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Our responsibility for improving the care of elderly cardiothoracic surgical patients

2002; Elsevier BV; Volume: 73; Issue: 2 Linguagem: Inglês

10.1016/s0003-4975(01)03468-3

1552-6259

Joseph LoCicero,

Hip and Femur Fractures

There comes a time in every surgeon’s life when immortality meets reality. The source of the realization might come from the illness of a particular patient. It might come from that of a grandparent or a parent, an aunt or an uncle, a spouse or a sibling. It might come from the demise of a mentor or a teacher. Or it might even come from a change in the “invincible” surgeon—that morning joint stiffness as we start to operate or that momentary mental lapse we now euphemistically call a “senior moment.” It is at that moment that the unique problems of elderly patients hit home. At some point, we all realize that we will neither stay young nor live forever. Like our patients, eventually we age and join the ranks of the “elder” generation. Every day in the United States those ranks loom larger. The population boom of older people is in full swing and will become explosive after 2011 as the “baby boom” generation hits retirement age. Conservative assumptions predict that the 65 years-and-over population in this country will grow from 35 million in 2000 to 78 million in 2050 (from 13% to 20% of the population), and the 85 years-and-over population will grow from 4 million to 18.2 million [1Statistical Abstract of the United States 1998. The national data book. Washington: U.S. Census Bureau, Sept. 16, 1998.Google Scholar]. Moreover, if life expectancy continues to increase at the same rate seen in the 1990s, then the projected population of people 85 years-and-over could balloon to 31.2 million by the year 2050. Our specialty, by nature, deals with patients of all ages. Statistically, mature adults comprise our specialty’s largest group of patients in both Cardiac Surgery and General Thoracic Surgery. In fact, The Society of Thoracic Surgeons (STS) database demonstrates that the average age of our adult patients continues to rise yearly. In general, the elderly are more susceptible to many perioperative problems and complications including any or all of the following: acute renal failure, adverse drug events (incidence 10% to 15%) [2Gray S.L. Sanger M. Lestico M.R. Jalauddin M. Adverse drug events in hospitalized elderly.J Gerontol Med Sci. 1998; 53A: 59-63Crossref Google Scholar, 3Leape L.L. Brennan T.A. Laird N. et al.The nature of adverse events in hospitalized patients results of the Harvard Medical Practice Study II.N Engl J Med. 1991; 324: 377-384Crossref PubMed Scopus (2990) Google Scholar], functional decline due to de-conditioning and immobility (incidence 32%) [4Hansen K. Mahoney J. Palta M. Risk factors for lack of recovery of ADL independence after hospital discharge.J Am Geriatr Soc. 1999; 47: 360-365PubMed Google Scholar, 5Sager M.A. Franke T. Inouye S.K. et al.Functional outcomes of acute medical illness and hospitalization in older persons.Arch Intern Med. 1996; 156: 645-652Crossref PubMed Google Scholar], dehydration (prevalence 7%) [6Warren J.L. Bacon E. Harris T. McBean A.M. Foley D.J. Phillips C. The burden and outcomes associated with dehydration among US elderly, 1991.Am J Public Health. 1994; 84: 1265-1269Crossref PubMed Scopus (179) Google Scholar], delirium (10% to 50% in postoperative patients) [7Inouye S.K. Delirium in hospitalized elderly patients recognition, evaluation, and management.Conn Med. 1993; 57: 309-315PubMed Google Scholar], depression, falls (incidence 4 to 11 per 1,000 patient-days) [8Mahoney J.E. Immobility and falls.Clin Geriatr Med. 1998; 14: 699-726PubMed Google Scholar], incontinence (prevalence 11% on admission and 23% on discharge) [9Palmer M.H. McCormick K.A. Langford A. Langlois J. Alvaran M. Continence outcomes documentation on medical records in the nursing home environment.J Nurs Care Qual. 1992; 6: 36-43Crossref PubMed Scopus (13) Google Scholar], infection (especially pneumonia and urinary tract infection), malnutrition (prevalence as high as 61%) [10Covinsky K.E. Martin G.E. Beyth R.J. Justice A.C. Sehgal A.R. Landefeld C.S. The relationship between clinical assessment of nutritional status and adverse outcomes in older hospitalized medical patients.J Am Geriatr Soc. 1999; 47: 532-538Crossref PubMed Scopus (230) Google Scholar, 11Reuben D.B. Greendale G.A. Harrison G.G. Nutrition screening in older persons.J Am Geriatr Soc. 1995; 43: 415-425Crossref PubMed Scopus (156) Google Scholar], pressure ulcers (incidence 5%) [12Allman R.M. Pressure ulcer prevalence, incidence, risk factors, and impact.Clin Geriatr Med. 1997; 13: 421-436PubMed Google Scholar], and untreated or under-treated pain syndromes. We as thoracic surgeons feel that we are as well prepared as anyone to manage the elderly sick patient because we have more training than nearly any other physician has. Our minimum of 7 years of residency has trained us to be more than a “slick and quick” pair of hands. We all firmly believe that we are “internists with the ability to cure.” Yet, the knowledge base we must master in the various fields of Medicine has burgeoned to astronomical proportions. Each of us can barely keep up in our own narrow field of focus. More and more, we must rely on specialists to take us beyond the basic level of care to provide that margin that will mean the difference between the good result and the great result. Thoracic surgeons acknowledged the special problems of the elderly many years ago. As early as the second volume of The Annals of Thoracic Surgery, Sensening and colleagues addressed pulmonary resection in the geriatric population [13Sensening D.M. Rossi N.P. Ehrenhaft J.L. Pulmonary resection for bronchogenic carcinoma in geriatric patients.Ann Thorac Surg. 1966; 2: 508-513Abstract Full Text PDF PubMed Scopus (11) Google Scholar]. But, among the more than 125 clinical works dealing specifically with the older population that have appeared subsequently in the journal, many only show what we as surgeons can get away with in the elderly. Our other Thoracic Surgery journals around the world have done no better. We show impressive results because we are fast and accurate or because we have a new device or technique. We shorten length of stay because we have a great rehabilitation facility or because we treat the seniors with as much vigor as the younger generation. We even show that we can beat the average by unique evaluations of the variables. Only a handful of investigators attempted to understand the physiologic changes of aging as it relates to thoracic diseases. Only a handful of authors investigated the reasons why the elderly have altered responses to various stresses encountered in the perioperative period following cardiothoracic procedures. Only a handful of researchers tried to define the psychological aberrations some elderly experience with our life-saving operations. Geriatricians, where available, have been great resources in assisting in identifying and managing the issues that are peculiar to the older patient population. However, they are in short supply and will remain so for the foreseeable future. There are about 9,000 geriatricians now, while estimates of the need hover around 30,000. The shortage of academic geriatricians is particularly pressing [14Reuben D.B. Bradley T.B. Zwanziger J. et al.The critical shortage of geriatrics faculty.J Am Geriatr Soc. 1993; 41: 560-569PubMed Google Scholar]. Geriatricians realize that the surgical specialties can identify and manage many of the problems of the elderly with appropriate support. With their help, we can address the special problems of the elderly undergoing a cardiac or thoracic procedure. To this end, several meetings were held between the leadership of the American Geriatrics Society (AGS) and selected surgical and medical specialties including The Society of Thoracic Surgeons. These discussions took place in May and September 1998, and were revisited in June 1999, at a series of meetings under the auspices of a major project funded by The John A. Hartford Foundation and carried out by the AGS. They recognized the changing elder demography, the expansion in eligibility of even very old patients for surgery, the shortage of geriatricians, and the growth of knowledge of how best to manage postoperative and other critically ill elders. They concluded that surgical and medical specialists must carry the responsibility for geriatric care in the future. It is urgent that surgical and medical specialists have enhanced opportunities to learn the principles, strategies, and tactics of excellent geriatric care and apply them for the benefit of their patients. Only in this way are outcomes likely to improve. Starting today, we have a responsibility to understand the pathophysiologic changes that occur in the geriatric patient. We thoracic surgeons are in a unique position to identify the specific situations that initiate problems in the patients upon whom we operate. More research into the specific problems our procedures cause the elderly and the special challenges the elderly present to us are necessary for us to significantly improve our elders’ lives. We need to identify the potential pitfalls presented by the older adult, and establish protocols to modify any potential adverse events and verify their successes in a scientific way. We need to educate ourselves as well as the rising generations of cardiothoracic surgeons to be able to manage these conditions. Our specialty regulatory organizations and the cardiothoracic residency program directors must set the standards by which we will account for our specialty to the ever-growing elder population.