An 86-year-old female with Alzheimer’s dementia, hypertension, type 2 diabetes, and chronic obstructive pulmonary disease was admitted with lethargy, fever, and vomiting. After she was diagnosed with necrotizing cholecystitis, she underwent an emergent cholecystectomy. Three days later the patient was short of breath, confused, and hadn’t urinated since the indwelling catheter was removed.
Sound familiar? If this scenario doesn’t ring a bell now, then it soon will. The 65-and-up age group is the fastest growing section of the United States population. A recent poll found that elderly patients now account for more than 60% of most general surgeons’ practices. Additionally, the use of minimally invasive surgical techniques and advanced perioperative monitoring has permitted elderly patients who were previously considered too debilitated to now become surgical candidates.
Though patients and their families most often worry about events in the operating room, the vast majority of complications occur in the postoperative period. Morbidity and mortality rates double during the first 24 hours after surgery and are tenfold higher over the remainder of the first postoperative week. In a recent study of more than 500 elderly general surgery patients, 21% experienced complications during this period.
The most common postoperative complications in the geriatric population include delirium, ileus, nutritional deficiencies, respiratory complications—including pulmonary embolism—and urinary retention. The goal in managing any elderly patient is to preserve cognitive and physical function. Maintaining this goal in the postoperative setting requires the early implementation of preventive measures, as well as an understanding of when age-appropriate intervention is necessary.
Hospitalists are often the first line of defense for postoperative situations in medically ill patients, and an amplification of issues unique to the geriatric patient follows.
Postoperative delirium occurs in 10%-15% of older general surgery patients and in 30%-60% of older patients who undergo orthopedic procedures. The most common presentation of delirium in the elderly postoperative patient is a “quiet confusion” that is more pronounced in the evening—otherwise known as sundowning. An acute change in mental status, manifested as a fluctuating level of consciousness or a cognitive deficit, is also common. Though delirium may result solely from the acute stress of the operation, other medically relevant causes include metabolic abnormalities, abnormal respiratory parameters, infections, and medications, and these causes should be aggressively investigated and treated.
After potential medical etiologies have been addressed, focus the treatment of delirium in the elderly postoperative patient on interventions to restore mental and physical function as well as pharmacotherapy. Measures to restore function, such as early mobilization and ambulation, sleep hygiene, volume repletion, and restoration of vision and hearing with appropriate devices, have been shown to decrease the duration of the delirium episode. Other non-pharmacologic interventions, including placing a patient near the nurses’ station, encouraging social visits with caregivers, and avoiding the use of physical restraints (which can aggravate agitation) may also prove helpful.
Avoid the use of psychoactive medications (e.g., antiarrhythmic agents, tricyclic antidepressants, neuroleptics, gastrointestinal medications, antihistamines, ciprofloxacin, nonsteroidal anti-inflammatory drugs, meperidine, and cimetidine) as much as possible during the acute confusional state.
Pharmacologic treatment of delirium may be warranted in patients experiencing symptoms of psychosis or in those exhibiting signs of physical aggression or severe personal distress. Haloperidol and risperidol are the medications of choice, though the FDA has approved neither drug specifically for this indication. High doses of these medications are associated with extrapyramidal effects, dystonic reactions, and torsade de pointe. Once the delirium begins to resolve, doses should be tapered gradually over several days.
Postsurgical ileus can cause profound clinical consequences in elderly patients. This complication is associated with delayed enteral feeding and malnutrition, increased length of hospital stay, and increased risk of pulmonary complications. Patients present with abdominal distension, nausea and vomiting, limited flatus, and a decreased presence of bowel sounds on auscultation. In cases of prolonged postsurgical ileus, consider pseudo-obstruction (Ogilvie’s syndrome) and mechanical obstruction.
Intravenous hydration and nutrition (in prolonged cases), assisted ambulation, and the avoidance of opiates remain the mainstays of treatment. Nasogastric tubes may provide symptomatic relief in patients with nausea and vomiting, but studies don’t support the use of this intervention to enhance resolution of the ileus. Many prokinetic agents have been examined for this use, including neostigmine and cisapride, but the results have been mixed, and the side effect profiles are generally unacceptable for elderly patients. Delay oral feeding until satisfactory bowel function has been restored.
An estimated 12%-50% of geriatric patients are found to be malnourished in the acute hospital setting. The adverse effects of malnutrition include delayed wound healing, greater risk of sepsis and wound infections, deterioration of functional status secondary to muscle wasting, and increased mortality.
Early identification of the patient’s feeding limitations is the key to preventing adverse outcomes. If a patient is restricted from oral or enteral feeding, parenteral nutrition should be started within 48 hours. When volitional food intake is permitted, the addition of canned nutritional supplements, fortified meals, and between-meal snacks may improve elderly patients’ energy and protein intake.
Initiate enteral feeding in patients for whom voluntary food intake is decreased. Parenteral nutrition may still be required until enteral feeding is established, however, and prescribed nutrients can be administered enterally. Because glucose tolerance diminishes with normal aging and may be further reduced in a state of acute illness, initiation of insulin therapy may be necessary in patients receiving either enteral or parenteral supplementation. Additionally, supplementation with a zinc-containing daily multivitamin has been shown to enhance immune function and prevent infections.
Respiratory function may be diminished in elderly patients due to age-related changes in the upper and lower respiratory tracts. Factors that contribute to an increased rate of pulmonary postoperative complications include diminished protective mechanisms like coughing and swallowing, decreased compliance of the chest wall and lung tissue, inadequate mucociliary transport, and a blunted ventilatory response to hypoxia and hypercapnia. Postoperative respiratory complications, including pneumonia, hypoxemia, hypoventilation, and atelectasis, occur in 2.1%-10.2% of elderly patients. These complications are associated with increased length of stay and a higher risk of long-term mortality.
Respiratory function may be preserved in the postoperative geriatric patient using a variety of measures. Effective pain control is essential in maintaining adequate lung volumes, and regional analgesia is associated with less-severe postoperative decreases in vital capacity and functional residual capacity (FRC). Once postoperative pain has been controlled, encourage the early resumption of physical activity (with appropriate assistance). Positioning patients in a seated position increases FRC and improves gas exchange in those recovering from abdominal procedures. Additionally, incentive spirometers, breathing exercises, and intermittent positive-pressure breathing may reduce the incidence of pulmonary complications after upper-abdominal operations, shortening the length of hospital stay.
Fatal pulmonary embolism accounts for a large proportion of postoperative deaths in the elderly population. Between 20%-30% of patients undergoing general surgery without prophylaxis develop deep vein thrombosis, and the incidence is as high as 40% in those undergoing orthopedic surgeries, gynecologic cancer operations, and major neurosurgical procedures.
The Fifth American College of Chest Physicians Consensus Conference on Antithrombotic Therapy recommends the following postoperative interventions for older surgical patients:
- General surgery without clinical risk factors for thrombosis: Give low-dose unfractionated heparin two hours before and every 12 hours after the operation;
- General surgery with any clinical risk factors such as prolonged immobilization or paralysis, obesity, varicose veins, congestive heart failure, or pelvic or leg fractures: Administer low molecular weight heparin (LMWH) or low-dose unfractionated heparin every eight hours. If the patient is also prone to bleeding or infection, intermittent pneumatic compression (IPC) can be used instead;
- General surgery with multiple clinical risk factors or with a history of previous deep vein thrombosis, malignancy, stroke, spinal cord injury, or hip fracture: Use low dose unfractionated heparin or LMWH combined with intermittent pneumatic compression; for very high risk patients, perioperative warfarin is an alternative;
- Total hip replacement: Give postoperative LMWH every 12 hours; initiate low-intensity warfarin therapy—to keep International Normalized Ratio of 2-3—preoperatively or immediately postoperatively;
- Total knee replacement: Administer postoperative LMWH every 12 hours. IPC is the most effective non-pharmacologic regimen and is comparable to LMWH. Low-intensity warfarin can also be used; and
- Hip fracture repair: Start preoperative fixed-dose LMWH or low-intensity warfarin.
The incidence of postoperative urinary retention in elderly patients has been reported to be as high as 87%. Factors contributing to the development of this complication include immobility, analgesics and opiates, intravenous hydration, and general anesthesia. Urinary retention can lead to overflow incontinence and urinary tract infection and is associated with a decline in function and nursing home placement. The first indication of urinary retention may be a diminished urinary output after removal of an indwelling catheter, overflow incontinence, or the frequent voiding of small amounts of urine.
Urinary retention is treated with catheterization. This prevents bladder distension, which leads to reduced detrusor contractile function, and helps restore preoperative bladder function.
Recent studies have found that normal voiding resumes earlier with the use of intermittent catheterization (if begun at the onset of urinary retention and repeated every six to eight hours) than with the use of an indwelling catheter. Additionally, the use of indwelling catheters in the elderly after the immediate perioperative period is associated with an increased risk of urosepsis and a more dependent postoperative functional status.
The 65-and-up age group is the fastest growing section of the United States population. The vast majority of complications for this age group occur in the postoperative period. It’s important for hospitalists to remain involved in key areas of postoperative complications in the geriatric population—specifically, delirium, ileus, nutritional deficiencies, respiratory complications—including pulmonary embolism—and urinary retention. TH
Jill Landis is a frequent contributor to The Hospitalist.
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