to the management of acute cholecystitis: a review and appraisal. Surg Laparosc Endosc Percutan Tech 2005; 15:1-8. [PMID: 15714147 DOI: 10.1097/01.sle.0000153730.24862.0a] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
Acute cholecystitis is one of the most common emergency admissions in surgical practice. This review appraises the available evidence from the English-language literature regarding the minimally invasive approaches to the management of this condition. The following aspects of care are reviewed and appraised: (1) the diagnostic criteria for acute cholecystitis, (2) the optimal timing for cholecystectomy (early, delayed, or interval surgery), (3) the optimal approach to cholecystectomy (laparoscopic versus open), (4) the role of intraoperative cholangiography, and (5) the management of patients unfit for surgery.
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109
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Watanabe H, Saito H, Rychahou PG, Uchida T, Evers BM. Aging is associated with decreased pancreatic acinar cell regeneration and phosphatidylinositol 3-kinase/Akt activation. Gastroenterology 2005; 128:1391-404. [PMID: 15887120 DOI: 10.1053/j.gastro.2005.03.016] [Citation(s) in RCA: 57] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
BACKGROUND & AIMS The effects of aging on pancreatic acinar cell proliferation have not been clearly defined. Phosphatidylinositol 3-kinase (PI3K)-mediated phosphorylation of Akt is a critical step for proliferation of various cell types and insulin secretion from pancreatic endocrine cells; however, its role in acinar cell proliferation is not known. The purpose of this study was to (1) delineate the effects of aging on pancreatic regeneration after partial pancreatectomy (Px) and (2) define the involvement of the PI3K/Akt pathway in pancreatic regeneration. METHODS Following partial Px, pancreatic regeneration and activation of the PI3K pathway were compared in young and aged mice. Activation of the PI3K/Akt pathway was evaluated by Akt phosphorylation (pAkt). The role of the PI3K pathway in pancreatic regeneration after partial Px was assessed by effects of a pharmacologic PI3K inhibitor wortmannin or small interfering RNA (siRNA) to the p85alpha regulatory subunit. To confirm further the critical role of the PI3K/Akt pathway in pancreatic acinar cell proliferation, IGF-1-mediated cell proliferation was determined in cultured acinar cells pretreated with wortmannin or p85alpha siRNA. RESULTS Pancreatic regeneration and pAkt expression after partial Px were significantly decreased with aging. Treatment with wortmannin or p85alpha siRNA reduced pancreatic regeneration after partial Px. The IGF-1-mediated cell proliferation in vitro was completely blocked by wortmannin or p85alpha siRNA but not by the MEK/ERK inhibitor PD98059. CONCLUSIONS PI3K/Akt activation plays a critical role in the regeneration of pancreatic acini after resection. Furthermore, pancreatic regeneration is markedly attenuated in the aged pancreas most likely because of decreased PI3K/Akt activation.
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Affiliation(s)
- Hiroaki Watanabe
- Department of Surgery, The University of Texas Medical Branch, Galveston 77555-0536, USA
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110
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Beardsley SL, Shlansky-Goldberg RD, Patel A, Freiman DB, Soulen MC, Stavropoulos SW, Clark TWI. Predicting Infected Bile Among Patients Undergoing Percutaneous Cholecystostomy. Cardiovasc Intervent Radiol 2005; 28:319-25. [PMID: 15886948 DOI: 10.1007/s00270-003-0260-1] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
PURPOSE Patients may not achieve a clinical benefit after percutaneous cholecystostomy due to the inherent difficulty in identifying patients who truly have infected gallbladders. We attempted to identify imaging and biochemical parameters which would help to predict which patients have infected gallbladders. METHODS A retrospective review was performed of 52 patients undergoing percutaneous cholecystostomy for clinical suspicion of acute cholecystitis in whom bile culture results were available. Multiple imaging and biochemical variables were examined alone and in combination as predictors of infected bile, using logistic regression. RESULTS Of the 52 patients, 25 (48%) had infected bile. Organisms cultured included Enterococcus, Enterobacter, Klebsiella, Pseudomonas, E. coli, Citrobacter and Candida. No biochemical parameters were significantly predictive of infected bile; white blood cell count >15,000 was weakly associated with greater odds of infected bile (odds ratio 2.0, p = NS). The presence of gallstones, sludge, gallbladder wall thickening and pericholecystic fluid by ultrasound or CT were not predictive of infected bile, alone or in combination, although a trend was observed among patients with CT findings of acute cholecystitis toward a higher 30-day mortality. Radionuclide scans were performed in 31% of patients; all were positive and 66% of these patients had infected bile. Since no patient who underwent a radionuclide scan had a negative study, this variable could not be entered into the regression model due to collinearity. CONCLUSION No single CT or ultrasound imaging variable was predictive of infected bile, and only a weak association of white blood cell count with infected bile was seen. No other biochemical parameters had any association with infected bile. The ability of radionuclide scanning to predict infected bile was higher than that of ultrasound or CT. This study illustrates the continued challenge to identify bacterial cholecystitis among patients referred for percutaneous cholecystostomy.
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Affiliation(s)
- Shannon L Beardsley
- Section of Interventional Radiology, Department of Radiology, Hospital of the University of Pennsylvania, 3400 Spruce Street, Philadelphia, PA 19104, USA
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111
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Arain SR, Kern S, Ficke DJ, Ebert TJ. Variability of duration of action of neuromuscular-blocking drugs in elderly patients. Acta Anaesthesiol Scand 2005; 49:312-5. [PMID: 15752394 DOI: 10.1111/j.1399-6576.2005.00634.x] [Citation(s) in RCA: 61] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
BACKGROUND Steroid-based, non-depolarizing neuromuscular-blocking (NMB) drugs (e.g. rocuronium, vecuronium) are characterized by organ-dependent elimination and significantly longer durations of action in elderly compared to young patients. Cisatracurium is a benzylisoquinolinium NMB drug with a duration of action not altered by ageing. The objective of the study was to determine if elderly patients had less variability in duration of action with 2 x ED95 of cisatracurium compared to equipotent doses of rocuronium or vecuronium. METHODS Informed consent was obtained from 66 elderly patients with normal renal and liver function. Preoperative midazolam (1 mg) was given IV. The anaesthestic induction was with 5 mg kg(-1) thiopental and 2 microg kg(-1) fentanyl. The patients received 0.6 mg kg(-1) rocuronium, 0.1 mg kg(-1) vecuronium or 0.1 mg kg(-1) cisatracurium. Anaesthetic maintenance was with sevoflurane in oxygen/nitrous oxide. Neuromuscular-blocking duration of action was defined as the return of T1 twitch height to 25% of control. Variability was determined by subtracting the actual duration of action from the mean duration of action for each drug. RESULTS The durations of action (range, min) were: cisatracurium, 37-81; vecuronium, 35-137; and rocuronium, 33-119. The median of the variability of duration was significantly less with cisatracurium (7 min) compared to vecuronium (18 min) and rocuronium (18 min) (P < 0.05). CONCLUSION When used with sevoflurane/N(2)O, there was a two-fold greater variability of duration of neuromuscular blockade in elderly patients receiving rocuronium or vecuronium compared with cisatracurium.
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Affiliation(s)
- S R Arain
- Department of Anaesthesiology, Medical College of Wisconsin, Zablocki VA Medical Center, Milwaukee, WI, USA
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112
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Toneto MG, Moreira LF, Jeckel Neto E, Souza HPD. Gastrectomia em pacientes idosos: análise dos fatores relacionados a complicações e mortalidade. Rev Col Bras Cir 2004. [DOI: 10.1590/s0100-69912004000600008] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
OBJETIVO: Verificar as variáveis que influenciam os resultados pós-operatórios no tratamento do adenocarcinoma gástrico em pacientes idosos. MÉTODO: Foi realizada uma coorte histórica onde as principais variáveis em estudo foram: idade, localização do tumor, estadiamento, doenças associadas, complicações do procedimento cirúrgico e mortalidade operatória. Os pacientes foram separados em dois grupos em relação à idade [Grupo I (< 65 anos) e Grupo II ( 65 anos)], de maneira que os fatores associados com maior mortalidade fossem analisados de forma independente. RESULTADOS: Foram avaliados 160 pacientes submetidos à ressecção gástrica. A média de idade foi 60,7 anos. Presença de doenças associadas, classificação ASA III ou IV e mortalidade operatória foram associados com indivíduos mais velhos. Não houve diferença entre os grupos em relação à localização do tumor no estômago, ressecção empregada, estágio dos tumores e complicações pós-operatórias. A mortalidade operatória foi 6,1% no Grupo I e 12,9% no Grupo II. O principal fator de risco para o óbito na análise univariada foi a presença de doenças associadas (p<0,03). Na análise multivariada, o único fator de risco significativo para maior mortalidade foi classificação ASA mais avançada. CONCLUSÃO: Os idosos operados por adenocarcinoma gástrico apresentam fator de risco mais acentuado de morte pós-operatória. Contudo, a idade cronológica não pode ser definida como um fator determinante, e sim circunstâncias de doenças associadas e condições fisiológicas que os acompanham nessa faixa etária.
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113
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Oncology Nursing Society and Geriatric Oncology Consortium Joint Position on Cancer Care in the Older Adult. Eur J Cancer Care (Engl) 2004; 13:434-5. [PMID: 15606710 DOI: 10.1111/j.1365-2354.2004.00539.x] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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114
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Tambyraja AL, Kumar S, Nixon SJ. Outcome of laparoscopic cholecystectomy in patients 80 years and older. World J Surg 2004; 28:745-8. [PMID: 15457351 DOI: 10.1007/s00268-004-7378-4] [Citation(s) in RCA: 52] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Advanced age is associated with an increase in postoperative complications. This study assesses the indications and outcome for laparoscopic cholecystectomy (LC) in patients aged 80 years or older. Consecutive, unselected patients aged 80 years or over undergoing LC between 1991 and 2000 were included. A retrospective case review enabled analysis of clinical and operative factors together with in-hospital morbidity, 30-day mortality, and duration of hospital stay. A series of 117 patients, 79 women and 38 men with a median age of 83 years (range 80-93 years), underwent LC. Indications for LC were chronic cholecystitis in 62 (53%) patients, acute cholecystitis in 28 (24%), gallstone pancreatitis in 12 (10%), and other conditions in 15 (13%). Six (5%) patients required conversion to an open procedure. Overall, 26 (22%) patients developed a postoperative complication. There were no bile leaks or bile duct injuries. One patient, with gangrenous cholecystitis, died after LC. The median postoperative hospital stay was 3 days (range 1-31 days). LC can be performed safely with low morbidity in patients over age 80 years.
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Affiliation(s)
- Andrew L Tambyraja
- Department of Surgery, Western General Hospital, Crewe Rd, EH4 2XV, Edinburgh, UK.
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115
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Richardson JD, Cocanour CS, Kern JA, Garrison RN, Kirton OC, Cofer JB, Spain DA, Thomason MH. Perioperative risk assessment in elderly and high-risk patients. J Am Coll Surg 2004; 199:133-46. [PMID: 15217641 DOI: 10.1016/j.jamcollsurg.2004.02.023] [Citation(s) in RCA: 41] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2002] [Revised: 02/20/2004] [Accepted: 02/24/2004] [Indexed: 12/20/2022]
Affiliation(s)
- J David Richardson
- Department of Surgery, University of Louisville School of Medicine, Louisville, KY 40292, USA
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116
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Alliot C, Barrios M. Oxaliplatin- or irinotecan-based chemotherapy for metastatic colorectal cancer in the elderly. Br J Cancer 2004; 90:2050-1; author reply 2051-2. [PMID: 15138493 PMCID: PMC2409475 DOI: 10.1038/sj.bjc.6601805] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022] Open
Affiliation(s)
- C Alliot
- Hematology/Oncology Division, General Hospital of Annemasse, BP 525, Annemasse Cedex 74107, France
- Hematology/Oncology Division, General Hospital of Annemasse, BP 525, Annemasse Cedex 74107, France. E-mail:
| | - M Barrios
- Laboratory of Biochemistry, Avicenne University Hospital, Bobigny, France
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117
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Truchon G, Perrault G, Tardif R. Toxicologie industrielle et vieillissement. PERSPECTIVES INTERDISCIPLINAIRES SUR LE TRAVAIL ET LA SANTÉ 2004. [DOI: 10.4000/pistes.3279] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
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118
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John V, Mashru S, Lichtman S. Pharmacological factors influencing anticancer drug selection in the elderly. Drugs Aging 2004; 20:737-59. [PMID: 12875610 DOI: 10.2165/00002512-200320100-00003] [Citation(s) in RCA: 32] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
Persons over the age of 65 years are the fastest growing segment of the US population. In the next 30 years this segment will represent more than 20% of the population. Fifty percent of all cancers occur in this age group and therefore the total cancer burden is expected to rise. Data are becoming available that will better guide the use of chemotherapy in the older patient population. Studies are presented discussing pharmacokinetic data on a number of chemotherapeutic agents with an emphasis on those that have entered clinical practice over the past few years. Many of these agents seem to have a beneficial therapeutic index, particularly in regard to older patients. Aging can affect the pharmacokinetics of chemotherapy in a number of ways. Absorption is only modified minimally by age. The greater concern with the use of oral drugs is patient compliance. Volume of distribution is affected by changes in body composition, anaemia and decreased plasma albumin concentration. There are many drugs in which renal excretion plays an important role. Decline in glomerular filtration is a consistent phenomenon with aging. Drug metabolism is primarily affected by changes in the P450 system and coadministration of drugs which also interact with this important enzyme system. The selection of chemotherapy in the elderly is frequently determined by degree of comorbidity and the patients' functional status. These factors are critical and can often determine response and toxicity. This article discusses the changes that occur with antimetabolites, camptothecins, anthracyclines, taxanes, platinum compounds, epipodophyllotoxins and vinca alkaloids. There has also been an increasing trend toward the use of oral chemotherapy. Factors that must be considered in selecting chemotherapeutic agents include limitations of saturability of absorption, patient compliance and the pharmacokinetic and pharmacodynamic changes that occur in older patients. Interpatient variability and age-related changes in drug metabolism are discussed. Careful attention to the physiological changes with age and dose adjustments necessary for end-organ dysfunction (renal, hepatic) are needed to ensure the safe administration of chemotherapy. In this article specific diseases are discussed (breast, colon, ovarian and non-small lung cancers) with recommendations for drug selection in adjuvant chemotherapy and the treatment of metastatic disease. Future studies will need to incorporate these various factors to properly evaluate chemotherapy in older patients. Research and educational initiatives targeted to this population will need to be a priority.
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Affiliation(s)
- Veena John
- Don Monti Division of Medical Oncology, North Shore University Hospital, NYU School of Medicine, Manhasset, New York, USA
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119
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Scheinfeld N, Yu T, Weinberg J, Gordon M, Silapunt S, Norman RA, Alam M. Cutaneous oncologic and cosmetic surgery in geriatric patients. Dermatol Clin 2004; 22:97-113. [PMID: 15018014 DOI: 10.1016/s0733-8635(03)00110-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
A wide array of surgical procedures is available to geriatric patients. These interventions can enhance the appearance of patients and facilitate the removal of skin cancers. Pre-existing medical conditions of geriatric patients must be considered comprehensively when selecting and performing cutaneous surgical procedures. Many older patients suffer from a variety of diseases and take a variety of medications and herbal supplements to ameliorate the consequences of such diseases. In general, skin surgery can be performed safely on even very old patients, provided precautions are followed. The biopsychosocial well-being and essence of patients must also be addressed when performing dermatologic surgery. If patients are treated holistically and comprehensively, their surgical experience can be enhanced and their health and appearance improved.
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Affiliation(s)
- Noah Scheinfeld
- Department of Dermatology, St. Luke's-Roosevelt Hospital Center, 1090 Amsterdam Avenue, Suite 11-D, New York, NY 10025, USA
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120
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Abstract
The geriatric patient has a high incidence of foot deformities and may be considered a good surgical candidate if healthy and psychologically ready for the surgical procedure. Foot problems in the geriatric population that may require surgical intervention can be grouped into approximately five categories, including (1) localized orthopedic disorders (ie, bunions, hammer toes, and so on); (2) skin and nail problems (ie, onychomycosis); (3) degenerative and inflammatory arthritis; (4) diabetic foot disorders; and (5) neuromuscular disease. However, age-related changes in cardiovascular, pulmonary, and renal function increase the risk of perioperative complications. The higher rates of complications seen in the older surgical patients result in part from existing comorbidity and age-associated changes in organ function. Extensive procedures depending on good bone healing for success should usually not be attempted on older patients. Office surgery for the geriatric patient should involve only the simplest procedures and should be kept to a minimum because of the increased possibility of postoperative complications. In the hospital there is better preoperative evaluation, operating room conditions, and postoperative care.
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Affiliation(s)
- Ellen Sobel
- New York College of Podiatric Medicine, Division of Orthopedics, 53 East 124 Street, New York, NY 10035, USA.
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121
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Abstract
The physiological changes that occur with increasing age can have significant effects on the pharmacokinetics of neuromuscular-blocking drugs. Changes in cardiac output can affect drug distribution and therefore the speed of onset of neuromuscular block. A decrease in muscle mass and increase in body fat with age can also affect their distribution. The deterioration in renal and hepatic function associated with aging affects the clearance and elimination of many neuromuscular-blocking drugs. The effects of these physiological changes on the pharmacokinetics of neuromuscular-blocking agents may not become apparent clinically in healthy individuals until the age of at least 75 years. There is very little evidence to suggest any alteration in the sensitivity of the neuromuscular junction to neuromuscular-blocking drugs with increasing age. Neuromuscular-blocking drugs that undergo a significant degree of organ-dependent elimination, such as pancuronium bromide, vecuronium bromide, rocuronium bromide and doxacurium chloride, may have a significantly prolonged duration of action in elderly patients. These drugs can be used safely in elderly patients if the anaesthetist is aware of their altered pharmacokinetics in this patient group. Appropriate changes must be made to drug dosage and dose intervals. As the pharmacokinetic changes can be unpredictable, monitoring of neuromuscular block is strongly advised when using these drugs in such patients. The risk of residual block occurring postoperatively after the use of pancuronium bromide increases with age. The duration of action of mivacurium chloride may also be prolonged in the elderly; this change has not been demonstrated to be a result of an alteration in plasma cholinesterase activity. In contrast, there is no evidence of an alteration in the action of suxamethonium chloride (succinylcholine chloride) with increasing age. Atracurium besilate and cisatracurium besilate undergo predominantly organ-independent elimination. Onset of block with these two drugs may be prolonged in the elderly, but their clinical duration of action does not alter significantly with age, making them particularly suitable for use in this patient group. Although atracurium besilate may cause histamine release, there is little evidence of it producing haemodynamic changes in the elderly. Its (1R,1R')-isomer, cisatracurium besilate, has very little direct or indirect cardiovascular effect and is, therefore, the most suitable nondepolarising agent to use in elderly patients.
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122
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Lichtman SM, Skirvin JA, Vemulapalli S. Pharmacology of antineoplastic agents in older cancer patients. Crit Rev Oncol Hematol 2003; 46:101-14. [PMID: 12711355 DOI: 10.1016/s1040-8428(02)00120-8] [Citation(s) in RCA: 37] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Persons over the age of 65 years are the fastest growing segment of the United States population. In the next 30 years it will comprise over 20% of the population. Fifty percent of all cancers occur in this age group and therefore there will be an expected rise in the total cancer burden. Data is becoming available which will better guide the use of chemotherapy in the older patient population. Studies will be presented discussing pharmacokinetic data on a number of chemotherapeutic agents with an emphasis on those which have entered practice over the past few years. Many of these agents seem to have a beneficial therapeutic index, particularly in regard to older patients. There has also been an increasing trend toward the use of oral chemotherapy. Factors that must be considered in choosing chemotherapy include limitations of saturability of absorption, patient compliance and the pharmacokinetic and pharmacodynamic changes which occur in older patients. Interpatient variability and age related changes in drug metabolism are discussed. Careful attention to the physiologic changes with age, and dose adjustments necessary for end organ dysfunction (renal, hepatic) are needed to ensure the safe administration of chemotherapy.
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Affiliation(s)
- Stuart M Lichtman
- Department of Medicine, Don Monti Division of Medical Oncology, North Shore University Hospital, New York University School of Medicine, 300 Community Drive, Manhasset, NY 11030, USA.
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123
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Fuentes-Vargas M, Santiago-Mejia J, Pinzon E, Rodriguez R. Age-related susceptibility to brain ischemia in mice. Drug Dev Res 2003. [DOI: 10.1002/ddr.10149] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
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124
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Javier Grau Talens E, García Olives F, Huertas Vega B, Prado Moralesd Á. La colecistitis aguda tratada con colecistostomía y extracción de cálculos bajo anestesia local en el paciente anciano de alto riesgo. Cir Esp 2003. [DOI: 10.1016/s0009-739x(03)72114-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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125
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Abstract
The open organ preservation surgical procedures are an important part of the head and neck surgeon's armamentarium for treating laryngeal cancer. The principles of organ preservation surgery as they apply to laryngeal cancer must be thoroughly appreciated and strictly applied for oncologic and functional success. The selection of eligible patients for these procedures is an art and requires a keen clinical acumen. The vertical partial laryngectomy and supraglottic laryngectomy have defined clinical applications that are relatively well accepted. The supracricoid laryngectomy continues gaining acceptance as a means of treating more extensive glottic and transglottic lesions while maintaining physiologic speech and swallowing without the need for a permanent tracheostoma. The inability to include and use the open surgical organ preservation approaches in the organ preservation paradigm for larynx cancer severely limits the patient's treatment options. Total laryngectomy and medical organ preservation protocols may not be acceptable to the patient from a quality-of-life standpoint. Therefore, it is incumbent upon the head and neck surgeon to have a thorough understanding of all the options available for treatment in the organ preservation paradigm for laryngeal cancer. These options must be skillfully evaluated as they relate to the patient's disease process and confidently used to provide the best oncologic and functional outcome.
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Affiliation(s)
- Ralph P Tufano
- Department of Otolaryngology, Head and Neck Surgery, 6th Floor, Johns Hopkins Outpatient Center, 601 N. Caroline Street, Baltimore, MD 21287, USA.
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126
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Skirvin JA, Lichtman SM. Pharmacokinetic considerations of oral chemotherapy in elderly patients with cancer. Drugs Aging 2002; 19:25-42. [PMID: 11929325 DOI: 10.2165/00002512-200219010-00003] [Citation(s) in RCA: 48] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022]
Abstract
Persons over the age of 65 years are the fastest growing segment of the US population. In the next 30 years they will comprise over 20% of the population. Fifty per cent of all cancers occur in this age group and therefore there will be an expected rise in the total cancer burden. There has been an increasing trend over the past 20 years toward the use of oral chemotherapy. This change has been encouraged by the need to decrease the costs of chemotherapy administration, patient preferences and quality of life issues. Factors that must be considered with oral chemotherapy administration include limitations of saturability of absorption, patient compliance and pharmacokinetic/pharmacodynamic changes which occur in elderly patients. Interpatient variability and drug metabolism, particularly age-related changes in drug metabolism are being studied. The cytochrome P450 system has been intensively studied because of its importance with regard to chemotherapeutic drugs. This article reviews these issues and provides details regarding specific drugs including temozolomide, thalidomide, topotecan, the fluoropyrimidines, etoposide, hydroxycarbamide (hydroxyurea), tamoxifen, and alkylating drugs. Complementary and alternative therapies are also discussed.
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Affiliation(s)
- J Andrew Skirvin
- College of Pharmacy and Allied Health Professions, St. Johns University, Jamaica, New York, USA
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127
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Simpson JK, Rosenzweig MQ. Treatment considerations for the elderly person with cancer. AACN CLINICAL ISSUES 2002; 13:43-60. [PMID: 11852722 DOI: 10.1097/00044067-200202000-00006] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
In an aging population, the number of patients with cancer continues to rise. Little research has focused on the treatment of cancer in the elderly. Therefore, the treatment for various cancers differs across the healthcare system. A uniform approach in assessing the elderly person with cancer is lacking. This article describes two case studies in the elderly population, focusing on two common cancers: acute myelogenous leukemia and breast cancer. Common side effects of treatment and determinants of treatment options are discussed. It is important that the elderly receive appropriate screening, early detection, treatment, and management of comorbidities.
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Affiliation(s)
- Jennifer K Simpson
- University of Pittsburgh, Graduate School of Public Health, Women's Health Office, 516 Parran Hall, 130 DeSoto Street, Pittsburgh, PA 15261, USA.
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128
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Spira RM, Nissan A, Zamir O, Cohen T, Fields SI, Freund HR. Percutaneous transhepatic cholecystostomy and delayed laparoscopic cholecystectomy in critically ill patients with acute calculus cholecystitis. Am J Surg 2002; 183:62-6. [PMID: 11869705 DOI: 10.1016/s0002-9610(01)00849-2] [Citation(s) in RCA: 121] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND The ultimate therapy for acute cholecystitis is cholecystectomy. However, in critically ill elderly patients the mortality of emergency cholecystectomy may reach up to 30%. Open cholecystostomy performed under local anesthesia was considered to be the procedure of choice for treatment of acute cholecystitis in high-risk patients. In recent years, ultrasound- or computed tomography (CT)-guided percutaneous transhepatic cholecystostomy (PTHC) replaced open cholecystostomy for the treatment of acute cholecystitis in critically ill patients. METHODS The aim of the present study was to evaluate the results of a 5-year protocol using PTHC followed by delayed laparoscopic cholecystectomy for the treatment of acute cholecystitis in critically ill patients. We reviewed the charts of 55 patients who underwent PTHC at the Hadassah University Hospital Mount Scopus during the years 1994 to 1999. RESULTS The main indications for PTHC among this group of severely sick and high-risk patients was biliary sepsis and septic shock in 23 patients (42%); and severe comorbidities in 32 patients (58%). The median age was 74 (32 to 98) years, 33 were female and 22 male. Successful biliary drainage by PTHC was achieved in 54 of 55 (98%) of the patients. The majority of the patients (31 of 55) were drained transhepaticlly under CT guidance. The rest, (24 of 55) were drained using ultrasound guidance followed by cholecystography for verification. Complications included hepatic bleeding that required surgical intervention in 1 patient and dislodgment of the catheter in 9 patients that was reinserted in 2 patients. Three patients died of multisystem organ failure 12 to 50 days following the procedure. The remaining 52 patients recovered well with a mean hospital stay of 15.5 plus minus 11.4 days. Thirty-one patients were able to undergo delayed surgery: 28 underwent laparoscopic cholecystectomy of whom 4 (14%) were converted to open cholecystectomy. This was compared with a 1.9% conversion rate in 1,498 elective laparoscopic cholecystectomies performed at the same time period (P = 0.012). Another 3 patients underwent planned open cholecystectomy, 1 urgent and 2 combined with other abdominal procedures. There was no surgery associated mortality, severe morbidity, or bile duct injury. CONCLUSIONS The use of PTHC in critically ill patients with acute cholecystitis is both safe and effective.
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Affiliation(s)
- Ram M Spira
- Department of Surgery, Hadassah University Hospital, Mount Scopus and Hebrew University-Hadassah Medical School, P.O. Box 24035, Jerusalem, il-91240, Israel
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129
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Street JT, Wang JH, Wu QD, Wakai A, McGuinness A, Redmond HP. The angiogenic response to skeletal injury is preserved in the elderly. J Orthop Res 2001; 19:1057-66. [PMID: 11781005 DOI: 10.1016/s0736-0266(01)00048-1] [Citation(s) in RCA: 42] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
Angiogenesis is essential for normal bone formation and repair. Avascularity characterizes aberrant fracture union in the elderly, while angiogenic mechanisms during cutaneous wound repair are attenuated in aged humans. We hypothesized that skeletal injury results in local (circulating) and systemic (fracture site) 'angiogenic' responses and that these reparative mechanisms are attenuated with advanced patient age. This prospective study examined peripheral blood and fracture hematoma from 32 patients, 16 under 40 years and 16 over the age of 75, undergoing emergent surgery for isolated fracture. The angiogenic cytokines vascular endothelial growth factor (VEGF) and platelet-derived growth factor (PDGF) were assayed. Endothelial cell cultures were supplemented with patient plasma and fracture hematoma and angiogenesis determined in vitro by measuring cell proliferation and blood vessel tube formation. Angiogenesis was determined in vivo using a murine dorsal wound pocket model and quantification of new blood vessel formation after 7 days. We found that all injured patients, irrespective of age, have elevated plasma and fracture hematoma levels of VEGF and PDGF. These elevated cytokine concentrations translate into biologically significant angiogenic effects, in vitro and in vivo. These effects are primarily VEGF mediated and are not dependent on patient age. The biological activity of these growth factors does not diminish with advanced age. Thus skeletal injury does result in local and systemic angiogenic responses whereby angiogenic cytokine availability and activity is preserved in the aged suggesting alternative mechanisms for the development of avascularity in delayed and fracture non-union in the elderly.
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Affiliation(s)
- J T Street
- Department of Academic Surgery, National Univesity of Ireland, Cork.
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130
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Fang W, Igaki H, Tachimori Y, Sato H, Daiko H, Kato H. Three-field lymph node dissection for esophageal cancer in elderly patients over 70 years of age. Ann Thorac Surg 2001; 72:867-71. [PMID: 11565672 DOI: 10.1016/s0003-4975(01)02896-x] [Citation(s) in RCA: 44] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
BACKGROUND The risk and benefit of esophagectomy with three-field lymph node dissection has not been well defined in elderly esophageal cancer patients. METHODS A total of 441 patients underwent three-field lymph node dissection from 1986 to 1998. Patients were divided into two age groups: group 1 consisted of 79 patients aged 70 years or over, and group 2 consisted of 362 patients under 70 years of age. Patients' characteristics and surgical outcomes were compared between groups. Risk factors for morbidity, mortality, and survival of patients in group 1 were further studied by multivariate analysis. RESULTS Significantly more patients had multiorgan dysfunction preoperatively in group 1 (24; 30.4%) than in group 2 (34; 9.4%, p < 0.001). The overall (65.8% vs 61.6%, p = 0.483) and surgically related complication rates (41.8% vs 52.2%, p = 0.093) were similar, but significantly more organ failure (11.4% vs 5.0%, p = 0.031) and infection (22.8% vs 13.8%, p = 0.045), defined as medical complications, occurred in group 1. There was no significant difference in 30-day (3.8% vs 0.8%, p = 0.074) or in-hospital mortality (7.6% vs 3.3%, p = 0.082) between groups. The overall (40.9% vs 48.1%, p = 0.235) and cause-specific 5-year survivals (55.4% vs 59.1%, p = 0.688) were comparably good in both groups, but the risk of death due to causes other than esophageal cancer was much higher in the elderly (p = 0.028). Multiorgan dysfunction was an independent predictive factor in elderly patients for overall and medical morbidity, overall survival, and risk of death from causes other than esophageal cancer. CONCLUSIONS Esophagectomy with three-field lymph node dissection could be carried out safely in patients over 70 years of age with satisfactory long-term results. For elderly patients with multiorgan dysfunction, however, less invasive procedures might be more appropriate.
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Affiliation(s)
- W Fang
- Department of Surgery, National Cancer Center Hospital, Tokyo, Japan
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131
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Deiwick M, Röschner C, Rothenburger M, Schmid C, Scheld HH. Feasibility and risks of heart surgery in very elderly: analysis of 200 consecutive patients of 80 years and above. Arch Gerontol Geriatr 2001; 32:295-304. [PMID: 11395175 DOI: 10.1016/s0167-4943(01)00088-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
A continuing increase in the number of very elderly patients with symptomatic heart disease referred for cardiac surgery has been observed in the past. Since 1990 all patients of 80 years and above have been included in a prospective study. We report on the results of the first 200 consecutive patients (mean age: 82.2+/-2.1 years). Operative procedures ranged from isolated myocardial revascularization and valve replacement to very complex operations. In a majority of patients, the operations had to be performed as urgent or emergency cases because of advanced heart disease. Overall 30 day mortality was 9.5%. More than two thirds of patients needed treatment of perioperative complications. During long-term follow-up, cardiac surgery in octogenarians has proved to be very effective with excellent functional status and quality of life. Because of favorable results elderly patients should not be denied the benefits of cardiac surgery requiring utilization of significant medical resources.
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Affiliation(s)
- M Deiwick
- Department of Cardiovascular Surgery, Westfälische Wilhelms-University, Albert-Schweitzer-Str. 33, D-48129, Münster, Germany
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132
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Chelluri L. Critical Illness in the Elderly: Review of Pathophysiology of Aging and Outcome of Intensive Care. J Intensive Care Med 2001. [DOI: 10.1046/j.1525-1489.2001.00114.x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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133
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Abstract
The incidence of most cancers increases with age. Although the risk for surgery increases in elderly patients who have comorbidities, evaluations of risk can allow interventions that may decrease morbidity and mortality. Appropriate treatments should be offered to the elderly until studies demonstrate the elderly can safely be managed differently from younger patients. The elderly should not be denied adequate treatment simply because of age.
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Affiliation(s)
- M M Kemeny
- Department of Surgery, State University of New York at Stony Brook, USA
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134
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Silverman MA, Zaidi U, Barnett S, Robles C, Khurana V, Manten H, Barnes D, Chua L, Roos BA. Cancer screening in the elderly population. Hematol Oncol Clin North Am 2000; 14:89-112, ix. [PMID: 10680074 DOI: 10.1016/s0889-8588(05)70280-x] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
This article reviews the current state of knowledge regarding cancer screening in the geriatric population. Care of the elderly requires knowledge of underlying physiologic changes, comorbidities, quality-of-life factors, and life expectancies. There is always the danger that ageism may prevent elderly cancer patients from receiving the proper treatment. On the other hand, overzealous treatment can lead to adverse results if elderly patients are not properly targeted based on current evidence of the benefits and risks of specific screening practices.
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Affiliation(s)
- M A Silverman
- Division of Gerontology, University of Miami School of Medicine, Florida, USA
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135
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Frankenfield D, Cooney RN, Smith JS, Rowe WA. Age-related differences in the metabolic response to injury. THE JOURNAL OF TRAUMA 2000; 48:49-56; discussion 56-7. [PMID: 10647565 DOI: 10.1097/00005373-200001000-00009] [Citation(s) in RCA: 60] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE To investigate the effect of age on the metabolic response to injury. METHODS Fifty-two trauma patients meeting entrance criteria were prospectively enrolled. Patients were grouped by age: elderly, >60 years; and young, < or =60 years. After 4 days of nutrition support, physiologic and laboratory data were collected. Energy and nitrogen metabolism, and body composition were evaluated. RESULTS Elderly patients demonstrated a reduced incidence of fever (48% vs. 77%,p = 0.027). Independent of body composition, temperature, and injury severity, oxygen consumption was 8% lower in the elderly (p = 0.0032). However, nitrogen loss and myofibrillar catabolic rate was not altered by age. Elderly subjects were more often hyperglycemic (38% vs. 0%, p < 0.0001) and azotemic (62% vs. 22%, p = 0.004), despite similar carbohydrate and protein intake. CONCLUSION Fever is less common and oxygen consumption lower in elderly trauma patients. Postinjury myofibrillar protein catabolism and nitrogen loss are not influenced by aging. Metabolic complications of nutrition support (hyperglycemia, azotemia) are more common in elderly trauma patients.
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Affiliation(s)
- D Frankenfield
- Department of Clinical Nutrition, Milton S. Hershey Medical Center, Hershey, PA 17033, USA
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136
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Abstract
The majority of vascular patients are elderly and present a unique set of problems after an operation. Age plays a major role in their recovery, but the greatest challenge is their preexisting medical problems. The changes that occur with aging in the following body systems will be discussed: cardiac, pulmonary, renal, gastrointestinal, genitourinary, and central nervous system. Special concerns related to pain management, risk of delirium, and wound healing present continuing nursing challenges that require close observation after surgery.
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Affiliation(s)
- V Dixon
- London Health Sciences Centre, Division of Vascular Surgery, Ontario, Canada
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137
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Borzellino G, de Manzoni G, Ricci F, Castaldini G, Guglielmi A, Cordiano C. Emergency cholecystostomy and subsequent cholecystectomy for acute gallstone cholecystitis in the elderly. Br J Surg 1999; 86:1521-5. [PMID: 10594498 DOI: 10.1046/j.1365-2168.1999.01284.x] [Citation(s) in RCA: 74] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
BACKGROUND The morbidity and mortality rates associated with acute cholecystitis are higher in the elderly. This study reports the results of treatment of acute cholecystitis in the elderly with emergency ultrasonographically guided percutaneous cholecystostomy followed by elective cholecystectomy after endoscopic treatment of any common bile duct stones diagnosed by percutaneous cholangiography. METHODS From January 1989 to December 1998, 92 patients aged over 70 years were treated for acute gallstone cholecystitis. A group of 84 patients with ultrasonographic signs of severe cholecystitis or an American Society of Anesthesiologists score of II to IV were submitted to ultrasonographically guided percutaneous cholecystostomy. Transcatheter cholangiography was performed in all patients and endoscopic sphincterotomy was performed before operation in patients with common bile duct stones. After resolution of the acute phase and treatment of any associated diseases, patients were submitted to cholecystectomy. RESULTS Cholecystostomy was performed successfully in 83 patients and permitted resolution of the acute attack in all after a mean period of 1.8 days. Cholangiography yielded a diagnosis of non-gallstone obstruction in one patient and common bile duct stones in 19 patients; preoperative endoscopic sphincterotomy and stone extraction was performed in 18 patients. Elective cholecystectomy was then performed in 70 patients with no deaths and a morbidity rate of 24 per cent. CONCLUSION Combining emergency ultrasonographically guided percutaneous cholecystostomy, preoperative endoscopic treatment of common bile duct stones and subsequent elective cholecystectomy constitutes an optimal treatment regimen for acute gallstone cholecystitis in selected elderly patients with a mortality rate of zero in the authors' experience.
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Affiliation(s)
- G Borzellino
- Istituto di Semeiotica Chirurgica, Università di Verona, Ospedale Maggiore, Verona, Italy
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138
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Moorthy S, Radpour S. Management of Anesthesia in Geriatric Patients Undergoing Head and Neck Surgery. EAR, NOSE & THROAT JOURNAL 1999. [DOI: 10.1177/014556139907800711] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Surgical outcomes of patients aged 65 and older depend in part on the patient's physiologic status and coexisting disease and whether the surgery is elective or urgent. As our overall population continues to grow older, more elderly patients with head and neck cancers are being scheduled for surgery. In addition to the usual problems of aging, older head and neck surgery patients have unique airway issues that must be addressed preoperatively. Likewise, thorough planning for perioperative management is imperative to reduce morbidity and mortality. Because pharmacokinetics and pharmacodynamics are different in older patients than in younger patients, the administration of anesthesia must be adjusted accordingly.
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Affiliation(s)
- S.S. Moorthy
- Department of Anesthesia, Indiana University Medical Center and the Richard L. Roudebush VA Medical Center. Indianapolis
| | - Shokri Radpour
- Department of Otolaryngology-Head and Neck Surgery, Indiana University Medical Center and the Richard L. Roudebush VA Medical Center. Indianapolis
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139
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Abstract
The elderly currently represent 11 per cent of the Australian population. By the year 2051 it has been estimated that 24 per cent of the population will be older than 65 years. One of the hazards facing the elderly is the risk of trauma. With this in mind, this paper has two major aims: one is to review the incidence and outcome of elderly trauma and the other is to identify pertinent points when assessing and managing the elderly trauma patient. Background information for this paper was obtained from the Australia Bureau of Statistics, Roads and Traffic Authority and Injury Surveillance Unit. A comprehensive literature review was then undertaken using the Medline and CINAHL databases.
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140
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Cullinane DC, Morris JA. The Impact of Age and Medical Comorbidities on the Outcome Following Severe Trauma. J Intensive Care Med 1999. [DOI: 10.1177/088506669901400204] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
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141
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Laccourreye O, Brasnu D, Périé S, Muscatello L, Ménard M, Weinstein G. Supracricoid partial laryngectomies in the elderly: mortality, complications, and functional outcome. Laryngoscope 1998; 108:237-42. [PMID: 9473075 DOI: 10.1097/00005537-199802000-00015] [Citation(s) in RCA: 52] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
A review of the postoperative course, complications, and functional outcome of 69 elderly patients (older than 65 years of age) consecutively managed with a supracricoid partial laryngectomy between 1977 and 1993 is presented. The tumors were glottic and supraglottic in origin in 53 and 16 patients, respectively. A cricohyoidoepiglottopexy, a tracheo-cricohyoidoepiglottopexy, and a cricohyoidopexy were performed in 48, five, and 16 patients, respectively. Immediate laryngeal, cervical, and medical complications were noted in 5.8%, 10.2%, and 10.2% of patients, respectively. Supracricoid partial laryngectomies never resulted in perioperative or postoperative death. The 5-year actuarial survival and local control estimates were 68%, and 93.9%, respectively. Late surgical complications included laryngocele, laryngeal stenosis, and pneumonia from aspiration-related death in 4.3%, 4.3%, and 1.4% of patients, respectively. Completion total laryngectomy, permanent gastrostomy, and permanent tracheostomy were requested in 1.4%, 1.4%, and 2.91% of patients, respectively. Overall a 92.8% laryngeal preservation rate was achieved. Univariate analysis of the potential correlation of different factors with the mortality incidence and causes, the incidence and type of the various complications, and the incidence for postoperative aspiration is presented.
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Affiliation(s)
- O Laccourreye
- Department of Otorhinolaryngology-Head and Neck Surgery, Laënnec Hospital, Assistance Publique des Hôpitaux de Paris, University Paris V, France
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142
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Muraki T, Kaneko T, Setoh N, Yoneda T, Taketomi Y. Characteristics of Respiratory Function of Aged Female Community Dwellers and Institutional Residents. PHYSICAL & OCCUPATIONAL THERAPY IN GERIATRICS 1998. [DOI: 10.1080/j148v15n02_04] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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143
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Abstract
As the elderly population continues to expand, more elderly patients will undergo surgical procedures. This patient population provides challenges for perioperative nurses, surgeons, and anesthesia care providers. By understanding normal age-related body system changes that may affect anesthesia, perioperative management team members can prevent complications and provide positive outcomes for elderly surgical patients.
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Affiliation(s)
- S E Hazen
- Wichita State University School of Nursing, Kan, USA
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144
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Beard CM, Kokmen E, O'Brien PC, Anía BJ, Melton LJ. Risk of Alzheimer's disease among elderly patients with anemia: population-based investigations in Olmsted County, Minnesota. Ann Epidemiol 1997; 7:219-24. [PMID: 9141646 DOI: 10.1016/s1047-2797(97)00015-x] [Citation(s) in RCA: 80] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
PURPOSE To evaluate the association, if any, between Alzheimer's disease (AD) and anemia among the elderly. METHODS Both case-control and cohort methodologies were used to evaluate this association. The case-control study included all incident cases of AD whose onset occurred during 1980-1984 in Rochester, MN (n = 302). An age- and gender-matched control was selected from among Rochester residents seen for care at Mayo Clinic during the year of onset of the case. All community medical records for cases and controls were reviewed to identify women with hemoglobin levels of < 12 g/dL and men with hemoglobin levels of < 13 g/dL during the year of onset and the prior year for cases and during the index year and year prior for controls. Logistic regression was used to estimate odds ratios (OR). The retrospective cohort study used the 618 residents of Olmsted County, MN, who were > or = 65 years of age and whose anemia, as defined above, was newly recognized in 1986. Standardized incidence ratios (SIR) for AD were estimated by use of the person-years of follow-up in the cohort and the incidence rates of AD for this community. RESULTS In the case-control study, an almost twofold increase in occurrence of AD was associated with anemia (OR, 1.88; 95% CI, 1.17-3.03). For men and women, respectively, the ORs were 1.81 (95% CI, 0.75-4.39) and 1.96 (95% CI, 1.11-3.47). The cohort study showed no overall increase in risk of AD (SIR, 0.98; 95% CI, 0.67-1.37). For men, the SIR was a comparable 1.49 (95% CI, 0.79-2.56), whereas for women the SIR was only 0.79 (95% CI, 0.49-1.23). CONCLUSIONS Although anemia may be a risk factor for AD in the elderly, the mechanism by which anemia contributes to the pathogenesis of AD or to the unmasking of AD symptoms is unknown.
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Affiliation(s)
- C M Beard
- Section of Clinical Epidemiology of the Department of Health Sciences Research, Mayo Clinic and Mayo Foundation, Rochester, Minnesota 55905, USA
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145
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Audisio RA, Veronesi P, Ferrario L, Cipolla C, Andreoni B, Aapro M. Elective surgery for gastrointestinal tumours in the elderly. Ann Oncol 1997; 8:317-26. [PMID: 9209660 DOI: 10.1023/a:1008294921269] [Citation(s) in RCA: 40] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023] Open
Abstract
The geriatric population is expanding and clinical decision-making is often complicated by the effects of ageing. Age should not be the only parameter considered when addressing medical problems. Elderly subjects have been denied surgery because of their presumed higher mortality and morbidity. The present review summarises the physiology of the aged and discusses operative risks, mortality and morbidity rates as well as therapeutic results for the different gastrointestinal sites when affected by cancer. Reports on surgical treatments are revisited and compared to the same procedures delivered to younger patients in the context of the ethical issue of offering the best care to every patient. Elective operations by surgical oncologists are found to be safe with the exception of major liver resections. Complication rates and mean hospital stay do not differ between the two age groups provided the procedure is conducted with the best-known technique in expert hands. A drop in operative morbidity has occurred in the past three decades. Several investigators have emphasised the marked increase in morbidity and mortality experienced by elderly patients when undergoing emergency procedures. Associated diseases have to be properly assessed, as the elderly have a frail physiological balance with a reduced capacity for recovery from traumatic events including major surgical procedures. Careful preoperative evaluation, intraoperative conduct and postoperative care are presently achieved in almost every major hospital. Good clinical practice is based on the balance between probability of cure and toxic effects. Treatment of the elderly should no longer be based on untested beliefs and personal opinions. The elderly should be accrued for prospective clinical evaluation and should not be denied optimal surgical treatment.
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Affiliation(s)
- R A Audisio
- EIO-European Institute of Oncology, Milan, Italy
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146
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147
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Vaz M, Rajkumar C, Wong J, Mazzeo RS, Turner AG, Cox HS, Jennings GL, Esler MD. Oxygen consumption in the heart, hepatomesenteric bed, and brain in young and elderly human subjects, and accompanying sympathetic nervous activity. Metabolism 1996; 45:1487-92. [PMID: 8969281 DOI: 10.1016/s0026-0495(96)90177-8] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
Although the reduction in whole-body energy expenditure with aging has been well documented, there is little information about the changes that individual organs undergo. We therefore measured oxygen consumption in the heart, hepatomesenteric bed, and brain in elderly subjects and young controls, using central venous catheter techniques and the application of Fick's principle. We also measured whole-body, cardiac, and hepatomesenteric sympathetic nervous activity using isotope dilution methodology. Cardiac, hepatomesenteric, and cerebral oxygen consumption was similar in both groups. Whole-body and hepatomesenteric sympathetic nervous activity was also similar in the study groups, whereas cardiac norepinephrine (NE) spillover was significantly higher in the elderly. In contrast to the young, cardiac sympathetic nervous activity as assessed from NE spillover was not related to either cardiac oxygen consumption or cardiac work in the elderly. The data suggest that although oxygen consumption in the heart, hepatomesenteric bed, and brain are not different between young and elderly individuals, the relationship between sympathetic nervous activity and oxygen consumption in individual organs may alter with aging.
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Affiliation(s)
- M Vaz
- Human Autonomic Function Laboratory, Baker Medical Research Institute, Prahran, Victoria, Australia
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148
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Stoop MJ, Dirksen R, Hendriks T. Advanced age alone does not suppress anastomotic healing in the intestine. Surgery 1996; 119:15-9. [PMID: 8560380 DOI: 10.1016/s0039-6060(96)80207-8] [Citation(s) in RCA: 22] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Because retrospective clinical studies yield conflicting results and experimental data are completely absent, this study was performed to determine whether anastomotic repair in the intestine deteriorates with age. METHODS Ileal and colonic anastomoses were constructed in two groups of healthy rats, ages 2 to 3 months and 27 to 30 months, respectively. Healing was assessed, both 3 and 7 days after operation, by measuring anastomotic bursting pressure, breaking strength, and collagen content, the latter both biochemically (hydroxyproline) and morphometrically. In addition, the ex vivo collagen synthetic capacities were compared. RESULTS The development of anastomotic strength was similar in young and old rats; average strength increased from 3 to 7 days and was never lower in the older animals. This was true for both bursting pressure and breaking strength. The collagen production capacity was suppressed in the old rats, particularly in the ileum (p < 0.05), whereas the synthesis of noncollagenous protein remained unaltered. However, this did not result in a reduced accumulation of collagen in the anastomotic area--both anastomotic hydroxyproline content and the volume percentage of collagen in the actual wound area were unchanged. CONCLUSIONS Advanced age per se does not affect development of strength or deposition of collagen during early repair of intestinal anastomoses.
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Affiliation(s)
- M J Stoop
- Department of Surgery, University Hospital Nijmegen, The Netherlands
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