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Five Practical Tips for the Older
Surgical Patient:
From a Geriatrician’s Perspective
G. Paul Eleazer, MD,FACP,AGSF
University of South Carolina
School of Medicine
Visualize a patient who is 80
years old. What does he or
she look like ?
Tip One
• All Older People Are Not Alike!
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Don’t Base Judgments On Age Alone
Don’t Deny Surgery Unnecessarily (Agism)
Don’t Press For Surgery If Benefit Is
Minimal
Aging Heterogeneity
Source: Solomon, UCLA
Review Course 2002
Why Is There So Much Variance
In Older Adults?
• Genetic Differences
• Environmental Stresses Differ
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Tobacco
Alcohol
Exercise
• Aging Dependant Diseases
Aging Changes from the Geriatric
Perspective
• Disease Versus Normal Aging
• Decreased Reserve Capacity

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Varies Between and Within Individuals
After Age 30, most “typical” declines are 510% declines in Physiologic Function
Aging Changes from the Geriatric
Perspective
• Homeostenosis
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Impaired Response To Physical,
Emotional, And Environmental Stresses
Example:
Fluid Challenge of 1000cc:
35 year old
70 year old
35 Year Old with 1000 cc
Fluid Bolus
• Excess of 500 cc

What are the
likely
Consequences?
80 Year Old with 1000 cc
Fluid Bolus
• Excess of 500 cc

What are the
likely
Consequences?
Relevant Changes That Occur
With Aging
• Physiology
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Pulmonary
Cardiac
Pharmacologic
Wound Healing
Immune function
• Anatomic
• Functional
• Social
Age Related Changes in
Pulmonary Function
Impact of Training on VO2Max with
Age
Heath 1981;
Lakatta,1993
Impact of Training on VO2Max with
Age
Heath 1981;
Lakatta,1993
Impact of Training on VO2Max with
Age
Heath 1981;
Lakatta,1993
Pulmonary Changes with Aging

Declines In:
 Alveolar Surface
Area
 Diffusion Capacity
 Hypoxic Drive
 Arterial PO2
Arterial PO2 Correction for Age
(Room Air)
Expected PaO2 = 100 – (Age/3)
• For a 20 year old = 93 mmHg
• For a 90 year old = 70 mmHg
Airway Changes
• Swallowing Changes
Predispose to Aspiration
• Decreased Numbers and
Function of Cilia
• Diminished Cough
• Pneumonia More Common
Cardiac Changes with Aging
Changes in Conduction
• Multiple Changes, Net Results:

Decline in Maximum Heart Rate
220 minus Age [or other formula]
• Decreased Beta-2 Receptors

Decreased Response to Beta
Agonists
Heart Rate And Age
• Rounds on Two Post Op
Patients:
20 year old with HR of 100
 95 Year old with HR of 100

• What is your Level of Concern
for Each?
Calculate
Predicted Maximum Heart Rate
• 20 year old = 220 – 20 = 200
• 95 Year old =220 - 95 = 125
20 Year Old with Heart Rate of
100
• Percent of Maximum
HR= Actual/Predicted
x 100
• 100/200 = 50% Maximum
Predicted HR
95 Year old with Heart
Rate of 100
Percent of
Maximum HR=
Actual/Predicted
x 100
100/125 = 80%
Maximum
Predicted HR
Each Patient has Heart Rate of
100
• 20 year old = 100/200 = 50% Maximum
Predicted HR
• 95 Year old =100/125 = 80% Maximum
Predicted HR
Equivalent to an ongoing Cardiac
Stress Test!
Functional Cardiac (Pump)
Changes
• Resting Cardiac
Output - Little
Change
• Maximum Cardiac
Output - Declines
Functional Cardiac (Pump)
Changes
• Decreased LV Compliance
• Increased Diastolic Dysfunction
• Increased Importance of Atrial
Contraction
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Decreased Tolerance for Atrial Fibrillation
Increased Importance of Atrial
“Kick” with Age
Atrial Fibrillation Less Well Tolerated
From Swinn,1989
Age Associated Declines in GFR
and Renal Plasma Flow
Based on Data from Davis
JCI 29:496-507 (1950)
Tip Two

Be Gentle
• In Relationship
• In Caring
• In Doing Anything !
Tip Three
• Medications are Dangerous in Older
Adults
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Start Low, Go Slow
Avoid all Medications, if Possible
Particularly Avoid Certain Medications
Tip Three:
Medications are
Dangerous in Older
Adults
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Start Low, Go Slow
Avoid all Medications, if Possible
Particularly Avoid Certain
Medications
Medications in Older Adults
• Older People Take More Medications
• Drug-drug Interactions More Likely
• Adverse Drug Reactions More Serious
Two Patients, Both Get 1mg
Lorazepam for Agitation
• 20 Year Old
• 80 Year Old
Unsteady Gait
Fall
Two Patients, Both Get 1mg
Lorazepam for Agitation
• 20 Year Old
• 80 Year Old
Unsteady Gait
No Injury
Fall
Hip Fracture
Delirium
• In Post Operative Patients
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Often Due to Medications
May be Due to Other
•
•
•
•
•
Hypoxia
Pain
Infection
Sleep Deprivation
Others
Delirium
• Adding a Medication to Treat Delirium
May Be Hazardous
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More Drug Interactions
More Adverse Reactions
Often Does Not Help the Patient !
• If you “must” – low dose Haloperidol
(0.5 mg)
Mortality of Delirium
• Mortality of in-hospital delirium
25-33%
• Unrecognized by Physicians
30-50% of the Time !
Inouye SK et al, American
Journal of Medicine May 1999
Diagnosing Delirium
Confusion Assessment Method
1. Acute Onset & Fluctuating Course
Plus
2. Inattention
And One Of The Following:
3. Disorganized Thinking
4. Altered Level of Consciousness
Inouye SK, et al. Ann Intern Med
1990; 113:941-8
Commonly Used Drugs That Should
Be Avoided In Older People
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Propoxyphene ( Darvon, Darvocet)
Meperidine (Demerol)
NSAID’s – (Indocin, Toradol)
Diphenhydramine (Benadryl)
Muscle Relaxants (Flexeril, Robaxin)
Benzo’s -especially Valium, Dalmane
Beers, MA Archives IM 1997,157:15311536), Updated 2002
Start Low,
Go Slow ...
Tip Four
• Function is Most Important
Pre Op
 Post Op
 Long Term
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Function is Most Important
• Pre Operatively
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Baseline Function Predicts Morbidity
and Mortality
• 4 MET Equivalent
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Consider “Prehab”
Realistic Goal Setting
Planning for Post Operative Care
Function is Most Important
• Post Operatively
Early Mobilization
 Rehabilitation

Function is Most Important
• Long Term
Prevention of Functional Decline
 Planning, Ethical Issues

Tip Five
There are no “Benign Procedures” in
Older Adults!
Where I First Learned About
Iatrogenesis
• Summer of 1979 Mr. Monroe H.
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76 Year Old Admitted with Diarrhea and
Weight Loss
Admission U/A showed 10-20 WBC’s and
many epithelial cells
Where I First Learned About
Iatrogenesis
• 76 Year Old Admitted with Diarrhea and
Weight Loss
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“To Catheterize or Not To Catheterize” for
a repeat U/A - ????
“It’s a Benign Procedure”
Where I First Learned About
Iatrogenesis
• Catheterized
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Vagal Reaction
Unresponsive
Code Called
Right Central Line Placed “for access”
Moved to the ICU
Where I First Learned about
Iatrogenesis
• Post Central Line CXR
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Pneumothorax
Chest Tube Placed
SBFT Placed
Long, Tortuous, Hospital Course
Death about 1 month after admission.
Conclusion
There are NO Benign
Procedures in Someone over
Age 65 !
Summary of Tips from the
Geriatrician’s Perspective
1. All Older People Are Not Alike!
2. Be Gentle
3. Medications are Dangerous in Older
Adults
4. Function is Most Important
5. There are No Benign Procedures in
Older Adult