The elderly population is gradually increasing with increased longevity of life. This may be due to better medical care and improvement in medical technology and pharmaceuticals. The various disease condition especially cancer which was considered incurable decades back are better managed now. However, this special population regards cautious vigilance in perioperative management for various cancer related procedures. There are various physiological and pathological; changes. These changes not only requires assessment but also require optimization. In spite of best effort, sometimes, disease may not be cured fully. This is the time these patients requires good palliative care to improve quality of life. This review article will help understand the physiological and pharmacological changes occurring because of age. The intraoperative and post-operative care of the elderly cancer patient will also be discussed. In addition to this the review will also touch upon issues of palliative care in elderly cancer patients.
Keywords geriatric, elderly, cancer, anaesthesia, palliative care.
1 Department of Anaesthesiology, Dr BRAIRCH, All India Institute of Medical Sciences.
2 JPNATC, All India Institute of Medical Sciences.
RecievedMay 19 2014 AcceptedSep 2 2014 PublishedSep 17 2014
CitationGarg R, Yadav N (2014) Perioperative and palliative concerns in geriatric cancer patients. Science Postprint 1(1): e00032. doi: 10.14340/spp.2014.09R0003
Copyright©2014 The Authors. Science Postprint is published by General Healthcare Inc. This is an open access article under the terms of the Creative Commons Attribution-NonCommercial-NoDerivs 2.1 Japan (CC BY-NC-ND 2.1 JP) License, which permits use and distribution in any medium, provided the original work is properly cited, the use is non-commercial and no modifications or adaptations are made.
FundingNo funding. No financial conflict to be disclosed.
Competing interestNo conflict of interest.
Corresponding authorRakesh Garg
AddressRoom No 139, Department of Anaesthesiology, Dr BRAIRCH, All India Institute of Medical Sciences, Ansari Nagar, New Delhi-110029, India.
With advances made by medical sciences and improvement in social conditions in last few decades, the life span has increased in almost all the countries. It has been reported that elderly population would increase by 223% or 694 million by year 2025 1. With substantial increase in the life expectancy, the number of malignant cases has also increased. The occurrence of cancer may be associated with various aetiologies like genetic, infections, chemicals, and chromosomal damage. Some of the viral infections have also been associated with increased occurrence of certain specific neoplasia 2. With advances in medical technology and diagnosis and treatment, most of the patients nowadays undergo early surgery and need palliative care. With most of the malignancy patients lying in the geriatric age group, most of these patients have common chronic diseases, psychological problems and social problems. The physiological changes in the elderly malignancy patients are marked and they have profound impact on the anaesthesia provided to them for surgery. This review article will help understand the physiological and pharmacological changes occurring because of age. The intraoperative and post-operative care of the elderly cancer patient will also be discussed. In addition to this the review will also touch upon issues of palliative care in elderly cancer patients.
Most of the physiological studies have shown that the basal function of various organ systems is relatively uncompromised by the aging process per se. The main difference which arises is the functional reserve and ability to compensate for physiological stress.
Cardiovascular changes can affect every organ bed. These changes have implications for anaesthetic care. There is a nearly linear increase in systolic blood pressure from age 30 to 84 years as documented by Framingham Heart study 3. Arterial stiffness (50%–75%) and systemic vascular resistance (25%) contribute to the age related hypertension 3, 4. In addition, decreased peripheral β-adrenergic responsiveness and increased sympathetic nervous system activity contribute to the hypertension of aging 5. Increased after load, increasing wall stress and myocardial oxygen demand leads to ventricular hypertrophy. All these changes also increase the susceptibility to ischaemia. In addition, ventricular stiffness and hypertrophy limit the ability of the heart to adjust stroke volume and impair passive ventricular filling 6. Fatty infiltration and fibrosis in heart lead to conduction defects 7. Aging also causes decreased myocardial responsiveness to catecholamine’s and a diminished heart rate response 6. All these changes lead to decreased ability to buffer changes in circulatory volume, leading to congestive heart failure and hypotension. The autonomic control of heart rate, cardiac output, peripheral vascular disease, and the baroreceptor response is deranged with age 8. Thus age related changes are seen in both mechanics and control mechanisms in cardiovascular system.
Age related changes in pulmonary system are same as in cardiovascular system. With age, thorax becomes stiffer increasing the work of breathing and reducing maximum minute ventilation [9, 10]. Functional residual capacity (FRC) and residual volume (RV) both increase with each decade, however forced expiratory volume in 1 s (FEV1) is reduced approximately 6%–8% per decade 9. Because of reduced elastic coil, the closing volume increases such that it exceeds FRC by age of 65 9-11. Functional reserve, both during inspiration and expiration decreases with aging. Even normal matching of ventilation and perfusion decreases. The respiratory response to hypoxia also diminishes with aging; there is decrease in ciliary function, and cough is also reduced 9, 10. Also, with exposure to inciting factors like tobacco (smoking and smokeless) and passive smoking could further compromise the respiratory function in elderly 12.
Aging effects both central and peripheral nervous system 13. Starting from middle age there is a decrease in cortical grey matter, resulting in cerebral atrophy 14. In cortical grey matter, decrease in neuronal volume appears to be more important than neuronal loss 15, 16. At cellular level there is reduction in complexity of neuronal connections, decrease in synthesis of neurotransmitters and an increase in the enzymes responsible for post synaptic degradation 14. In spinal cord also there is neuronal loss and demyelinization 17. Even functionally there are changes in spinal cord reflexes and reduction in proprioception. There is decline in audio and visual perception. Also the property to acquire and process these information also decreases leading to postoperative delirium, drug toxicity and falls.
In addition there is neuronal loss of aging in autonomic nervous system also. The impaired cardiovascular reflexes are because of peripheral neuronal adrenergic loss. Simultaneous decrease in adrenoreceptor responsiveness results in increased intramedullary output and plasma catecholamine concentrations 17. Decrease in skeletal muscle innervations leads to loss of motor units, leading to decrease in strength, coordination and, fine motor control 18. Joint position and proprioception may also be compromised.
There is progressive decrease in renal blood flow 19. With age nephrons are sclerotic, reducing the functional residual capacity. There is progressive decrease in glomerular capillary surface area and glomerular filtration rate. With age there is difficulty in maintaining circulating blood volume and sodium haemostasis perioperatively 20. There is less efficient renal excretion of acid leading to perioperative metabolic acidosis.
With age the number of medications taken by the elderly increases. In addition to this the adverse events related to drugs are the main reason for hospital admission in such patients. Due to changes in the pharmacodynamics and pharmacokinetics induced by aging, elderly patients are very sensitive to the effect of drugs. Factors like increase in fatty mass, decreased muscle tissue and reduced total body water compared to younger subjects is also seen. Along with this there is age related changes in metabolism of drugs there is increase in plasma concentration of water soluble drugs and decrease in plasma concentrations of lipid soluble drugs 21. The lean body mass is usually low in elderly due to changes in metabolism. However, the occurrence of obesity has increased not only in young but may also be seen in elderly. This may have impact on already compromised various body systems. These individuals should be encouraged with appropriate diet and suitably selected physical activity to prevent occurrence of other age related issues 22.
Change in hepatic blood flow and decreased serum albumin concentration causes change in drug distribution and excretion. Reduced renal secretion lead to decreased glomerular filtration rate. This decreases lead to reduced renal excretion and accumulation of metabolites. Hypoalbuminemia together with reduced vascular compartment capacity cause increase in the early plasma concentration with increased effect of drugs. In skeletal muscles, there is depletion of neurotransmitters, reduced neuronal density and reduced innervations of muscles which leads to decreased consumption of anaesthetics. Baroreflex response is reduced which leads to decrease compensatory response to tachycardia due to enhanced hypotensive response to vasodilator drugs.
Preoperative assessment of geriatric patients guided risk assessment and helps in decision for the need of further evaluation and optimization. It also helps provide a baseline data on which the success of surgical intervention can be predicted. Although at extremes of age in geriatric patients, there are certain physiological changes that occur, but with advancement in perioperative care, these changes should not prevent from providing anaesthetic management. However, these do require more vigilance as compared to younger population. Changes in physiology of the patient and multiple comorbidities present, this should not hinder from giving anaesthetic. What is more important is to identify which patients will do well and which will do poorly. The preoperative assessment of the geriatric patient can be broadly classified into three interrelated functions: history and physical examination, including functional assessment of the geriatric patient; preoperative testing; and in some cases if required preoperative optimization 23-37.
Functional assessment of the elderly should be very meticulous. This is because of several reasons. Most important is that assessment of the resting patient will not give an idea how the patient will respond to during surgery. Age in itself may not be considered as risk factor in the perioperative period 38. The increased mortality has been reported in elderly patient for oncology surgery in the early postoperative period undergoing emergency procedures and those having associated significant comorbidities 39. The other associated factors in elderly population with cancer like comorbidities and tumor biology has been reported to be more robust predictor in perioperative period in patients with prostate cancer 40. Other important thing is heterogeneity of the patient population in elderly age group in terms of activity of daily living, cognitive and emotional status, or urologic functions. Preoperative functional assessment is important as the goal of surgery is to return of the elderly to the preoperative activity level. Comprehensive geriatric assessment (CGA) is now an established method for evaluating and optimising physical, psychological, functional and social issues in elderly population 23. These have been found to improve perioperative outcome 23. CGA is multi-dimensional assessments involving an interdisciplinary team.
The American Society of Anaesthesiologists (ASA) physical status classification is being used to stratify the risk preoperatively. It includes ASA Physical Status 1 (a normal healthy patient), 2 (a patient with mild systemic disease), 3 (a patient with severe systemic disease), 4 (a patient with severe systemic disease that is a constant threat to life), 5 (A moribund patient who is not expected to survive without the operation) and 6 (a declared brain-dead patient whose organs are being removed for donor purposes). The ASA score has been evaluated as predictor tool in elderly patients for oncology surgery 41. ASA score and modality of the operation (elective vs. emergency) has been found to have correlation with postoperative mortality and morbidity 39. The various predictors of increased morbidity and mortality in the elderly undergoing oncology procedures includes included age, the American Society of Anesthesiologists (ASA) score, hospital volume, and metastatic disease. However, these predictors have better reliability when used in combination rather than as individual 42. However, elderly patients have been reported to have more aggressive disease and thus affects age related morbidity and mortality in elderly patients 38. Thus the risk stratification needs to include age, nature and severity of the operative procedure, anaesthetic techniques, the competency of the surgical team, ASA score, and duration of surgery or anaesthesia 24, 25.
Preoperative cognitive and psychological assessment of the elderly surgical patient deserves special mention. It has been seen that frank delirium and dementia at admission in elderly surgical patient is associated with poorer outcome 26, 27. Preoperative depression and alcohol abuse are relatively frequent and can affect outcome of the surgery.
The other pre-operative assessment contributing to the preparation of the elderly patient is pre-operative testing. In general population, the bulk of routine testing are not indicated. Tests like electrocardiogram, chest radiograph and urinalysis are not directly predictive of postoperative complications in elderly patients 28, 29. It has been seen that routine screening of the elderly patients does not add significantly to the clinical findings. Secondly, in a general population, the positive predictive value of abnormal findings on routine screening is limited. Also, it has been seen that the screening test have little effect on the clinical course of the patient. It is also important to understand the different type of surgery require different type of screening in elderly patients. For example preoperative tests like echocardiography and thallium scanning can have predictive value and can alter the course of the care in certain subset of patients. Tests like assessment of nutritional status may have a role in abdominal surgery. Therefore further studies are needed to divide the patients on the basis of pre-existing co morbid illnesses and do specific testing as required according to the surgical procedure. Also, the interpretation of the radiological needs to be done carefully to prevent any misinterpretation 30.
In addition to providing the assessment of risk factors of the surgical patients and help guide perioperative management, the preoperative assessment will also help in optimising the patient. Little research has been done in the area of preoperative optimization of geriatric patients. The value of pre-operative optimisation of cardiac and pulmonary status has been shown to benefit in some high risk surgery cases 31-33. From cardiac point of view, coronary interventions and stenting can be done in elderly patients with reasonably high success and acceptable complication rates 34. More research is needed in improvement of nutritional status, preoperative hydration, or renal function whether they alter the outcome in certain subset of population. Studies have shown the benefit of preoperative intervention on pain management and rehabilitation and reduce delirium 35-37.
Anaesthetic care is episodic in geriatric surgeries and therefore the criteria for success in intraoperative management for long term cannot be easily defined. Short term management intraoperatively does not affect morbidity and mortality. Much of the recent work in the elderly has been devoted to ultra-short acting anaesthetics. The research carried out with these anaesthetics may shorten recovery but long term outcome are not much of significance. Another important area of research in elderly is to compare regional and general anaesthesia.
Lot of research has been done in geriatric patients comparing regional and general anaesthesia. These studies have examined cardiovascular stability in the elderly, pain control, cardiopulmonary and thrombotic complications and cognitive outcomes. Although a few early studies reported that regional anaesthesia for orthopaedics surgery was associated with better outcomes, subsequent investigations have not confirmed this across broad populations of the patient 43-45. Sorenson in their analysis were unable to identify any difference in mortality or blood loss by regional or general anaesthetic technique 44. Although the study showed that there is clearly reduced incidence of deep vein thrombosis (DVT) in regional anaesthesia group 44. The authors described reduced incidence of deep venous thrombosis and 1 month mortality in 2162 hip fracture patients receiving regional anaesthesia, although the result is not statistically significant 45. With regard to cognitive functions several studies have been carried the difference of regional anaesthesia versus general anaesthesia in orthopaedic patients, bulk of the investigations could not identify much of the difference in two groups 46, 47.
It is important in the elderly to maintain the normal intraoperative physiology. Maintenance of normal intraoperative physiology in geriatric patient have a more of a modulatory rather than primary role in outcome. Except for any major pathophysiologic event initiated during intraoperative period, the major mortality and morbidity in the operating room are rare. Alteration in physiology of autonomic function along with anaesthetic make it more difficult for geriatric patient to maintain temperature control 48, 49. Other area of concern in intraoperative area is the use of antiplatelet drugs and histamine -2 blockers in elderly surgical patients.
The importance of acute pain management has same importance as in any other group of patients. The elderly patient benefits most from the post-operative analgesia. The potential benefits of pain relief in post-operative period are decreased ischemic heart disease and diminished pulmonary reserve. But it is also important that the side effects caused by these drugs are because of altered drug clearance and increased drug sensitivity. Inadequacy of analgesia in the post-operative period is associated with stress and increased inflammatory response and that leads to morbidity. Studies in high risk groups have shown that use of intense analgesia with regional anaesthesia has shown marked improvement in cardiovascular, neurological and respiratory outcomes 50. In addition to the activation of sympathetic adrenal axis in many type of surgeries leading to stress response, this is also associated with catabolic state. Use of analgesia may inhibit the catabolic state and help facilitate the state of anabolism post operatively in elderly surgical patient. The benefits of patient controlled analgesia (PCA) to the as and when requirement of analgesic may be of more importance in the elderly 51. But it is important to understand that use of PCA although beneficial but altered mental status makes it problematic in elderly. There is not much data available about the advantage and disadvantages of various routes of analgesic administration. The elderly are very susceptible to the side effects if analgesics like respiratory depression, paralytic ileus, constipation and post-operative falls 52-54. These are influenced by choices in post-operative analgesia and may differ by route of administration. The study of acute pain management in elderly may bear on rehabilitation and subsequently on discharge of the elderly cancer patient 55.
Due to changes in respiratory mechanics and effect of anaesthetics, the elderly surgical patients are prone to several respiratory complications. This is mainly because of residual neuromuscular blocking agents, atelectasis, fluid shifts and other post-operative physiologic changes. Most of the elderly patients undergo conscious sedation outside the operating room 56. Age related changes in pharyngeal function and diminished cough reflex are aggravated by pharyngeal instrumentation, relaxant, anaesthetics and abdominal surgery. Appropriate research need to be carried out to understand the impact of anaesthetics on respiratory complications 57-59.
Post-operative delirium affects 5%–10% of elderly patients 60-62. The onset of delirium usually starts on first to third post-operative day and may sustained for more than a week 61, 62. Post-operative delirium has several other impacts like other medical complications, prolonged hospitalization and decreased functional status on discharge. Delirium is not only associated with drugs (narcotics, sedative and anticholinergic) but also with clinical conditions like urinary tract infection, pneumonia, fever, hypoxia and blood loss 60, 61. Chronic patient conditions like pre-existing dementia, other organic brain damage and decreased vision or hearing is also associated with post-operative dementia 60-64. Certain studies have identified several important risk factors leading to delirium; vision impairment, severe illness, coexisting cognitive impairment and a blood urea/creatinine ratio ≥18 65-67. These type of data from several studies confirm the importance of short mental status examination as part of pre-operative interview in elderly surgical patients.
The other important aspect which takes importance after the surgery in these geriatric cancer patients is the palliative care. In situations of inoperability or advanced cancers, patient may not be provided curative therapy and thus becomes a candidate for palliative care. Certain factors have important role to play in palliative care of geriatric cancer patients. The occurrence of common chronic diseases in the elderly, psychological problems and social problems are the major associated contributors for the need of palliative care. Degenerative diseases of heart and blood vessels, diabetes, arthritis, incontinence and frequency of urine are common chronic disease of the elderly which have significant impact on the palliative care in elderly. Psychological problems like impaired memory, cognition, judgement, anxiety and depression have negative impact on palliative care of the elderly cancer patients 1. The elderly population requires at least the same levels of palliative care as any other age group. They have higher levels of dyspnea, fatigue, emotional distress at the end of life care. They also require help for information and in decision making 67. The palliative care of these patients is riddled with several social problems like financial burden, loneliness, neglect, abuse and social security (especially in developing countries). At time, analysis by way of population survey may help to decipher the specific issues. Though this tool of continuous cycle of survey and improvement, the elderly population may be provided the best services 68.
It is humane to give comfort and provide best supportive care to those suffering from cancer, particularly at end of life situations. The palliative care is provided at various places like hospices, home or at times even in nursing homes. Majority of deaths in cancer patients takes place in hospitals in the absence of supportive care at other places 69. In cases of absence of family support, hospice may be considered the alternative option. So, there is need of availability of hospices for such patients. The quality of care has been compared at hospital and hospice and it has been found that there is no substantial differences between two settings 70. Thus hospice may be considered an alternative to hospital and thus may be a good cost constraint as well. However, the best place for the elderly to be cared is at his own home 71, 72. The cancer patients have desired home to be the place of their last journey 73. The various medications for concomitant disease needs to be continued carefully with adequate monitoring and supervision 73. The best nursing support may also be provided. The familiarity to the environment at home is very reassuring to the patient. The short term admission to the palliative care institution may be helpful for acute sickness. The role of professional care providers is very important in providing care and teaching both family and the community about the care. There are certain possible areas of intervention in palliative care of elderly which may improve the life of the patients. These include healthy diet, regular exercise, life style modification, social activities and prevention of accident and falls. However, it is needless to emphasise the futile effort of intensive therapy in a terminally ill patients 74. However good communication and discussion with the patient and care givers is essential before deciding against the intensive care or resuscitative efforts.
There is another concern about resource allocation and costs for elderly population treatment especially about the palliative care. With increase in the elderly population because of better medical care, the allocation of resources to these elderly needs an emphasis by the managers 74. Such fair allocation is a bioethical issues and is need of the day 75. In the absence of income source of an elderly patient and lack of family support, it becomes an ethical issue to have some public domain for financial support for care of these group of population.
Dr. Garg R: conceptualized, collected articles, wrote, review, and approve the final version
Dr. Yadav N: collected articles, wrote, review, and approve the final version