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Nowadays, the punchline doesn't carry the same comical weight as it would have 20 years ago. And not only are people living longer, but they are being operated on at increasingly later stages in life. Not only are these surgeries less risky, there is a greater expectation by physicians and patients that the elderly still have many years of productive and fulfilling life ahead of them.

The numbers are staggering. Currently, one out of eight Americans is older than 65; by 2050, one in five will be older than 65. The fastest growing segment of this population is those over 85. Twenty years ago, 19 percent of those operated on were over 65; by 1996, that figure had climbed to 36 percent. In short, a 65-year-old man today can expect to live another 16 years, a woman 20 additional years.

These trends have caused a subtle shift in decision-making about surgery. No longer are they based solely on the risk of surgery itself, but on optimal disease management and the preservation of the quality of life. One of the issues facing physicians, elderly patients and their families is the effects of surgery on those mental functions ‚ memory, cognition and intellect that make us who we are.

Are the elderly at greater risk for impairment of mental functioning after surgery, and if so, why? How can it be prevented? To try to answer these questions, a group of international experts convened at Duke last week for the second Duke Conference on Surgery and the Elderly.

"This topic is so vitally important," Dr. Robert Anderson, chairman of surgery at Duke, told the assembled group of 40-plus physicians. "As cardiac surgeons, we operate on elderly patients all the time. We can keep the heart muscle viable, but what we worry about the most is cerebral preservation. It's a difficult problem, and one that needs more investigation."

Already, research led by Duke cardiac anesthesiologist Dr. Mark Newman has shown that a significant number ‚ 42 percent ‚ of patients who received coronary bypass surgery had measurable cognitive decline five years after surgery.

"To help us understand these issues we need better animal models for pre-clinical studies," Newman said. "We also need to be able to identify high-risk patients and to organize large multi-center trials to test new brain-protection ideas."

In other surgical areas, the data aren't as clear. In hip fracture patients, for example, Dr. Kenneth Koval, orthopedic surgeon at the Hospital for Joint Diseases at New York University, reported that 5 percent of his patients suffered cognitive impairments after surgery.

It doesn't appear that the type of anesthesia used has an impact on cognitive decline. After an exhaustive review of the studies to date, Dr. Pamela Williams-Russo from Cornell could not find a difference in outcomes between general and regional anesthesia.

"Aging is a rampant global issue," said Dr. Joseph Ouslander, president of the American Geriatric Society. "We will be taking care of older and older patients, and they are different."

While all agree that more research is needed, there were certain trends that emerged:

… The older the patient, the higher the risk for cognitive impairment.

… The temperature of the patient during surgery seems to play a role.

… Genetics, through the role of the APOE variant, may be important.

… Education seems to protect against impairment.