Much like the fact that we were once taught to never take a patient with diabetes to surgery, we also were once told to never take a geriatric patient to surgery. My how things have changed.

Now, with proper training and good common sense, we can make a difference in our patients’ lives at any age or with any disability.

In their article in the Journal of the American Board of Family Medicine (www.jabfm.org), also reported on Medscape, Drs. Daniel Lee and Gerit Mulder gave an elegant little report on the statistics supporting doing surgery on the geriatric population and surgical interventions at each anatomic level of the foot for the geriatric patient.

They also do a great job of disussing the peri-operative considerations and the post-operative management requirements that are unique to this population, with a special nod to the nutritional needs of the geriatric patient. I highly recommend the article.  

In my time I have done more than just a few surgeries on the over-65 patient population out of ncessity. I don't know how I would feel about doing elective surgery though.

My question is to the readers here:

Have you done elective surgery on geriatric patients? Do you think that this represents more risk than on the younger population?  I have no qualms about necessary surgery but I still have some misgivings about elective surgery...yes, I guess I'm a bit of a wimp.

Surgery in the geriatric population should be considered just as in the pediatric patient population, but with considerations in mind and greater pre-operative planning/considerations. Sometimes these patients (usually in their 70s-80s) say "I'm too old to have surgery." My response is that "I have patients in their 40-50s that I would never take to an operating room." Age alone is NOT the main factor in the determination if a patient is a surgical candidate.

1. Planning the surgical procedure, what is the goal? Usually PAIN RELIEF or PREVENTION OF INFECTION/ULCERATION. When it comes to this I think of a saying..."The enemy of good is perfection." What do I mean by this? The surgical procedure selected in this patient population may not be the one selected in a younger patient. For example, if one has a obese, geriatric patient with mild osteopenia with a recurrent ulceration/infection history at the dorsal-medial aspect of the first metatarsal-phalangeal joint and a high intermetatarsal angle between the first and second metatarsal. Should a closing base wedge osteotomy be considered with the patient expected to be non-weightbearing in this patient? Would the patient achieve a "better" result with less risk with a distal osteotomy of the first metatarsal with joint arthroplasty. Although the deformity is lessened, it is not the result one would accept in a 40-50 y/o patient?
There is the matter of what form of bone fixation would be indicated. Does the mild to moderate osteopenic patient fare better with K-wire fixation versus internal screw fixation which may have a higher propensity to fail?

2. Medications...this an extremely important consideration. Is the patient on an aspirin regimen which should be stopped 7-10 days pre-operatively? Is the patient on Vitamin E / fish oils which may affect bleeding? Is the patient on coumadin/warfarin which is usually stopped 48-72 hours pre-operatively and 48 hours post-operatively?  Considerations such as renal and liver functions are important with appropriate non-steroidal selection post-operatively. Also, selection of pain medications with dosages is an important consideration. In many of these patients, dosages are best used in lower than usual dosages initially in light of their metabolic states with monitoring prior to any increase in their dosages. Antibiotic prophylaxis?....this is somewhat controversial. However, I think less so in this population, especially if there is a joint replacement history, previous history/ulceration history of the site of surgery, history of certain metabolic diseases (eg. diabetes) or cardiac/mitral valve stenosis/atrial fibrillation history (controversial for some practitioners, but does warrant some pre-operative consideration.) 

3. Social history....The effects of smoking in these patients, even in the absence of other metatabolic diseases, predispose these patients to infection and/or non-healing? How much do they drink (caffeine or alcohol)? This is the most important question for me....Do they have help for their post-operative recovery? Does that influuence selection of the procedure or even doing it at all? Another consideration is the mental state of the patient...are they depressed? Depressed patients may have lower thresholds for pain tolerance. The depressed patient may need psychological evaluation pre-operatively and the intervention of family/friends in the post-operative recovery. The patient who is depressed and not well clinically managed may prevent a surgical intervention (except in an urgent situation) till the psychological situation is stabilized in this patient.

4. Nutrition....Is the patient well-nourished? I suspect this is rarely considered. A serum albumin level indicates a healing potential post-operatively. I utilize this even in diabetic patients with an assessment for ulcer / wound healing and infection resolution potential.

5. Pre-operative laboratories..... These are important with particular attention to renal and liver function tests in regard to medication selection. Arterial doppler studies, including toe pressures, skin perfusion pressures, and evaluation of waveforms to assess macro- and micro-vascular states. Cardiac function tests with appropriate medical clearances are extremely important to me.

Excellent points, Gino! Thanks for adding these.

I have always made it a point to add to these tests the valuable lab test – prealbumin.

This test is also known as a Tryptophan-rich prealbumin or thyroxine-binding prealbumin. It is of increased value because it gives a closer look, nearer to the time of the surgery, of the patient’s nutritional status. This is especially important if you suspect that your patient is CHRONICALLY malnourished.

Remember too that obesity does not equate to nutritionally sound!  I live in the land of tortillas, tamales and tacos, all of which have a lot of carbohydrates that turn into sugar once consumed. But these foods are protein-deficient and my patients were equally protein deficient and so I was not surprised to find that their prealbumin scores were in the low range and they needed supplementation pre- and post-surgery even though they were morbidly obese! It was a learning curve.

If you are like I was for the longest time and you are still relying on a dogeared Washington Manual or  another residency manual you got years ago during your training, I have discovered a very useful on-line tool to keep up with the newest tests: www.labtestsonline.org

I would have to agree with the above comments--these are excellent points.  Age alone is not absolute contraindidcation for surgery, and in my practice, advanced age simply requires  a more thorough and thoughtful perioperative management to allow the case to procede safely.

In addition to increased testing pre-operatively, geriatric patients often require additional surgical planning to address the inherent weaknesses they may posses due to advanced age.  For example, often these patients require wound and bone healing augmentation, such as DBM or autogenous platelet concentration, to progress toward appropriate healing, and the clinician needs to be ready to assess the need for such augmentation and to provide it when necessary.

Upon the completion of the procedure, these high risk geriatric patients require a more aggressive follow-up because they are at increased risk for common (and sometimes not-so-common) post operative complications.  While this is not necessarily a problem, the clinican must be ready to anticipate the potential problems and intervene appropriately.

While certainly age presents as a compounding risk factor, it is one that generally be managed effectively with a conscientious team approach which includes the patient, the surgeon, the PCP, and the patient's supporting fmily members.