Preoperative Evaluation of the Elderly Surgical Patient

  • Darlene Gabeau
  • Ronnie A. Rosenthal


The aging of the American population has created the need to provide surgical care to an ever-increasing number of older persons. In the United States over the short period from 1980 to 1996 the percentage of operations for which the patient was over age 65 increased from 19% to 36%; when obstetrical procedures are excluded this portion rises to 43%.1 It is now estimated that at least half of the patients in most general surgical practices are over age 65. During the next 50 years the portion of the population over age 65 is expected to continue to grow from the present 12.5% to 20%, or nearly 80 million people. Those over age 85 are the most rapidly growing segment of this population, and their number is expected to increase sixfold to 18 million by the year 20502 (Fig. 10.1).


Chronic Obstructive Pulmonary Disease Preoperative Evaluation Pulmonary Complication Postoperative Delirium Noncardiac Surgery 
These keywords were added by machine and not by the authors. This process is experimental and the keywords may be updated as the learning algorithm improves.


Unable to display preview. Download preview PDF.

Unable to display preview. Download preview PDF.


  1. 1.
    Peebles RJ, Schneidman DS (eds). Socio-economic Factbook for Surgery 1997, Chicago: American College of Surgeons, 1997.Google Scholar
  2. 2.
    Day JC. Population projections of the United States by age, sex, race and Hispanic origin: 1993–2050. In: Current Population Reports, US Department of Commerce Bureau of the Census, P25–1104. 1993.Google Scholar
  3. 3.
    Thomas DR, Ritchie CS. Preoperative assessment of older adults. J Am Geriatr Soc 1995;43:811–821.PubMedGoogle Scholar
  4. 4.
    Rosenthal RA, Andersen DK. Surgery in the elderly: observations on the pathophysiology and treatment of cholelithiasis. Exp Gerontol 1993;28:459.PubMedCrossRefGoogle Scholar
  5. 5.
    Keller SM, et al. Emergency and elective surgery in patients over age 70 years. Am Surg 1987;53:636.PubMedGoogle Scholar
  6. 6.
    Zenilman ME. Considerations in surgery in the elderly. In: Master Series in Surgery 2. Advances in Surgery in the Elderly. New York: World Medical Press, 1993.Google Scholar
  7. 7.
    Boyd BJ, et al. Operative risk factors of colon resection in the elderly. Ann Surg 1980;192:743.PubMedCrossRefGoogle Scholar
  8. 8.
    Yancik R, et al. Comorbidity and age as predictors of risk for early mortality of male and female colon carcinoma patients: a population based study. Cancer 1998;82: 2123–2134.PubMedCrossRefGoogle Scholar
  9. 9.
    Tiret L, et al. Complications associated with anaesthesia—a prospective survey in France. Can Anaesth Soc J 1986;33: 336–344.PubMedCrossRefGoogle Scholar
  10. 10.
    Escarce JJ, et al. Outcomes of open cholecystectomy in the elderly: a longitudinal analysis of 21,00 cases in the prelap-aroscopic era. Surgery 1995;117:156.PubMedCrossRefGoogle Scholar
  11. 11.
    Kannel WB, Dannenberg AV, Abbott RD. Unrecognized myocardial infarction and hypertension: Framingham Study. Am Heart J 1985;109:581.PubMedCrossRefGoogle Scholar
  12. 12.
    Pinholt EM, et al. Functional assessment of the elderly: a comparison of standard instruments with clinical judgement. Arch Intern Med 1987;147:484.PubMedCrossRefGoogle Scholar
  13. 13.
    Buxbaum JL, Schwartz AJ. Perianesthetic considerations for the elderly patient. Surg Clin North Am 1994;74:41–61.PubMedGoogle Scholar
  14. 14.
    Djokovic JL, Hedley-White J. Prediction of outcome of surgery and anesthesia in patients over 80. JAMA 1979; 242:2301.Google Scholar
  15. 15.
    Khuri SF, et al. The National Veterans Administration Surgical Risk Study: risk adjustment for the comparative assessment of the quality of surgical care. J Am Coll Surg 1995;180:519–531.PubMedGoogle Scholar
  16. 16.
    Khuri SF, et al. Risk adjustment of the postoperative mortality rate for the comparative assessment of quality of surgical care: results of the National Veterans Affairs Surgical Risk Study. J Am Coll Surg 1997;185:315–327.PubMedGoogle Scholar
  17. 17.
    Daley J, et al. Risk adjustment of the postoperative morbidity rate for the comparative assessment of the quality of surgical care: results of the National Veterans Affairs Surgical Risk Study. J Am Coll Surg 1997;185:341–351.PubMedGoogle Scholar
  18. 18.
    Khuri SF, et al. The Department of Veterans Affairs’ NSQIP. Ann Surg 1998;228:491–507.PubMedCrossRefGoogle Scholar
  19. 19.
    Narain P, et al. Predictors of immediate and 6-month outcomes in hospitalized elderly patients. The importance of functional status. J Am Geriatr Soc 1988;36(9):775–783.PubMedGoogle Scholar
  20. 20.
    Seymour DG, Pringle R. Post-operative complications in the elderly surgical patient. Gerontology 1983;29:262.PubMedCrossRefGoogle Scholar
  21. 21.
    Browner WS, Mangano DT. In hospital and long-term mortality in male veterans following non-cardiac surgery: the study of perioperative ischemia research group. JAMA 1992;268:228.PubMedCrossRefGoogle Scholar
  22. 22.
    Shahar A, Powers KA, Black JS. The risk of postoperative deconditioning in older adults. J Am Geriatr Soc 1996;44:471.PubMedGoogle Scholar
  23. 23.
    Gerson MC, et al. Cardiac prognosis in noncardiac geriatric surgery. Ann Intern Med 1985;103:832.PubMedCrossRefGoogle Scholar
  24. 24.
    Gerson MC, Hurst JM, Hertzberg VS, et al. Prediction of cardiac and pulmonary complications related to elective abdominal and noncardiac thoracic surgery in geriatric patients. Am J Med 1990;88:101–107.PubMedCrossRefGoogle Scholar
  25. 25.
    Older P, et al. Preoperative evaluation of cardiac function and ischemia in elderly patients by cardiopulmonary exercise testing. Chest 1993;103:701.CrossRefGoogle Scholar
  26. 26.
    Eagle KA, Brundage BH, Chaitman BR, et al. ACC/AHA task force report: guidelines for perioperative cardiovascular evaluation for noncardiac surgery. Circulation 1996;93: 1278.PubMedGoogle Scholar
  27. 27.
    Hlatky MA, et al. A brief self-administered questionnaire to determine functional capacity (the Duke’s Activity Status Index). Am J Cardiol 1989;64:651.PubMedCrossRefGoogle Scholar
  28. 28.
    Reuben DB, Greendale GA, Harrison GG. Nutrition screening in older persons. J Am Geriatr Soc 1995;43:415.PubMedGoogle Scholar
  29. 29.
    Rosenberg IH. Nutrition and aging. In: Hazzard WR, Bierman EL, Blass JP, Ettinger WH, Halter JB (eds). Principles of Geriatric Medicine and Gerontology, 3rd ed. New York: McGraw-Hill, 1994.Google Scholar
  30. 30.
    Corti M, et al. Serum albumin level and physical disability as predictors of mortality in older persons. JAMA 1994;272: 1036.PubMedCrossRefGoogle Scholar
  31. 31.
    Gibbs J, Cull W, Henderson W, Daley J, Hur K, Khuri SF. Preoperative serum albumin level as a predictor of operative mortality and morbidity. Arch Surg 1999;134:36.PubMedCrossRefGoogle Scholar
  32. 32.
    Detsky AS, et al. What is subjective global assessment of nutritional status? JPEN 1987;11:8–13.CrossRefGoogle Scholar
  33. 33.
    Detsky AS, et al. Predicting nutrition-associated complications for patients undergoing gastrointestinal surgery. JPEN 1987;11:440–446.CrossRefGoogle Scholar
  34. 34.
    Souba WW. Nutritional support. N Engl J Med 1997;336:41.PubMedCrossRefGoogle Scholar
  35. 35.
    Lynch EP, et al. The impact of postoperative pain on the development of postoperative delirium. Anesth Analg 1998;86:781–785.PubMedGoogle Scholar
  36. 36.
    Fisher BW, Flowerdew G. A simple model for predicting postoperative delirium in older patients undergoing elective orthopedic surgery. J Am Geriatr Soc 1995;43:175.PubMedGoogle Scholar
  37. 37.
    Inouye SK. Delirium in hospitalized elderly patients: recognition, evaluation and management. Conn Med 1993;57: 309–312.PubMedGoogle Scholar
  38. 38.
    Inouye S, van Dyck CH, Alessi CA, Balkin S, Siegal AP, Horwitz RI. Clarifying confusion: the confusion assessment method; a new way for detecting delirium. Ann Intern Med 1990;113:941.PubMedCrossRefGoogle Scholar
  39. 39.
    Folstein MF, Folstein SE, McHugh PR. The Mini-mental State Examination: a practical method for grading the cognitive state of patients for the clinician. J Psychiatr Res 1975;12:189.PubMedCrossRefGoogle Scholar
  40. 40.
    Brandt J, Spencer M, Folstein MF. The telephone interview for cognitive status. Neuropsychiatry Neuropsychol Behav Neurol 1988;1:111.Google Scholar
  41. 41.
    Galazka SS. Preoperative evaluation of the elderly surgical patient. J Fam Pract 1988;27:622.PubMedGoogle Scholar
  42. 42.
    Larsen EB, Kukull WA, Buchner D, Reifler BV Adverse drug reactions with global cognitive impairment in elderly persons. Ann Intern Med 1987;107:169.CrossRefGoogle Scholar
  43. 43.
    Williams MA, Campbell EB, Raynor WJ, et al. Predictors of acute confusional states in hospitalized elderly patients. Res Nurs Health 1985;8:31–40.PubMedCrossRefGoogle Scholar
  44. 44.
    Gustafson Y, Berggren D, Brannstrom B, et al. Acute confusional states in elderly patients treated for femoral neck fracture. J Am Geriatr Soc 1988;36:525–530.PubMedGoogle Scholar
  45. 45.
    Rogers MR, Liang MH, Daltroy LH, et al. Delirium after elective orthopedic surgery: risk factors and natural history. Int J Psychiatry Med 1989;19:109–121.PubMedCrossRefGoogle Scholar
  46. 46.
    Francis J, et al. A prospective study of delirium in hospitalized elderly. JAMA 1990;263:1097–1101.PubMedCrossRefGoogle Scholar
  47. 47.
    Marcantonio ER, Goldman L, Mangione CM, et al. A clinical prediction rule for delirium after elective noncardiac surgery. JAMA 1994;271:134.PubMedCrossRefGoogle Scholar
  48. 48.
    Inouye SK, et al. A predictive model for delirium in hospitalized medical patients based on admission characteristcs. Ann Intern Med 1993;119:474–481.PubMedCrossRefGoogle Scholar
  49. 49.
    Schor JD, et al. Risk factors for delirium in hospitalized elderly JAMA 1992;267:827–831.Google Scholar
  50. 50.
    Inouye SK. The dilemma of delirium: clinical and research controversies regarding diagnosis and evaluation of delirium in hospitalized elderly medical patients. Am J Med 1994;97:278–288.PubMedCrossRefGoogle Scholar
  51. 51.
    Williams-Russo P, et al. Post-operative delirium: predictors and prognosis in elderly orthopedic patients. J Am Geriatr Soc 1992;40:759–777.PubMedGoogle Scholar
  52. 52.
    Marcantonio ER, Goldman L, Orav JE, Cook FE, Lee TH. The association of intraoperative factors with the development of postoperative delirium. Am J Med 1998; 105:380.PubMedCrossRefGoogle Scholar
  53. 53.
    Kaneko T, Takahashi S, Naka T, Hirooka Y, Inoue Y, Kaibara N. Postoperative delirium following gastrointestinal surgery in elderly patients. Surg Today 1997;27:107.PubMedCrossRefGoogle Scholar
  54. 54.
    Inouye SK, Charpentier PA. Precipitating factors for delirium in hospitalized elderly persons: predictive model and interrelationship with baseline vulnerability. JAMA 1996; 275:852–857.PubMedCrossRefGoogle Scholar
  55. 55.
    Moller JT, Cluitmans P, Rasmussen LS, et al. Long-term postoperative cognitive dysfunction in the elderly: ISPOCD1 study. Lancet 1998;351:857.PubMedCrossRefGoogle Scholar
  56. 56.
    Hosking MP, et al. Outcomes of surgery in patients 90 years of age and older. JAMA 1989;261:1909–1912.PubMedCrossRefGoogle Scholar
  57. 57.
    Eagle KA, et al. Guidelines for perioperative cardiovascular evalution for noncardiac surgery: an abridged version of the American College of Cardiology/American Heart Association task force on practice guidelines. Mayo Clin Proc 1997;72:524–531.PubMedCrossRefGoogle Scholar
  58. 58.
    Campeau L. Grading of angina pectoris. Circulation 1976; 54:522–523.PubMedGoogle Scholar
  59. 59.
    Lawrence VA. Incidence and hospital stay for cardiac and pulmonary complications after abdominal surgery. J Gen Intern Med 1995;10:67–68.CrossRefGoogle Scholar
  60. 60.
    Smetana GW. Current concepts: preoperative pulmonary evaluation. N Engl J Med 1999;340:937–944.PubMedCrossRefGoogle Scholar
  61. 61.
    Hall JC, et al. A multivariate analysis of the risk of pulmonary complications after laparotomy. Chest 1991;99: 923–927.PubMedCrossRefGoogle Scholar
  62. 62.
    Charlson ME, et al. A new method of classifying prognostic comorbidity in longitudinal studies: development and validation. J Chron Dis 1987;40:373–383.PubMedCrossRefGoogle Scholar
  63. 63.
    Goldman L, et al. Multifactorial index of cardiac risk in non-cardiac surgical procedures. N Engl J Med 1997;297:845–850.CrossRefGoogle Scholar
  64. 64.
    Lawrence VA, et al. Risk of pulmonary complications after elective abdominal surgery. Chest 1996;110:744–750.PubMedCrossRefGoogle Scholar
  65. 65.
    Tarhan S, et al. Risk of anesthesia and surgery in patients with bronchitis and chronic obstructive pulmonary disease. Surgery 1973;74:720–720.PubMedGoogle Scholar
  66. 66.
    Stein M, Cassara EL. Preoperative pulmonary evaluation and therapy for surgery patients. JAMA 1970;211:787–790.PubMedCrossRefGoogle Scholar
  67. 67.
    Varon J, Marik P. Letter to editor. N Engl J Med 1999;341:613.PubMedCrossRefGoogle Scholar
  68. 68.
    Delgado-Rodriguez M, et al. Usefulness of intrinsic wound infection risk indices as predictors of postoperative pneumonia. J Hosp Infect 1997;35:269–276.PubMedCrossRefGoogle Scholar
  69. 69.
    Rose DK, et al. Critical respiratory events in the postanesthesia care unit: patient, surgical and anesthetic factors. Anesthesiology 1994;81:410–418.PubMedCrossRefGoogle Scholar
  70. 70.
    Fujita T, Sakurai K. Multivariate analysis of risk factors for postoperative pneumonia. Am J Surg 1995;169:304–307.PubMedCrossRefGoogle Scholar
  71. 71.
    Pedersen T, et al. A prospective study of risk factors and cardiopulmonary complications associated with anaesthesia and surgery: risk indicators of cardiopulmonary morbidity. Acta Anaesthesiol Scand 1990;34:144–155.PubMedCrossRefGoogle Scholar
  72. 72.
    Gracey DR, et al. Preoperative pulmonary preparation of patients with chronic obstructive pulmonary disease: a prospective study. Chest 1979;76:123–129.PubMedCrossRefGoogle Scholar
  73. 73.
    Garibaldi RA, et al. Risk factors for postoperative pneumonia. Am J Med 1981;70:677–680.PubMedCrossRefGoogle Scholar
  74. 74.
    Philips EH, et al. Comparison of laparoscopic cholecystectomy in obese and nonobese patients. Am Surg 1994;60: 316–321.Google Scholar
  75. 15.
    Southern Surgical Club. A prospective analysis of 1518 laparoscopic cholecystectomies. N Engl J Med 1991;324: 1073–1078.CrossRefGoogle Scholar
  76. 76.
    Mitchell CK, et al. Multivariate analysis of factors associated with postoperative pulmonary complications following general elective surgery. Arch Surg 1998; 133: 194–198.PubMedCrossRefGoogle Scholar
  77. 11.
    Alexander JW. Transfusion-induced immunomodulation and infection. Transfusion 1991;31:195–196.PubMedCrossRefGoogle Scholar
  78. 78.
    Hogue CW Jr, et al. Swallowing dysfunction after cardiac operations: associated adverse outcomes and risk factors including intraoperative transesophageal echocardiography. J Thorac Cardiovasc Surg 1995;110:517–522.PubMedCrossRefGoogle Scholar
  79. 79.
    Brooks-Brunn JA. Postoperative atelectasis and pneumonia. Heart Lung 1995;24:94–115.PubMedCrossRefGoogle Scholar
  80. 80.
    Cushieri RJ, et al. Postoperative pain and pulmonary complications: comparison of three analgesic regimens. Br J Surg 1985;72:495–198.CrossRefGoogle Scholar
  81. 81.
    Tisi GM. Preoperative evaluation of pulmonary function. Am Rev Respir Dis 1979;119:293–310.PubMedGoogle Scholar
  82. 82.
    Kroenke K, et al. Postoperative complications after thoracic and major abdominal surgery in patients with or without obstructive lung disease. Chest 1993;104:1445–1451.PubMedCrossRefGoogle Scholar
  83. 83.
    Williams-Russo P, et al. Predicting postoperative pulmonary complications: is it a real problem? Arch Intern Med 1992;152:1209–1213.PubMedCrossRefGoogle Scholar
  84. 84.
    Cain HD, et al. Preoperative pulmonary function and complications after cardiovascular surgery. Chest 1979;76: 130–135.PubMedCrossRefGoogle Scholar
  85. 85.
    Preoperative pulmonary function testing. American College of Physicians position statement. Ann Intern Med 1990; 112:793–794.CrossRefGoogle Scholar
  86. 86.
    Hnatiuk MOW, et al. Adherence to established guidelines for preoperative pulmonary function testing. Chest 1995; 107:1294–1297.PubMedCrossRefGoogle Scholar
  87. 87.
    Satish S, Winograd CH, Chavez C, Bloch DA. Geriatric targeting criteria as predictors of survival and health care utilization. J Am Geriatr Soc 1996;44:914.PubMedGoogle Scholar
  88. 88.
    Landefeld CS, et al. A randomized trial of care in a hospital medical unit especially designed to improve the functional outcome of acutely ill older patients. N Engl J Med 1995; 332:1338.PubMedCrossRefGoogle Scholar

Copyright information

© Springer Science+Business Media New York 2001

Authors and Affiliations

  • Darlene Gabeau
  • Ronnie A. Rosenthal

There are no affiliations available

Personalised recommendations