Thoracic Anesthesia for the Geriatric Patient

Introduction

Among the geriatric population, there is great variability in physiologic condition from person to person. Because of this variability, the patient’s preoperative functional status, comorbidities, and tumor stage may influence surgical outcomes more than chronologic age alone. However, even an otherwise healthy older person will exhibit limited physiologic reserve because of the normal process of aging. Optimal management of these patients in the perioperative period will necessitate an understanding of changes in physiologic reserve and consideration of comorbid conditions and overall health status. Chronic obstructive pulmonary disease (COPD) and congestive heart failure in particular have implications for postoperative morbidity and mortality. Patient quality of life, overall life expectancy, and functional status must also be considered.

Various studies involving preoperative assessment aim to elucidate risk factors and implement resources to optimize overall patient health and physiologic condition, and thus decrease morbidity and mortality. Minimally invasive surgical techniques, extent of surgical resection, and anesthetic considerations may all play roles in achieving satisfactory outcomes in this population.

Demographics

It is predicted that by the year 2030, there will be more than 70 million United States citizens over the age of 65 years. Adults 85 years old or older are the fastest growing age group in the United States. By 2060, the number of people aged 85 years and older is expected to nearly triple from 6.4 million in 2016 to 19 million.

Cancer is the second leading cause of death in the United States, and the probability of developing cancer increases with age. Among people age 60 to 79 years, it is the leading cause of death. The incidence of cancer is 9.8 times greater among people older than 65 years than those younger than 65 years. According to the National Cancer Institute Surveillance, Epidemiology, and End Results (SEER) Program, 56% of all new cancer diagnoses were among patients older than 65 years. Almost two-thirds of cancer survivors are aged 65 years or older. People older than 85 years make up 2% of the population, but 8% of all new cancer diagnoses. It is estimated that there were 228,150 new diagnoses of cancer of the lung or bronchus, and 142,670 deaths from these cancers in 2019. Lung cancer is the most common cause of cancer death, compromising 25% of all cancer deaths. It is the second most common cancer diagnosis for both men and women. The median age of lung cancer patients presenting for surgery is greater than 70 years.

The expanding geriatric population, with its increased risk of cancer compared with younger patients, will lead to an increase in elderly patients presenting for thoracic surgery. Thoracic anesthesiologists must be adept at caring for patients who may have a wide range of chronic conditions, as well as suffer from expected age-related physiologic changes.

Physiology of Aging

Elderly patients may exhibit a limited ability to respond to the stress of illness or major surgery because of the natural decline of maximal physiologic reserves. Manifestations of pathology may be blunted, and a geriatric patient may have symptoms that are atypical, diminished, or misdiagnosed as simply because of “old age.” The incidence of comorbidities is increased in this patient population, especially cardiovascular disease and pulmonary disease. These comorbidities superimposed on normal senescence can make management of elderly patients more complex.