Improvements in living conditions and progress in medical management have resulted in better quality of life and longer life expectancy. Therefore, the number of older people undergoing surgery is increasing.
Short- and long-term outcomes of elderly patients having surgical infections are often associated with higher mortality, increased morbidity, and consequently higher utility of intensive care resources and longer hospital stay, and even limitations in ability to live an independent life after the septic insult.
Elderly patients with surgical infections are usually in poor clinical condition due to poor physiological reserve and the additional stress caused by sepsis response. Moreover octa- and nonagenarians with acute peritonitis present with fewer signs of peritonitis and have the risk of long delays to definitive treatment and increased risk of mortality.
In 2014 the World Society of Emergency Surgery (WSES) designed a global prospective observational study (CIAOW Study). The CIAOW study (Complicated intra-abdominal infections worldwide observational study) is a multicenter observational study underwent in 68 medical institutions worldwide during a six-month study period (October 2012-March 2013). The study included 1898 patients older than 18 years undergoing surgery or interventional drainage to address complicated intra-abdominal infections (IAIs). All the risk factors for occurrence of death during hospitalization were evaluated. According to stepwise multivariate analysis (PR = 0.005 and PE = 0.001), several criteria were found to be independent variables predictive of mortality, including patient age (OR = 1.1; 95%CI = 1.0-1.1; p < 0.0001).
Ageing is an inexorable intrinsic process that affects all individuals, due to a diminished homeostasis and increased organism frailty, causes a reduction of the response to environmental stimuli and, in general, is associated to an increased predisposition to illness and death. Several studies investigating ageing physiopathology report that old age is followed by a low-grade inflammatory process, which may be upregulated during sepsis and surgical procedures.
Frailty is an important potential risk factor in treating elderly patients. It is a state of increased vulnerability to poor resolution of homeostasis following a stress, which increases the risk of adverse outcomes including falls, delirium and disability. It is a long established clinical expression that implies concern over an older person’s vulnerability and prognosis. Frailty is a disorder of multiple inter-related physiological systems. There is a gradual decline in physiological reserve with ageing but, in frailty, this decline is accelerated and homeostatic mechanisms start failing. An important perspective for frailty, therefore, is to consider how the complex mechanisms of ageing promote cumulative decline in multiple physiological systems, consequent erosion of homeostatic reserve and vulnerability to disproportionate changes in health status following relatively minor stressor events. The brain, endocrine system, immune system and skeletal muscle are intrinsically inter-related and are currently the organ systems best studied in the development of frailty.
The two principal emerging models of frailty are the phenotype model and the cumulative deficit model underpinning the Canadian Study of Health and Aging (CSHA) Frailty Index. Multiple frailty scoring systems exist, broadly categorized into the “Frailty Phenotype” and the “Deficit Accumulation Model”. Frailty Phenotype is based on assessment of unintentional weight loss, grip strength, self-reported exhaustion, gait speed, and low physical activity. The Deficit Accumulation Model summates the number of deficits an individual has accumulated across a number of domains including illness and activities of daily living. Studies demonstrating the correlation of scores with increased morbidity and mortality are growing, but it remains unclear which score is the “best” to use in the clinical setting. It is also yet to be established if frailty is modifiable or optimizable. Current options for assessing frailty include the original frailty scores (phenotype or deficit accumulation models), mixed models (such as combining Katz score, Charlson Index, timed get up and go, albumin, anemia, Mini-Cog score, and recent fall), independent surrogate markers (such as gait speed and grip strength), or more complex modeling based on matching frailty markers against the preoperative variables in the National Surgical Quality Improvement Program (NSQIP) database to identify “simplified” frailty indices.
In front at an elder patient admitted surgeons must decide whether surgical treatment is justified in these patients, balancing eventual benefits and surgical risks, markedly increased in elder population because of pre-existing illness, and frailty.
Improving outcomes in surgical infections for the geriatric population is a multifaceted task.
Management of elderly patients with surgical infections has great clinical and health care system implications and an adequate organization of emergency care is important to better treat elderly patients.
References
Fried LP, Tangen CM, Walston J, Newman AB, Hirsch C, Gottdiener J, Seeman T, Tracy R, Kop WJ, Burke G, McBurnie MA. Frailty in older adults: evidence for a phenotype. J Gerontol A Biol Sci Med Sci. 2001;56(3):M146–56
Ajitsaria P, Eissa SZ, Kerridge RK. Risk Assessment. Curr Anesthesiol Rep.2018;8(1):1-8.
Clegg A, Young J, Iliffe S, Rikkert MO, Rockwood K. Frailty in elderly people.Lancet. 2013 Mar 2;381(9868):752-62.
Sartelli M, Catena F, Ansaloni L, Coccolini F, Corbella D, Moore EE, et al. Complicated intra-abdominal infections worldwide: the definitive data of the CIAOW Study. World J Emerg Surg. 2014;9:37.
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