Portelli Tremont Jaclyn N, Sloane Philip D
Department of Surgery, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA.
Department of Family Medicine, Center for Aging and Health, and Cecil G. Sheps Center for Health Services Research, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA.
J Am Med Dir Assoc. 2022 Apr;23(4):537-546. doi: 10.1016/j.jamda.2022.02.013. Epub 2022 Mar 15.
Although outcomes for older adults undergoing elective surgery are generally comparable to younger patients, outcomes associated with emergency surgery are poor. These adverse outcomes are in part because of the physiologic changes associated with aging, increased odds of comorbidities in older adults, and a lower probability of presenting with classic "red flag" physical examination findings. Existing evidence-based perioperative best practice guidelines perform better for elective compared with emergency surgery; so, decision making for older adults undergoing emergency surgery can be challenging for surgeons and other clinicians and may rely on subjective experience. To aid surgical decision making, clinicians should assess premorbid functional status, evaluate for the presence of geriatric syndromes, and consider social determinants of health. Documentation of care preferences and a surrogate decision maker are critical. In discussing the risks and benefits of surgery, patient-centered narrative formats with inclusion of geriatric-specific outcomes are important. Use of risk calculators can be meaningful, although limitations exist. After surgery, daily evaluation for common postoperative complications should be considered, as well as early discharge planning and palliative care consultation, if appropriate. The role of the geriatrician in emergency surgery for older adults may vary based on the acuity of patient presentation, but perioperative consultation and comanagement are strongly recommended to optimize care delivery and patient outcomes.
尽管接受择期手术的老年人的手术结果通常与年轻患者相当，但急诊手术的结果却很差。这些不良结果部分归因于与衰老相关的生理变化、老年人合并症几率增加以及出现典型“警示信号”体格检查结果的可能性较低。与急诊手术相比，现有的循证围手术期最佳实践指南在择期手术中表现更佳；因此，对于进行急诊手术的老年人，外科医生和其他临床医生的决策可能具有挑战性，且可能依赖主观经验。为辅助手术决策，临床医生应评估病前功能状态，评估是否存在老年综合征，并考虑健康的社会决定因素。记录护理偏好和指定替代决策者至关重要。在讨论手术的风险和益处时，采用以患者为中心的叙述形式并纳入老年患者特有的结果很重要。使用风险计算器可能有意义，尽管存在局限性。术后，应考虑对常见术后并发症进行每日评估，以及在适当情况下进行早期出院规划和姑息治疗咨询。老年病医生在老年人急诊手术中的作用可能因患者病情的严重程度而异，但强烈建议进行围手术期咨询和共同管理，以优化护理服务和患者手术结果。
