The Fundamental Importance of Perioperative Care


Proportionately, the elderly are the major consumers of health care in our society. Surgery is similar to all other areas of medicine, in that the operating room lists are becoming dominated by senior citizens. Many of the high volume surgical procedures (most cancers, prostate resection, joint replacement, and coronary artery surgery) are performed predominantly on the elderly. A few years ago, an article was published in the Lancet about colon resection in octogenarians. By using minimally invasive surgery, nerve blocks to decrease narcotic use, and promoting early activity and feeding, the authors were able to discharge these patients on the third postoperative day. The message is simple. Even though new surgical techniques are crucial in decreasing morbidity, we lose much of their benefit if we do not modify our perioperative medical management.

Some of the most important interventions are relatively straight forward, and although most commonly required in the elderly, are similar at any age. These include anticoagulation for high-risk joint replacement and beta-blockers for those with coronary artery disease. Dr. Geerts and Dr. Shammash, respectively, discuss these topics in articles in this issue.

Postoperative pain relief is a major issue in the elderly, particularly in those who are frail or have pre-existing cognitive impairment. Pain must be relieved, but the health care team has to be vigilant in anticipating and preventing complications. Pam Larsen addresses these issues in her article.

Laurie Jacobs addresses the issue of perioperative evaluation and management, particularly when to start medications and, in his article, Dr. Muravchick reminds us about the intraoperative management of older patients.

In my practice, the most vexing perioperative problem is that of delirium. This is particularly a problem in elderly patients with fractured hips. Not only is it difficult to identify the contributing factors, the management requires much attention to behavioural issues--an area requiring special expertise. Even more problematic, some delirious patients never seem to regain their baseline cognitive function, no matter how careful the management of their acute confusional state. Dr. Little, a regular contributor, reviews the information on how to prevent postoperative delirium.

Our senior editor, Shabbir Alibhai, a noted expert in the field of cancer and aging, reviews the evidence concerning surgical risk and aging. You might be surprised by his conclusions, and you will certainly be impressed by his knowledge in the field.

As usual we have a large number of other articles on areas of interest in the elderly. There is an article by Sudeep Gill and Barbara Liu on avoiding dangerous prescribing habits in the elderly. I suspect that improved prescribing (avoiding both errors of omission and commission) is the single most important thing we can do to improve health care of the elderly.

Also included is the second part of our series on the treatment of cardiovascular disease in nursing homes--the remaining articles focus on acute coronary syndromes and pacemakers in the elderly. There are also articles on falls prevention strategies (Clare Robertson) and living wills in long-term care (Michael Gordon).

Enjoy this issue.