Aging is associated with disorders of the musculoskeletal system16 that increase the likelihood for elective26 and emergent orthopaedic procedures, such as repair of hip fracture.8 The outcome from elective procedures in older patients is overwhelmingly positive but less than that seen in younger age groups.39
Surgical outcomes for geriatric patients are limited by complications likely tied to age-related changes and diseases in other organ systems.39 Fortunately, the common age-related changes in physiology are predictable, and simple management strategies compensate sufficiently to promote good outcomes and reduce complications.23
Older patients take a disproportionate number of medications.18 They are also predisposed to development of adverse drug reactions related to aging changes in pharmacokinetics and pharmacodynamics.1,38 Understanding aging pharmacology is key to optimizing outcomes in the perioperative period.
Some understanding of the common central nervous system problems seen in older patients that directly impact management is important in orthopaedic practice. Dementia increases the risk of falls and fractures and is as important a comorbidity as heart failure to understand and manage perioperatively.25 Delirium is a common complication of hip fracture that increases length of stay and mortality.12 Fortunately, it is substantially preventable.17,23
Most nonadherence to treatment recommendations is because of the patient’s lack of understanding27 or to age-related limitations in communication, and simple measures to compensate can improve adherence and outcome.27
Related to changes in vision, hearing, and cognition,20 a significant proportion of older patients have difficulty providing fully informed consent. All clinicians treating older patients will be aided by simple rules to decide if a patient’s choices are ethically and legally valid.
This review focuses on aspects of physiology, pharmacology, neurology, communication, and informed consent that influence surgical outcomes for older patients. The emphasis here is on where these issues directly affect perioperative management and on practical guides to improve daily practice.
Age-Related Physiologic Changes
Aging in Bone and Collagen
Fractures are attributable to Type I (postmenopausal) and Type II (age-associated) osteoporosis.32 Type I osteoporosis is characterized by rapid bone loss (3–5% per year) in 10–15 years after onset of menopause and is linked to estrogen deficiency. Type I osteoporotic fracture sites are vertebrae, pelvis, distal radius, and proximal femur—bones with higher trabecular content. Type II osteoporosis affects both genders and is characterized by less rapid bone loss (0.5–3% per year). Hip fractures are the most common Type II osteoporotic fractures. Type II osteoporosis is attributable to increases in parathyroid hormone levels, and decreased circulating vitamin D, growth hormone, and insulin-like growth factors. Patients with multiple risk factors can be screened and diagnosed with bone mineral density (BMD) measurement. The National Osteoporosis Foundation recommends measuring BMD to assess bone loss in patients with estrogen deficiency if severity of bone loss would affect treatment; osteopenia is found incidentally on radiographs; long-term glucocorticoid treatment is prescribed; and asymptomatic primary hyperparathyroidism is diagnosed. If BMD values are > 2.5 SD below the mean of young adults, the patient has osteoporosis. Studies should be done to rule out Cushing’s disease, hyperparathyroidism, hyperthyroidism, hypogonadism, liver disease, multiple myeloma, and renal disease.
Diet should include 1500 mg of calcium and 800 IU of vitamin D (multivitamins or supplements).9 Treatment also includes at least 30 minutes of weightbearing exercise three times a week and, possibly, pharmacologic intervention with bisphosphonates (alendronate or residronate), reloxifene, or calcitonin.10,13,19
Osteomalacia21 is a slowly progressing disease in which lack of mineralization of new bone matrix results from vitamin D deficiency. Symptoms include bone pain and muscle weakness. Much more common than true deficiency is vitamin D insufficiency. Vitamin D levels decline with age34 and even 25-OH vitamin D levels in the low normal range (< 25 nmol/L) are associated with gait disorders, falls, and fractures.9,11 When these problems occur with low normal vitamin D levels, patients should receive vitamin D, 50,000 IU orally twice weekly for 5 weeks,2 and the usual calcium and vitamin D supplementation.
Tendons and ligaments have less water content, resulting in increased stiffness. Reduced collagen turnover also occurs. Articular cartilage also has less tensile strength and biochemical composition changes often leading to osteoarthritis.
General Responses: Blood Pressure, Body Temperature, Skin Changes, and Infection
Most body systems are affected by aging. Hypertension is more common among older persons because of increased arterial stiffness, weight gain, sedentary lifestyles, and age-related insulin resistance.37 The range of blood pressure necessary to adequately perfuse the central nervous system is narrower in older patients. Vascular changes not only predispose older patients to systolic hypertension but also to syncope, orthostatic and postprandial hypotension, falls, and hypotensive responses to antihypertensive medication. All patients who fall should have their blood pressure checked while seated and while standing.24
Age also affects ability to regulate body temperature, making older patients more susceptible to hypothermia and hyperthermia.29 Hypothermia occurs because older patients produce less heat per kilogram of body weight and their skin arterioles do not vasoconstrict as well, which impairs perception of feeling cold. Patients can become hyperthermic because of impaired vasodilation and decreased sweat production. Febrile response to infection also is altered and afebrile infection occurs in as many as 25% of older patients who have clinical sepsis.37 If infection is suspected, a leukocyte count and differential should be obtained.
In older individuals, skin is thinner, less effective as a barrier, and slower to heal. Pressure ulcers, lacerations, and abrasions are more likely with minor trauma, thereby making the older patient more vulnerable to infection or bacteremia.14 Similarly, mucous membranes in the respiratory tree and genitourinary tract are less effective in protecting the older patient from colonization by gram-negative and other bacteria.37
Older patients also are more susceptible to urinary tract infection, because urine is less acidic and concentrated, and has a lower concentration of bacterial-adherence-blocking proteins.37 Early removal of catheters and treatment of bladder infection should reduce seeding to prosthetic joints. Urinary incontinence affects the majority of older patients with hip fracture because of mobility limitation. This can lead to cellulitis and pressure ulcers and is best treated with timed (every 2 hours) toileting.
Because of low-grade activation of clotting factors, D-dimer levels, often used to diagnose pulmonary embolus, must be more than twice normal to be predictive.37 The partial pressure of oxygen (PaO2) declines approximately 3 mm Hg per decade (formula: 100 – (age ÷ 3). Sedimentation rates (useful to detect joint infection) increase with age. Age-adjusted normals are age plus 10 divided by 2 for women and simply age divided by 2 for men.37
Beginning at age 65, patients experience steady declines in visual acuity, contrast sensitivity, glare tolerance, and visual fields and, after age 75, declines in depth perception.31 Sensorineural hearing loss affects 25–40% of people older than 65 years.28
The weight of the brain decreases with age and neuronal loss occurs37; however, cognitive loss is not a part of normal aging.
Cardiovascular and Respiratory Systems
In general, heart rate, myocardial contractility, and vasodilatation of blood vessels are reduced, characterized clinically by reduced cardiac output during stress (such as surgery).37 While older patients often require a fluid load to maintain blood pressure intraoperatively, that fluid load may be mobilized postoperatively and produce heart failure. Diuretics often are needed to force excretion of the extra fluids given during surgery.
The respiratory system undergoes mechanical and functional changes with advancing age. The chest wall expands less because of cartilage calcification and the lung tissues become less elastic. Supine positioning results in lower PO2 levels and prevents full lung expansion. After age 65, it is necessary for the older person to stand and breathe to achieve full lung expansion and prevent atelectasis and pneumonia.7,35 Having the patient sit up in a chair (although a good idea) is not sufficient to prevent this complication.
Because of an increase in opioid receptors in the colon, older patients are more likely to experience constipation associated with postoperative pain medications.30 Therefore, stimulant (senna) or osmotic laxatives should be started at the same time as opioid analgesics.
Kidney mass decreases between 25–30% between ages 30 and 80 years.37 Decreased renal function affects drug excretion, necessitating adjustment of many renally excreted drugs.
Hemoglobin declines somewhat with age; however, levels below 12.5 gm% in women and 13.5 gm% in men are abnormal regardless of age and should be evaluated.3
Most people 65 years and older take several prescription medications, in addition to over-the-counter products and herbal remedies. Questioning older patients about their medications and over-the-counter products is extremely important to avoid intraoperative and postoperative complications, interactions, and withdrawal. Because patients frequently do not know precisely what they are taking and why, patients should be asked to bring all medications with them to their appointments.
Pharmacokinetic and Pharmacodynamic Changes
Table 1 outlines why and how doses of many drugs must be adjusted, such as low-molecular-weight heparins, nonsteroidal antiinflammatory drugs (NSAIDs), and narcotics.
Adverse Events and Drug Interactions
Older patients taking multiple drugs are at higher risk for adverse events and drug interactions. The most common side effects of medications are constipation, nausea, and sedation. Adverse events can present as disorders that commonly affect older persons, such as falls, anorexia, fatigue, cognitive impairment, urinary incontinence, and constipation. When these problems develop, an adverse drug effect always should be suspected. Coumadin is useful in preventing postoperative deep venous thrombosis; however, it interacts with many drugs that are best avoided while patients are treated with Coumadin.
Prescribing Drugs for Older Patients
In selecting drug doses for older patients, the rule is to start low and go slow. Drugs for perioperative or orthopaedic conditions that should be used with caution in older patients are listed in Table 2.4 Opioids can be used safely and effectively for postoperative and chronic pain as long as meperidine, propoxyphene, and pentazocine are avoided (all cause delirium).30 Also, clinicians should be aware that intentional nonadherence (deciding to discontinue or change the dose of a drug) and unintentional nonadherence (misreading the label or forgetting a dose) are common among older patients.5
Communicating with Older Patients
Communicating with older patients can be more difficult because of time constraints. Older persons may be more anxious during office visits, which can negatively affect how much information they understand and retain. Although impaired cognitive status is not a normal part of aging, when present, it challenges clinicians.
Effective communication can be enhanced by15 choosing a well-lit room or area with minimal extraneous noise and interruptions; facing the patient at eye level; speaking slowly in a deep voice; introducing yourself carefully and using the patient’s last name: asking about hearing or visual deficits (if present, increase the volume of your voice or write questions in large print, asking open-ended questions such as “What would you like me to do for you?” and allowing sufficient time for the patient to answer) asking direct and simple questions that can be answered with yes or no; touching the patient gently on the hand, arm, or shoulder during the conversation; providing written instructions for treatment recommendations; and offering to discuss the patient’s treatment options with family or caregivers.
Dementia and Delirium
Dementia is defined as “an acquired syndrome of decline in memory and other cognitive functions sufficient to affect daily life in an alert patient.6 Alzheimer’s disease is the most common cause of dementia. Patients admitted to the hospital with dementia are at high risk for delirium, characterized by acute onset of cognitive fluctuations, impaired consciousness and attention, altered sleep cycles, and hallucinations. At least 40% of patients with hip fractures become delirious during their hospital stay and have a poorer functional outcome.22 Delirium can be brought on by infection, dehydration, drug toxicity, or other medical conditions. However, a recent study showed that delirium can be prevented.33 In a controlled clinical trial the following interventions have been shown to prevent the onset of delirium in hospitalized patients.33
Environmental modifications can be made, such as communication to reorient to new surroundings; objects that provide orientation (calendar, clock); quiet, well-lit surroundings (night lights); and familiar faces (family members) at bedside for reassurance, or sitters. Stimulating activities during daytime can include cognitive activities (current events discussion, word games) and ambulation and active ROM exercises. Correction of sensory deficits can be made, including eyeglasses, adequate lighting, magnifying lenses, cerumen removal, hearing aids, and portable auditory amplifiers. Measures to promote normal sleep include warm milk at bedtime, relaxation-tapes, back massage, and night-time noise reduction. Prevention of dehydration with oral or parenteral supplementation if BUN/creatinine ratio >18 is helpful. Physical restraints should be used only as a last resort to maintain patient safety and to prevent patients from pulling out tubes or catheters.
Rights of the Older Patient
The ethical and legal principles of informed consent, patient rights, and choices regarding medical treatment require careful attention when treating older patients. If the patient has visual, hearing, or cognitive impairments, family involvement should be sought regarding treatment decisions. In determining whether an older patient is capable of making informed choices, clinicians should focus on three elements that must be present for treatment choices to be ethically and legally valid36: (1) the patient’s participation and decision must be free of force, fraud, duress, intimidation, or undue constraint or coercion, (2) the patient’s choice must be informed, ie, the healthcare team must communicate information that might affect a patient’s choice, and (3) the patient must be able to think rationally regarding medical alternatives. Furthermore, surgeons should determine whether the patient is capable of making and expressing personal preferences, can explain the reasons for the choice rationally and logically, and whether the patient understands the risks, benefits, and implications. Many older patients are capable of making informed decisions if the physician provides additional information about the procedure or treatment, answers their questions, and responds to their fears and reservations. When a patient is incapable of making informed decisions, involvement of an interdisciplinary team will facilitate decision making, through such avenues as guardianship or protective services.
Living wills or advance directives enable a patient to specify which treatments and life-sustaining care they want to receive when they are no longer able to make that decision. A Durable Power of Attorney names another person to act on his or her behalf in making treatment decisions. In addition, patients often verbally express their wishes concerning advanced directives. Healthcare professionals should document such statements in the medical record and encourage patients to provide written preferences for future treatment. Patients’ rights include whether to accept or refuse life-sustaining efforts, such as artificial nutrition and hydration, and “do not” orders (do not resuscitate).
This review highlights strategies to prevent, treat, and manage the common problems experienced when caring for older orthopaedic patients. These include osteoporosis, infection, heart failure, incontinence, pain, delirium, dementia, and altered decision making.
Most fractures in elderly patients occur with a fall that only produces a fracture because of preexisting osteoporosis. Investigating the cause of the fall can be complex, but a check of the orthostatic blood pressure is a good first step. Because these fractures are caused by osteoporosis, many orthopaedists begin therapy with calcium, vitamin D, and a bisphosphonate as part of fracture care.
Infections in the bladder and lung are common and can be subtle when they occur without fever, in which case an elevated leukocyte count will help to confirm the diagnosis. Removing Foley catheters and early ambulation are important preventive measures. If the patient is incontinent when the catheter is removed, scheduled toileting will usually alleviate that problem.
Postoperative volume overload will occur when fluids administered intraoperatively are mobilized in the postoperative period. Checking the anesthesia records provides a good estimate of how much fluid will need to be diuresed to avoid intravascular volume overload (congestive heart failure).
Using opioids for pain is appropriate as long as agents likely to cause delirium are avoided (meperidine and propoxyphene) and the expected constipation is treated with stimulant laxatives. Delirium should now be viewed as a substantially avoidable problem. Patients’ adherence to treatment recommendations is improved by helping them compensate for limitations of vision and hearing and by providing clear written instructions. A little extra time is often needed to ensure that the patient is reliably participating in decision making and, if they are not, to identify a family member or friend to assist them.
I thank Dr. Ed Fehringer for review of the manuscript and Patricia Schott for preparation of the typescript.
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