Enhanced recovery programmes for the elderly

The number of elderly patients undergoing major surgical procedures is increasing and this is posing a major challenge for anaesthetists and surgeons. There is a general agreement that there is a higher risk of postoperative complications in the elderly patient and that preoperative assessment is necessary to detect significant co-morbidity,1 but such risk assessment does not necessarily translate into a decreased postoperative morbidity. Instead, we should ask ‘Why is the surgical patient at risk?’2 and ‘Why is the patient in hospital today?’3 In this context, the last decades have seen a continuous development and optimisation through implementation of evidence-based care programmes with multimodal interventions to improve recovery and decrease morbidity.3 Such programmes have been called ‘fast-track surgery’ or ‘enhanced recovery after surgery’. The question is whether these developments can also be used in the elderly surgical population and whether the benefits obtained also apply to this population?3 Well recognised preoperative risk factors1 may not have the same impact in a fast-track surgical setting, as demonstrated for cardiopulmonary disease, diabetes, smoking and alcohol abuse.3,4 The studies conducted so far in the elderly surgical population have shown that these populations also benefit from enhanced recovery programmes1,5,6 and those programmes should therefore be applied whenever possible. A short hospital stay is desirable as the hospital environment is associated with fasting, sleep disruption, immobilisation and medication errors. However, several challenges present in the elderly surgical population need to be overcome to accommodate this desire. The doses of drugs used during and after anaesthesia should be modified in the elderly as these patients may be more sensitive to them because of changes in pharmacokinetics and pharmacodynamics. Postoperative opioids should be avoided or reduced whenever possible through the use of multimodal analgesic regimens.7 As the elderly population has a higher risk of impaired muscle function, questions regarding preoperative rehabilitation and cardiopulmonary exercise testing are relevant but, so far, answers require more high-quality studies.8 Postoperative delirium and cognitive dysfunction are much more common in the elderly population with inadequate pain relief being a very important risk factor for delirium. In this context, preliminary observations from fast-track programmes in hip and knee arthroplasty, with opioid-sparing analgesia, early mobilisation and return to home, suggest the virtually elimination of delirium and also a reduction, but not elimination, of the risk of postoperative cognitive dysfunction.9 Consequently, every effort should be made to improve our multimodal opioid-sparing regimes, and the use of a high-dose preoperative glucocorticoid may further improve opioid-sparing analgesia and well-being.10 Even with a fast-track setup, there are severe postoperative sleep disturbances, especially with early postoperative disappearance of REM sleep,11 and addressing this requires the development of techniques that can restore sleep architecture.11 Other well known components of enhanced recovery programmes such as appropriate fluid management and early mobilisation should also be instituted: the latter is important because immobilisation-induced loss of muscle function may take much longer to resolve in elderly patients.12 Furthermore, it seems that early mobilisation also decreases the risk of thromboembolic complications in the elderly population.13 Finally, perioperative haematological management may be of increased importance in elderly patients who more often present with preoperative anaemia and coronary artery disease. Consequently, further research is required as regards to preoperative haemoglobin optimisation and the transfusion thresholds for elderly surgical patients.14 The considerations above are mainly related to elective surgery but it must be acknowledged that a significant proportion of elderly surgical patients are undergoing emergency surgery where careful preoperative assessment may be very difficult and pre-existing cognitive impairment is frequently overlooked. Thus, in the frail elderly, who can be identified using specific frailty scoring systems,15 enhanced recovery after surgery may be less successful. In conclusion, there is no doubt that enhanced recovery programmes or fast-track surgery are beneficial for the elderly surgical patient, but the question remains as to how we can further improve the care of these often very high-risk patients, with many comorbidities, who require major surgical procedures. Future achievements will need close multidisciplinary collaboration between anaesthetists, surgeons and surgical nurses, with all efforts striving to normalise postoperative pathophysiology and counteract organ dysfunction.3 The early phase of recovery from anaesthesia is often prolonged in the elderly, and the response to hypothermia, hypoxaemia and hypercapnia is also attenuated. We need better studies to define whether a sub-fraction of elderly patients should stay longer in the post-anaesthesia care unit or in an intermediate care unit, and whether postoperative rounds for such patients should be made by a surgeon teamed with either an anaesthetist16 or a geriatrician.17 To improve surgical outcome in elderly patients then, undoubtedly, the next few years will see major progress within the topics discussed above. Acknowledgements relating to this article Assistance with the Editorial: none. Financial support and sponsorship: LSR has received support from the Tryg Foundation. Conflicts of interest: CCJ has received fees for speaking at Zimmer Biomet. HK is a member of Advisory Board, Zimmer Biomet in Rapid Recovery Programs.