Oral Maxillofacial Surg Clin N Am 18 (2006) 19 – 34

Perioperative Risk Assessment in the Surgical Care of

Geriatric Patients
Leslie R. Halpern, DDS, MD, PhD, MPHa,b,T, Seth Feldman, DDSb,c
a
Department of Oral and Maxillofacial Surgery, Massachusetts General Hospital, Boston, MA, USA
b
Harvard School of Dental Medicine, Boston, MA, USA
c
Cambridge Health Alliance, Cambridge, MA, USA

The geriatric population comprises an increasing General medical history and informed consent
percentage of the overall population in the United
States. Currently 13.6% of the population is age 65 Retrospective studies, using hospital database
or older, and 6% are 80 or older [1]. The importance chart reviews, have examined the predictor variables
of oral health within the geriatric sector has been of age and severity of illness in geriatric surgical
given more recognition, because there is a synergistic patients on outcome and length of hospital stay.
relationship between oral health and overall health. When age and severity of illness are compared, the
Advances in surgical and anesthetic techniques com- severity of illness provides a better predictor of sur-
bined with sophisticated perioperative monitoring are gical outcome and length of hospital stay [2 – 4]. As
factors that have contributed to an expanding number such, the perioperative assessment of elderly patients
of older adults undergoing oral surgery. The elderly should begin the moment they enter the office. A first
often have multiple comorbid conditions limiting their impression of a patient’s physical appearance, gait,
functional capacity to withstand the stress of surgery posture, attitude, and behavior should be noted [5].
and postoperative recovery. As such, surgical manage- Many practitioners find inconsistencies when history
ment becomes more challenging and the role of oral forms are filled out in the waiting area and then are
and maxillofacial surgeons becomes paramount. It in- reviewed prior to treatment planning [6]. Medical con-
volves clinical competency and ability to evaluate sultations must be undertaken judiciously for patients
carefully the pathophysiologic risk of comorbid dis- whose medical histories are uncertain and when
ease in order to provide safe, expedient, and effective the physical assessment uncovers an untreated medi-
surgical care. cal problem.
This review paper attempts to focus on the im- A thorough preoperative workup includes medi-
portance of perioperative risk assessment when cal, social, and cognitive history; physical examina-
applying oral surgical therapeutics to geriatric tion; laboratory profile; and nutritional status.
patients. Specifically, medical workup of comorbid
systemic illnesses and pharmacologic therapy are
assessed in order to determine appropriate treatment Nutrition and fluid electrolytes
strategies for successful surgical outcomes.
Nutritional deficits of a multifactorial etiology are
most prevalent in elderly surgical patients. Risk
factors for malnutrition either are macronutrient (pro-
T Corresponding author. Department of Oral and Max- tein, fats, and carbohydrates) or micronutrient (vita-
illofacial Surgery, Massachusetts General Hospital, Warren mins and minerals) in origin. In addition, malnutrition
1201, 55 Fruit Street, Boston, MA 02114. can be iatrogenic as a result of adverse drug-
E-mail address: [email protected] (L.R. Halpern). nutrient interactions, causing a depletion of daily

1042-3699/06/$ – see front matter D 2005 Elsevier Inc. All rights reserved.
doi:10.1016/j.coms.2005.09.006 oralmaxsurgery.theclinics.com
20 halpern & feldman

needed elements as a trade-off for treatment of sys- natriuretic peptide, and aldosterone can initiate or
temic illnesses [7]. Perioperative risk assessment of exacerbate the systemic neurologic and cardiovascu-
nutritional status requires clinical, biochemical, anthro- lar complications of hyperkalemia, hypernatremia,
pometric, and dietary monitoring strategies. Specifi- and volume depletion and the complication of post-
cally, rapid weight loss greater than 10% should be operative delirium (discussed later) [11].
of concern. Laboratory panels should be ordered Strategies to preventive imbalances include peri-
to characterize the severity of malnutrition [7 – 9]. operative measurements of serum electrolytes, urea
Protein energy malnutrition is most common and nitrogen, serum creatinine, and creatinine clearance
arises from a deficit in serum albumin [10]. Post- and a baseline urinalysis. Normal fluid management
operative sequelae in patients who have protein energy should be maintained in a range of 1.5 to 2.0 L/d with
malnutrition include poor wound healing, increased an average urine output of 20 to 30 mL/h [11].
wound infection, and risk of mortality. Albumin levels Elderly patients who have undergone uncomplicated
of less than 3.2 g/dL in hospitalized older persons dentoalveolar surgery are encouraged to resume oral
are highly predictive of subsequent mortality [8]. Cho- intake as soon as possible in order to maintain fluid
lesterol levels of less than 160 mg/dL in frail elderly and electrolyte balance. Patients who may vomit or
persons also are a risk marker for increased mortality develop severe diarrhea after surgery also should be
[9]. Complete blood cell counts should include a total monitored, because metabolic acidosis or alkalosis
lymphocyte count (no less than 1500/mL) and anergy can precipitate the adverse events of delirium and
skin testing. Although the latter have not proved useful cardiac dysrhythmias. Patients who are in the post-
nutritional markers in older persons, these predictors operative phase after general anesthesia must be
must be considered, because the elderly population monitored for ongoing fluid losses from all sites,
often suffers from opportunistic infections and delayed including insensible losses. Adverse drug effects
healing resulting from chronic diseases, such as from postoperative ‘‘polypharmaceutical administra-
diabetes and peripheral vascular disease [8,10]. tion’’ also can alter salt and water balance. The
Specific nutritional supplements for proteins and adequacy of free-water replacement should be guided
kilocalorie replacement should be prescribed pre- by the serum electrolyte concentration gradients with
operatively and during the perioperative period. judicious monitoring to prevent these events. Dehy-
Common protein supplement recommendations are dration is seen more often than overhydration and it
Ensure/Ensure Plus (Abbott Labs, Abbott Park, IL) may be wise to maintain fluids and electrolytes pa-
and Sustacal (Mead Johnson, Evansville, IN) along rentally along with monitoring vital signs preopera-
with resuming a well-balanced diet as tolerated. Post- tively and postoperatively.
operative laboratory analyses, using the criteria de-
scribed previously, allow for immediate resolution of Social history
any physiologic imbalances that can impede surgical
recovery [9]. Postsurgical care should include nutri- Social history and lifestyle issues, especially use
tional counseling with dietary suggestions that can be of tobacco and alcohol, need to be documented. Ces-
understood easily and reinforced at follow-up visits. sation of smoking can be accomplished even in
Postoperative planning includes a team approach with geriatric patients. Studies suggest that elderly patients
a general dental practitioner, because loss of teeth or should refrain from tobacco use up to 6 months prior
poor-fitting dentures contribute significantly to mal- to any surgical procedures [12]. Alcohol consumption
nutrition and depression, with resultant weight loss in is associated with complex changes in cerebral vas-
these patients. culature and structure in older adults. Often, alcohol
Fluid and electrolyte balance play a pivotal role in abuse is misdiagnosed and the cause of falls and
perioperative surgical risk assessment. With aging, accidents. It also is associated with severe malnu-
there are increases in total body fat and decreases in trition, poor wound healing, and decreased immune
total body water. Both can contribute to an imbalance competence. The role of alcohol consumption and
in fluids and electrolytes. Decreased urinary concen- the incidence of dementia are less clear but often
trating ability; limitations in excretion of water, so- considered in the elderly. Studies suggest that par-
dium, and potassium; and ‘‘iatrogenic injury’’ with ticipants who drink no alcohol at midlife and those
intravenous fluid overload can exacerbate trauma to who drank alcohol frequently are twice as likely to
tissues further and alter the hemodynamic state of have mild cognitive impairment in old age as those
patients [11]. Furthermore, impaired thirst perception, participants who drink alcohol infrequently [13].
decreased glomerular filtration rate, and alterations Preoperative risk assessment with the CAGE protocol
in hormonal levels of antidiuretic hormone, atrial or use of laboratory tests (discussed previously) allow
 perioperative risk assessment of geriatric patients 21

surgeons to determine if patients need any prophy- they are taking, and a medical consultation is nec-
laxis for complications of alcoholism withdrawal essary to obtain an accurate list. The most common
during the perioperative period. types of medications that the elderly take are over-
the-counter (OTC) medications for pain and other
Cognitive evaluation and informed consent chronic ailments.

Cognitive assessment and the ability to give in- Over-the-counter drugs

formed consent are of major concern when evalu- Data shows that only 11% of physicians ask
ating geriatric patients for surgery. Simple questions routinely about OTC drug use during primary care
can evaluate patients’ orientation to time and place visits [13]. It is important to discuss the use of
and ability to recall information, perform simple cal- nonprescription medications with elderly patients,
culations, or understand speech. Doctors should because adverse effects can be seen when combined
speak directly to patients when reviewing health with any prescribed agents during the perioperative
history and should make sure the wording is under- period. Many geriatric patients forget to write the
stood, because many patients have hearing and visual type and number of OTC drugs on the history form.
impairments [6,14]. Many patients do not admit The most common ailment for which 66% of the
readily that they did not understand questions. elderly use OTC drugs is arthritis and the most
Although modifying the history-taking by including common medications used are acetaminophen,
family members and caregivers may be considered, aspirin, or other nonsteroidal anti-inflammatory drugs
it is important to remember that even cognitively (NSAIDs). Other OTC drugs used on a daily basis
impaired patients can provide useful information if include a variety of gastrointestinal agents, such as
the questions are presented in a concrete and simple antacids and H2-blockers, both of which can interfere
manner. Decision capacity should be predicated on with medications adversely for cardiovascular func-
formal mental status criteria in order to judge whether tion (ie, anticoagulants and antiarrhythmia agents,
or not patients are capable of receiving informed such as digoxin, lidocaine, and procainamide). Sur-
consent. Patients can be lucid during specific periods geons must educate patients and their caregivers
of time but not others (sundowning) and still be able carefully on side effects and emphasize cautiousness
to give informed consent. If patients cannot provide when they use OTC drugs. In addition, medicines
informed consent, alternative choices include written should be catalogued and dated so that patients do
documents for power of attorney by chosen executors not take any expired drugs that can exacerbate
or power of living wills [15]. side effects.

Medications Pain control

Strategies for pain management must be orches-
The physiologic and pathologic changes occurring trated carefully, because the central nervous system –
in older patients can lead to adverse events with depressant effects of analgesic medication can initiate
respect to medications taken. Blood flow to the liver or exacerbate the postoperative depression and de-
decreases with age and the bioavailability of drugs lirium observed when the elderly undergo surgical
can be altered depending on their metabolic pathway treatment. The main first-line choices for mild to
[16]. Renal clearance is altered significantly with age moderate pain are aspirin and acetaminophen. The
because of the morphologic decrease in mass asso- preferred choice for pain relief is acetaminophen
ciated with decreased tubular function and glomeru- (200 to 400 mg every 4 to 6 hours with a maximum
lar filtration rate. Other systemic factors can affect of 1.2 grams per day) [17]. Acetaminophen with
the distribution of drugs in the elderly, such as de- codeine is useful when used with appropriate pre-
creased cardiac output, increased peripheral vascular caution. Pain that is more severe requires the adminis-
resistance, and increases in percentage of adipose tration of narcotics. Each narcotic should be prescribed
tissue in the body [17,18]. Other organ functions based on the individual. Side effects of confusion,
can be affected, such as the digestive system, gastric respiratory depression, and constipation should be
acid production, and gastric emptying time. It is not weighed against the benefits of the drug [17,18].
unusual for patients to be taking from 4 to 8 other Aspirin should be used with caution, because it
medications depending on their degree of chronic can potentiate bleeding resulting from altered platelet
illnesses. Surgeons must be judicious in cataloguing function and increased capillary fragility in the
all drugs prior to beginning treatment. Patients often elderly. NSAIDs may be an alternative when patients
may not remember the names of all the medications are unable to tolerate a narcotic. Advantages include
22 halpern & feldman

the avoidance of respiratory depression, peripheral Local anesthesia

activity, and minimal neural side effects. Disadvan-
tages include increased fluid retention, renal failure, Local anesthetic administration at low doses often
hepatotoxicity, gastrointestinal ulceration, and respi- is the preferred method for pain management in the
ratory compromise in patients sensitive to aspirin or elderly. Careful titration always is prudent, because
aspirin-like products [19,20]. there can be cardiovascular responses to epinephrine-
Other centrally acting agents are suggested, such containing anesthetic agents [27]. There are few in-
as tramadol (Ultram). It can be used to treat moderate cidences of hypersensitivity or allergic reactions to
to severe pain and is the drug of choice for patients local anesthetics and few adverse effects with normal
who have malignant pain [21]. dosage on the cardiovascular or respiratory system. For
Dosing for moderate to severe pain can vary from these patients, generally, not more than 2  1.8 mL
50 to 100 mg every 4 to 6 hours with a maximum carpules of 2% Lidocaine with 1:100,000 epinephrine
dose of 400 mg per day. Side effects include nausea, should be used for anesthesia, because minimal car-
dizziness, seizures, and somnolence. Careful choices, diac side effects are seen with this dosage [17]. The
therefore, must be made with respect to the patients body produces endogenous epinephrine in far greater
who would benefit from this pain medication [22]. amounts in response to a stressful situation, which
can occur during surgical procedures. During deeper
sedation, the recommended doses of epinephrine are
Sedation strategies for elderly surgical patients limited further in the elderly in order to avoid ar-
rhythmias and hypertensive episodes [17,27].
The ideal sedative should have some basic re-
quirements that permit safety to the recipient and Inhalation sedation with nitrous oxide
provide operating conditions that permit high-quality
surgical intervention [23,24]. Sedation techniques Nitrous oxide is a safe method for pain and
usually are based on the nature and severity of spe- anxiety management in the elderly because of its
cific risk factors, such as comorbid systemic illnesses rapid elimination and nondepressant effect on car-
[25,26]. Basic criteria for the use of sedation in the diovascular function. It is noninvasive, titratable, and
elderly are listed in Box 1. The methods of sedation easily reversible. Patient acceptance, cost, ease of use,
used most often in geriatric patients to treat pain rapid onset, and rapid elimination make it preferable
and anxiety are oral, inhalation, and intravenous to oral and intravenous sedation. Retrospective cross-
approaches and general anesthesia. Each method sectional studies show that a majority of patients,
applies the adjunctive use of local anesthesia for pain young and older, have fair acceptance to the use of
control [27]. nitrous oxide for pain and anxiety [28]. Careful
preoperative assessment should include a cognitive
examination, because the elderly are susceptible to
bouts of dementia and may not be aware of their
Box 1. Criteria for sedation in the elderly surroundings in order to cooperate [29].

 Refusal of care Oral sedation

 Unpredictable behavior patterns
 Health problems exacerbated The use of oral sedation in the elderly is accept-
by stress able and often chosen for the reduction of preopera-
 Noncompliance and inability to tive pain and stress prior to and during surgical
obey instructions treatment. The advantages of using oral sedating
 Danger of hurting themselves agents include low cost, ease of administration, and
 Aggressiveness while under therapy decreased adverse reactions (depending on the oral
agent). Disadvantages of oral sedation include patient
Adapted from Matear DW, Clarke D. Con- compliance, frequent in the elderly, and the inability
siderations for the use of oral sedation in to properly dose or titrate the drug. The pharmaco-
the institutionalized geriatric patient dur- logic agents used most commonly include sedative
ing dental interventions: a review of the hypnotics (such as barbiturates), antihistamines, nar-
literature. Special Care Dent 1999;19: cotic analgesics, and benzodiazepines [23,30 – 32].
56 – 63. The first three drug groups often are contraindicated
because of many side effects. Their use, however, can
 perioperative risk assessment of geriatric patients 23

and depression and those who are on erythromycin

Box 2. Criteria for the ideal
antibiotics or who are suffering from degenerative
benzodiazepine
neurologic disorders, such as myasthenia gravis,
 Rapid onset (ie, 15 – 30 minutes) should not be given triazolam [30,32].
 Short acting (ie, 30 – 60 minutes) Table 1 compares the choices for oral sedation
 Rate of elimination less than with dose and peak onset of action. Regardless of the
choice of sedation drug, basic guidelines include a
8 – 10 hours
 Small titrating doses comprehensive preoperative medical history, famil-
 No active metabolites iarity with the sedation medication used, titration
based on specific body morphometry and lowest dose
needed, and, most important, ensuring that staff is
Adapted from Leffler PM. Oral benzodi- trained properly in the event of an emergency. Pa-
azepines and conscious sedation. J Oral tients who have any baseline disorientation must be
Maxillofac Surg 1992;50:989 – 97. assessed and observed overnight, because temporary
postoperative delirium can occur in a large percentage
of geriatric patients. Nothing-by-mouth status, immo-
bilization, and the presence of midazolam also can
be predicated upon careful titration in order to avoid increase the risk of postoperative delirium. Sensory
hypotension, apnea, and unconsciousness resulting aids, reorientation, and family contact are key in the
from cardiovascular compromise and respiratory prevention of delirium (postoperative delirium is
depression (discussed later). discussed later) [31].
The benzodiazepines are the drug group of choice,
because they have proved over time to be efficacious
and safe when given to patients who are medically Intravenous sedation
compromised and cognitively [26,30 – 32].
Box 2 describes the ideal benzodiazepine. Benzo- Studies show that IV conscious sedation provides
diazepines may be given orally for anxiety control or a clinical scenario in which healthy or disabled
intravenously as part of conscious sedation. These elderly patients can be treated safely and effectively
medications again are usually given in lower doses [33 – 35]. Advantages of IV sedation include predict-
for the elderly because of decreased metabolism and ability, titratablity, rapid onset, patient acceptance,
clearance of the agents [30 – 32]. Diazepam (Valium), and reversibility. Disadvantages include difficulty in
for example, has a long half-life and active metabolic developing the technique, operator training, state and
products, which, in the presence of impaired metabo- office requirements, monitoring and record keeping,
lism and excretion of the drug, increase the like- cost with respect to operator and patient, and proper
lihood and duration of possible side effects, such as assistant training. The logistics of patient preparation
confusion and gait instability. A benzodiazepine, such entails a stepwise algorithm starting with the place-
as triazolam (Halcion) or lorazepam (Ativan), with a ment of the monitoring devises without undue stress.
shorter half-life, is a more appropriate choice [30]. Continuous monitoring is required before, during,
Contraindications for triazolam use occur in patients and after procedures. Recommended monitoring
who have a history of depression and glaucoma. In includes pulse oximetry, ECG, blood pressure moni-
addition, patients who are on Phenytoin for seizures toring, and a continuous recording of vital signs.

Table 1
A comparison of triazolam, oxazepam, and lorazepam for oral sedation
Sedating agent Oral dosagea Onset of action Peak blood level
Triazolam (Halcion) 0.0625 – 0.125 mg Within 30 minutes 30 – 120 minutes
Oxazepam (Serax) 10 – 30 mg Within 60 – 120 minutes 120 – 240 minutes
Lorazepam (Ativan) 0.5 – 2.0 mg Within 30 – 60 minutes 30 – 180 minutes
a
Dosage: healthy adult doses are greater than 10 times the dose stated for elderly patients.
Adapted from Matear DW, Clarke D. Considerations for the use of oral sedation in the institutionalized geriatric patient during
dental interventions: a review of the literature. Spec Care Dent 1999;19:56 – 63.
24 halpern & feldman

Extra padding should be placed on the dental chair shows that the frequency of complications was 0.5%
to prevent compression sores. Placement of the in ages greater than 80 [38]. A case series at the
catheter must be done with care, because the skin Mayo Clinic indicates a 9.4% morbidity rate in
often is fragile and the veins can tear more easily with 795 patients 90 years of age and older and only one
formation of a painful hematoma. Adhesive tape to major complication in 31 patients’ ages 100 to 107
stabilize the site must be positioned carefully so as to [39]. Recent studies show a decline in the morbidity
not tear the skin. and mortality rates and the overall frequency of
The half-life of many IV sedation drugs, such as perioperative complications in the elderly who have
fentanyl, diazepam, and midazolam, is increased undergone surgical procedures with general anesthe-
significantly in older adults [33,34,36]. In the elderly, sia [26,35]. Such data suggest that anesthetic manage-
slower stepping of the dosage is recommended, ment in the operating room should not be denied on
allowing more time for peak effect under lower doses the basis of age alone.
[35,36]. Table 2 lists acceptable dosing of seda- The preanesthetic evaluation of elderly patients is
tion medications for IV procedures. These doses accomplished best a few days before the procedure.
allow patients to maintain their own airway with little This allows a therapeutic alliance to develop between
chance for significant respiratory complications patient, anesthesiologist, and nursing and allied staff.
[34,36]. Comprehensive postoperative monitoring Safety of anesthetic techniques can be discussed com-
must be administered during recovery time, because pletely, which may reduce patient anxiety and precon-
adverse effects of IV sedation include postoperative ceived negative beliefs of the morbidity associated
delirium and increased risk for falls and subsequent with general anesthesia.
hospitalization [37]. The choice of anesthetic agent is predicated on
the specific cardiovascular status of patients [40]. In
General anesthesia general, with age, there is a concomitant decrease
in cardiac, vascular, and autonomic function. There
General anesthesia can be an alternative choice for also is a reduction in heart rate as a result of de-
elderly patients who are in excellent health or are no creased b-adrenergic stimulation. This compromises
longer able to tolerate treatment safely in an out- the baroreflex-mediated increase in heart rate result-
patient setting. There are significant risks, however, ing from hypotension. The elderly subsequently have
to general anesthesia, including episodes of severe a greater decrease in blood pressure at a given
hypotension or hypertension, hypothermia, hypoxia, concentration of volatile agent than younger patients
nausea, prolonged sedation or delirium, and even [40,41]. Furthermore, the elderly are more susceptible
pneumonia, cardiac arrest, and death. A survey done to enhanced decreased myocardial contractility with
in France from 1978 to 1982 indicates a tenfold in- volatile agents and any cardiac pathology already
crease in the rate of postoperative anesthetic compli- present is exacerbated. Most importantly, hemody-
cations as patients’ ages increases from 30 to 80 years. namic control may play a more important role in
The complication rate, however, when scrutinized, avoiding cardiovascular complications from general
anesthetics, because many elderly exhibit a con-
tracted volume state [41]. The choices of volatile
Table 2
Recommended dosing for sedation with intravenous agents
agents most likely to maintain hemodynamic balance
in the elderly are isoflurane and Desflurane [42]. Both
Midazolam Diazepam Meperidine
are eliminated safely by pulmonary ventilation that
Malamed 1 0.1.5 mg/kga 1.0 mg/kgb N/A avoids a compromise of hepatic and renal distribu-
et al tion. Desflurane seems to have a more rapid elimi-
Galli and 2.0 – 2.5 mg/ 2 mg/10 – 1.0 mg/kgb nation and recovery time that improves cognitive
Henry 10 – 15a minute 15c minute
function and decreased postanesthetic management
intervals intervals
[41,42].
a
Maximum dose of midazolam not to exceed 10 mg. The American Society of Anesthesiologists (ASA)
b
Maximum dose of meperidine not to exceed 50 mg. suggests criteria for elderly patients who are being
c
Maximum dose of diazepam not to exceed 10 mg.
considered for general anesthesia [40]. These include
Adapted from Malamed SF, Gottschalk HW, Mulligan R,
Quinn CL. Intravenous sedation for conservative dentistry
and are not limited to:
for disabled patients. Anesth Prog 1989;36:140 – 2; and Galli
MT, Henry RG. Using intravenous sedation to manage 1. Individuals older than 65 have, on average,
adults with neurological impairment. Spec Care Dent 1999; 3.5 medical diseases that may be atypical
19:275 – 80. on presentation.
 perioperative risk assessment of geriatric patients 25

2. Significant interindividual variability exists Table 4

among elderly patients when evaluating their Cardiac risk computation for surgical intervention
medical diseases. Criteria as risk factor Point index
3. Unpredictability of diminished organ reserves 1. History
is most apparent during surgery. Age  70 years 5
4. The impact of extrinsic factors (ie, smoking, Myocardial infarction  6 months 10
alcohol, socioeconomic status, and environment) 2. Physical examination
is difficult to quantify as predictors for success- S3 gallop or JVD 11
ful outcome. Valvular aortic stenosis 3
5. ASA status: ASA 1, age less than 70 years and 3. Electrocardiogram
nonemergent surgery; ASA II, patients more Rhythm other than sinus, PACs
On last ECG 7
than 70 years; ASA III, patients who have co-
> 5 PVCs/min documented preoperatively 7
morbid illnesses and are treated in the hospi- 4. General status
tal setting. Po2 < 60; Pco2 > 50 mm Hg
K < 3.0, Hco3 < 20 mEq/L
BUN > 50, Cr > 3.0 mEq/dL
Risk assessment of comorbid systemic disease Abnormal aspartate aminotransferase,
chronic liver disease
Table 3 lists the common chronic illnesses seen Bedridden patients from a noncardiac cause 3
within the geriatric population. The sections that 5. Operation
Intraperitoneal
follow discuss each comorbid disease with respect to
Intrathoracic, aortic 3
its pathophysiology and offer suggestions for evalua- Emergency 4
tion and treatment during the perioperative period. Total possible = 53 points
Adapted from Goldman L, Caldera DL, Nussbaum SR, et al.
Cardiovascular disease
Multifactorial index of cardiac risk in noncardiac surgical
patients. N Eng J Med 1977;297:845 – 9.
A high prevalence of coronary artery disease and
hypertension exists in the population at large, and
heart disease accounts for 33% of deaths in adults with dyspnea, orthopnea, or pedal edema; recent
over age 65 [43]. Common cardiovascular predictors myocardial infarction [MI]; and syncopal episodes).
of an adverse outcome include ischemic heart disease, Several evidence-based cardiac risk indices then
dysrhythmias, congestive heart failure (CHF), periph- can be applied to stratify patients for noncardiac
eral vascular disease, and hypertension. The evalua- surgery [44]. Most are predicated on the surgical
tion of patients’ cardiac status begins with specific procedure, specifically, whether or not it is a high-risk,
indications (ie, inability to walk less than 2 blocks; intermediate-risk, or low-risk intervention. Table 4
history of chest pain or jaw pain radiating to the left depicts approximate risk of a major cardiac complica-
arm; unstable angina; history of CHF or pump failure tion according to Goldman’s cardiac risk index. The
higher the number of points, the greater the risk of
morbidity or mortality [44,45]. Other preoperative as-
sessments include a recent ECG, echocardiograms,
Table 3 consultation with medical colleagues for medications
Prevalence of chronic conditions in persons 70 years of
that are being used, and whether or not any antibiotic
age and older in the United States, 1995
prophylaxis is indicated prior to surgical intervention.
Arthritis 56% More than half of the cases of bacterial endocarditis
Hypertension 34% that occur in people over age 60 are the result of an
Heart disease 25%
increased incidence of cardiac defects and age-related
Diabetes 11%
Respiratory diseases 11%
decreased immunocompetence. Most cases of infective
Stroke 9% endocarditis are not caused by dental treatment, but by
Cancer 4% dental disease, mastication, and poor oral hygiene [46].
The American Heart Association’s protocol 1-hour
Data from Centers for Disease Control and Prevention,
National Center for Health Interview Survey, Second prior to surgical treatment is well known by practi-
Supplement on Aging reprinted in: Helgeson MJ, Smith tioners. Adjuvant therapy with 0.12% chlorhexidine
BJ, Johnsen M, et al. Dental considerations for the frail rinses is recommended for patients who are susceptible
elderly. Spec Care Dent 2002;22:40S – 55S. to a bacteremia [47].
26 halpern & feldman

The stress of surgical treatment may precipitate of treatment until either medications are re-evaluated
serious medical emergencies, such as angina, arrhyth- or new onset hypertension is diagnosed.
mias, MI, stroke, or cardiac arrest. Oral surgeons
should be well prepared to apply emergency proto-
cols. If a MI has occurred within a 6-month period, Cardiovascular medications
only emergency dental care is undertaken. No elec-
tive care should be given to patients who have un- Anticoagulant therapy
stable angina or poorly controlled CHF. Patients The uses of oral anticoagulants are effective in the
who complain of chest pain should be monitored with management of thromboembolic disorders secondary
the ABCs of basic life support. Clothing should be to cardiovascular insufficiency in the elderly. Possible
loosened, oxygen should be administered and a bleeding diatheses from these medications, however,
325-mg aspirin can be given except in cases of pa- require careful assessment prior to any surgical
tients who are sensitive to aspirin, because it can therapy. Specific preoperative risk criteria for severe
precipitate a bronchospasm. The use of sublingual ni- bleeding include patient age and other comorbid ill-
troglycerin (NTG) is warranted in these patients with nesses, such as gastrointestinal bleeding, CVA, car-
a dose of 1 tablet every 5 minutes for a total of diac arrhythmia, type and chronicity of anemia, and
3 tablets or until a resolution of symptoms occurs. renal disease [20]. Other complications from bleeding
Patients who have NTG tablets should keep them on include severe capillary fragility, ecchymoses, and
the bracket table in case an anginal attack occurs. A necrotic skin lesions that can make access for IV
blood pressure reading follows each dose, because fluids and medications more tenuous [20,49].
the vasodilatory effect of NTG can precipitate or ex- Several algorithms exist for the management of
acerbate a significant hypotensive state. Patients also patients who are on anticoagulants and require oral
should be questioned about a headache during treat- surgery. Each decision is based on two criteria:
ment, because a side effect of NTG is headache. The (1) stopping anticoagulant therapy to avoid signifi-
headache should not be confused with one that can cant bleeding while (2) not exacerbating the compli-
precede the onset of a severe hypertensive episode. cations of disease for which the anticoagulant is
prescribed. Studies show that some patients do not
have to discontinue their oral anticoagulant prior
Hypertension to surgery [50]. Other studies suggest that patients
discontinue their medication for 72 hours and then
Hypertension is among the most common chronic resume it the evening or morning after surgery
illnesses seen in the elderly. In patients over age 65, [20,50]. Both studies require that the therapeutic
50% or more have elevations in either their systolic level of anticoagulant is measured by the interna-
or diastolic pressures that are being treated with tional normalized ratio (INR). Values at the low end
antihypertensive medications [48]. All antihyperten- of therapeutic range allow for surgical intervention
sive agents should be recorded in the chart and with a low incidence of severe postoperative bleed-
patients reminded to take their doses the morning of ing. An INR range of 2.0 to 3.0 for most conditions is
surgery. It is prudent to take a blood pressure reading acceptable except in patients who have artificial heart
at the first visit in order to have a baseline value prior valves, which require an INR in the range of 2.5 to
to surgical procedures, because noticeable fluctua- 3.5 [47]. A physician consultation should be done to
tions in blood pressures are seen during anesthetic determine patients’ current INR level before any
administration and dental procedures, such as tooth procedure that could cause bleeding is done. Usually,
extraction. Proper cuff size is paramount, as many when at therapeutic levels, most dentoalveolar pro-
geriatric patients have either a very thin cuff size or cedures can be performed with the use of local
an obese cuff size. It is imperative to maintain the hemostatic agents without changing the anticoagula-
cardiovascular reserve of patients and monitor any tion therapy regimen [50]. For more complicated
changes in their hemodynamic status [8]. This may surgical therapy, inpatient anticoagulation is designed
aid in warning of an untoward event and determine specific to the surgeon’s choice (discussed later).
the efficacy of their antihypertensive therapy. Local hemostatic measures include biting on
A diastolic pressure of 110 mm Hg or greater is gauze, sutures, oxidized cellulose, topical thrombin,
contraindicated when elective surgery is considered. and tranexamic acid mouthwashes [50]. Many anal-
Although systolic blood pressure readings have no gesics and antibiotics may affect the level and ac-
clear contraindication, the literature suggests a read- tivity of anticoagulation adversely. Examples of
ing greater than 180 mm Hg warrants a postponement antibiotics that potentiate the action of anticoagulants
 perioperative risk assessment of geriatric patients 27

are dephalosporins, amoxicillin, macrolides, sulpha opioids may potentiate their hypotensive effects [20].
drugs, and antifungals. Those that diminish anti- Table 5 outlines the interactions of antihyperten-
coagulant activity include rifampin. Anti-inflamma- sive agents with pharmacologic agents most com-
tory agents, anticonvulsants, certain antidepressants, monly prescribed.
and cholesterol-lowering drugs also can exacerbate
therapeutic levels of anticoagulants. It is judicious for
surgeons to catalogue all medications carefully and Cerebrovascular and neurologic disease
determine the risk-to-benefit ratio when prescribing
medications that can interact with anticoagulant drugs CVA disease is the third leading cause of death in
[20,50]. those over 65 years of age. This occurs as a result of
a 20% loss of cerebral tissue, a 28% reduction in
Other cardiac medications cerebral blood flow, and a 30% loss in neuron
Patients should maintain their regimens of cardiac number [48]. Transient ischemic attacks (TIAs),
medications the day of surgery. Medications com- thrombi, emboli, or hemorrhage in the brain further
monly prescribed include b-blockers, calcium chan- contribute to cerebrovascular disease. Other causes
nel blockers, angiotensin-converting enzyme that contribute to CVA are peripheral vascular disease
inhibitors, and centrally acting agents that block and COPD with thromoboemboli. Risk assessment
a-receptors and b-receptors. It is, however, judicious for neurologic damage is predicated by the symptoms
for surgeons to remember the adverse drug effects displayed. Individuals who have right brain damage
of these medications. Antihypertensives, such as present with a paralyzed left side, spatial perceptual
a-blockers, b-blockers, calcium channel blockers, defects, thought impairment, memory deficits, impul-
and anticholesterol drugs, can cause xerostomia or sive behavior, and difficulty performing motor tasks,
gingival hyperplasia and precipitate or exacerbate an such as oral hygiene. Individuals who have left brain
orthostatic hypotensive episode. In addition, the damage may present with a paralyzed right side,
concomitant use of NSAIDs can antagonize the anti- language and speech problems, memory deficits, and
hypertensive effects of some medications, whereas disorganized behavior.

Table 5
Drug interactions between antihypertensive agents and dental pharmacologic agents
Antihypertensive Dental agent Effect Recommendations
Diuretics
Furosemide NSAID Decreased renal blood flow Inform about risks versus benefit and consult
HCTZ Loss of antihypertensive effect physician based on stage of hypertension
b-adrenergic blockers
Metoprolol Epinephrine Transient hypokalemia Avoid use if patient is hypokalemic
Atenolol Levonordefrin Decreased renal blood flow Consult physician based on stage of
NSAID hypertension
Nonselective b-blockers
Propanolol Epinephrine Hypertension and bradycardia Monitor blood pressure. Consult physician
Levonordefrin based on stage of hypertension
Angiotensin-converting enzyme inhibitors
Captopril NSAID Decreased renal blood flow Consult physician and warn patient
Loss of antihypertensive effect Monitor blood pressure
Centrally acting a-adrenergic receptor agonists
Clonodine Opioids Increased central nervous system Use cautiously
depression
Respiratory depression decreased
mental awareness
Peripheral adrenergic neuronal blockers
Guanethidine Epinephrine Increased cardiovascular Use cautiously/monitor blood pressure
Levonordephrin
Adapted from Yagiela JA, Turner RN. Hypertension. In: Bennett JD, Rosenberg MG, editors. Medical emergencies in dentistry.
Philadelphia: WB Saunders; 2002.
28 halpern & feldman

Medical consultations should be obtained as tion is much greater in geriatric patients because
needed to assess patients’ neurologic status. Patients of diminished protective reflexes and increased
who have a history of TIAs should be evaluated for gastric emptying time [53]. The latter also can occur
carotid stenosis. No elective treatment should be in patients who are taking aspirin, NSAIDs, and
given to patients who have current TIAs or a history b-adrenergic blockers, such as those in ophthalmic
of stroke within the prior 6 months. Stress reduction solutions used for glaucoma. Accumulation of aspi-
techniques, monitoring of blood pressure, and limits rates then sets the stage for pneumonia and prolonged
on epinephrine (discussed previously) should be hospitalizations that can cripple healthy and un-
used. Stroke patients also often are on anticoagula- healthy geriatric patients.
tion therapy that needs to be managed by the INR Patients who have pulmonary problems may
(described previously). require appointments scheduled during the late
Parkinson’s disease is seen commonly in the el- morning or the afternoon to allow for a period of
derly. Movement disorders, such as tremors of the readjustment to clear their lungs of fluid that accu-
hands, are found in 43% of patients over age 65, mulates from being supine at night. Patient posi-
which may be attributed either to true Parkinson’s tioning during treatment should be either upright
or drug-induced Parkinson’s. The latter is seen in or no greater than a 45 angle. This allows for
geriatric patients who are taking calcium channel easy access and ability to breathe without restriction.
blockers, methyldopa (Aldomet), haloperidol (Haldol), Many patients who have COPD can suffer from
phenothiazines, and metochlopramide (Reglan) [51]. syncopal episodes secondary to continuous coughing
Drugs that replete endogenous dopamine also may with diminished venous return and concomitant
have interactions with the vasoconstrictors in local reflex vasodilatation. Even the mildest of sedation
anesthetics, which compromise cardiovascular func- strategies and surgical procedures can result in
tion. Again, good documentation of current medicines hypoventilation with concomitant atelectasis and
avoids any undue drug-drug interactions. increase the risk for hypoxemia and infection during
Strategies for pain and anxiety management in the postsurgical period. The administration of oxygen
these patients include inhalation and oral and IV requires careful titration, because patients who have
sedation. Specifically, benzodiazepines, opioids, and COPD disease require a continuous hypoxic drive.
alkyphenols are good choices. Careful monitoring of The dosing is low flow of 2 liters per minute versus
blood pressures prevents sudden episodes of hypo- the normal use of 4 liters of oxygen through a nasal
tension that originate from alterations in autonomic cannula. Patients who are on long-term cortico-
function on smooth muscle from concomitant drug steroids may require loading doses to avoid stress-
therapy. Pain management strategies are used care- induced adrenal suppression when surgical treatment
fully, because the myocardium becomes more sensi- is scheduled. The additional problems of xerostomia
tized to vasoconstrictors as a result of the drug from certain medications and palatal necrosis from
therapy for patients who have these neurologic the use of corticosteroid inhalers make treatment
diseases. It is prudent to contact neurologists with decisions complex. It is judicious to check with the
any questions about drug-drug interactions. patient’s physician as to whether or not pulmo-
nary function testing is necessary prior to any surgi-
cal procedure.
Respiratory disease Perioperative precautions for patients who have
pulmonary disease include increased use of broncho-
Chronic lower respiratory diseases are the fourth dilators, encourage coughing, deep breathing incen-
leading cause of death in the elderly [14]. Morpho- tive spirometry, and mobility [54]. Nitrous oxide and
logic changes in pulmonary function associated with oxygen sedation may be considered based on the type
aging are decreased elasticity of the chest wall, de- of respiratory problem. If patients develop dyspnea
creased muscle strength, and decreased vital capacity during treatment, dentists need to consider cause:
with less efficient ventilation. Pulmonary diseases in pulmonary, psychologic, cardiovascular, allergic, for-
the elderly mainly are of the obstructive airway type eign body, and so forth. Patients are assessed with
(COPD), including chronic bronchitis, emphysema, auscultation and respiratory rate to determine if any
and adult-onset asthma [52]. The most common obstruction is present resulting from foreign bodies or
perioperative respiratory sequelae are atelectasis, secretions. It is judicious for practitioners to have an
pneumonia, and acute bronchitis. In addition, alter- emergency drug kit in their practice that contains
ations in esophageal motility can lead to dyspnea and b-agonist bronchdilators. The onset of action occurs
an increased risk for aspiration. The risk for aspira- within a few minutes and doses can be repeated for
 perioperative risk assessment of geriatric patients 29

several rounds. Treatment then should be discontin- Endocrine disorders

ued and patients rescheduled with possible medical
reassessment before further treatment. Diabetes mellitus
Diabetes mellitus (DM) is a common illness in the
geriatric population, affecting more than 20% who
Smoking and pulmonary complications are age 65 or older [59]. Adult onset non – insulin-
Smoking cessation is pivotal in reducing the risks dependent DM (type 2 DM) is the most common
of pulmonary complications. Prospective studies form encountered. DM is a clinical predictor of
suggest improved postoperative complication rates perioperative myocardial ischemia because of the
in patients who stop smoking for up to 2 months association between DM and coronary artery disease
prior to surgery [55]. Perioperative strategies consist and the increased incidence of other perioperative
of discontinued tobacco use for a minimum of 2 to complications, including stroke, renal failure, diabetic
3 weeks to allow for decreased hypersecretion of ketoacidosis, and sepsis. Elevated blood glucose
mucus and tracheobronchial clearance that compro- levels (greater than 300 mg/dL) set the stage for
mise their postoperative course. Although there is no increased infection resulting from poor wound heal-
evidence-based data for a specific algorithm, post- ing [8,60]. In addition, hyperglycemia causes an
operative treatment for patients who are smokers increased red blood cell turgor and viscosity and
include chest physiotherapy, incentive spirometry, decreased polymorphonuclear leukocyte chemotactic
bronchodilators, steroids, and empiric antibiotic ther- mechanisms. The latter hampers cellular defenses.
apy as needed [55,56]. Concomitant impairment of healing coupled with
cardiovascular, renal, and neurologic impairment
ultimately compromise successful surgical outcomes.
Thomboembolic complications Diabetics are most commonly referred to oral
Thromboembolic complications during the peri- surgery practitioners because of their prevalence of
operative period are a common event. Studies suggest oral-health related sequelae (ie, severe odontogenic
that 20% to 30% of patients undergoing surgical abscesses, xerostomia, burning mouth, and fungal
interventions without prophylaxis are predisposed to infections) [61]. It is important to assess diabetic
developing pulmonary emboli secondary to deep vein patients’ level of glycemic control prior to surgical
thrombosis [56 – 58]. The incidence rate of deep intervention. Patients should be asked about their
venous thrombosis increases with age and accounts glucose levels, frequency of testing levels, and com-
for a large proportion of operative complications pliance with diabetic medications. Scheduling of
in elderly persons as a result of compromise of appointments for diabetic patients is predicated on
respiratory and cardiovascular function [53]. Man- their level of glycemic control. Patients who have
agement strategies to avoid the occurrence of type 2 DM that is well controlled with diet and
thromboembolic events include clinical examination exercise require no alteration in the perioperative
and preoperative imaging. The gold standard for treatment plan. Those patients who require hypo-
diagnosis of pulmonary emboli is the ventilation- glycemic agents should take their medications the
perfusion scan [58]. Suggestions for prophylaxis night before or discontinue them for up to 2 to 3 days
against thromboembolic events include the use of prior to surgery (based on the half-life of the agent),
low molecular weight heparin or adjusted-dose resuming it that evening depending on their blood
warfarin with an INR maintained in the 2 to 3 range glucose level [61,62]. A common complication that
[57,58]. Perioperative measures suggested most often can occur in elderly diabetics is a hypoglycemic
are 5000 U subcutaneous heparin 6 to 8 hours before episode. Before an appointment is started, patients
surgery and then 8 to 12 hours during the post- should be asked when their last meal was and their
operative period for up to 7 days [57]. The choices most recent blood glucose level. An acceptable target
for anticoagulation, however, must be monitored range for blood glucose is 150 to 200 mg/dL. Patients
carefully to avoid catastrophic hemorrhagic events on oral hypoglycemic agents should hold their
that can hamper even the most routine of surgical medication the day of surgery and treat hyper-
procedures. Aspirin, intermittent pneumatic devices, glycemia with short-acting insulin until they can
compression stockings and early postoperative ambu- resume the oral agents. It is imperative for sur-
lation are advantageous for all elderly patients during geons to remember that oral hypoglycemics as a
the perioperative and postoperative period in order to drug group can contribute to bouts of leukopenia
decrease the risk for deep venous thrombosis and and thrombocytopenia that can exacerbate wound in-
pulmonary emboli. fections, severe bleeding, and delayed wound healing
30 halpern & feldman

[20,61,62]. The early identification and rapid treat- malignant external otitis, necrotizing fasciitis, and
ment of a hypoglycemic episode avoids more serious rhinocerebral mucormycosis. Empiric antibiotic treat-
complications of seizures and coma (Box 3) [62]. ment therapies that decrease the degree of oral disease
Guidelines for self-monitoring blood glucose after extensive surgical procedures concomitantly de-
levels are straightforward in patients who have crease the risks for further multiorgan failure.
insulin-dependent DM (type 1 DM). The American
Dental Association currently recommends evaluation Thyroid disease
of the level of glycosylated hemoglobin (range Many thyroid disorders occur with advancing age
7.0%), which reflects the mean level of glycemic because of age-related changes in the morphology
control for a period of 2 to 3 months. This assay is and physiology of the gland [63]. Subclinical hyper-
shown to be a predictor of development of post- thyroidism and hypothyroidism thus are seen fre-
operative complications [61]. The hyperglycemic quently in the geriatric population. Unlike younger
state is easier to treat than hypoglycemic episode. populations, elderly patients often have multiple
Patients who type 1 DM and have single-dose per day complex illnesses with their thyroid disease, in-
insulin are advised to reduce dosing of insulin to cluding osteoporosis, DM, lipid abnormalities, auto-
50% to 66% the morning of surgery; IV fluids are immune diseases, dementia, and malnutrition, that
administered with glucose. Patients who need multi- tend to exacerbate the subclinical manifestations of
ple dosing of insulin receive 50% preoperatively with thyroid dysfunction [64]. In addition, geriatric
glucose solutions followed by a sliding-scale insulin patients who have unexplained atrial fibrillation and
regimen as needed [61,62]. Extensive procedures high-output cardiac failure with angina may be
requiring hospital admission and a nothing-by-mouth diagnosed with a hyperthyroid state, referred to as
status require a prior medical clearance in order to thyrotoxicosis. Most of the elderly also can develop
readjust medication dosing and nutritional require- hypothyroidism secondary to an autoimmune thyroi-
ments. Monitoring blood glucose levels before and ditis [65]. A detailed medical history should elicit
during the surgical procedure is accomplished with clues suggestive of either a hyperthyroid state or a
a sliding-scale regimen of regular insulin. This is hypothyroid condition, because hypothyroid patients
continued in order to readjust any dosing of their may be euthyroid at the present time with medi-
medications. Blood glucose monitoring is predicated cations. Assessment of thyroid medications allows
on duration of therapy and the degree of metabolic surgeons to tailor specific anesthetic and pain
control to be achieved. management strategies for patients. Hormonal
Antibiotic therapy is recommended in all surgical replacement therapy for geriatric patients versus
patients who have diabetes because of increased risk younger patients varies considerably. Young patients
for infection and poor wound healing. The dosages who have hypothyroidism usually take 75 to 150 mg
may need to be reduced in the elderly because of the synthroid per day, whereas geriatric patients are
compromised renal and hepatic function seen most titrated at 25 mg per day to prevent coronary
often as a result of diabetes [62]. Elderly patients are occlusion and angina. Patients may record allergies
especially susceptible to unusual infections, such as to vasoconstrictors, caffeine, and cola if they are hy-
perthyroid and central nervous system depressants,
benzodiazepines, and antihistamines if they are hypo-
Box 3. Risk factors for a hypoglycemic thyroid [64,66].
episode in the elderly Elective and emergent surgical intervention
requires careful evaluation of thyroid function. Se-
Sulfonylurea or insulin therapy vere hypothyroidism and hyperthyroidism (thyroid
Renal insufficiency storm) are associated with significant increases in
Liver disease perioperative morbidity and mortality. Untreated
Cognitive impairment hypothyroidism can exacerbate depression and respi-
Autonomic neuropathy ratory insufficiency and slow down drug metabolism.
Malnutrition Complications of hyperthyroidism of surgical signifi-
ETOH cance are fever, tachyarrhthmias, and CHF [66].
Sedative agents Within an office setting, the treatment of patients who
Polypharmacy have thyroid problems is based on symptomatology.
Recent hospitalization Until a definitive diagnosis is established, all elective
Cardiovascular disease surgical therapy should be avoided with only
palliative treatment rendered. Elective procedures
 perioperative risk assessment of geriatric patients 31

can be done on patients who are euthyroid. In cases of togenous total joint infection’’ [67]. Antibiotic
emergent surgery, medical clearance of hypothyroid prophylaxis is suggested within the first 2 years after
patients involves dosing with corticosteroids and joint replacement, if there was previous joint infec-
levothyroxine. In patients who have hyperthyroidism tion, and in patients who have immunosuppression,
who require emergent surgical intervention, patients’ inflammatory arthropathies, and type 1 DM, because
endocrinologists can prescribe propylthiouracil, corti- bacteremias can cause hematogenous spread.
costeroids, and b-blockers. An acute exacerbation of Oral surgeons should provide an environment that
patients who have a hyperthyroid state can lead to a minimizes these symptoms. Positioning in the dental
thyrotoxic crisis, or thyroid storm, often seen in hyper- chair and use of neck pillows and special cushions
thyroid patients who are poorly treated and who have can make the treatment comfortable. Issues of post-
undergone sudden increases in stress, sepsis, or operative care may involve homecare with special
emergency surgery. A physical examination reveals irrigation and ergonomic adjustments as advised by
fever, palpitations, and tachycardia. Blood pressure their physical therapists. It also is judicious for sur-
monitoring reveals a hypotensive state and if an ECG geons to stress that the use of OTC medications can
is placed, patients may exhibit cardiac arrhythmias. All cause adverse events when used with postoperative
treatment is stopped and patients are given oxygen. drugs (discussed previously).
Access for an intravenous line should be attempted and
patients then given IV fluids depending on their other Dementia and postoperative delirium
medical problems (dextrose in normal saline versus
lactated ringers, depending on other systemic ill- Cognitive dysfunction in elderly surgical patients
nesses). The use of NTG tablets is not contraindicated can present as either dementia or delirium. Dementia
but monitoring of blood pressure is imperative to avoid is a syndrome characterized by deterioration of the
significant hypotension (discussed previously). An es- organic functions of the brain that is chronic and
tablished office algorithm for endocrine emergencies usually lasting more than 1 year. The risk of dementia
should be in place with staff drills. increases 0.01% to 0.74% in age 60 and over per
year, with 2.2% to 3.5% per year over age 80 [68].
Arthritis Symptoms of delirium may mimic those of dementia.
Delirium, however, has a rapid onset and is charac-
Arthritis is the most common chronic disease in terized by a fluctuating state of alertness, confusion,
adults, with 38% afflicted at ages older than 65 years disorientation, memory impairment, apprehension,
[43]. Its affect on muscles, bones, and ligaments and agitation. More than 15% of elderly patients
cause many to suffer during the most simple daily who undergo surgery are susceptible to some form of
routines. Patients who have arthritis are prescribed postoperative delirium [69]. The most common cause
many medications containing aspirin, NSAIDs, and of delirium stems from drug toxicity and metabolic
corticosteroids that may cause or exacerbate severe problems. Other causes of delirium are malnutrition,
bleeding, wound healing, and ulcerations that com- dehydration, uncontrolled endocrine disorders, organ
plicate surgical therapy. A recent update of pre- failure, stress of surgery, and length of the operation
scribed medicines allows for readjustments and bolus [68]. As such, delirium is a more acute, usually re-
steroid dosing depending on the invasiveness of versible disorder secondary to a concomitant medi-
the procedure. cal problem.
Antibiotic prophylaxis often is considered on an Surgeons should be cognizant of the timeline
individual basis. Although the risk for prosthetic joint when the symptoms of delirium first occur. Studies
infection is low (0.5% – 5.0%), it is a major cause of indicate a period of 4 days with a prodromal phase.
joint failure. The advisory committee jointly de- Subtle behavioral changes are noted during the im-
veloped by the American Academy of Orthopedic mediate postoperative period and become erratic
Surgeons and the American Dental Association has a as the delirium progresses. Patients can present
consensus statement as to recommendations for initially as depressed, perplexed, or agitated [70].
antibiotic prophylaxis in patients who have joint The treatment strategies for postoperative delirium
replacements: ‘‘Antibiotic prophylaxis is not indi- include rapid laboratory panels of liver function,
cated for dental patients with pins, plates, screws, nor urinalysis, complete blood count, serum urea nitrogen
is it routinely indicated for most dental patients with (SUN), creatinine, drug screens for therapeutic ranges
total joint replacements. However it is advisable to and determinations of toxic levels of drugs. CT is
consider premeditation in a small number of patients essential to rule out bleeding diatheses and presence
who may be at potential increased risk for hema- of fluid indicative of any brain infection. Spinal taps
32 halpern & feldman

also are indicated, especially in patients who have  Mobilize promptly and control pain on an
comorbid illnesses, such as diabetes and thromboem- individual basis.
boli. Careful monitoring of fluid and electrolytes is  Monitor risk for postoperative delirium.
imperative to avoid neurologic sequelae of hyper-
natremia, hyponatremia, and surgically induced dia-
betes insipidus. The use of certain anesthetic drugs
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