CARE OF THE ELDERLY PATIENT
What are the main health issues of this patient
population? What do older people need from their health care that younger people
do not?
The greatest concern of elderly patients is to maintain independence.
Therefore, the most important outcome and overall objective of perioperative care
of the geriatric population is to speed recovery and avoid functional decline. The
overall goal of maintaining autonomy and function after an acute surgical intervention
needs to be incorporated into the decision-making process of anesthetic evaluation.
A comprehensive geriatric evaluation includes determination of
the physical, psychosocial, and environmental factors that can affect the health
of the elderly and optimization of functional outcomes.[41]
Perioperative physicians must be able to assess the capacity of geriatric patients
for independent function.[42]
Both home support
systems[43]
and functional measures have been shown
to be
strong predictors of short- and long-term outcome.[44]
[45]
Thus, preoperative evaluation of a geriatric
patient should include an assessment of activities of daily living, as well as instrumental
activities.[46]
This idea is not unique to the
geriatric population and has been incorporated into the evaluation process focused
on specific organ systems. For example, the concept of METS (metabolic equivalent
of activities of daily living) has been integrated into the cardiac evaluation.[47]
A variety of instruments are available to evaluate functional activity[48]
and health-related quality of life after various types of surgery.[49]
For purpose of ease, activities of daily living, as well as instrumental activities
of daily living, may be assessed with the use of standardized forms.[50]
The successful end point of surgical intervention should be, at
the very least, to return patients to their previous level of activity and independence.
Preoperative functional assessment provides a baseline to determine whether quality
of life has been maintained by the surgical intervention. This issue is underscored
by studies of certain high-risk patients in whom return to baseline function may
be the exception rather than the norm. For instance, 39% of patients undergoing
vascular surgery show evidence of a decline in capacity for independent function.
[51]
These types of findings suggest that physicians
must begin to think about modification of treatment strategies in the hope of improving
independent living status after vascular surgery. In the bigger picture, future
research on perioperative care of geriatric patients will focus on the relationship
between quality-of-life issues and surgical decision making.
