Collective reviewStrategies to Minimize Postoperative Deconditioning in Elderly Surgical Patients
Section snippets
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
References (90)
- et al.
Perioperative care for the elderly patient
Med Clin North Am
(2003) - et al.
Is revascularization and limb salvage always the best treatment for critical limb ischemia?
J Vasc Surg
(2003) The stress response to trauma and surgery
Br J Anaesth
(2000)- et al.
Exercise-based rehabilitation for patients with coronary heart disease: systematic review and meta-analysis of randomized controlled trials
Am J Med
(2004) - et al.
Effects of aerobic exercise on the physical performance and incidence of treatment-related complications after high-dose chemotherapy
Blood
(1997) - et al.
Correlation between physical performance and fatigue in cancer patients
Ann Oncol
(1997) - et al.
Dietary supplementation in elderly patients with fractured neck of femur
Lancet
(1990) - et al.
Minimally invasive surgery in the elderly patient
Surg Clin North Am
(1994) - et al.
Laparoscopy-assisted colectomy versus open colectomy for treatment of non-metastatic colon cancer: a randomized trial
Lancet
(2002) - et al.
Perioperative outcomes after open and endovascular repair of intact abdominal aortic aneurysms in the United States during 2001
J Vasc Surg
(2004)
Multimodal strategies to improve surgical outcome
Am J Surg
Benefits of early feeding and early hospital discharge in elderly patients undergoing open colon resection
J Am Coll Surg
Randomized controlled trial comparing the controlled rehabilitation with early ambulation and diet pathway versus the controlled rehabilitation with early ambulation and diet with preemptive epidural anesthesia/analgesia after laparotomy and intestinal resection
Am J Surg
Enforced mobilization, early oral feeding, and balanced analgesia improve convalescence after colorectal surgery
Nutrition
Is risk of indicated operation too great in the elderly?
Geriatrics
Preoperative assessment of older adults
J Am Geriatr Soc
The outcome of hospitalization for acute illness in the elderly
J Am Geriatr Soc
Functional recovery after hip fracture
Arch Phys Med Rehabil
Management of chronic ischemia of the lower extremity
Functional outcome after infrainguinal bypass for limb salvage
J Vasc Surg
Deconditioning
Dynamic exercise performance in Masters athletes: insight into the effects of primary human aging on physiological functional capacity
J Appl Physiol
Hazards of hospitalization of the elderly
Ann Int Med
What is sarcopenia?
J Gerontol Ser A
Human major psoas muscle and serospinalis muscle in relation to age: a study by computed tomography
J Gerontol
Histochemical characteristics of human skeletal muscle during aging
Acta Physiol Scand
Muscle strength and speed of movement in relation to age and muscle morphology
J Appl Physiol
Leg extensor power and functional performance in very old men and women
Clin Sci
Physiological limiting factors and distance running: influence of gender and age on record performances
Greater rate of decline in maximal aerobic capacity with age in physically active vs. sedentary healthy women
J Appl Physiol
Peak aerobic power is an important component of physical performance in older women
J Gerontol Ser A
Aerobic capacity and cognitive performance in a cross-sectional aging study
Med Sci Sports Exerc
Changes in musculoskeletal structure and function with prolonged bed rest
Med Sci Sports Exerc
Effects of lower limb unloading on skeletal muscle mass and function in humans
J Appl Physiol
Lower limb skeletal muscle function after 6 weeks of bed rest
J Appl Physiol
Regional changes in muscle mass following 17 weeks of bed rest
J Appl Physiol
Bone mineral loss and recovery after 17 weeks of bed rest
J Bone Miner Res
Physiology and complications of bed rest
J Am Geriatr Soc
Cardiac atrophy after bed-rest deconditioning
Circulation
Metabolic response to severe surgical illness: overview
World J Surg
Sequential changes in the metabolic response in severely septic patients during the first 23 days after the onset of peritonitis
Ann Surg
Correlates of recovery among older adults after major abdominal surgery
Nursing Res
Exercise standards for testing and training: a statement for healthcare professionals from the American Heart Association
Circulation
Cardiac rehabilitation as secondary preventionAgency for Health Care Policy and Research and National Heart, Lung, and Blood Institute
Clin Pract Guide
Canadian guidelines for cardiac rehabilitation and atherosclerotic heart disease prevention: a summary
Can J Cardiol
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