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.
Delirium
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.
