Gynecologic surgery in the geriatric patient.

In the United States, 237,000 gynecologic procedures, mostly hysterectomy, oophorectomy, or hysterectomy and oophorectomy, are performed annually in women aged 65 years and over for an age-adjusted surgical rate of 63.8 gynecologic procedures per 10,000 women aged 65 years and over.( 1 ) As women age, uterine leiomyoma and endometriosis decline as indications for surgery in postmenopausal women while uterine prolapse and gynecologic malignancies persist. ( 2 ) The U.S Census bureau has predicted that the population of adults over the age of 65 will increase from 46,059,000 in 2010 to 108,189,000 in 2050. Additionally, the age structure among adults over 65 years old is predicted to shift with the largest proportion of this older population shifting from the 65 to 69 year old age group in 2010 to the 80 to 84 year old age group in 2050. Therefore, the number of older women in need of gynecologic surgical procedures will rise in the upcoming decades. Four common postoperative complications among older women are falls, delirium, surgical site infections, and electrolyte imbalance.( 3 ) Falls are common. Thirty percent of community dwelling adults over 65 years old fall every year and 10% of these falls result in a major injury including fracture, serious soft tissue injury, or traumatic brain injury.( 4 ) Another serious consequence is the inability to get up after a fall which can result in significant morbidity including dehydration, pressure ulcers, and rhabdomyolysis. Risk factors predisposing older adults to falls include previous falls, balance impairment, gait disturbances, decreased muscle strength, visual impairments (including cataracts), polypharmacy (> 4 medications), functional impairment of activities of daily living, depression, low body mass index, age > 80 years, female gender, and cognitive impairments.( 4 ) Delirium is an acute state of confusion and is a common complication reported in 17% of older women undergoing procedures for gynecologic cancer. Delirium is often unrecognized, so the true occurrence of postoperative delirium may be higher. Postoperative delirium is common in older patients and associated with increased mortality, longer hospital stays, and increased discharge to skilled nursing facilities. Unfortunately, 50 to 80% of acute episodes of delirium in hospitalized patients are unrecognized. The Confusion Assessment Method diagnostic algorithm is an easy assessment tool for identifying delirium.( 5 , 6 ) ( Box 1 ) Surgical site infections. Increase with increasing age. Impaired functional status for activities of daily living (ADLs) is an important independent predictor of surgical site infection, especially methicillin-resistant Staphylococci infections, even after stratifying patients by age.( 3 , 7 ) Electrolyte imbalance is common in older patients. With aging, glomerular filtration rate, sodium reabsorption and potassium secretion decrease, resulting in diminished renal reserve and electrolyte imbalances.( 8 ) ( 9 ) Perioperative fluid management in older patients should be carefully monitored to avoid either fluid overload or dehydration. A review of a woman's personal risk factors and mobility screening can identify patients at risk of fall. A simple screening test for mobility is the Get up and Go test. Patients are asked to get up from a chair without using the armrests, walk 10 feet, turn and return to the chair and sit down. A total “Get up and Go” test time of less than 12 seconds indicates normal mobility. Patients should be referred for a more comprehensive mobility assessment if the time exceeds 12 seconds or if balance or gait challenges are observed. Interventions studied to reduce falls include home safety modifications, medication reduction, physical therapy, exercise, and vision improvements. Although some single intervention and multiple intervention trials were shown to be ineffective, most of the effective trials for the prevention of falls include a tailored combined intervention that addresses an individual's specific risk factors for falls. ( Table 1 ) : for example, cataract surgery to improve vision or comprehensive medication review to reduce polypharmacy. Women with balance or gait impairments benefit from physical or occupation therapy for progressive strength, balance and gait training. Home visits are helpful to implement adaptive devices (grab bars, raised toilet seats, and shower chairs), remove tripping hazards such as throw rugs, ensure adequate lighting (nightlights for women with nocturia), place an accessible telephone on the floor level, and enroll women in emergency response systems for help if they do experience a fall. Two types of emergency response systems exist. One system triggers an automatic call if the patient falls. The other system needs to be triggered by the patient. Both have been shown beneficial in patients with a history of falls. Attempting to avoid all inpatient falls, through prolonged bedrest and mobility only with strict supervision may result in decreased mobility, decreased strength, unnecessary restrictions on patient autonomy and decreased patient dignity. A balanced approach to fall prevention that encourages mobility is important in hospitalized patients. Risk factors included in one clinical prediction model for postoperative delirium after non-cardiac surgery include: age ≥ 70 years, alcohol abuse, preoperative cognitive impairment, preoperative physical impairment, and abnormal serum sodium (150 mmol/L), potassium (16.7mmol/L), or glucose (300mg/dL).( 10 ) In a study of women > 60 years undergoing surgery for suspected gynecologic malignancy, age >70 years, taking > 5 medications, and additional narcotic dosing to supplement intravenous patient-controlled analgesia independently predicted postoperative delirium.( 11 ) Postoperative delirium increases with increasing risk factors as well as the degree of stress or insult sustained. Because delirium is relatively common in elderly postoperative patients and prevention and treatment decrease morbidity, we assess all elderly women daily by noting if patients are easily distracted, disoriented, or have disorganized thinking or altered levels of consciousness (hyperalert or lethargic).( 12 ) We liberally consult geriatric colleagues if signs of delirium are recognized. Multi-component interventions to reduce delirium are aimed at recognizing its risk factors: cognitive impairment, sleep deprivation, immobility, visual impairment, hearing impairment, and dehydration. Interventions reduce both the occurrence of delirium in hospitalized patients and the duration of the delirium.( 13 ) To support the delirious patient: 1) provide easy to read clocks and calendars to allow patients to maintain orientation, 2) encourage frequent introductions and cognitive reorientation by staff, 3) encourage a normal sleep-wake cycle by reducing auditory alarms, 4) avoide routine vital signs collection and medication administration during sleep, 5) minimize indwelling catheters and other lines or “tethers” so the patient can move freely, 6) eliminate physical restraints as soon as possible, 7) optimize sensory input by ensuring correct usage of glasses and hearing aids, 8) monitor urine and stool output to prevent retention or impaction, and 9) support meals assistance of cutting food and hand-feeding if necessary. Specialized units, termed acute care of the elderly (ACE) units, have been implemented at hospitals to prevent delirium and provide supportive care to patients who develop delirium. Preoperative medical risk assessments should include a comprehensive cardiac and pulmonary history with an evaluation of clinical predictors of perioperative cardiac events, including ischemic heart disease, congestive heart failure, documented cerebrovascular disease, insulin-dependent diabetes mellitus, and/or serum creatinine > 2.0mg/dl.( 14 ) Using the algorithm outlined by the American College of Cardiology and the American Heart Association can help to identify patients who will benefit from preoperative cardiac testing (stress test or coronary angiography) or perioperative medical therapy with beta-blockers.( 15 ) In women undergoing intermediate risk surgery (laparotomy) with one or more of the above clinical risk factors for perioperative cardiac events abeta-blocker should be started pre-operatively. The exact timing of initiation and duration of therapy is still under debate. Review all medications a patient is taking including alternative and herbal medications to identify which medications should be continued through the operative period. For medications that will be stopped in the operative period, clearly communicate the timing of discontinuation and reinstitution. Preoperative smoking cessation counseling represents a unique opportunity to motivate change that can also decrease postoperative complications. Intensive interventions to promote smoking cessation with counseling sessions and nicotine replacement treatment for at least 4 to 8 weeks before surgery result in sustained abstinence after surgery and fewer postoperative complications.( 16 , 17 ) When smoking cessation is initiated within 4 weeks of surgery, postoperative complications are generally not reduced. It is thought that smoking can result in small impairments of the immune system that may take prolonged abstinence to recovery. It is also important to elicit preoperative alcohol intake. The four T-ACE (Tolerance, Annoyed, Cut down, and Eye-opener) questions are helpful in screening women for at-risk drinking.( 18 ) Patients identified for at-risk drinking can be offered referral for substance abuse care and treated for symptoms of alcohol withdrawal while inpatient after surgery. Another important intervention is preoperative exercise training or “prehabilitation”.( 19 ) Preoperative physical activity, either respiratory muscle training or aerobic activity over 3 weeks to 6 months, can decrease postoperative complications. Respiratory muscle training (deep breathing with a progressive increase in rate of perceived exertion) for 2 weeks before cardiac or major vascular surgery may improve some pulmonary outcomes . Similarly, preoperative aerobic activity or simple walking programs can improve walking capacity in patients. The indications for surgery may dictate the amount of time between deciding on surgery and when the surgery can be performed. Procedures for gynecologic cancer may need to be performed within weeks of diagnosis which may preclude “prehabiltation”. In contrast, procedures for pelvic floor disorders are often elective and may present a unique opportunity for these health interventions. Frailty is a common biologic syndrome of decreased reserve and resistance to stressors that increases with age. Easily measured markers of frailty include slow gait speed, low physical activity, unintentional weight loss, self-reported exhaustion, muscle weakness, cognitive impairment and depression. Frailty can be measured before overt functional disability is recognized by healthcare professionals or acknowledged by older adults. Frailty is an intermediate step predictive of morbidity before overt functional disability is evident. Postoperative complications are increased in women with frailty and overt functional disability for activities of daily living. ( 7 , 20 - 22 ), suggesting that frailty and functional status should be considered, in addition to age and medical comorbidities, in preoperative medical risk assessments. Malani et al has advocated for routinely assessing mobility, cognition and function in older adults before elective surgery pre-operatively.( 3 ) Assessment tools include the Get Up and Go test for mobility, the Mini-Cog screen for cognitive impairment ( Box 2 ), and a review of the functional and instrumental ADLs. The Mini-Cog screen is a simple screening test for cognitive impairment that asks a patient to remember three words and then draw a clock face correctly. Examples of errors in clock drawing are illustrated in Figure 1 . Functional ADLs include walking one block, walking across a room, putting on shoes and socks, bathing or showering, cutting food, getting in and out of bed, and using the toilet. Instrumental ADLs include ability to perform tasks such as balancing a checkbook, paying bills, and grocery shopping. Often, deficiencies in mobility and mild cognition impairment are present before overt functional disability is present. In our practice, we have added measures of frailty and functional status in women over 80 years prior to gynecologic surgery to complement the preoperative medical risk assessments. ( Table 2 ) This added evaluation takes between 5 and 10 minutes. While we chose to do this added evaluation, which takes between 5 and 10 minutes in women over 80 because of the clear increase in complication risk over this cut-point, further research is needed to merge aging related research with outcomes research in gynecology to provide more specific data on complications in women over 65 years, 80 years, and beyond.

A multiparous woman in her mid-80s presented with complete uterine procidentia and difficulty with urination to a tertiary care center for surgery. She denied urinary incontinence. She lived by herself and walked with a cane. She had a past medical history significant for hypertension, osteoporosis with vertebral fracture, and hypercholesterolemia. She had no history of acute myocardial infarction, cerebral vascular accident, or malignancy. Medications included a beta blocker, a thiazide diuretic, an HMG-CoA reductase inhibitor, and a bisphosphonate. She denied taking vitamins or herbal medications. Physical examination revealed complete uterine procidentia with vaginal atrophy but no ulcerations. Simple uroflow demonstrated an interrupted voiding pattern. No urine leakage was seen with stress maneuvers with a full bladder with the prolapse reduced. Papanicolaou test and endometrial biopsy were negative for malignancy. The patient elected to proceed with an obliterative procedure to correct her pelvic organ prolapse. Preoperatively, her serum sodium, serum creatinine, and estimated glomerular filtration rate were 132 mEq/L, 0.8 mg/dL and >60 mL/minute, respectively. Beyond noting her living arrangements, history of falls, and walking with assistance, her functional and cognitive status was not formally assessed preoperatively. The patient underwent an uncomplicated modified LeFort colpocleisis, perineorrhaphy, and cystoscopy under general endotracheal anesthesia. Regional anesthesia was not chosen due to her vertebral fracture. Total anesthesia time was 106 minutes and estimated blood loss was 50 mL. On the morning of postoperative day #1, she ambulated to the bathroom, tolerated a regular diet, and reported adequate pain control. Physical therapy, consulted to evaluate her balance and gait, recommended a rolling walker to use with ambulation. She could stand independently and navigate 5 stairs without assistance. Her serum sodium was 130 mEq/L. The patient was discharged home on postoperative day #1. On postoperative day #5, the patient fell in her home and was found by her daughter on the floor approximately 30 minutes later. She had used no narcotic pain medication since her surgery. She was re-admitted to the hospital for dehydration and hyponatremia (serum sodium 127 mEq/L) which was believed to have been the cause of her fall. Fortunately, no fracture was observed. She moved to her daughter's house. She continued to be hyponatremic despite discontinuation of thiazide diuretic. Eighteen months following surgery she reported having regained her strength and energy level. She experienced one additional fall with no major injury.