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May 2000
Volume 64 |
Number 5
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Elderly patients present confusing physiologic alterations
that can be attributed either to aging or a plethora of
disease states. ...Fortunately, the amount of knowledge
we can bring to the table in caring for these patients continues
to increase exponentially, spawning new research, reviews
and textbooks.
Functional Outcomes for Elderly Patients
The New Frontier
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Jeffrey H. Silverstein,
M.D.
Committee on Geriatric Anesthesia
As we embark upon the 21st century, it is fair to say that advances
in anesthetic care have had a most profound impact on the geriatric
population. In the middle of the last century, inguinal hernia
surgery was considered too onerous for a patient over 50 years
of age! Today, in many hospitals, 50 years is well below the mean
age of the surgical population. Patients over 100 can undergo
anesthesia for surgical procedures. The number of patients over
65 who undergo noncardiac surgery showed increase from 7 million
to 14 million over the next three decades. Can we conclude that
anesthesia is safe and effective for elderly patients? While the
answer must be "yes," a more rigorous evaluation of the question
suggests that the surgical experience exacts a high cost on our
elderly patients and provides anesthesiologists with exciting
opportunities for future improvements.
Elderly patients present confusing physiologic alterations that
can be attributed either to aging or a plethora of disease states.
The study of purely age-related changes associated with "successful
aging" seeks to multiply the number of vital and active 90-year-old
individuals. However, we are more frequently faced with patients
having multiple medical problems. Fortunately, the amount of knowledge
we can bring to the table in caring for these patients continues
to increase exponentially, spawning new research, reviews and
textbooks.
Many important issues are principally seen in elderly patients.
Postoperative cognitive dysfunction was the focus of the recent
Duke Conference reviewed in this issue of the NEWSLETTER.
Almost all of the work on the value of perioperative b-blockade
has been done on elderly patients. For the remainder of this article,
I would like to call your attention to an important facet of elder
surgical care: the fact that old folks take a long time to recover
from anesthesia and surgery.
From its early days as a medical specialty, anesthesiology has
focused on patient outcomes. The initial focus was anesthetic
deaths, which have now declined from approximately 1:10,000 to
1:200,000 (some say even lower) in the last half of this century.
In recent years, the focus of anesthetic outcome research has
broadened beyond the classical 48-hour postoperative period. Major
cardiovascular and neurologic morbidity extending from months
to years postoperatively are currently being investigated.1,2
The studies of cognitive dysfunction in particular have used batteries
of psychometric tests that have included rudimentary functional
outcome measures. The first randomized, controlled anesthetic
interventional trial to focus on geriatric patients (October 1999)
evaluated the effect of intraoperative hypotension on long-term
cognitive function.3 While representing
a landmark in the development of anesthetic care for the elderly,
it nonetheless did not focus on the impact of the surgical procedure
on patient independence, disability and the ultimate quality of
functional recovery.
Outcome literature from internal medicine and the surgical specialties
has considered a wider view and has taken broader approaches.
Medical and surgical studies have, until the Postoperative Functional
Outcomes in Elders study, focused on short-term operative risk
or examined long-term functional recovery in settings with limited
ability for generalization.4 Prior
studies of functional recovery targeted relatively low-risk operations
aimed at correcting specific physical impairments (e.g., cataract
extraction, hip or knee replacement, hip fracture repair) that
result in permanent disability, or focused on cardiac bypass operations.
The Veterans Affairs National Surgical Quality Improvement Program
(NSQIP) assessed morbidity and mortality after 417,944 major surgical
procedures.5 The ongoing objectives
of NSQIP are to develop and test risk models that predict surgical
mortality and morbidity in order to assess quality of care. The
study's outcome measures were 30-day mortality and morbidity rather
than long-term outcome, and there is no postoperative assessment
of functional status. Anesthetic data are rudimentary. Both preoperative
functional status and cognitive status are measured by relatively
insensitive tri-level classification systems.
Mangione, et al., used the Medical Outcomes Study SF-36 and
other instruments to assess changes in health status at one, six
and 12 months after surgery among principally elderly patients
who underwent total hip arthroplasty, thoracic surgery for the
treatment of non-small-cell lung cancer or abdominal aortic aneurysm
repair.6 The authors accurately predicted
that hip arthroplasty patients would manifest improved physical
domain scores. For the other surgeries, significant changes were
observed for all eight subscales of the SF-36, suggesting that
responsiveness was dependent on the type of surgery and the timing
of follow-up. This study confirmed the need for multidimensional
measures to fully capture changes in health-related quality of
life after surgery as used in the Postoperative Functional Outcomes
in Elders study. Evaluations of health-related quality of life
distinguished differences between various types of surgeries.
Focusing on abdominal surgeries, the first major evaluation of
functional outcomes for elder patients is currently in progress
under the direction of Valerie Lawrence, M.D., at the University
of Texas Health Science Center, San Antonio, Texas.4
How long does it take an 80-year-old to "recover" from anesthesia
and surgery? To answer this question, it is important to define
what we mean by "recovery." In order to classify patients according
to functional status, gerontologists have developed scales and
scoring systems. The most commonly used and intuitively appealing
constructs measure activities of daily living (ADL) and independent
activities of daily living (IADL). ADLs are those activities that
are important to daily existence such as bathing, toileting, dressing,
grooming and ambulation. IADLs are those necessary to maintain
an independent existence such as using the telephone, accessing
transportation, purchasing groceries, preparing meals, doing housework,
washing laundry, taking medications and managing money. Whatever
the pre-existing functional status, all major surgery is associated
with a decrease in ADLs and IADLs. Some elderly patients may actually
achieve a higher functional status following anesthesia and joint
replacement surgery.
Early data that evaluate patients undergoing abdominal surgery
under general anesthesia indicate that mean change scores are
significantly different from preoperative assessment at one, three
and six weeks. Recovery to preoperative ADL averages between six
weeks to three months. For IADLs, mean scores are significantly
decreased below baseline at one, three and six weeks and three
months. Fourteen percent and 19 percent of patients demonstrate
persistent disability in ADLs and IADLs, respectively, at six
months following the operation. As an example, bathing skills
appear most sensitive and take longer to recover than eating skills
following abdominal surgery.7 Is Dr.
Lawrence's data consistent with common experience? Discussions
with multiple senior anesthesiologists who have undergone surgery
in the last 12 months confirm that it takes a long time to "feel
normal" after anesthesia and surgery.
Does anesthesia have anything to do with postoperative functional
status? The answers are not available. It is tempting to speculate
that the physiologic response to surgical wounds, primarily activation
of cytokines, is the primary culprit. Some think that regional
anesthesia is the answer for elderly patients.8
Early work suggests that it is possible to design our anesthetic
techniques to alter some long-term outcomes.9
Functional status is directly linked to the need for support services
and care-giver burden. Interventions to improve early and long-term
functional postoperative recovery are important. The geriatric
population represents the group in which alteration in anesthetic
intervention is likely to make the biggest impact, and thus represents
the principal opportunity to improve anesthetic care in the coming
years.
References:
1. Poldermans D, Boersma E, Bax JJ, et
al. The effect of bisoprolol on perioperative mortality and myocardial
infarction in high-risk patients undergoing vascular surgery.
Dutch Echocardiographic Cardiac Risk Evaluation Applying Stress
Echocardiography Study Group [see comments]. N Eng J Med. 1999;
341:1789-1794.
2. Moller JT, Cluitmans P, Rasmussen LS,
et al. Long-term postoperative cognitive dysfunction in the elderly
ISPOCD1 study. Lancet. 1998; 351:857-861.
3. Williams-Russo P, Sharrock NE, Mattis
S, et al. Randomized trial of hypotensive epidural anesthesia
in older adults. Anesthesiology. 1999; 91:926-935.
4. Lawrence VA. Postoperative functional
outcomes in elders. National Institute of Aging RO1 AG14304. Personal
Communication. 1999.
5. Khuri SF, Daley J, Henderson W, et al.
The Department of Veterans Affairs' NSQIP: The first national,
validated, outcome-based, risk-adjusted, and peer-controlled program
for the measurement and enhancement of the quality of surgical
care. National VA surgical quality improvement program. Ann Surg.
1998; 228:491-507.
6. Mangione CM, Goldman L, Orav EJ, et al.
Health-related quality of life after elective surgery: Measurement
of longitudinal changes. J Gen Intern Med. 1997; 12:686-697.
7. Lawrence VA, Mulrow CD, Hazuda HP, et
al. Dancing again after the blade: How much, how soon? J Gen Intern
Med. 1996; 11(Suppl 1):144.
8. Roy RC. Choosing general versus regional
anesthesia for the elderly. Anesthesia Clinics of North America.
2000; 18:91-104.
9. Zaugg M, Tagliente T, Lucchinetti E,
et al. Beneficial effects from beta-adrenergic blockade in elderly
patients undergoing noncardiac surgery. Anesthesiology. 1999;
91:1674-1686.
Jeffrey H. Silverstein, M.D., is Vice-Chair
for Research and Assistant Professor of Anesthesiology, Surgery,
Geriatrics and Adult Development at Mt. Sinai School of Medicine,
New York, New York. He is also Chair of the ASA Task Force on
Practice Advisory for Recovery Care.
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