The Francis Report (Francis 2010) detailed the indignity suffered by elderly patients in the Mid-Staffordshire Hospital, where they were denied the basic courtesy of being addressed by their given name, allowed to lie in their own excrement, and left to become dehydrated and malnourished. For these patients hospital care became synonymous with declining health not healing. Evidence of the standard of elderly care as chronicled in this report has more resonance with accounts of nineteenth-century workhouses than healthcare delivery in the fifth richest country in the world, in the twenty-first century.

Similar dreadful and unacceptable events were recounted in the Health Ombudsman’s Report Care and Compassion? (Abraham 2011). This Report records the ill-treatment, neglect and abuse of ten elderly patients over the previous year who had the misfortune to require primary or acute care interventions from the NHS. Their maltreatment ranged from a failure to diagnose a condition through to failure to note that an elderly man was minutes away in the waiting room while his wife died alone, failure to respond to requests for medical consultations, and weighting the anticipated prognosis for an elderly patient against the cost of surgical intervention and choosing to deny active treatment. These all suggest that the media headlines pronouncing the elderly as a ‘­burden’ are accepted as a societal truth. The report makes for sobering and distressing reading.

The findings of the Care Quality Commission (2011) following unannounced visits to a number of NHS hospitals investigating the standard of care and nutrition for the elderly found additional evidence to illustrate the level of indifference, neglect and denial of dignified care to elderly patients. The Report highlights a situation in one hospital in which doctors resorted to prescribing water for elderly patients in an effort to get staff to give patients a drink of water and prevent dehydration.

In all the cases cited in these three reports there exist two common denominators:

• the patients afflicted by the callous lack of care and repeated indignities were the elderly and
  
• being elderly, these patients became invisible to healthcare practitioners.

The report by the King’s Fund (Foot 2011) clearly highlights the disparity in outcomes for the elderly who required surgical intervention for cancer in the UK versus a similar demographic in Scandinavia, Canada, Australia and some countries within mainland Europe. Indications are that the elderly in the UK fare less well (Foot 2011).

The National Confidential Enquiry in Patient Outcomes and Death (NCEPOD 2010b) reveals a lack of appropriate management of the elderly in hospitals. NCEPOD reports failures in having clinical assessments carried out by experienced doctors from a range of clinical specialities, in particular doctors trained in the care of elderly patients. Errors in the management of hydration and nutrition leading to delays in surgery which in turn led to placing the patient in more danger and the failure to provide suitable pain relief were found to be the greatest deficits in care of the elderly.

While recognising both the vulnerability of the elderly and the fact that the number of over 80-year-old patients coming to theatre is set to increase, the Association of Anaesthetists of Great Britain and Ireland (AAGBI) stipulate that with an experienced, well-trained perioperative team, age in itself does not constitute a reason to avoid surgical intervention (AAGBI 2001).

A vital prerequisite to elective surgical intervention is a thorough and comprehensive preoperative assessment of the patient. This should include an extensive search of the patient’s medical history, blood chemistry profile, physical examination for scars for evidence of previous surgery and accurate recording of the patient’s medication history (Hehir 2005).

The physiology of ageing dictates that the efficiency of the body systems deteriorates. The majority of elderly patients will be graded as ASA 2 under the American Society of Anesthesiologists grading system shown in Box 28.2.

Preoperative Assessment

Prior to surgery a detailed medical history is essential, which necessitates having access to the patient’s medical notes. These will provide the anaesthetist with reliable and up-to-­date information on the patient’s health status, knowledge of concurrent conditions and intelligence on the current management of any existing conditions, including any drug regime the patient may require (Hudsmith et al. 2004). Access to contem­porary medical notes will negate the possibility of the patient omitting details of current conditions and treatment but also forgetting to mention episodes of illness or surgical intervention which may have occurred in excess of 60 or 70 years previously.

A difference can be found to exist in how individuals react to any drug. These idiosyncratic responses are likely based on ‘ethnicity, existing co-morbidity and drug interactions’. The elderly more commonly have a propensity to be adversely affected by drugs due to changes in how the body handles pharmaceutical materials. Polypharmacy is characterised as a patient being prescribed multiple drugs for a variety of pathologies, and may also include the use of over-the-counter drugs, which in turn increases the risk of adverse drug interactions (Tabernacle et al. 2009). According to Dodds et al. (2007), ‘Organ function declines at an average rate of 1% a year from the age of 40’.

The Cardiovascular System

Stay updated, free articles. Join our Telegram channel

Join