Collective review
Strategies to Minimize Postoperative Deconditioning in Elderly Surgical Patients

Presented at the Symposium “Surgery in the Elderly Patient? Galveston III,” Galveston, TX, April 2006. This symposium was generously supported by Genitzinger Endowment Fund, the Sealy Center for Aging and the Department of Surgery, UTMB, and the American Geriatric Society.
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Factors contributing to deconditioning in the elderly postoperative patient

Three factors contribute to deconditioning in the elderly surgical patient: the aging process itself, bed rest associated with hospitalization and surgery, and the surgical procedure, with its resulting stress response, tissue injury, and metabolic changes.

Deconditioning and aging

The aging process itself produces deconditioning. An example of how this can be quantified comes from the work of Tanaka and Seals,10 who measured running and swimming times versus advancing age in highly trained athletes. Running performance is maintained until approximately 35 years of age; modest changes occur until 50 to 60 years; after this, performance declines exponentially. Ten-kilometer running times in 30-year-old individuals are in the range of 30 minutes; at 60 years they increase

Deconditioning and bed rest

When the elderly patient arrives at the hospital for a surgical procedure, there is a natural tendency to spend more time in bed than during life activities outside the hospital. The medical condition for which the patient enters the hospital often necessitates more time in bed. Bed rest is associated with negative changes in muscle, bone, cartilage, and the cardiovascular system.21 Muscle changes are particularly notable. Muscle mass can be lost at a rate of up to 5% per week of bed rest, and

Deconditioning and surgery

Surgery is associated with a “stress response” manifested as increased secretion of catabolic hormones, decreased secretion of anabolic hormones, hypermetabolism, increased cardiac work, impaired pulmonary function, pain, fatigue, and immunosuppression.28 Many of these responses contribute to deconditioning after the surgical procedure. One of the most important is protein catabolism, which is stimulated by increased cortisol. Protein catabolism occurs primarily in skeletal muscle, releasing

Strategies to minimize postoperative deconditioning

Strategies to minimize postoperative deconditioning include exercise rehabilitation, optimization of medical factors such as anemia, nutritional supplementation, minimally invasive surgery, multimodal programs, and the concept of “prehabilitation,” optimizing a patient’s functional status before the surgical procedure.

Exercise rehabilitation

Exercise rehabilitation was first introduced in the 1980s as a means of improving outcomes in patients with coronary artery disease, both those experiencing events such as myocardial infarction and those undergoing procedures including percutaneous coronary revascularization and bypass surgery. Although exercise is the main element of cardiac rehabilitation programs, it also includes other therapies such as risk factor education, psychological guidance, and drug therapy. Outcomes are expressed

Medical optimization: anemia

At least one recent study showed that higher hemoglobin levels are associated with improved walking distances in patients recovering from hip fracture.51 This was a retrospective cohort study of 5,793 patients undergoing hip fracture repair at 20 academic and community hospitals. The investigators demonstrated a linear relationship between higher hemoglobin levels and distance walked at discharge. At a hemoglobin level of 7 g/dL, mean distance walked was 56 feet; at 12 g/dL, distance walked was

Nutrition

The benefits of pre- and postoperative nutrition have been studied extensively in surgical patients, although the studies have not necessarily addressed functional status, deconditioning, or elderly patients. In fact, no studies have addressed the relationships between either parenteral nutrition (given pre- or postoperatively) or preoperative enteral nutrition and deconditioning.

The benefits of nutritional supplementation on deconditioning have been addressed in several studies of

Minimally invasive surgery

Minimally invasive surgery, the use of laparoscopic techniques or catheter-based procedures, has been advocated as a means to reduce postoperative deconditioning, shorten hospital stay, and reduce the morbidity and mortality of surgical procedures in the elderly. The use of laparoscopic procedures in the elderly has been reviewed by Weber56 for biliary tract and reflux disease and both benign and malignant processes in the colon. She noted that clinicians were initially reluctant to offer

Multimodal therapy: “fast track” surgery

In Europe, the concept of “fast track” surgery has been introduced. Fast track surgery uses a combination of methods, which can include minimally invasive surgery, to reduce perioperative morbidity and mortality. Operative interventions include the use of regional or local anesthesia techniques whenever possible, the use of minimally invasive surgery, and careful maintenance of intraoperative normothermia. Postoperative interventions include early removal of drains such as nasogastric tubes and

Prehabilitation

A limited number of studies have addressed the concept of “prehabilitation,” that is, optimizing a patient’s functional status before surgery (Table 2).81, 82, 83, 84, 85, 86, 87 This idea is based on studies in which patients in better physical condition before surgery were observed to have better postoperative outcomes. Katz and colleagues88 found that there was a marked positive correlation between preoperative physical condition and postoperative outcomes among patients undergoing surgical

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