Pre- and postoperative management of elderly surgical patients. The Edward Henderson Award lecture

Student attitudes about surgery in older patients before and after the surgical clerkship

Although emphasis has been placed on including content on treating the elderly in the medical school curriculum, little attention has been given to whether content on surgical management of the elderly should be provided in the surgical clerkship. The purpose of this paper is to describe geriatric principles emphasized in a surgical clerkship and changes in attitudes of students. Junior students (N = 175) were tested on attitudes before and after the clerkship. Attitudes about treating the elderly and surgery in the elderly changed significantly and positively. Attitudes about emergency surgery in the elderly became more realistic, particularly in those selecting surgery as a career. This study differs from others that found that students became more negative about treating the elderly as they progressed through medical school. The surgical clerkship provides a different perspective of the older patient from that seen on medicine or in long-term care, in that the elderly are usually admitted and treated successfully in a short time. The fact that the surgical clerkship, in contrast to other medical school experiences, can positively influence attitudes about aging for all students, regardless of career choice, is encouraging and suggests that including content on surgical management of the elderly can help students become more favorable about treating older patients.

The medical evaluation and management of the elderly surgical patient

Contrary to earlier findings, elderly patients are not at significantly greater risk of perioperative morbidity or mortality than younger patients simply because of advanced age. Increased risk, when present, is attributable to pathologic changes that are not uniformly seen in all geriatric patients. Most perioperative morbidity is caused by cardiovascular and pulmonary complications. The author discusses an appropriate preoperative evaluation and recommends selective ancillary tests to screen for high-risk patients.

The role of vaginal hysterectomy in the aged woman

The results of vaginal hysterectomy in 85 women over the age of 65 were reviewed. All the patients' complaints were attributable to uterine prolapse but the frequency of occurrence was not proportional to the given patients' degree of disability. Spinal anesthesia was used the most frequently, as it is usually not contraindicated in the elderly. Certain postoperative complications were encountered, but these did not cause prolongation of the hospital stay. No postoperative deaths occurred. Most of the patients showed complete improvement in terms of personal activity. It is concluded that vaginal hysterectomy for uterine prolapse is a safe and beneficial operation in the elderly and is preferable to the more limited procedures employed years earlier.

Major gynecologic surgical procedures in the aged

The results of major gynecologic operations in 160 women over the age of 65 were reviewed and compared with the results in 120 younger women 40--55 years old. Most of the complaints of the elderly group were related to genital prolapse. These conditions caused daily discomfort and anxiety. Contrary to the practice in the younger group, most of the operations in the elderly were vaginal. Vaginal hysterectomy was the preferred procedure in most cases of uterine prolapse. Spinal anesthesia was used, as it is rarely contraindicated in the elderly. Postoperative complications were few and did not cause prolongation of hospital stay. There was only one postoperative death, a mortality rate of 0.6 percent. When care is exercised in medical evaluation, choice of anesthesia, and performance of the operation, the elderly patient usually can tolerate major gynecologic surgical procedures well, and should not be lightly disqualified from receiving the benefits.

Surgical mortality in the elderly

Surgical mortality rates were reviewed for the four-year period 1970-1973, in a series of 2,186 operations. The majority of these operations were performed in patients aged 70 or older; of these, 116 were performed in patients of the 90+ age group. Predictably, the surgical mortality in the older groups was higher than in the younger groups. However, the overall mortality for patients aged 70 or older was 4.9 per cent as compared with 8 to 21 per cent for series reported in the literature. Gastrointestinal, biliary, and chest procedures carried a much higher mortality than did the other major categories. Minor surgical operations in the elderly should be approached with caution since they may be associated with a significant mortality rate. Nevertheless, elderly patients should not be denied surgical intervention, major or minor, on the basis of age alone when the operation can make their remaining years more comfortable.