What is the prognosis for appendicitis in individuals over 70?

Prognosis for Appendicitis in Patients Over 70 Years

Appendicitis in patients over 70 years carries a significantly worse prognosis compared to younger populations, with mortality rates reaching up to 16% in nonagenarians and increasing threefold with each decade of age beyond 65 years. 1

Mortality and Morbidity

• Mortality rates for elderly patients (>65 years) with appendicitis reach 8%, compared to rates between 0-1% in younger patients 2
• The case fatality rate after appendectomy increases threefold with each decade of age beyond 65, reaching more than 16% in nonagenarians 2, 1
• Mortality is directly related to disease severity:
  • Non-gangrenous appendicitis: <0.1% mortality 1
  • Gangrenous appendicitis: 0.6% mortality 1
  • Perforated appendicitis: approximately 5% mortality 1, 3

Disease Presentation and Progression

• Elderly patients have significantly higher rates of complicated appendicitis with perforation or abscess, ranging from 18-70%, compared to only 3-29% in younger patients 2
• The classic symptoms of appendicitis are rarely seen in elderly patients, leading to delayed diagnosis and treatment 4
• Only about 20% of elderly patients present with the classic symptoms of anorexia, fever, right lower quadrant pain, and elevated white blood cell count 5
• Diagnostic accuracy is lower in elderly patients (64%) compared to younger populations (78%) 2

Factors Contributing to Poor Outcomes

• Anatomical changes in the elderly appendix contribute to higher perforation rates:
  • Vascular sclerosis develops in the appendix 2
  • Muscular layers become infiltrated with fat 2
  • Structural weakness creates tendency toward early perforation 2, 1
• Delayed presentation is common:
  • Average pre-hospitalization symptom duration is 2.7 days overall, but 3.8 days for perforated cases 6
  • Up to one-third of elderly patients experience >48 hours delay to admission 5
• Diagnostic challenges:
  • Only 51% of elderly patients are correctly diagnosed with appendicitis at admission 5
  • 30% of cases require additional diagnostic investigations, with mean time to final diagnosis of 26 hours 6

Complications and Hospital Course

• Overall complication rate in elderly patients is 34.9%, but rises dramatically to 75% in perforated cases versus 16.2% in non-perforated cases 6
• Hospital stays are significantly longer:
  • 7.2 days for perforated appendicitis versus 5.1 days for non-perforated cases 6
  • 9.6 days for patients developing complications versus 5.6 days for those without complications 6
• Elderly patients are more likely to require complex surgical procedures compared to younger patients 2

Impact of Comorbidities

• Approximately 63.3% of elderly patients with appendicitis have associated comorbidities 6
• The presence of comorbidities significantly increases the risk of complications and mortality 6, 3
• Mortality is particularly high in elderly patients with both appendicitis and coexistent carcinoma 5

Surgical Considerations

• Laparoscopic appendectomy rates are lower in elderly patients compared to younger populations 2
• Operative times are typically longer in elderly patients 4
• Elderly patients with appendicitis associated with intra-abdominal abscess have significantly higher mortality rates 7