Special Problems In The Elderly

Increased age is known to increase postoperative morbidity, and possibility mortality, in general. This includes diabetic patients, but again there is no convincing evidence in the literature that the effect is significantly greater among such patients. In general, however, diabetic surgical patients are frequently older and 'sicker' than their non-diabetic counterparts (Sandler et al 1986) (e.g. amputees, coronary bypass surgery etc.); but when these factors are taken into account, any increased morbidity amongst diabetics becomes insignificant or much less significant.

When preparing the elderly for surgery, preoperative assessment should be particularly thorough because of comorbidity and polypharmacy. The patient may not be able to give an accurate history because of memory problems or communication difficulties. Ischaemic heart disease may be underestimated as the patient may not give a typical history of chest pain on exertion if exercise is limited by another pathology such as os-teoarthritis. Pressure management is important in the elderly throughout the period of immobility, but particularly so if the individual has diabetes, where peripheral vascular disease and peripheral neuropathy increase the risks. Nutritional status can already be compromised in the elderly hospitalized patient and be further exacerbated by surgery. Prophylaxis against venous thromboembolic disease must also be considered.

Later, we will be discussing potential iatrogenic complications of diabetes management during surgery. Elderly diabetic patients tolerate hypoglycaemia poorly (Jennings, Wilson and Ward 1989), and are less efficient at maintaining water homeostasis than their younger counterparts (Faull, Holmes and Baylis 1993), increasing the risk of fluid and electrolyte imbalance in the postoperative period. Renal impairment can be precipitated or exacerbated by these changes, but hydration can already be compromised by drugs, vomiting, preparation for the operation (e.g. bowel clearance), preoperative starvation or simply inability to obtain or reach fluids.

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