Department of Intensive Care Medicine, Center for Anesthesiology and Intensive Care Medicine, University Medical Center Hamburg-Eppendorf (UKE); Department of General, Visceral and Oncological Surgery Klinikum St. Georg, Leipzig; Clinic for Trauma and Reconstructive Surgery, BG Hospital, Tübingen; Department of General-, Visceral- and Vascular Surgery, Städtisches Klinikum Solingen gGmbH; Department of General Practice / Primary Care, Center for Psychosocial Medicine, University Medical Center Hamburg-Eppendorf (UKE); Department of Anesthesiology and Intensive Care Medicine, Rotkreuzklinikum München.
Dtsch Arztebl Int. 2019 Feb 1;116(5):63-69. doi: 10.3238/arztebl.2019.0063.
Elderly patients are a growing and vulnerable group with an elevated perioperative risk. Perioperative treatment pathways that take these patients' special risks and requirements into account are often not implemented in routine clinical practice.
This review is based on pertinent publications retrieved by a selective search in PubMed, the AWMF guideline database, and the Cochrane database for guidelines from Germany and abroad, meta-analyses, and Cochrane reviews.
The care of elderly patients who need surgery calls for an interdisciplinary, interprofessional treatment concept. One component of this concept is preoperative preparation of the patient ("prehabilitation"), which is best initiated before hospital admission, e.g., correction of deficiency states, optimization of chronic drug treatment, and respiratory training. Another important component consists of pre-, intra-, and postoperative measures to prevent delirium, which can lower the frequency of this complication by 30-50%: these include orientation aids, avoidance of inappropriate drugs for elderly patients, adequate analgesia, early mobilization, short fasting times, and a perioperative nutrition plan. Preexisting cognitive impairment predisposes to postoperative delirium (odds ratios [OR] ranging from 2.5 to 4.5). Frailty is the most important predictor of the postoperative course (OR: 2.6-11). It follows that preoperative assessment of the patient's functional and cognitive status is essential.
The evidence-based and guideline-consistent care of elderly patients requires not only close interdisciplinary, interprofessional, and cross-sectoral collaboration, but also the restructuring and optimization of habitual procedural pathways in the hospital. Elderly patients' special needs can only be met by a treatment concept in which the entire perioperative phase is considered as a single, coherent process.
老年患者是一个不断增长的脆弱群体，围手术期风险较高。考虑到这些患者的特殊风险和需求的围手术期治疗途径，在常规临床实践中往往没有得到实施。
本综述基于通过选择性搜索在 PubMed、德国和国外的 AWMF 指南数据库以及 Cochrane 指南数据库中检索到的相关出版物，包括荟萃分析和 Cochrane 综述。
需要手术的老年患者的护理需要采用跨学科、跨专业的治疗理念。该理念的一个组成部分是患者的术前准备（“预康复”），最好在入院前开始，例如纠正缺陷状态、优化慢性药物治疗和呼吸训练。另一个重要组成部分包括预防谵妄的术前、术中和术后措施，这可以将这种并发症的频率降低 30-50%：包括定向辅助、避免为老年患者使用不适当的药物、充分镇痛、早期活动、缩短禁食时间和围手术期营养计划。术前认知障碍使术后谵妄的发病风险增加（比值比范围为 2.5 至 4.5）。脆弱性是术后病程的最重要预测因素（比值比：2.6-11）。因此，术前评估患者的功能和认知状态至关重要。
基于循证和指南的老年患者护理不仅需要密切的跨学科、跨专业和跨部门合作，还需要对医院内习惯性程序途径进行重构和优化。只有将整个围手术期视为一个单一的连贯过程，才能满足老年患者的特殊需求。
