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Acs0901 The Elderly Surgical Patient


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  • 1. © 2008 BC Decker Inc ACS Surgery: Principles and Practices 9 CARE IN SPECIAL SITUATIONS 1 THE ELDERLY SURGICAL PATIENT — 1 1 THE ELDERLY SURGICAL PATIENT Sylvia S. Kim, MD, and Michael E. Zenilman, MD, FACS Older persons are the fastest-growing demographic group in status and advanced age is not considered an acceptable con- the United States. It is estimated that by 2020, Americans traindication to surgery, adequate assessment of functional older than 65 years will account for more than 20% of the age and physiologic reserve are of paramount importance in total population. By 2030, their numbers will have doubled the elderly surgical patient. to 70 million [see Figure 1], one fourth of whom will be 85 years of age or older.1 This segment of the U.S. population Nature and Clinical Impact of Physiologic Changes uses a substantial share of total health care resources. Centers Associated with Aging for Disease Control and Prevention (CDC) National Hospi- tal Discharge Survey data for 2004 indicate that the rate   of interventional and surgical procedures in Americans aged 65 years or older is 4,382.3/10,000. More than 50% of Aging is characterized by progressive loss of physiologic coronary artery bypass graft procedures and large bowel reserve in nearly all organ systems [see Table 1]. The changes resections—and approximately 35% of all procedures—are in cardiac function that occur in the elderly are particularly performed in persons belonging to this age group.2 These significant. Cardiac output is the product of the heart rate numbers will continue to increase as the elderly segment of and the stroke volume (which correlates with the end- the population continues to grow. Accordingly, surgical care diastolic volume, or preload). In elderly myocardium, the of elderly patients is likely to account for an increasing share resting heart rate, stroke volume, cardiac output, and ejection of surgeons’ workloads. fraction are all maintained,6 but the way in which these It must be kept in mind that the elderly are not a homoge- variables respond to stress is altered.7 The increased myocar- neous population. The average additional life expectancy for dial stiffness typical of aging leads to decreased ventricular a 65-year-old American is 18.4 years, and that for an 85-year- compliance and impaired end-diastolic filling.8,9 In addition, old is 6.8 years3; however, there is significant variability within the blunted chronotropic and inotropic response of aged each of these age groups. For example, there can be dramatic myocardium to adrenergic stimuli10 results in depression differences between “fit” and “frail” elderly persons of the of both the maximal heart rate and the increase in ejection same age. On the one hand, a fit 85-year-old woman may fraction in response to stress.11 Older persons thus are more have an additional 10 years of life expectancy. On the other dependent on preload to maintain cardiac output in the hand, the life expectancy of a frail 85-year-old man may be face of increased demand12 and, accordingly, are especially closer to 2 years [see Figure 2]4—and possibly much less (e.g., sensitive to the dangers of hypovolemia. a few months) if an acute event should occur that necessitates Cardiac complications remain a leading cause of peri- hospitalization.5 Given that chronologic age, by itself, alone operative morbidity and mortality, especially in older is a poor predictor of life expectancy, a more reliable approach patients. Myocardial infarction (MI) and congestive heart to estimating life expectancy involves assessing overall func- failure (CHF) are responsible for one fourth of all cardiac tional reserve, taking into consideration the myriad factors complications and perioperative deaths in elderly patients.13 that define the aging process. The first preoperative cardiac risk index for noncardiac Aging is a multifactorial process that encompasses more surgical procedures was developed by Goldman and col- than just physiologic changes. Although physiologic factors leagues in 1977.14 This index used nine clinical variables are undoubtedly significant and must always be taken into that had been found to correlate with an increased risk of account, there are several other factors (e.g., potential func- perioperative cardiac complications to determine a patient’s tional limitations, depression, or polypharmacy) that should overall level of cardiac risk. Several of these variables also be considered in dealing with older patients. Surgeons reflect correctable conditions, which suggests that in selected are often well trained in addressing the former but not the patients, delaying surgery to permit medical treatment latter; however, they will be able to achieve a more compre- may be a reasonable strategy. In 1999, Lee and colleagues hensive assessment of an elderly person’s wellness and reserve developed a simplified index known as the Revised Cardiac by considering all of these factors. Risk Index (RCRI), which included six variables that had Various scoring systems are being applied in the elderly been found to be independent predictors of cardiac complica- population in an effort to evaluate their overall functional tions [see ECP:4 Risk Stratification, Preoperative Testing, and status in a more accurate and quantifiable manner. One Operative Planning].15 In the RCRI, one point is given for example is the Comprehensive Geriatric Assessment (CGA), each of the following cardiac risk factors: (1) a history of a tool that is commonly used within the geriatric medicine CHF, (2) a history of ischemic heart disease, (3) a history of community and is currently being used with increasing cerebrovascular disease, (4) preoperative treatment with frequency in the nascent field of geriatric surgery. Because insulin, (5) a preoperative serum creatinine level higher than chronologic age alone is a poor predictor of performance 2.0 mg/dl, and (6) a high-risk surgical procedure. If none of DOI 10.2310/7800.2008.S09C01 04/08
  • 2. © 2008 BC Decker Inc ACS Surgery: Principles and Practices 9 CARE IN SPECIAL SITUATIONS 1 THE ELDERLY SURGICAL PATIENT — 2 Active cardiac conditions include unstable coronary syn- dromes (e.g., recent MI or unstable angina), decompensated heart failure, significant dysrhythmias (e.g., Mobitz II block, third-degree block, symptomatic ventricular arrhythmia, supraventricular arrhythmia with uncontrolled ventricular rate, symptomatic bradycardia, and new ventricular tachycar- dia), and severe valvular disease (e.g., severe aortic stenosis with a pressure gradient greater than 40 mm Hg or a valvular area smaller than 1 cm2, symptomatic aortic stenosis, or symptomatic mitral stenosis). If any of these conditions is present, the surgical procedure should be postponed until further testing and treatment are complete. If no active cardiac conditions demanding immediate attention are present, the patient’s functional status should be evaluated. For patients with good functional capacity (as evidenced by the ability to perform activities of daily living [ADL]), additional testing may not be necessary. For patients with limited or unknown functional capacity, formal cardiovascu- lar stress testing may be required, especially if the planned procedure is an intermediate-risk (e.g., intra-abdominal or intrathoracic) or high-risk (e.g., aortic, major vascular, or Figure 1 Shown is projected U.S. population by age, peripheral vascular) operation. 2000–2050.1 A number of randomized studies have examined the use of perioperative beta blocker therapy to reduce the risk of these risk factors is present, the probability of a major cardiac MI and death in noncardiac surgical patients [see ECP:4 Risk complication is 0.4% to 0.5%; if one factor is present, 0.9% Stratification, Preoperative Testing, and Operative Planning]. to 1.3%; if two factors are present, 4% to 7%; and if three or Although the benefits demonstrated in early trials17,18 were not more risk factors are present, 9% to 11%.15 seen in several later studies,19,20 most of the evidence still sug- A 2007 report from an American College of Cardiology gests that perioperative beta blockade is beneficial, especially (ACC)/American Heart Association (AHA) task force for in high-risk patients, such as those who have a history of perioperative cardiovascular evaluation recognized the utility cardiac disease or who have risk factors and are undergoing and efficacy of the RCRI and delineated a stepwise approach major surgery.16 A 2005 meta-analysis of all randomized to perioperative cardiac assessment.16 The first step is a controlled trials evaluating the use of preoperative beta block- basic clinical evaluation (history, physical examination, and ade in noncardiac surgery demonstrated that this measure 12-lead electrocardiography). The patient is assessed for had a protective effect.21 Aggregate data showed decreases any active cardiac conditions or clinical risk factors that in long-term cardiac mortality (from 12% to 2%) and in might have to be treated before surgery. (Obviously, such the incidence of myocardial ischemic events (from 33% to assessment may not be feasible in emergency situations.) 15%). a b 25 25 20 20 Life Expectancy (yr) Life Expectancy (yr) 15 15 10 10 5 5 0 0 70 75 80 85 90 95 70 75 80 85 90 95 Age (yr) Age (yr) Top 25th Percentile 50th Percentile Lowest 25th Percentile Figure 2 Shown are upper, middle, and lower percentiles for life expectancy in (a) women and (b) men at selected ages.4 04/08
  • 3. © 2008 BC Decker Inc ACS Surgery: Principles and Practices 9 CARE IN SPECIAL SITUATIONS 1 THE ELDERLY SURGICAL PATIENT — 3 Table 1 Physiologic Changes Associated with Aging172–174 Age-Related Changes Clinical Consequences Interventions Decreased maximal heart rate, cardiac output, Greater reliance on preload or end- Initiate vigorous fluid resuscitation and ejection fraction diastolic volume and ventricular to achieve and maintain optimal Decreased ventricular compliance with slowed filling to achieve increases in ventricular filling Cardiovascular system ventricular filling; increased reliance on cardiac output Avoid tachycardia; correct atrial contribution Intolerance of hypovolemia dysrhythmias Decreased inotropic and chronotropic Intolerance of tachycardia and Avoid dysrhythmogenic medications responses to sympathetic stimuli dysrhythmias such as atrial If pharmacologic support required, Decreased baroreceptor sensitivity fibrillation consider nonvasoconstricting Thickening of valvular ring and leaflets inotropes and afterload reduction Thickening of vessel walls; tendency toward vasoconstriction Increased prevalence of CAD (clinically apparent or occult) Lowered threshold for dysrhythmias Decreased lung compliance Decreased pulmonary capacity and Encourage early mobilization and Decreased strength and endurance of reserve upright, rather than supine, respiratory muscles Increased work of breathing position Increased stiffness of chest wall and Predisposition to aspiration and Provide effective pain relief to increased reliance on diaphragm function increased risk of pulmonary facilitate early mobilization and Respiratory system Decreased vital capacity and expiratory flow infections deep breathing; monitor closely if rate Predisposition to hypoxemia narcotics used Increased residual volume and functional Increased small airway closure, Use supplemental oxygen residual capacity especially postoperatively and in postoperatively as needed Increased alveolar-arterial gradient supine position, leading to Use nasogastric tubes sparingly Decreased arterial oxygen tension increased atelectasis and shunting Encourage preoperative smoking Decreased compensatory responses to Tachypnea and increased tidal cessation if applicable hypoxia or hypercarbia volume may be less apparent as Assess influenza and pneumococcal Decreased airway sensitivity; reduced respiratory failure develops immunization status efficiency of mucociliary clearance Recognize decreased ventilatory mechanisms responses to hypoxia and Increased sensitivity to narcotic respiratory hypercarbia depression Decreased glomerular filtration rate Predisposition to hypovolemia with Pay meticulous attention to fluid and Renal function, fluids, electrolytes Reduced renal mass, renal blood flow, increased risk of dehydration and electrolyte status glomerular filtration area, and permeability prerenal azotemia Estimate creatinine clearance using Decreased renal tubular function with Predisposition to extracellular fluid age-adjusted formulas, recognizing impaired ability to concentrate urine and volume expansion resulting that “normal” serum creatinine conserve water and solute in electrolyte disorders (e.g., value actually reflects decreased Reduced efficiency of water and solute hyponatremia) creatinine clearance because of excretion Predisposition to hyperglycemia and concurrent decreased muscle Dysregulation of renin-angiotensin system hyperosmolar states mass (with decreased creatinine Lowered sensitivity to fluid and electrolyte Increased risk of nephrotoxicity excretion) perturbations as consequence of decreased Avoid nephrotoxic drugs Impairment of vitamin D metabolism creatinine clearance Adjust drug doses appropriately for Decreased thirst mechanism renally eliminated drugs to Increased renal glucose threshold compensate for diminished creatinine clearance and altered pharmacokinetics Decreased salivary flow and impaired Decreased mucosal absorption of Exercise caution in prescribing Gastrointestinal swallowing medications medications utilizing cytochrome Decreased stimulated gastric acid output Decreased intestinal motility. P-450 pathway tract Impaired GI mucosal protective mechanisms Decreased pancreatic exocrine Take bowel history and prescribe Decreased intestinal motility and absorption function laxatives, especially when Impairment of hepatic drug clearance Decreased elimination of hepatically concurrent narcotics used metabolized drugs Significantly decreased muscle mass Erosion of muscle mass during acute Support and maintain physical Musculoskeletal system Increased fat mass illness may result in rapid loss of function by providing effective Decrease in bone mass muscle strength with clinical pain relief, avoiding unnecessary consequences (e.g., impairing tubes and drains that impair coughing, decreased mobility) mobility, and encouraging and Altered volumes of drug distribution assisting early mobilization Increased risk of falls and fractures Minimize fasting and provide early with delayed healing of fractures nutritional support Adjust drug doses for volume of distribution 04/08
  • 4. © 2008 BC Decker Inc ACS Surgery: Principles and Practices 9 CARE IN SPECIAL SITUATIONS 1 THE ELDERLY SURGICAL PATIENT — 4 Table 1 Continued Age-Related Changes Clinical Consequences Interventions Diminished sensitivity to ambient temperature Predisposition to hypothermia Initiate active warming measures to Thermoregulation Reduced efficiency of heat conservation, maintain normothermia during production, and dissipation surgery Blunted febrile response Decrease in thyroxine Decreased fever response Monitor patient closely for glucose Endocrine Decrease in free and total testosterone and Decreased libido with sexual intolerance system estrogen dysfunction Maintain high index of suspicion for Elevated fasting glucose level and impaired Increased risk of developing diabetes infection, even in absence of fever sensitivity to insulin Increased bone demineralization as result of increased serum PTH Changes in T cell– and B cell–mediated Increased susceptibility to infection Maintain heightened awareness of Immunologic immunity Increased risk of cancer secondary to increased risk of infections system Decreased neutrophil turnover and function perturbed immune surveillance Provide early, effective, and with decreased phagocytosis Impaired response to vaccines appropriate antibiotic treatment Neuronal loss Increased risk of delirium Reduce risk of delirium through Impaired memory and cognition Increased susceptibility to develop- screening, monitoring and Neurologic system Prolonged reaction time ment of peripheral neuropathy treatment of infections, and Impaired sensory function with visual, Altered pain perception regular orientation of patients, with auditory, and olfactory loss Difficulty in obtaining informed frequent contact Decreased peripheral nerve myelin consent and assessment of Assess and treat pain appropriately decision-making capacity Work with family and caregivers CAD—coronary artery disease PTH—parathyroid hormone Invasive hemodynamic monitoring has been employed in inspiratory and expiratory forces.30 Forced expiratory volume efforts to improve perioperative fluid management and reduce (FEV1) is reduced as well. Increased collapse of the small postoperative morbidity and mortality. Historically, it has airways leads to uneven alveolar ventilation and ventilation- been common practice to admit high-risk patients to the perfusion mismatch. Control of ventilation is also impaired, intensive care unit preoperatively for placement of a pulmo- with decreased responses to both hypoxia and hypercapnia. nary arterial catheter and optimization of cardiac function. Finally, reduced ability to clear the airway leads to an Data concerning the efficacy of this practice are conflicting. increased risk of aspiration and pneumonia. Some prospective studies and retrospective reviews suggested Pulmonary complications account for nearly 50% of post- that monitoring with a pulmonary arterial catheter was ben- operative complications in the total population of surgical eficial, especially in high-risk patients (e.g., elderly patients patients.31 They are even more frequent in the elderly surgical with high cardiac risk indices who were scheduled to undergo population and are one of the most common complications major abdominal or vascular surgery).22,23 A number of pro- seen in older patients.32,33 One large review of older patients spective, randomized, controlled trials, however, failed to undergoing surgery for colorectal cancer found that the inci- show any improvement in postoperative morbidity or mortal- dence of respiratory complications increased with advancing age: such complications occurred in 5% of patients aged 64 ity with such monitoring, even in high-risk patients undergo- years or younger, 10% of those aged 65 to 74, 12% of those ing major noncardiac surgery.24,25 Several large-scale studies aged 75 to 84, and 15% of those aged 85 years or older.34 actually found that invasive cardiac monitoring yielded Elderly patients undergoing major abdominal surgery are increased morbidity, without providing any demonstrable at higher risk for postoperative pneumonia than younger benefit.26,27 Increased rates of pulmonary embolism, CHF, patients are. These numbers are grounds for concern, in that dysrhythmia, and noncardiac complications have been the development of pneumonia is associated with increased observed in elderly, high-risk surgical patients who under- 30-day postoperative mortality.33 went pulmonary arterial catheter monitoring, compared with Risk factors for pulmonary complications include smoking, those who did not.27,28 The current ACC/AHA task force chronic obstructive pulmonary disease (COPD), poor exer- guidelines for perioperative cardiovascular evaluation cise capacity, shortness of breath, and active pulmonary acknowledge the potential benefit of such monitoring in infection.35 Elderly patients should be screened with a base- selected cases but do not endorse its routine use.16 line chest x-ray and baseline arterial blood gas determina- tions. Preoperative routine pulmonary function testing has   not been demonstrated to be useful for procedures other With aging comes a significant decline in respiratory than lung resection.36 Smoking cessation should be strongly function.29 Decreased elastic recoil of the lung and increased encouraged.37 Bronchodilators and incentive spirometry may stiffness of the chest wall lead to reduced lung and chest also be beneficial. Active respiratory infections should be wall compliance and, consequently, to decreases in maximal treated before elective surgical procedures are performed. 04/08
  • 5. © 2008 BC Decker Inc ACS Surgery: Principles and Practices 9 CARE IN SPECIAL SITUATIONS 1 THE ELDERLY SURGICAL PATIENT — 5     Aging is associated with a number of morphologic and Aging is associated with various structural and functional histologic changes in the renal system, including reduced changes in the musculoskeletal system. Muscle mass is lost, cortical mass and cortical area, interstitial fibrosis, tubular muscle strength declines, and body fat mass increases.56 By atrophy, and glomerulosclerosis.38 As a result of these changes, the age of 80 years, lean muscle mass may have fallen by as glomerular function declines with advancing age39: by the much as 40% to 50%.57,58 In addition, bone mass decreases, age of 80, the glomerular filtration rate (GFR) may be as and bone remodeling and cartilage healing are impaired, much as 45% lower. Impaired renal tubular function is resulting in cartilage damage and arthritis.59 These changes evident as well, resulting in disturbances of water, glucose, predispose the elderly to progressive loss of mobility, gait and and electrolyte balance.40 The renin-angiotensin axis is also balance disorders, and falls. To counter this predisposition, altered with aging.41 Decreased plasma renin activity, renal early ambulation in the postoperative period, with assistance vasoconstriction, reduced antidiuretic hormone responsive- as necessary, should be encouraged. The changes in body ness, and an impaired thirst mechanism all may develop in composition that occur with aging also leave the elderly this setting. vulnerable to protein malnutrition from depleted protein These physiologic changes place elderly surgical patients reserves.58 Finally, the various structural changes predispose at increased risk for dehydration and prerenal azotemia. elderly patients to soft tissue and joint injury. One should Acute renal failure can increase postoperative mortality sub- therefore take extra care when positioning patients in the stantially in these patients.42 Fluids and electrolytes should be OR, ensuring that appropriate padding and joint protection carefully monitored, exposure to nephrotoxic drugs should are provided. be minimized, and oliguria should be addressed promptly and aggressively. Renal drug elimination is also impaired,   and creatinine clearance is decreased; drug dosing should be A solid understanding of the physiologic changes associ- modified accordingly. ated with aging can facilitate preoperative assessment of the elderly patient’s functional reserve and thus, ultimately, help   ensure a more accurate assessment of the operative risk. GI changes associated with aging include decreased basal An appreciation of the characteristically diminished func- and stimulated salivary flow rates (which can lead to impaired tional reserve in this population also highlights the increased swallowing),43 reduced mucosal protection of the stomach,44 vulnerability of elderly patients to the effects of surgical and prolonged intestinal motility.45 Hepatobiliary function is complications, thereby underscoring the need for meticulous altered by age-related decreases in liver size and volume,46 as perioperative care aimed at minimizing the likelihood of well as by histopathologic changes leading to impaired elimi- potential complications whenever possible. Studies have nation of drugs, especially drugs metabolized by the cyto- shown that the development of postoperative complications chrome P-450 system.47 Clinicians should be aware of the risk (e.g., pulmonary infection and renal insufficiency) is associ- of potentially important cytochrome P-450–mediated drug ated with a higher 30-day postoperative mortality,60 as well interactions, particularly in the setting of polypharmacy. as an increased risk of death within the first 3 months after surgery.61 The occurrence of a postoperative complication    has also been identified as a predictor of impaired recovery Aging is associated with disruption of thermoregulation. of functional independence in elderly patients who have In comparison with younger patients, elderly patients are undergone major abdominal surgery.62 less sensitive to alterations in environmental temperature and less able to maintain thermal homeostasis.48 These changes account for the higher risk of both hypothermia and heat- Preoperative Assessment of the Elderly Patient stroke in this population. Heat conservation is impaired in the elderly, and the capacity for vasoconstriction in response    to cold stimulus may be decreased. The ability to shiver to In 1987, the National Institutes of Health (NIH) Con- produce metabolic heat is also impaired, and when this ability sensus Conference on Geriatric Assessment Methods for is used, it can impose substantial metabolic stress on an Clinical Decision-making defined the CGA as a “multidisci- older person.49 Therefore, maintaining normothermia during plinary evaluation in which the multiple problems of older surgical procedures is of particular importance in elderly persons are uncovered, described, and explained, if possible, patients.50,51 Intraoperative hypothermia has been associated and in which the resources and strengths of the person are with increased wound infection rates and longer hospital catalogued, need for services assessed, and a coordinated stays in elderly patients undergoing major abdominal care plan developed to focus interventions on the person’s surgery.52 problems.”63 The CGA differs from a standard preoperative Abnormal thermoregulation accounts for the blunted evaluation in that it is a truly multidimensional evaluation of febrile response seen in elderly persons fighting infections. the elderly patient. In addition to assessing comorbid condi- The immune system is also affected by aging,53 with both tions, cognitive ability, mental function, socioenvironmental cellular54 and humoral55 immunity being impaired. The factors, and nutrition status, it also scrutinizes medications increased sensitivity to infection and the reduced ability to and functional ability. mount a febrile response underscore the importance of main- The CGA may be used both to identify at-risk individuals taining a high index of suspicion for postoperative infection and to guide interventions. When evaluated as a screening in all elderly patients, even when fever is absent. tool in the geriatric community, it has been shown to detect 04/08
  • 6. © 2008 BC Decker Inc ACS Surgery: Principles and Practices 9 CARE IN SPECIAL SITUATIONS 1 THE ELDERLY SURGICAL PATIENT — 6 new and unsuspected problems in 76% of elderly persons postoperative morbidity and mortality.71 The preoperative living at home.64 It has been found to be potentially beneficial level of functional performance has also been shown to be an in reducing the incidence of hospitalization, falls, delirium, independent predictor of the extent to which elderly patients and readmission in geriatric medical studies.65 It is predictive recover functional independence after major abdominal of both morbidity and mortality in older patients.66 surgery.62 Because the CGA is designed to take into account the The performance status scores commonly used in oncology multidimensional nature of aging, it may provide the best include the Eastern Cooperative Oncology Group (ECOG) estimate of functional reserve in the elderly population, grade [see Table 3] and the Karnofsky score [see Table 4]. Both as well as a gross estimate of life expectancy.67 Although of these are essentially global indicators of overall functional the CGA has not yet been standardized, there are several status. Studies involving older cancer patients have shown elements that, in our view, should always be included in the that adding assessment of ADL and IADL substantially evaluation [see Table 2]. enhances the functional status evaluation provided by Karn- ofsky scores or ECOG grades alone. In one study of older Function patients with ECOG grades of at least 2, more than half had Functional status may be measured in several diferent significant limitations in IADL.72 ways. In geriatric medicine, evaluation of functional status Recognizing the limitations of questionnaire-based assess- typically includes assessment of the patient’s ability to per- ments for predicting true functional status, some groups have form ADL and instrumental activities of daily living (IADL). elected to integrate objective performance-based measures of ADL are personal care tasks, such as bathing, showering, functional status into the CGA. Among the most commonly eating, getting in and out of a bed or chair, using the toilet, maintaining continence, and walking68; they are skills neces- sary for maintaining independent living at home. IADL are Table 3 Eastern Cooperative Oncology Group* Performance Assessment175 everyday tasks, such as housework, laundry, preparing meals, shopping, managing personal finances, negotiating transpor- Grade Patient Description tation, and taking medications69; they are skills necessary 0 Fully active and able to carry out all predisease for maintaining independence within the community. activities without restriction Impaired ability to perform ADL and IADL has been associ- 1 Restricted in physically strenuous activity but ambula- ated with increased mortality in older patients both within tory and able to carry out work of light or sedentary the community and in the hospital.64,70 In particular, pre- nature (e.g., light house work, office work) operative impairment of ADL or IADL capacity has been 2 Ambulatory and capable of all self-care but unable to found to place elderly surgical patients at increased risk for carry out any work activities; up and about more than 50% of waking hours Table 2 Multidisciplinary Workup of Elderly Patients: 3 Capable of only limited self-care; confined to bed or Elements of Comprehensive Geriatric Assessment67,106,112,113 chair more than 50% of waking hours Domain Measure 4 Completely disabled and not capable of any self-care; confined to bed or chair Functional status Activities of daily living Instrumental activities of daily living 5 Dead Karnofsky score *Used by permission of Eastern Cooperative Oncology Group, Robert Comis, ECOG grade M.D., Group Chair Timed up and go test Number of falls within past 6 months Table 4 Karnofsky Score176 Comorbidity Cumulative Illness Rating Scale–Geriatrics Charlson Comorbidity Index Score Patient Description Older American Resources and Services Subscale 100 Normal, with no complaints or signs of disease Nutrition Mini Nutritional Assessment 90 Showing minor signs and symptoms but capable of Body mass index normal activity Percentage of unintentional weight loss within 80 Showing some signs or symptoms but capable of normal past 6 months activity with some effort Cognition Mini-Mental State examination 70 Capable of self-care but unable to do active work Blessed Orientation-Memory Concentration Test 60 Requiring occasional assistance but able to take care of most personal needs Depression Geriatric Depression Scale Hospital Anxiety and Depression Scale 50 Requiring frequent medical care Beck Depression Scale 40 Disabled, requiring special care and assistance Social support RAND Medical Social Support Scale 30 Severely disabled, hospitalized Medical Outcome Study Social Support Survey 20 Hospitalized and very ill, requiring active supportive Seeman and Berkman Social Ties Score treatment Polypharmacy 10 Moribund, with rapidly progressing fatal disease process ECOG—Eastern Cooperative Oncology Group 0 Dead 04/08
  • 7. © 2008 BC Decker Inc ACS Surgery: Principles and Practices 9 CARE IN SPECIAL SITUATIONS 1 THE ELDERLY SURGICAL PATIENT — 7 used measures of physical mobility is the timed “up and go” 1.0 performance test,73 which measures (in seconds) the time it 0.9 takes a person to stand up from a standard armchair with a seat height of 46 cm, walk a distance of 3 m, return to the 0.8 chair, and sit again. Other measures include walking a short Proportion Surviving 0.7 course, assessing grip strength, and having the patient stand 0.6 on one leg. Many patients who have good performance status according to their ECOG grades have been found to have 0.5 poor performance when timed tests of basic mobility are 0.4 employed.74 Such measures also seem to be predictive of progressive declines in the ability to carry out ADL and IADL 0.3 at 1 year and 4 years.75 Whether these measures correlate 0.2 with overall survival in elderly surgical patients remains to be studied. It is likely that they will prove to be just as impor- 0.1 tant as the well-established comorbidities of the cardiac, 0 pulmonary, and renal systems. 0 200 400 600 800 1,000 1,200 1,400 1,600 1,800 2,000 Time after Operation (days) Comorbidity Comorbid conditions are common in elderly surgical ASA I (N = 241) ASA III (N = 240) patients and frequently translate into adverse outcomes.76,77 ASA II (N = 345) ASA IV or V (N = 44) The scoring system that is almost universally employed for assessing comorbidity in surgical patients is the American Figure 3 Depicted is correlation between American Society of Society of Anesthesiologists (ASA) physical status classifica- Anesthesiologists (ASA) grade and postoperative survival.171 tion [see Table 5].78 For decades, the ASA score has been used to stratify the operative risk of all patients who undergo surgery. It accurately reflects how the severity of a patient’s scores are independently predictive of mortality in older comorbidities reliably predicts surgical outcome in terms of surgical patients.70 The CCI, initially developed as a method postoperative morbidity and mortality [see Figure 3]. In one of estimating the risk of death on the basis of comorbid dis- multicenter prospective study, the ASA score was the single ease and designed for prospective use in longitudinal studies, best predictive measure of postoperative morbidity and the examines 19 categories of comorbidity, each weighted accord- second best predictive indicator of postoperative mortality.79 ing to the adjusted risk of 1-year mortality [see Table 6]. Analyses aimed at identifying risk factors predictive of According to the original study by Charlson and colleagues, adverse outcome specifically in geriatric surgical patients have with each increase in the level of the comorbidity index, there shown that a high ASA score is an independent predictor of is a statistically significant, stepwise increase in the cumula- postoperative morbidity and mortality in older surgical tive mortality attributable to comorbid disease.83 The 1-year patients.80,81 mortality rates for a score of 0, 1–2, 3–4, and 5 or greater Additional measures of comorbidity include the Cumula- were 12%, 26%, 52%, and 85%, respectively. The CCI can tive Illness Rating Scale–Geriatrics (CIRS-G)82 and the be used today to provide a summary score denoting the Charlson Comorbidity Index (CCI).83 The CIRS-G is a burden of illness, which correlates both with ability to tolerate global assessment of the severity of comorbid disease. treatment and with overall survival.84,85 Fourteen organ systems are evaluated for the presence of comorbid disease. Weights are assigned according to the Nutrition severity of disease in terms of disability, chronicity, and Impaired nutritional status is highly prevalent among end-organ failure. A total score is then calculated; higher the elderly. As many as 12% of men and 8% of women in the healthy geriatric population are undernourished.71 Nutritional impairment is even more common among hospitalized Table 5 American Society of Anesthesiologists Physical patients, with reported rates ranging from 37% to 85%.86–88 Status Classification Malnutrition is known to be associated with adverse surgical outcomes. Higher rates of surgical complications89 and Class* Patient Status increased postoperative mortality have been observed in I Healthy patient patients with poor nutritional status, as determined by a II Patient with mild systemic disease low body mass index (BMI),70 weight loss,90 a low preopera- tive serum albumin level,89,91 or a low Mini Nutritional III Patient with severe but not incapacitating systemic Assessment (MNA) score.92 In the National Veterans Affairs disease (VA) Surgical Risk Study, declining serum albumin levels IV Patient with severe systemic disease that poses constant were associated with an exponential increase in mortality threat to life (from less than 1% to 29%) and morbidity (from 10% to V Moribund patient who is not expected to survive 65%) in patients undergoing major noncardiac operations.91 without surgery In a 2002 study, the MNA, which measures 18 factors by VI Patient who has been declared brain-dead and whose means of a self-reporting questionnaire and anthropometric organs are being removed for donor purposes measurements to assess nutritional status in elderly patients, *Suffix E added for emergency operations. was predictive of mortality in hospitalized geriatric patients.92 04/08
  • 8. © 2008 BC Decker Inc ACS Surgery: Principles and Practices 9 CARE IN SPECIAL SITUATIONS 1 THE ELDERLY SURGICAL PATIENT — 8 Table 6 Charlson Comorbidity Index83 to 40% of geriatric patients routinely screened for depression as part of a CGA may exhibit depressive symptoms.106 Depres- Condition Assigned Weight sion has been linked to decreased survival in older patients Myocardial infarction undergoing orthopedic104 or oncologic surgical procedures.108 Congestive heart failure The lack of social support has also been correlated with Peripheral vascular disease higher mortality in the geriatric and geriatric oncology litera- Cerebrovascular disease ture.109,110 A tool that is commonly employed in screening Dementia 1 for depression in the elderly is the Geriatric Depression Chronic pulmonary disease Connective tissue disease Scale (GDS) [see Table 8]. According to this simple 15-point Ulcer disease scale, a score greater than 5 in an elderly patient diagnoses Liver disease, mild depression with 69% sensitivity and 77% specificity rates. Diabetes Hemiplegia Social Support Renal disease, moderate or severe Several tools are available for quantifying social support Diabetes with end-organ damage resources in elderly patients. One such tool is the Medical 2 Any malignancy Leukemia Outcome Study Social Support Survey (MOS-SSS), which Malignant lymphoma yields a score on a scale of 0 to 100 and includes “emotional” and “tangible” subscales.111 Another commonly used mea- Liver disease, moderate or severe 3 sure of social support is the Seeman and Berkman Social Metastatic solid malignancy 6 Ties Score, which measures social ties in four areas: marital AIDS status, close contact with at least two close friends or rela- tives, church attendance, and membership in other groups. The presence of social ties has been found to be inversely related to mortality in the elderly.109 Preoperative identification of malnourished patients and nutritional supplementation before major surgical procedures Polypharmacy may reduce the chances of an adverse outcome.93,94 The physiologic changes associated with aging lead to Cognition alterations in pharmacokinetics, and these alterations, in conjunction with polypharmacy, leave the older patient Preoperative cognitive dysfunction has been associated susceptible to adverse drug interactions. Review of the with increased postoperative complications and worse sur- patient’s medication list is an integral component of the vival in elderly surgical patients.95–97 Such dysfunction may CGA. Nonessential mediations should be discontinued and take the form of either dementia or delirium. Dementia is a potential drug interactions screened for. chronic baseline impairment of cognitive function. Demented patients are known to experience higher postoperative mor- Summary tality than patients with intact cognitive function.98 Delirium The variables examined during the course of the CGA are is an acute confusional state associated with multiple possible often predictive of morbidity and mortality in elderly patients. causes. The incidence of postoperative delirium in older Accordingly, there is growing support for use of the CGA in patients ranges from 20% to 60%.99,100 This state is associated the assessment of older patients undergoing evaluation for with a prolonged hospital stay, functional decline, and surgery.112,113 increased mortality.101–104 Risk factors for the development In the field of geriatric surgical oncology, this assessment is of postoperative delirium include preexisting dementia, visual taken one step further by the tool known as the Preoperative impairment, alcohol consumption, infection, narcotic use, Assessment of Cancer in the Elderly (PACE).71 The PACE and polypharmacy. incorporates several components of the CGA, as well as the Cognitive ability can be assessed with the Mini-Mental ECOG performance grade, the ASA classification, and the State examination (MMSE) [see Table 7].105 Baseline cogni- Brief Fatigue Inventory (BFI) score. It is currently being tive function should be established preoperatively. Studies assessed in a multinational study as a tool for evaluating func- in elderly cancer patients that used a screening cognitive tional capacity and overall health status in older cancer examination as part of the CGA found that in 25% to 50% patients being considered for surgery. Preliminary results of patients, abnormalities were discovered that prompted with this tool support the correlation between functional further evaluation.106 Cognitive impairment assessed by the status (as measured by capacity for ADL and IADL) with MMSE within an ambulatory primary care setting has been subsequent postoperative outcomes. associated with an increased risk of mortality, even after confounding effects from chronic comorbid conditions have been controlled for.107 In addition to identifying at-risk Special Surgical Considerations patients, the MMSE provides a standard measure that may The elderly account for the majority of cancer patients: be applied if postoperative cognitive deterioration becomes a according to data from the National Cancer Institute (NCI) concern. Surveillance, Epidemiology, and End Results (SEER) pro- gram for the 5-year period from 2000 to 2004 (inclusive), Depression 56% of all newly diagnosed cancers and 70% of cancer deaths Depression and the lack of social support are also linked to are found within the group of patients aged 65 years and adverse outcomes in older surgical patients. As many as 14% older [see Figure 4].114 The increased incidence and preva- 04/08
  • 9. © 2008 BC Decker Inc ACS Surgery: Principles and Practices 9 CARE IN SPECIAL SITUATIONS 1 THE ELDERLY SURGICAL PATIENT — 9 Table 7 Mini-Mental State Examination for Cognitive Function105 Maximum Score Score Item Orientation 5 () ‘What is the date?’ Give 1 point each for year, season, date, day, month. 5 () ‘Where are we?’ Give 1 point each for state, county, town, building, floor, or room. Registration 3 () Name three objects. Take 1 second to say each, then ask patient to name all three. Give 1 point for each correct answer. Repeat until patient learns all three (for later testing). Attention and Calculation 5 () Ask patient to subtract serial sevens, starting at 100. Give 1 point for each correct answer. Stop after five answers. (Alternatively, ask patient to spell ‘world’ backward.) Recall 3 () Ask patient to name the three objects mentioned previously. Give 1 point for each correct answer. Language Point to a pencil and a watch and ask patient to name them. Give 1 point for each correct answer. Ask patient to repeat the following: ‘No ifs, ands, or buts.’ Give 1 point if successful. Give patient a three-stage command: ‘Take a paper in your right hand, fold it in half, and put it on the 9 () floor.’ Give 1 point for each correct action. Ask patient to read and obey the following: ‘Close your eyes.’ Give 1 point if patient closes eyes. Ask patient to write a sentence. Give 1 point if sentence has a subject and a verb and makes sense. Ask patient to copy a simple design. Give 1 point if drawing is correct. 30 () Total Score* *A score of 24 or more is considered normal. Table 8 Geriatric Depression Scale (Mood Scale) lence of cancer in older patients, coupled with the increased (Short Form)177 projected longevity within the geriatric population, make cancer treatment in the elderly a common concern. Patient Name: Give 1 point if The cancer treatment plans employed in elderly patients Date: answer is: Choose the best answer for how you differ from those employed in younger patients. One have felt over the past week: difference is that elderly patients may not receive surgical 1. Are you basically satisfied with your No treatment for many potentially curable cancers. In a compre- life? hensive SEER database analysis published in 2004, the rates 2. Have you dropped many of your Yes of curative surgery for adenocarcinoma of the breast, esopha- activities and interests? gus, stomach, pancreas, colon, or rectum; non–small cell lung carcinoma (NSCLC); and sarcoma were compared across 3. Do you feel that your life is empty? Yes age groups.115 For all categories of local-stage cancers, onco- 4. Do you often get bored? Yes logic resection rates declined steadily with increasing age. 5. Are you in good spirits most of the No Whether this decline is a reflection of appropriate patient time? selection based on objective risk assessment or of undertreat- 6. Are you afraid that something bad is Yes ment of elderly cancer patients is difficult to determine. going to happen to you? Those elderly patients who do undergo oncologic resection 7. Do you feel happy most of the time? No can fare well. The Surgical Task Force report from the International Society for Geriatric Oncology (Société 8. Do you often feel helpless? Yes Internationale d’Oncologie Gériatrique; SIOG) reported in 9. Do you prefer to stay at home, rather Yes 2004 that for many neoplasms, surgical outcomes were much than going out and doing new things? the same for older patients as for younger patients.116 10. Do you feel you have more problems Yes Another difference is that adjuvant treatment measures, with memory than most? such as chemotherapy117 and radiation therapy,118 may be 11. Do you think it is wonderful to be No underused in older cancer patients. Yet another difference is alive now? that the elderly are substantially underrepresented in cancer 12. Do you feel pretty worthless the way Yes treatment trials, especially in view of the much greater cancer you are now? burden in the geriatric population.119–122 13. Do you feel full of energy? No In what follows, we focus on selected topics germane to 14. Do you feel that your situation is Yes the treatment of elderly patients with some of the more com- hopeless? monly seen cancers, where surgical intervention is generally 15. Do you think that most people are Yes accepted to be part of the standard of care. better off than you are?  Total: ___ The incidence of breast cancer is six times higher in older For clinical purposes, a score > 5 points is suggestive of depression and warrants a follow-up interview. Scores > 10 almost always indicate patients than in younger ones.123 Many elderly breast cancer depression. patients may be undertreated119: studies have shown that 04/08
  • 10. © 2008 BC Decker Inc ACS Surgery: Principles and Practices 9 CARE IN SPECIAL SITUATIONS 1 THE ELDERLY SURGICAL PATIENT — 10 Figure 4 Depicted is cancer incidence for 1994–1998 by age group (all SEER sites combined, both sexes).114 such patients are less likely to undergo radiation treatment, offers a real therapeutic benefit has come under scrutiny and chemotherapy, or axillary dissection.124–126 Even when comor- remains controversial.134 bidity is adjusted for, patient age is predictive of prescribed Postoperative radiation therapy is an important adjunctive treatment plans.124 Choosing to proceed with adjuvant measure for preventing local recurrence after BCT.135,136 The treatment in an elderly patient can be a difficult decision. benefit of adding radiation therapy has been confirmed by Whereas older women are more likely than younger women studies that look selectively at older breast cancer patients.137 to present with advanced-stage breast cancer,127 their disease In a 2004 trial involving older patients with early breast may be less aggressive than it would be in a nongeriatric pop- cancer, the recurrence rate was lower in those who were ulation. There is evidence to suggest that the biologic behav- treated with BCT, tamoxifen, and radiation (0.6%) than in ior of breast tumors differs in the elderly. Older women with those who were patients treated with surgery and tamoxifen breast cancer are more likely to have estrogen receptor (ER)– alone (7.7%).138 Despite the benefits with regard to local con- positive tumors that are amenable to hormonal therapy.128 trol and survival, radiation therapy is often omitted in the In addition, they are more likely to have a lower rate of elderly population.124 A 2006 report addressing the omission tumor cell proliferation, diploidy, normal p53 expression, and of radiotherapy in older breast cancer patients found that the reduced HER-2/neu expression.129 The potential differences frequency of omission increased significantly with increasing in tumor biology seen in older patients, the common comor- age (7% in those aged 50 to 64, 9% in those aged 65 to 74, bid conditions, and the typical functional impairments must and 26% in those aged 75 and older).139 Omission of radio- be taken into consideration in planning treatment, along with therapy was associated with reductions in local control, the understanding that undertreatment is associated with cancer-specific survival, and overall survival. The risks of higher recurrence rates and increased mortality.130,131 omitting radiation treatment should be carefully considered Surgery remains a mainstay of breast cancer treatment in the light of the patient’s overall life expectancy, the comor- [see 3:5 Breast Procedures]. Older patients tolerate breast- bid conditions present, and the toxicity of treatment. Although conserving therapy (BCT) and mastectomy as well as younger serious adverse effects are rare (incidence < 1%), they can be patients do. In elderly women with breast cancer, overall severe, including radiation pneumonitis, pericarditis, and operative mortality is typically quite low: less than 1% for possible rib fractures. relatively fit patients.132 Generally, operative morbidity and Hormonal treatment is commonly employed in the elderly mortality reflect the severity of any comorbid conditions breast cancer population. In particular, tamoxifen has proved present, rather than the patient’s chronologic age.133 Axillary beneficial in numerous studies.140,141 These findings are par- lymph node dissection had been considered part of the stan- ticularly germane to older patients, more than 80% of whom dard of care in breast cancer surgery as a means of controlling are likely to be ER positive and endocrine responsive. In nodal disease and providing accurate staging. Whereas it approximately 1% of patients treated with tamoxifen, serious is clear that fewer elderly breast cancer patients are offered adverse effects may occur, including endometrial carcinoma axillary dissection, it is not clear whether the morbidity asso- and thromboembolism. The newer aromatase inhibitors (e.g., ciated with the procedure is indeed more prevalent among anastrozole, letrozole, and exemestane) may have better toxi- the elderly. Ultimately, this may be a moot point. With the city profiles than tamoxifen does and may confer a survival increasingly widespread application of sentinel lymph node benefit. The American Society of Clinical Oncology (ASCO) biopsy, the issue of whether axillary lymph node dissection recommends the aromatase inhibitors for postmenopausal 04/08
  • 11. © 2008 BC Decker Inc ACS Surgery: Principles and Practices 9 CARE IN SPECIAL SITUATIONS 1 THE ELDERLY SURGICAL PATIENT — 11 women with ER-positive breast cancers142; however, the The advent of minimally invasive techniques, such optimal timing and duration of treatment have not yet been as video-assisted thoracoscopic surgery (VATS) [see 4:10 established. The optimal approach to endocrine therapy in Video-Assisted Thoracic Surgery], has also made an impact on elderly patients remains to be determined.143 lung cancer treatment in the elderly. Several studies have The use of chemotherapy in elderly breast cancer patients shown VATS to be efficacious in the treatment of early is also an area under scrutiny.144 According to the latest SEER NSCLC.152,154 One study found that whereas survival rates registry data, a substantial proportion of elderly breast cancer did not differ significantly between patients who underwent patients have poor prognostic factors that warrant consider- thoracotomy and those who underwent VATS, patients in the ation of adjuvant chemotherapy. In a study involving more latter group experienced fewer postoperative complications, than 23,000 elderly (> 65 years old) women with breast despite having more comorbid conditions.155 VATS, being cancer, 35% had positive lymph nodes, and as many as 24% less invasive than thoracotomy, can allow patients with had other poor prognostic markers, such as a large tumor or impaired cardiopulmonary reserve to tolerate surgery. How- ER-negative status.129 At present, little evidence is available ever, patients with poor performance status who are unable concerning the performance of elderly patients on chemo- to perform their ADL will have a high perioperative mortality therapy regimens, in part because of the underrepresentation even with minimally invasive surgery156—a result that, once of elderly participants in clinical trials. However, one analysis again, underscores the importance of appropriate patient of SEER registries done by a group from the Memorial Sloan- selection. Kettering Cancer Center did demonstrate a survival benefit in patients aged 66 years or older who had endocrine-  unresponsive tumors that were treated with adjuvant chemo- Colorectal cancer is the second most common cancer in therapy.145 Optimal chemotherapy regimens for elderly the United States, with over 150,000 new cases and 50,000 patients have yet to be established. Commonly used regimens deaths estimated for 2007.157 It is predominantly a disease of include cyclophosphamide with methotrexate and fluoroura- the elderly. Whether elderly colorectal cancer patients have a cil (CMF) and an anthracycline (e.g., doxorubicin) with worse prognosis than younger patients is a subject of debate. cyclophosphamide (AC). Anthracycline-containing regimens A large cancer database study from the United Kingdom are known to have cardiotoxic side effects (including CHF) reported that outcomes grew progressively worse with increas- and must therefore be used cautiously in the elderly. At lower ing age in elderly patients who underwent colorectal cancer doses, however, AC therapy may prove to be less toxic and surgery.158 However, these elderly patients also had higher more effective in older breast cancer patients.146,147 Trials ASA grades, more frequent emergency operations, and more aimed at determining optimal treatment of breast cancer in frequent palliative procedures, all of which would portend older women are currently under way. worse outcomes for any age group. In contrast, other studies  have been able to demonstrate good oncologic outcomes in selected elderly colorectal cancer patients after surgery,159,160 Lung cancer is the leading cause of cancer-related death in thereby emphasizing the importance of using other criteria Western nations.148 More than 50% of persons diagnosed besides chronologic age alone in the process of patient with lung cancer are older than 65 years. According to the selection. latest SEER data, the median age of lung cancer patients is The mainstay of curative treatment for colorectal cancer is 73 years.149 surgery: segmental resection for colon cancer and additional For patients with early NSCLC, surgery affords the best total mesorectal excision (TME) for rectal cancer [see 5:34 chance of a cure [see 4:14 Pulmonary Resection]. Lobectomy Segmental Colon Resection and 5:35 Procedures for Rectal (i.e., removal of one of the five lobes of the lung, along with Cancer]. In selected elderly patients, functional outcomes associated lymph nodes) is currently the surgical standard after low anterior resection may be as good as those in younger of care for these patients. Traditionally, advanced age has patients, with similar subjective findings of satisfaction been considered a risk factor for postoperative death after with bowel function and similar objective findings from thoracotomy. In multiple early single-institution studies, manometry data.161 postoperative mortality for patients aged 70 years or older Minimally invasive procedures may have an emerging was as high as 14% after lobectomy and higher than 20% role to play in surgical management of colorectal cancer in after pneumonectomy.150 Subsequent improvements in peri- the elderly. A number of series have shown laparoscopic operative care, anesthesia, and patient selection, however, colectomy to be safe and efficacious for treatment of colon have caused the reported postoperative mortality to drop below 5%.151 Because the morbidity and mortality of lung cancer.162,163 It yields complication rates and survival out- cancer surgery are directly correlated with the amount of comes comparable to those of open colectomy, and it results tissue removed, considerable attention has been focused on in faster recovery and earlier return to daily activity.162 Such examining the efficacy of lung-sparing procedures such as advantages may be especially important with elderly patients, segmentectomy and wedge resection. These procedures are for whom postoperative alterations in the ability to carry out now being performed with increasing frequency in elderly ADL can precipitate the transition from independence to lung cancer patients, with good long-term results.151,152 An dependent living situations. extensive analysis of SEER data from 5,219 patients aged Since randomized trials established that fluorouracil-based 65 to 74 years and 2,382 patients aged 75 years or older adjuvant chemotherapy after resection of stage III colon who underwent curative surgery for early NSCLC concluded cancers reduces mortality by as much as 30%, adjuvant that wedge resection and lobectomy had similar long-term chemotherapy has become the standard of care for stage III survival benefits for patients older than 71 years.153 colon cancer.164 The extent to which adjuvant therapy is 04/08
  • 12. © 2008 BC Decker Inc ACS Surgery: Principles and Practices 9 CARE IN SPECIAL SITUATIONS 1 THE ELDERLY SURGICAL PATIENT — 12 employed in the elderly population has been studied by some chemotherapy protocols. Some studies have suggested investigators. One large retrospective cohort study using a that toxicity rates are higher in elderly patients undergoing SEER/Medicare linked database found that the chemother- adjuvant chemotherapy than in younger patients,165–167 but apy treatment rate declined markedly with chronologic age.117 the data are by no means unanimous on this point. There The cause of this apparent reluctance to use chemotherapy in is, in fact, a growing body of evidence supporting the idea the elderly population is probably multifactorial. One factor that elderly patients are capable of tolerating adjuvant chemo- is the underrepresentation of the elderly in clinical trials, therapy and deriving a demonstrable survival benefit compa- which hinders the extrapolation of study results to treatment rable to that observed in younger patients.168–170 Increasingly, recommendations for these patients. Another is the higher the data suggest that elderly patients who are fit enough to prevalence of comorbid conditions in older persons; these tolerate chemotherapy will reap its benefits. Judicious use conditions are competing causes of mortality. Impaired of chemotherapy in the elderly surgical population should functional status may also impair the ability of elderly therefore be considered and should not be rejected solely patients to tolerate the toxic effects associated with current on the basis of the advanced age of the patients. References 1. U.S. Interim Projections by age, sex, race, risk of noncardiac surgery. 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