Risks of Surgery and Anesthesia in Elderly Patients

It is estimated that in the United States, 4 million surgeries per year are performed on patients who are aged 65 and older. Surgery in this group, however, requires special considerations. In addition to an overall frailty of the population in comparison to younger surgical candidates, the presence of chronic diseases such as hypertension, diabetes, and coronary and cerebrovascular disease are more likely to be present. It is important for patients to understand the preoperative process and ask questions in order to remain informed, understand their risks, and make appropriate decisions that meet their individual needs. Studies suggest that older adults overwhelmingly decide against procedures that would prolong life at the cost of independence or functional decline.1

Preparation

When appropriate, surgery may be scheduled in an ambulatory surgery center, often referred to as “outpatient surgery.” This may be done for certain surgical procedures, including cataracts, carpal tunnel repairs, knee arthroscopies, and hernia repairs. However, these procedures may need to be done in a hospital if the patient has a complicated medical history or needs assistance after surgery.

Most importantly, according to Johns Hopkins Medicine, is the assessment and recommendation from the surgeon and anesthesiologist for deciding if a patient is appropriate for outpatient surgery. For patients aged 65 plus, age is not a reason to disqualify an elderly patient from outpatient surgery. But age does affect how some patients react to anesthetic medicines. Comorbidities, or other diagnoses, of the older adult are also factored in during their pre-surgical evaluation.2 The patient should discuss with their family, surgeon, and primary care physician if they are suitable for ambulatory surgery and whether they will need home health care.

The surgeon may request preoperative testing. There are no mandatory preoperative tests or studies based solely on age. Rather, the decision to order tests depends on the presence of disease and type of surgical procedure. Studies may be ordered to establish a baseline, screen for common diseases, or assess the patient’s ability to process the anesthesia during and after the procedure. Some common tests include an electrocardiogram (an assessment of the heart’s ability to function properly), a basic metabolic panel (a blood test establishing how well your body is processing energy and waste), and a complete blood count (CBC) which measures the many different components of blood.

Patients with complicated medical histories who are scheduled for general anesthesia are often sent for medical clearance by their primary care physician, who is more familiar with their medical history. In certain circumstances, a patient may need clearance by a specialist such as a cardiologist, pulmonologist, or endocrinologist. These physicians can assist with giving a detailed assessment of a patient's health and ordering specialized tests that can provide an idea of their ability to tolerate the stress of surgery. Primary care physicians often refer patients to their surgeon and are aware that a surgery may be indicated. However, it is recommended that patients inform their primary care doctor and specialists if they are scheduled to have a procedure or surgery.

Patients should be given instructions on their medication schedule for the days prior to the surgery and on the morning of the procedure. This decision is based upon the medical team’s expertise and policies. In addition to being instructed not to eat or drink after midnight on the day of surgery, the patient will be asked to stop using tobacco products during the same period. A variety of medications like some blood pressure pills, diuretic prescriptions, blood thinners, or oral diabetes medications, as well as many others are often stopped before surgery. It is important to discuss with your medical team your specific preoperative plan. Appropriate management and adherence to instructions can avoid cancellation of surgery and decrease the risk for complications.

Anesthesia

Depending on the surgical setting, type of surgery, and medical history, the patient may be asked to schedule an appointment in a preoperative anesthesia clinic or receive a phone call the day prior. If a patient has questions or concerns about their anesthesia, they have the right to contact the anesthesia department and discuss them before their scheduled surgery. On the day of surgery, the patient will meet their anesthesiologist face-to-face and a thorough medical history will be obtained including allergies, last meal or drink, medication list, history of previous surgeries, problems with anesthesia, as well as heart, lung, brain, and kidney function.

An airway exam will be performed on all patients and includes asking the patient to open their mouth and say “ahhh” so the doctor can observe the structures of the mouth and throat. This simple exam allows the anesthesiologist to assess the ease of inserting airway devices to assist with breathing and deliver inhaled anesthetic medications. In patients undergoing sedation for their procedure, information from this exam is useful if the patient has a history of lung or airway problems, or is otherwise considered high risk.

Based upon the doctor's assessment of the patient's overall health, an ASA (American Society of Anesthesiologists) grade of 1 to 5 will be assigned. This classification system is not necessarily affected by chronological age. The score is used to assess the risk that anesthetics may pose for a patient during their procedure. For example, classification grade 1 is given to a healthy patient in good physical condition, and a classification grade 5 is given mostly to emergency situations where the patient is not expected to live without urgent surgery.3

The anesthesiologist will formulate and describe a plan of care and will obtain consent from the patient. The patient will have the opportunity to ask specific questions about the type of anesthesia that will be administered, how their pain will be managed, and what are the possible risks.

Pain relief during or after the surgery may be provided by intravenous or oral medications. In certain circumstances, Epidural Anesthesia, or placing anesthetic medication directly into the epidural space of the spine, may be appropriate. This can provide excellent pain relief, cause less nausea or vomiting, and reduce the risk of developing a blood clot in your legs (Deep Vein Thrombosis, DVT), when compared to general anesthesia.4

Awareness Under Anesthesia

During the Civil War, anesthesia was provided by dipping a sponge in liquid chloroform or ether and putting it atop a cone placed over a patient's nose and mouth. There are some obvious concerns with this technique and fortunately anesthesia has come a long way since then.5 Today, anesthetic medications are delivered in a controlled (and more civilized) manner through specialized devices to provide loss of sensation to pain with or without loss of consciousness for surgery.

Over the last several years, there has been significant media coverage of “waking up” during surgery. Also known as intraoperative awareness, this implies that during a period of intended general anesthesia, the brain is aroused by stimuli that are stored in memory. Fortunately, intraoperative awareness is extremely rare and studies have shown an estimated incidence of 0.1 percent of all patients across surgery types.6 However, this value is not zero and a patient's concerns and fears are real.

Media coverage of this issue has resulted in the medical community proactively addressing and researching methods to prevent, identify and treat intraoperative awareness. In fact, public knowledge about intraoperative awareness is a good thing, especially when it is discussed factually and not sensationalized. Here are some facts every patient undergoing general anesthesia should know:

• General anesthesia is a medication-induced, sleep-like state during which the brain does not respond to pain or stimulus.7
• While you are asleep, your anesthesiologist utilizes sophisticated technology to deliver specific dosages of anesthetic medications. They also carefully monitor your heart rate, blood pressure, and breathing pattern to help gauge the depth of anesthesia. Specialized brain function monitors can assess electrical activity and potentially help the anesthesiologist identify a patient's need for more or less sedation. However, these monitors have limitations and the decision to use them should be individualized to your case.
• It is possible to remember events or conversations in the operating room before going to sleep or after awakening from your surgery. However, this does not constitute awareness under anesthesia. Additionally, some procedures are performed with sedation, which is a sleep-like state that does not block pain or stimuli, instead of general anesthesia.
• “Not giving enough” anesthesia is not the only cause of intraoperative awareness. More commonly, awareness occurs in patients who have impaired heart function, have lost a significant amount of blood, or are undergoing emergency surgeries or Cesarean sections. These patients may not be able to tolerate the blood pressure lowering effects of anesthetic medications. Your anesthesiologist may face the difficult choice between keeping the patient alive and unharmed versus keeping them asleep.
• Patients with chronic pain conditions or opioid tolerance, substance use or abuse including smokers, and ASA class 4 or 5, may have higher drug requirements.8
• Not all awareness is the same. It can vary from specific and vivid to dream-like memories of your surgery. Most patients who have experienced awareness did not feel pain, although some described experiencing pressure.

Doctors and researchers have shown when intraoperative awareness is identified early and appropriately managed, there is a decreased occurrence of sleep disturbances, anxiety or post-traumatic stress disorder (PTSD), and patients are less likely to avoid future medical care. If you feel you may have experienced awareness under anesthesia, alert your anesthesiologist as soon as possible. He or she should obtain a detailed account of your experience and appropriately document it in your chart and report it to the hospital. When appropriate, you may be offered counseling or psychological support.

As a patient, there are a number of things you can do that may decrease your risk of intraoperative awareness. During your preoperative interview, it is important to provide an accurate list of medications (e.g. pain, anxiety, and/or sleep medications.) Be forthright about how much alcohol you drink (or if you use any illegal drugs) and the approximate amount you consume in a day or week. Anesthetic medications act on the same brain receptors as a number of these medications or substances like alcohol, and you may require higher doses. If you have encountered, or believe you have encountered awareness under anesthesia, this should also be disclosed so your doctor can try to figure out why it happened and make specific attempts to prevent it from happening again. Be clear about what type of anesthesia you will be receiving because in some instances, sedation may be most appropriate and safest. And finally, ask the anesthesiologist if you have an increased risk.

Complications

A person’s age, in and of itself, does not increase the risk of postoperative complications. However, because patients over the age of 65 are more likely to have chronic disease as compared to younger patients, the frequency of overall complications is increased. According to one study, an estimated 3.75 million postoperative complications occurred in the US in 2018, and the study even notes that the actual number is most likely higher due to constraints of the research.9 The percentage of that involving older adults is unclear, but one can assume that since they are the largest surgical population,10 they also experienced the most complications. Complications can involve the heart, brain, lungs, or kidneys. Your anesthesiologist should be able to discuss these risks with you after evaluating your history.

Cognitive issues, including delirium and postoperative cognitive dysfunction (POCD), are serious postsurgical concerns for patients older than 65. Postoperative delirium is the most common complication reported for older adults, affecting up to 50 percent of patients in that demographic. Some of the symptoms that indicate a patient is experiencing delirium are agitation, fatigue, restlessness, aggression, confusion, slurred speech, or hallucinations, but there are many others. These seniors are at a higher risk for physical injury, extended hospitalization, or even transfer to long-term care facilities.11 Delirium may present immediately after waking up from anesthesia or one to three days after.. Treatment consists of removing potential causes, supportive care, and, if appropriate, medications.

Postoperative cognitive dysfunction (POCD) describes a deterioration of cognition after surgery and anesthesia. It is an evolving concept that is characterized by a persistent deterioration of mental performance. Older patients are at a much higher risk for POCD, “with around 40 percent over the age of 60 who are hospitalized for surgery experiencing POCD on discharge, and 10 percent three months later.12” Diagnosis of this condition is done via neuropsychological cognitive testing. It remains an active area of ongoing research and a major concern for the future given the growing elderly population and their increased need for surgical procedures. Some of the main risk factors for POCD are advanced age, alcoholism, the use of anticholinergic drugs, extended duration of anesthesia, and major invasive surgery.13