Surgery

Geriatric Essentials

• Surgical risk is related more to comorbidity than to chronologic age.
• Certain surgical complications (eg, delirium, pressure ulcers, deconditioning) are more common and more serious (even life threatening) in elderly patients than in younger patients.

In the US, surgical rates are nearly twice as high for people > 65 as for people < 65. About 25 to 40% of all surgical procedures and about 50% of emergency surgical procedures are done in people > 65.

Age is sometimes considered an independent risk factor for surgical complications and death, especially during emergency surgery. Mortality rates for most surgical procedures increase nearly linearly with aging, and 75% of all postoperative deaths occur in the elderly. Nonfatal complications are also more common among the elderly. However, most of the age-related increase in surgical risk results from increased comorbidity rather than from chronologic age. Thus, the exact contribution of age to surgical risk is still debated, and the decision to perform surgery should be based more on the patient's general health.

Life expectancy is a major determinant of potential benefit from surgery. For example, elective surgery done solely to correct a life-threatening disorder (eg, aortic aneurysm resection) is not indicated if the patient's life expectancy is already very brief. However, brief life expectancy does not necessarily contraindicate surgery done to improve quality of life (eg, vascular bypass to relieve severe ischemic pain, joint replacement to preserve ambulation).

A patient's age can affect the timing of surgery. For elderly patients with cholecystitis, cholecystectomy should be done early because the mortality rate increases from 2% when surgery is done within 12 to 24 h of diagnosis to 10% when surgery is delayed; however, these data may reflect a severity-of-illness bias. For elderly patients with other disorders, the mortality rate is lower when certain procedures (eg, for an inguinal hernia or abdominal aortic aneurysm) are done as elective surgery rather than as emergency surgery, so delay may be warranted. Delay may allow for better control of comorbidities (eg, diabetes, hypertension), which are common among the elderly, and for more thorough technical preparation for the surgical procedure.

Certain surgical complications (eg, delirium, pressure ulcers, deconditioning) are common among elderly patients and can be life threatening; in younger patients, these complications are uncommon and are usually short-lived and less serious. Monitoring for and prevention of these complications is essential.

Plastic surgery is often done in the elderly. It can be reconstructive or cosmetic (ie, for no medical indication). Common reconstructive surgical procedures include skin tumor removal, flap reconstruction of pressure ulcers and other wounds, some head and neck surgical procedures, and reconstructive breast surgery.

Cosmetic surgery should not be denied solely because of age. Such surgery may improve self-esteem and quality of life and may be affordable for the first time during older age. Indications and risks are about the same as those for younger people. Risk should be fully assessed.

This topic was last updated March 2006.