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Geriatric surgery in otolaryngology

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March 14, 2018
by Robert T. Sataloff, MD, DMA, FACS, Editor-in-Chief


More than one-third of all inpatient surgical procedures are performed on patients age 65 and over.1 This is not surprising. In 2015, people ≥65 years constituted 15% of the U.S. population, and this percentage is expected to grow to 24% by 2060.2 In 2010, nearly 40% of hospital discharges (including short-stay hospitals) involved patients ≥65 years of age.3 This means that approximately 200 million operations a year are performed on elderly (≥65 years) patients. While these data are not specific to otolaryngology, it is likely that the age profile of our patients is similar; and, with changing population demographics, it is certain that the percentage of otolaryngology patients who are elderly will increase.

We have been trained to understand that pediatric patients are not just “small adults.” Similarly, geriatric patients are not just “old adults.” They have special problems and require knowledgeable diagnostic and therapeutic intervention. The American Academy of Otolaryngology-Head and Neck Surgery acknowledged the importance of geriatric otolaryngology by publishing with Thieme a multidisciplinary textbook of geriatric otolaryngology-head and neck surgery in 2015.4 That text makes it clear that special knowledge of geriatric otolaryngology is important in all subspecialties except pediatric otolaryngology, and such knowledge is especially important in surgical decision making.

On one hand, surgery should not be denied to patients simply because they are “old.” Moreover, “old” is hard to define. More and more people are living beyond 100 years, so denying surgery to an 80-year-old and condemning him/her to suffer from a potentially correctable problem for another 15 to 20 years is not right. We need to be concerned about quality of life. On the other hand, surgery that is unlikely to improve quality of life, or that presents a high risk of ending life without a concomitant benefit (such as some surgery for advanced head and neck cancer), might not be appropriate in this population.

Numerous articles on surgery in the elderly have been published-far too many to reference in an editorial. Discussions of this topic appear regularly in publications of the American College of Surgeons, for example. The underlying theme of most of these articles is the need to improve preoperative assessment. Surgical decision making must focus on more than surgical mortality and morbidity. We must consider maintenance of independence, quality of life, return to at least preoperative functional activity levels, the likely consequences of each person's physiologic reserve, the cognitive effects associated with general anesthesia in the elderly, and the patient's desires regarding quality of life and longevity.

Ideally, with the help of a healthcare team, the surgeon needs to consciously assess cognitive function, nutrition, risk of falls, geriatric syndromes, and other special healthcare issues in all elderly patients for whom surgery is contemplated. Such preoperative assessments help not only in surgical decision making, but also in perioperative care of elderly patients.

Elderly patients have increased risk of postoperative morbidity, sometimes after even relatively short general anesthesia. Problems may include long-term cognitive impairment, delirium, deep vein thrombosis, myocardial ischemia, infection, and others. It is essential for the physician, patient, and family to review these risks and make sure everyone agrees that they are justified and weighed against potential benefits. Physician and patient education are required, but much of the necessary knowledge is still being developed.

While there is no specific measure that will guide us in decisions about whether to perform surgery, assessments of frailty can be helpful and enlightening. This topic, as well as other tools for clinical assessment that predict adverse outcomes in geriatric patients, is covered in other literature.4-10 Interesting studies in geriatric trauma patients have shown the value of frailty assessment. For example, Joseph et al looked at elderly trauma patients (a particularly vulnerable population) and found that a 50-variable frailty index predicted unfavorable discharge disposition in geriatric patients.11 In a follow-up paper published during the same year, they validated a 15-variable trauma-specific frailty index (TSFI).12 The TSFI proved to be an effective instrument for predicting discharge disposition in geriatric trauma patients.

Similar studies in otolaryngology patients have not been performed. Other frailty instruments have been used to predict surgical survival and outcomes, although most otolaryngologists are not using frailty assessment routinely and knowledgably. There are exceptions, such as the University of Pittsburgh Medical Center, where targeted assessments of elderly patients have shown great value.

Nearly all otolaryngologists care for elderly patients, and the percentage of elderly patients in our practices will continue to increase. As a field, it is past time for us to study otolaryngology-specific implications of advanced age, to apply and study assessment tools that have proven useful in other specialties, and to develop assessments and guidelines of our own to assist our trainees and our patients in providing optimal care for patients 65 and older.



References

  1. Hall MJ, DeFrances CJ, Williams SN, et al. National Hospital Discharge Survey: 2007 summary. National Health Statistics Reports. U.S. Department of Health and Human Services. October 26, 2010. www.cdc.gov/nchs/data/nhsr/nhsr029.pdf. Accessed Jan. 26, 2018.
  2. U.S. Census Bureau. 2014 national population projections summary tables. Table 6: Percent distribution of the projected population by sex and selected age groups for the U.S.: 2015 to 2060. www.census.gov/data/tables/2014/demo/popproj/2014-summary-tables.html. Accessed Jan. 26, 2018.
  3. Centers for Disease Control and Prevention. Number of discharges from short-stay hospitals, by first-listed diagnosis and age: United States, 2010. www.cdc.gov/nchs/data/nhds/3firstlisted/2010first3_numberage.pdf. Accessed Jan. 26, 2018.
  4. Sataloff RT, Johns MM, Kost KM (eds.) Geriatric Otolaryngology. New York:Thieme Medical Publishers and the American Academy of Otolaryngology-Head and Neck Surgery; 2015.
  5. Boyd CM, Darer J, Boult C, et al. Clinical practice guidelines and quality of care for older patients with multiple comorbid diseases: Implications for pay for performance. JAMA 2005; 294 (6): 716-24.
  6. Woods NF, LaCroix AZ, Gray SL, et al. Frailty: Emergence and consequences in women aged 65 and older in the Women's Health Initiative Observational Study. J Am Geriatr Soc 2005; 53 (8): 1321-30.
  7. Fried LP, Kronmal RA, Newman AB, et al. Risk factors for 5-year mortality in older adults: The Cardiovascular Health Study. JAMA 1998; 279 (8): 585-92.
  8. Zafonte RD, Hammond FM, Mann NR, et al. Relationship be- tween Glasgow Coma scale and functional outcome. Am J Phys Med Rehabil 1996; 75 (5): 364-9.
  9. Foreman BP, Caesar RR, Parks J, et al. Usefulness of the abbreviated injury score and the injury severity score in comparison to the Glasgow Coma Scale in predicting outcome after traumatic brain injury. J Trauma 2007; 62 (4): 946-50.
  10. Shah MK, Al-Adawi S, Burke DT. Age as predictor of functional outcome in anoxic brain injury. J Appl Res 2004; 4 (3): 380-4.
  11. Joseph B, Pandit V, Rhee P, et al. Predicting hospital discharge disposition in geriatric trauma patients: Is frailty the answer? J Trauma Acute Care Surgery 2014; 76 (1): 196-200.
  12. Joseph B, Pandit V, Zangbar B, et al. Validating trauma-specific frailty index for geriatric trauma patients: A prospective analysis. J Am Coll Surg 2014; 219 (1): 10-17.
Ear, Nose & Throat Journal
Ear Nose Throat J. 2018 March;97(3):50-52