Anesthesia for the elderly outpatient

Published in Current Opinion in Anaesthesiology: December 2014 – Volume 27 – Issue 6 – p 563–575

Authors: Aurini, Lucia et al

Purpose of review: As the number of ambulatory surgery procedures continues to grow in an aging global society, the implementation of evidence-based perioperative care programs for the elderly patients will assume increased importance.

Recent findings: Increasing evidence supports the expanded use of ambulatory surgery for managing elderly patients undergoing elective surgery procedures.

Summary: This review article describes the demographics of ambulatory surgery in the elderly population. This review article describes the effects of aging on the responses of geriatric patients to anesthetic and analgesic drugs used during ambulatory surgery. Important considerations in the preoperative evaluation of elderly outpatients with co-existing diseases, as well as the advantages and disadvantages of different anesthetic techniques on a procedural-specific basis, and recommendations regarding the management of common postoperative side-effects (including delirium and cognitive dysfunction, fatigue, dizziness, pain, and gastrointestinal dysfunction) after ambulatory surgery. Finally, we discuss the future challenges related to the continued expansion of ambulatory surgery practice in this growing segment of our surgical population. The role of anesthesiologists as perioperative physicians is of critical importance for optimizing surgical outcomes for elderly patients undergoing ambulatory surgery. Providing high-quality, evidence-based anesthetic and analgesic care for elderly patients undergoing elective operations on an ambulatory basis will assume greater importance in the future.

INTRODUCTION
The global population is aging as a result of the parallel decline in mortality and fertility rates. Public health initiatives have also directly contributed to aging population. Whereas the US population less than 65 years of age is increasing by 1% per year, the population aged 65–79 years is increasing by more than 2% per year and the population aged at least 80 years is increasing by 3% per year. The number of elderly population (>65 years) has tripled over the last 50 years and will more than triple again over the next 50 years. On a global level, the most rapidly growing age group is aged more than 80 years (‘oldest-old’ or geriatric). Although this demographic still constitutes a relatively small proportion of the total worldwide population, their numbers are becoming increasingly important for the female population as older women outnumber older men and the difference increases with age greater than 80 years.

According to the US Census Bureau, the elderly population numbered 39.6 million in 2009, or 12.9% of the population. By 2030, there is expected to be approximately 72.1 million elderly population (or 19% of the US population). A similar trend is reported in Europe, where elderly population will account for 30% of the population by 2060. The US National Hospital Discharge Survey reported in 1999 that 12% of US citizens aged more than 65 years constituted 40% of all hospital discharges and 48% of inpatient care-days. One-third of the operations involve cataract and lens procedures, a low-risk procedure performed under local anesthesia. According to Medicare statistics, the frequency of preoperative consultation for cataract surgery increased from 11.3% in 1998 to 18.4% in 2006 and was primarily related to the increasing age of the population (75–84 years old vs. 66–74 years old). In the outpatients more than 90 years old, hip surgery and cataract procedures accounted for more than 35%. The indications for ambulatory surgery are evolving along with the demands of modern medicine, healthcare services, and economics. Recently, vascular and neurovascular procedures are being performed on a day-surgery basis. Elderly patients require more medical services relative to their younger counterparts. Given the economic and social pressure to reduce healthcare expenditures, anesthesiologists will be required to treat an increasing number of elderly as outpatients, bearing in mind that ‘the straw which breaks the camel’s back may be a very small one when the camel is nearing the end of its journey.

Of the 70+ million procedures performed annually in the USA, more than 30% occur at free-standing ambulatory surgical centers (ASCs), where no hospital or emergency department is attached and patients are expected to go home the same day (or within 24 h). The Anesthesia Quality Institute National Anesthesia Clinical Outcomes Registry (NACOR) reported that the largest number of elderly patients had surgery in the medium-sized community hospitals. In the last decade, all the European countries were able to reduce the length of stay after elective surgery with the exceptions of Italy, France, and Denmark.

THE RATIONALE FOR AMBULATORY SURGERY IN THE ELDERLY PATIENTS

It is important to consider the potential benefits for this patient population beyond the expected monetary savings to the healthcare system. Elderly patients are less able to adapt to unfamiliar environments and recover faster in their familiar ‘home’ environment, with minimal disruption to their daily routine. A study by Canet et al. suggested that the avoidance of hospitalization in elderly patients undergoing minor surgery resulted in less postoperative cognitive dysfunction (POCD) at 1 week. Other benefits include a reduction in respiratory events, nosocomial infections, and early postoperative complications. A lower incidence of adverse events in the postanesthesia care unit (PACU) results in shorter recovery time and fewer unanticipated hospital admission in outpatients.

The aging process results in a progressive functional decline in all organ systems. Elderly patients possess decreased homeostatic reserves which can compromise their ability to deal with stress and inflammatory processes during the perioperative period. These physiological changes affect the pharmacokinetics and pharmacodynamics of anesthetic and analgesic drugs. Advancing age is associated with an overall ‘stiffening’ of the heart and vascular system, as well as autonomic nervous system dysfunction, and the elderly patients are at greater risk of perioperative hypothermia. Lung compliance and vital capacity decline are important predictors of postoperative pulmonary complications. The number of neurons and the cerebral perfusion decrease with age, and predispose the elderly patients to POCD. Elderly patients are also more sensitive to the central depressant effects of anesthetic drugs. Furthermore, deterioration of renal and hepatic function affects the metabolism and excretion of many drugs. Elderly patients are more likely to be diabetic and experience perioperative hypoglycemic episodes.

The increased adipose tissue expands the ‘lipid reservoir’ for centrally active anesthetic drugs, contributing to prolonged elimination half-life. In addition, the reduction in total body water decreases the central volume of distribution for water-soluble drugs, and elderly patients with poor nutrition can have decreased albumin levels that increase the free-drug concentrations. A recent study comparing gastric cancer patients more than 75 years vs. more than 85 years found that the preoperative serum albumin level is a significant predictor of postoperative complications in the oldest old group. Nutritional screening tools and anthropometric measures can be used to predict hospital discharge outcomes.

It is estimated that 40% of elderly patients take at least five drugs per week and 12–19% use at least 10. Anesthetic and analgesic drugs can interact with chronic neurologic medications. Finally, elderly patients with drug-eluting stents are at increased risk to perioperative hemorrhage. Use of double antiaggregative therapy excludes patients from undergoing day surgery. It is imperative that anesthesia providers be aware of all prescription, ‘over the counter’, and even herbal medications.

PREOPERATIVE PREPARATION AND RISKS OF CO-EXISTING DISEASES

In order to minimize the perioperative adverse events, anesthesiologists need to focus on the risks related to the operative procedure, the anesthetic and analgesic techniques, and the patient’s underlying medical, physical, and functional condition. Risk reduction strategies for elderly outpatients involve optimization of co-existing diseases, including preoperative interventions and prophylactic therapies. Emotional and cognitive factors were predictors of postoperative side-effects such as pain, nausea, and fatigue. Requiring outpatients to be routinely evaluated in preoperative clinics failed to produce a cost–benefit with respect to improved patient outcomes. Even though preoperative clinic patients were more ‘optimally prepared’ for surgery, their adjusted risk of unanticipated intraoperative events was actually higher than nonclinic evaluated patients. Ordering routine ‘screening’ tests for elderly outpatients has been a long-standing practice. However, no significant differences were found in the rates of acute perioperative adverse events 30 days after surgery between preoperative screened and not-screened outpatients. Hospital revisits less than 7 days were actually higher in the indicated testing group. For the vast majority of elderly patients with stable coexisting diseases, routine laboratory testing is a waste of time and financial resources. However, a baseline potassium level should be checked in elderly outpatients with renal insufficiency. Diabetic outpatients should undergo preoperative assessment of their fasting blood glucose level and treated if not well controlled; frequent assessment of postoperative blood glucose levels reduces infectious complications. Elderly patients with severe chronic obstructive pulmonary disease should undergo preoperative pulmonary function testing. Smoking cessation decreases the risk of perioperative complications.

A clear consensus exists to continue most, if not all, chronic medications up to and including the day of surgery. Although there are no studies in elderly outpatients, London et al. found that exposure to β-blockers on the day of and after major noncardiac–nonvascular surgery was associated with lower mortality rates at 30 days after surgery in patients with at least two cardiac risk index factors. Statins improved long-term survival after endovascular and open aneurysm repair. Less compelling evidence exists on continuing calcium-channel blockers, angiotensin-converting enzyme inhibitors, and angiotensin-receptor-blocking drugs. An increasingly important and controversial issue in elderly outpatients is the use of antithrombotic agents and platelet inhibitors, particularly when regional anesthesia is planned. The European Society of Anesthesiologists on Regional Anesthesia suggested that elderly outpatients continue antiplatelet drug therapy. Most experts also recommend that elderly patients continue taking aspirin prophylaxis because there is no evidence of an increased risk of perioperative bleeding. Another study reported on the safety of continuing warfarin and rivaroxaban therapy in outpatients undergoing atrial fibrillation ablation procedures.

Although obese, elderly patients with obstructive sleep apnea (OSA) are more frequently presenting for ambulatory surgery, neither obesity nor OSA per se is a significant independent risk factor for unplanned admission or adverse events. However, these patients are at increased risk of a perioperative complication. In decision-making for the acceptability of obese outpatients with OSA, clinicians should consider the invasiveness of the procedure, severity of the airway obstruction, co-morbidities, analgesic requirements, and the level of home care. A total of 3 h recovery time may be unnecessary for outpatients with OSA following moderate sedation. Preventing acute renal failure and avoiding hypovolemia in the postoperative period are important in the elderly patients, particularly if co-morbidities exist. Anemia and renal dysfunction in older heart-failure patients appears to be independently associated with cognitive impairment.

Improving functional status may be as important as optimizing their medical treatment, as the majority of the elderly patients are inherently frail. Frailty is currently the ‘elephant in the (operating) room: it is easy to spot, but is often ignored. Frailty can be assessed through scoring systems that include assessment of weakness, weight loss, low levels of physical activity, and slow walking speed. Frailty is a predictor of perioperative complications, need for institutionalization, and death. Prehabilitation is the optimal approach to reversing frailty. Data from the Veterans Affairs Surgical Quality Improvement Program showed that functional capacity for ASA-III patients aged more than 80 years was a significant independent predictor of mortality. The Association of Anaesthesiologists of Great Britain and Ireland suggested the anesthesiologists to evaluate the utility of surgery and resuscitation more than the age per se.

CHOICE OF ANESTHETIC TECHNIQUE

General and regional and local-sedation techniques can all be utilized for the elderly population undergoing ambulatory surgery. Our recommendations for anesthesia and analgesia for the most common ambulatory procedures in the elderly patients.

General Anesthesia

Elderly patients may have higher risk of complications for general anesthesia compared with local anesthesia–regional anesthesia. Age per se was not an independent risk factor of serious morbidity or mortality after ambulatory surgery under general anesthesia in a study involving 800 000 consecutive patients in the Netherlands. However, NACOR data reported that elderly patients had greater mortality and more complications than younger adults for surgical procedures. Exploratory laparotomy had the greatest rate of death in any age category except at least 90 years, in which small bowel resection predominated. Elderly patients have higher incidence of transient POCD after general anesthesia compared with local anesthesia– regional anesthesia, but no causative relationship was found between general anesthesia and long-term POCD. The ambulatory setting is beneficial in reducing POCD after general anesthesia. In elderly patients undergoing general anesthesia, the frequency and severity of postoperative pain and nausea appear lower than in younger outpatients.

It is important to reduce the dosage of the anesthetic and analgesic drugs. Propofol maintenance infusion rates are only slightly decreased; however, its onset time may be slower and the time to maximal cardio-respiratory depression be delayed. Psychomimetic ketamine-related reactions appear less common in the elderly patients, particularly in combination with benzodiazepine or propofol. Dexmedetomidine allows spontaneous ventilation, but its residual sedation can be problematic in the elderly patients. The timing of recovery from sevoflurane anesthesia may be slightly faster compared with propofol, but the difference does not affect the time to ‘home-readiness’ in day-case surgery. Deep levels of desflurane and sevoflurane anesthesia are associated with transient POCD. The dosage of neuromuscular-blocking drugs should also be reduced in the elderly patients. The nonsteroid-based muscle relaxants have a more predictable duration of effect in the ambulatory setting; however, the steroid-based muscle relaxants allows for the use of a reversal drug, sugammadex.
General anesthesia induction with titrated intravenous doses of propofol will minimize acute cardio-respiratory depression. A small dose of a potent opioid (e.g., fentanyl 0.5 ug/kg intravenously) may be useful prior to the procedures to minimize acute autonomic responses and movements in response to painful stimuli. Supraglottic airway devices are associated with minimal hemodynamic changes during general anesthesia. Use of the Bispectral Index (BIS) monitor facilitates early recovery after general anesthesia.

Spinal and epidural anesthesia

Compared with general anesthesia, central neuraxial blockade may be associated with lower pain and decreased need for opioids in the PACU, producing an overall cost-saving. In comparing the randomized controlled trials of general anesthesia vs. regional anesthesia for ambulatory surgery, Liu et al. concluded that central neuraxial block and peripheral nerve block (PNB) were associated with prolonged induction times, reduced pain, and decreased opioids requirements in the PACU; central neuroaxial block was not associated with enhanced PACU bypassing or reduced postoperative nausea and vomiting (PONV) and prolonged discharge-readiness time; and use of a PNB was associated with decreased PACU stay and reduced PONV, but failed to decrease the time to discharge home. Patients of advanced age have a higher risk of hypothermia during regional anesthesia but are at lower risk of postdural puncture headache. Regional anesthesia does not decrease long-term morbidity but reduces postoperative neurological, pulmonary, cardiac, and endocrine complications. A large French survey reported permanent nerve damage following local anesthesia–regional anesthesia in the elderly patients.
Ultra-short-acting local anesthesias combined with potent opioids may shorten the recovery time. A recent study suggested that bupivacaine 4 mg combined with fentanyl 20–25 μg provide shorter PACU stay with better hemodynamic stability compared with prilocaine 50 mg with fentanyl 25 μg for transurethral prostate surgery in elderly. Prilocaine may be associated with urinary retention and a longer discharge time. Use of clonidine as an adjuvant to local anesthesia may produce significant hemodynamic changes and prolong recovery in the ambulatory setting. Interestingly, when intravenous sedation is used to supplement local anesthesia–regional anesthesia, the risks of respiratory depression and hemodynamic instability are similar or even higher than with general anesthesia.

Peripheral nerve blocks

Although they require more expertise, PNBs are extremely useful for elderly outpatients. Ilioinguinal–hypogastric, transversus abdominis plane (TAP) block  and paravertebral blocks have been successfully used for hernia surgery, have better recovery profile and analgesia compared with general anesthesia-spinal and simple local anesthetic infiltration (LAI) alone. Paravertebral blocks for breast surgery had better outcomes than general anesthesia. Combined saphenous–popliteal block with short-acting local anesthesia provides better analgesia and faster recovery than regional anesthesia for saphenous vein stripping. During orthogeriatric limb surgery, single-shot interscalene block before arthroscopic rotator cuff repair reduced hemodynamic variability and the fentanyl requirement, and femoral and popliteal–sciatic blocks can offer advantages over general anesthesia-spinal. However, the cost–benefit of the newer and more costly major PNBs (e.g., TAP block) compared to simple ‘distal’ nerve blocks combined with LAI remains unproven.

Furthermore, continuous PNBs (CPNBs) may be utilized following hospital discharge. In a national survey, the incidence of catheter dislocation was 4.7%. For painful orthopedic procedures, CPNBs reduced the economic impact by decreasing parenteral analgesics need. However, in a large prospective study, 4% of patients receiving CPNBs could not move their arm or hand for 16 h after surgery and Feibel et al. reported a 0.7% rate of falling following total knee arthroplasty with a femoral CPNB. Compared to general anesthesia– regional anesthesia, PNBs reduce pain, opioid consumption, PONV incidence, PACU stay, and provide ‘fast-track’ recovery with increased patient satisfaction, particularly after CPNBs.

Monitored anesthesia care and local anesthesia

For minor procedures in the elderly patients, monitored anesthesia care (MAC) offers significant advantages over all other anesthetic techniques with respect to recovery times and side-effects. LAI techniques are simple, well tolerated, and inexpensive. Wound catheters for continuous local anesthesia delivery can be used to reduce pain after discharge for painful orthopedic procedures. Standard monitoring practices for MAC include pulse oximetry, blood pressure, ECG, heart rate, sedation (observer assessment of alertness and sedation, observer’s assessment of alertness/sedation, Ramsey scale, and BIS monitoring), and respiratory rate or capnography. Aging is an independent risk factor for hypoxemia.

Propofol produces a rapid and controllable reduction of consciousness with a predictably rapid recovery and is the ‘drug of choice’ for MAC sedation in the elderly outpatients. Target-controlled infusion of propofol for moderate sedation reduces sympathetic activity and baroreflex responses to hypotension. When used in combination with propofol, dexmedetomidine can increase the risk for cardiovascular depression. Although dexmedetomidine can reduce the analgesic requirement, recovery is significantly slower in the elderly. Small doses of midazolam provide anxiolysis and anterograde amnesia but may delay the discharge. Overall, MAC has shorter recovery time than general anesthesia or regional anesthesia and is more cost-beneficial for superficial operations.

PERIOPERATIVE SIDE-EFFECTS AND COMPLICATIONS

A large retrospective elderly outpatient outcome study reported a 4.0% incidence of adverse events in the operating room, 9.6% in the PACU, and 7.9% in the ambulatory surgery unit. Elderly patients are four times less likely to experience any adverse event; ten-fold less likely to complain of pain, shivering, and agitation; and four-fold less likely to develop PONV and drowsiness than their younger counterparts. Postoperative complications are more often related to the type of procedure than to the patient’s age.

Postoperative delirium (POD) occurs in 5–15% of elderly patients undergoing noncardiac surgery and POCD in 10–13% at 3 months, and can have significant socioeconomic and medical implications. Marcantonioet al. identified seven risk factors: age greater than 70 years; alcohol abuse; poor cognitive status; poor functional status; abnormalities of serum sodium, potassium, or glucose; noncardiac thoracic surgery; and abdominal aneurysm surgery. POD is a predictor of long-term cognitive impairment, and it is a risk factor for post-traumatic stress disorder at 3 months. Unfortunately, it is unclear whether preventive strategies lessen the incidence of POCD. In a large-scale study involving patients more than 60 years, Canet et al found a lower incidence of POCD 1 week after minor surgery in ambulatory (vs. inpatient) setting. However, no significant differences were found at the later assessments. As expected, POCD at 7 days was significantly lower after minor (6.8%) vs. major surgery (25.8%), and similar to the incidence in ‘control’ patients who did not undergo surgery.

Choice of anesthesia is not a significant risk factor for POCD. The incidence of POCD at 1 week after general anesthesia was 19.7% compared to 12.5% after regional anesthesia, and at 3 months POCD was found in 14.3 vs. 13.9%, respectively. Similar results were confirmed comparing the incidence of POCD after general anesthesia or regional anesthesia for extracorporeal shock-wave lithotripsy, suggesting that the procedure itself may contribute to the development of POCD.

PONV is an uncommon event in elderly. However, for some ambulatory procedures (e.g., brachytherapy neurological, head or neck, and abdominal laparoscopic), a high incidence of PONV has been reported. The occurrence of PONV is influenced by patient, anesthetic, analgesic and surgical factors. Importantly, postoperative factors like postural hypotension due to inadequate hydration and opioid use can contribute to postdischarge nausea and vomiting (PDNV).

Apfel et al. developed a simplified risk scoring system that identified four primary predictors: female sex, nonsmoking status, history of PONV or motion sickness, and use of postoperative opioids. With respect to PDNV, the original Apfel criteria are less predictable. Use of parenteral ketorolac can enhance analgesia and reduce emesis in the PACU compared with steroid antiemetics. Sympatholytic drugs (e.g., esmolol and labetalol), alpha-2 agonist/antagonists, and ketamine may reduce PONV by reducing opioid requirement during and after surgery. Other useful antiemetics include dopamine, serotonin (5-HT3), and neurokinin-1 (NK1) antagonists. Apfel et al. demonstrated that ondansetron, dexamethasone, and droperidol all reduced PONV by approximately 25%. Optimal prophylaxis can be achieved in high-risk patients by utilizing triple-drug therapy.

The Society for Ambulatory Anesthesia (SAMBA), the American Society of Peri-Anesthesia Nurses (ASPAN), and the ASA have developed guidelines for managing PONV and PDNV. Only 61% of clinicians adhered to the ASA guidelines for prophylaxis even in high-risk patients. Use of propofol, nonopioids, and antiemetic prophylaxis are cost-effective multimodal therapies for preventing emetic sequelae after ambulatory surgery.

POSTOPERATIVE PAIN MANAGEMENT

Multimodal analgesic interventions minimize the side-effects of opioids in the elderly. Recent multimodal analgesia studies reported additional beneficial effects of using ibuprofen or celecoxib in the postdischarge period. A multimodal analgesic regimen including acetaminophen, NSAIDS, glucocorticoid steroids, and local anesthesias is recommended.

Acetaminophen is a very safe oral analgesic in the elderly, and dosage adjustments were not recommended despite a reduced clearance rate. The efficacy of NSAIDs in preventing postoperative pain and reducing opioids requirement is also well documented. However, the potential occurrence of side-effects (e.g. gastrointestinal bleeding and thrombotic events) is a consideration in the elderly patients. Cyclooxygenase-2 (COX-II) inhibitors were useful adjuncts to opioids, but long-term use may increase the risk of cardiovascular events. For procedures at low risk for hemorrhage, traditional nonselective NSAIDs are a more cost-effective alternative. Ibuprofen 1.2 g/day compared favorably to celecoxib 400 mg/day.

A single dose of glucocorticoid steroid can reduce pain following ambulatory surgery without increasing postoperative bleeding risk in the elderly patients.

The administration of LIA during general anesthesia and MAC is effective for day-case surgery in the elderly patients (i.e., hernia repair). Adjunctive use of epinephrine or a small amount of opioid can prolong the duration of analgesia. Ketorolac also significantly improves the quality of postoperative analgesia without increasing side-effects after hernia repair or anorectal procedures under MAC. Glucocorticoids can also enhance the effects of LIA. The risk associated with the use of CPNBs (e.g. nerve damage, bleeding or hematoma, and catheter infections) in the elderly patients also related to the difficulty in managing the disposable infusion systems in their home.

Among nontraditional drugs, ketamine has been used to reduce early postoperative pain. Gabapentanoids can reduce pain, but pregabalin causes sedation and dizziness. Turan et al. found similar effects for gabapentin and COX-II inhibitor rofecoxib in women undergoing abdominal hysterectomy. Premedication with oral clonidine decreased postoperative pain, provided sedation, and facilitated emergence from anesthesia. Dexmedetomidine infusion 0.2–0.8 μg/kg/min decreased perioperative propofol, remifentanil and fentanyl use, postoperative antiemetic requirements, and reduced the PACU stay, but did not facilitate late recovery. White and colleagues have reported beneficial effects on postoperative pain management when an infusion of esmolol is used during ambulatory surgery.

The use of ‘alternative’ analgesic therapies could also provide beneficial effects in the elderly outpatients because of their simplicity and lack of side-effects. Transcutaneous electrical stimulation (TENS) and transcutaneous acupoint electrical stimulation (TAES) produce opioid-sparing effects.

KEYS TO FUTURE EXPANSION OF AMBULATORY SURGERY FOR THE ELDERLY PATIENTS
There are clear economic, societal, and patient benefits related to treating elderly patients on an ambulatory basis. Moreover, elderly patients typically prefer the ambulatory (vs. hospital) setting. Some procedures may not be cost–beneficial in the elderly patients (e.g., minimally invasive sacral colpopexy and elective laparoscopic cholecystectomy for mild biliary disease). Although cost-containment has been the major driving force for the growth in ambulatory surgery, the economic benefits related to avoiding the need for acute hospitalization after surgery must be balanced against the additional costs associated with unplanned hospital admissions to treat postoperative complications, the increased need for postoperative medical and social support in extended care facilities and the home environment. In addition, it is necessary to implement evidence-based clinical and social criteria for optimizing preoperative preparation and recovery after ambulatory surgery. Improving of physical conditioning (e.g., prehabilitation) and early mobilization with physical therapy can enhance recovery after surgery and is a key part of orthogeriatric rehabilitation.

Recently, endoscopic colon mucosal resection in elderly patients was a well tolerated and effective approach to managing colorectal lesions when performed at an experienced center. A recent study could not find any age-related effect on recovery time after knee arthroscopy under general anesthesia in a population aged more than 65 years. Even elderly patients with significant comorbidities, with the exception of acute heart failure, can successfully undergo ambulatory surgery.

Bed rest induces functional decline in elderly patients after only 2 days of hospitalization. Paradoxically, the worse the patient’s functional status is preoperatively, the greater the expected benefit of avoiding hospitalization.

Future studies are needed to determine whether it is better to treat the frail elderly as outpatients (vs. inpatient care) with the attendant risk of loss of autonomy, POCD, nosocomial infections, and thrombotic complications, as well as the functional decline because of bed rest in the hospital setting.
With the expected growth in minimally invasive procedures, robotic surgery, and tele-medicine, as well as improved anesthetic and analgesic techniques, the growth in ambulatory surgery for the elderly patients is likely to continue to increase. The use of mobile health systems and home tele-medicine can lead to improved follow-up care and avoid unnecessary emergency room visits. The ASA is encouraging the anesthesiologists to include the ‘surgical home’ care program as part of the perioperative care.

CONCLUSION

As ambulatory surgery continues to expand in our aging society, implementing evidence-based perioperative care programs for the elderly patients will lead to improved outcomes at a lower cost to the healthcare system. Given the recent advances in anesthesia, surgery, and monitoring technology, the ambulatory setting can offer many potential advantages for the elderly patients requiring elective surgery.