Download Preoperative evaluation of the elderly patient:

9/21/2015
Preoperative evaluation of
the elderly patient:
It’s not just about age anymore!
Anne Donovan, MD
Assistant Clinical Professor
UCSF Anesthesia and Critical Care Medicine
https://www.census.gov/prod/cen2010/briefs/c2010br-03.pdf. Accessed 9.1.15.
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Surgery in the elderly
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Approximately 50% of patients over 65 will require surgery during
their lifetime
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> 33% of inpatient procedures in 2007 were performed on patients
aged 65+
 Expected to double by 2020
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Cancer is the leading cause of mortality in patients over 65 years
 Suboptimal management may decrease quality of life and increased dependency
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Age (by itself) is no longer an acceptable exclusion criterion for
surgery
Kim S, et al. Clin Int Aging. 2015. 10:13-27
Yang R, et al. Ger Ortho Surg & Rehab. 2(2):56-64
Ploussard G, et al. World J Urol. 2014. 32:299
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Case discussion
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89-year-old man with invasive squamous cell carcinoma scheduled for
maxillectomy, radical neck dissection, and right thigh free flap.
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PMH:
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Severe aortic stenosis (valve area 0.9 cm2, peak/mean gradients 56/35)
CAD s/p 4 vessel CABG in 2000
Carotid artery stenosis (60% L, < 50% R)
Third degree heart block, s/p dual chamber pacemaker placement
Hypertension
SH:
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Lives at home, partially dependent on care from his nephew
Ambulates with walker
No problems with oral intake
Cognitive function and decision making capacity intact
What would you do?
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Not happening! Case cancelled.
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Discuss surgical indications and alternative treatment
options with the surgeon
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Seek input from a cardiologist
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Proceed with the case
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Outline
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Decision making in the perioperative period
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Preoperative risk and risk stratification in geriatric surgical patients
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Functional status
Cognition
Frailty
Scoring systems
Preoperative evaluation of geriatric surgical patients
 Medical testing
 Geriatric-specific assessments
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Preoperative optimization
Surgical decisionmaking
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Adapted from Oresanya LB, et al. JAMA. 2014. (311);20: 2111.
9/21/2015
Focusing on patient goals
Technique
Description
Best case/worst case
Decision-making tool allowing presentation of multiple
treatment options and range of outcomes
Eliciting patients’ care
goals, concerns,
triggers for considering
transition to palliative
care
- What is the most important to you right now? (life
prolongation, maintaining independence, pain control, etc)
- What makes life worth living?
- Can you imagine anything that would be worse than death?
- Would you be willing to go through anything to achieve this
goal?
- Can you imaging a scenario where you would just want to
be kept comfortable?
Advance directives
Establishing alternate decision makers
Kruser JM, et al. J Am Ger Soc. 2015. Epub ahead of print
Oresanya LB, et al. JAMA. 2014. (311);20: 2111
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Perioperative risk in
geriatric surgical
patients
Physiologic changes in the elderly
Organ System
Age related changes (not inclusive)
Neurologic
Loss of brain mass, < cerebral blood flow, < cerebral oxygen consumption, <
neurotransmitters, cognitive decline, behavioral variability, < PNS conduction velocity,
loss of peripheral neurons, denervation
Cardiovascular
CAD, < CO, < LV compliance, autonomic dysfunction, < baroreceptor response,
conduction system changes, valvular disease, < vascular compliance
Pulmonary
> parenchymal compliance, < chest wall compliance, > V/Q mismatch, < respiratory
muscle mass, rapid shallow breathing, > RV and FRC, < FVC and FEV1, < central
response to hypoxia and hypercapnia, < ciliary function
Gastrointestinal
Protein malnourishment, < hepatic blood flow, < hepatic microsomal enzyme function,
< drug metabolism, < plasma protein concentration
Renal
< renal mass, < renal blood flow, < GFR, < urine concentrating ability, < response to
plasma hormones
Hematologic
Anemia, < blood volume, < bone marrow cellularity
Immunologic
< immune system function
Endocrine
Insulin resistance, < hormone (free T3, GH, aldosterone) production
Musculoskeletal
Decreased muscle mass, increased fat mass, impaired thermoregulation, skin fragility
Yang R, et al. Ger Ortho Surg & Rehab. 2(2):56-64.
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Additional considerations in the
elderly
• Comorbidities
• Communication
and
comprehension issues
• Polypharmacy
 Altered drug metabolism
• Functional
• Nutritional
• Frailty
• Social
status
needs
status
Geriatric
syndromes
Pressure
ulcers
Delirium
Incontinence
Physiologic
decline
Falls
Functional
decline
Jones TS et al. JAMA Surg. 2013. 148(12):1132.
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Perioperative stress in the elderly
Surgical
stress
response
Decreased
physiologic
reserve
Poor
outcomes
“… Age per se should not be considered an
exclusion criterion for surgery.
Biological age, which is the result of pathophysiologic
aging processes, comorbidity, and genetic factors, seems to
be more predictive than chronological age in defining the
degree of fitness and performance of a given individual
when facing health problems.”
Bettelli G. Minerva Anes. 2011. 77(6):637.
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Preoperative risk
stratification
Traditional risk stratification tools
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Revised cardiac index
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Comorbidities
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Exercise tolerance (METs)
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Basic laboratory studies
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ASA classification
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Factors associated with poor surgical
outcomes in the elderly
Outcome
Condition
Mortality
Cognitive impairment
Functional dependence
Malnutrition (?)
Frailty
Delirium
Cognitive impairment
Frailty
Discharge to a facility
Cognitive impairment
Frailty
Admitted from care facility
Functional decline
Cognitive impairment
Preoperative functional decline
Oresanya LB, et al. JAMA. 2014. (311);20: 2111.
Impaired sensorium and functional dependence
are predictors of poor outcomes after surgery
Gajdos, et al. JAMA Surg. 2015.
150(1):36.
Scarborough JE, et al. Ann
Surg. 2015. 261(3): 432.
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Propensity-matched cohorts from ACS
NSQIP database
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Propensity-matched cohorts from ACS
NSQIP database
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Patients with preoperative impaired
sensorium had higher rates of:
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Complex vascular or general surgery
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Functionally dependent patients had
higher rates of:
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Pneumonia
Ventilator dependence
Renal failure
Urinary tract infection
Stroke
Venous thromboembolism
Death
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Mortality (OR 1.75, 95% CI 1.54 – 1.98)
Major morbidity (OR 1.51, CI 1.41 – 1.62)
Minor morbidity (OR 1.28, CI 1.18 – 1.39)
Reoperation (OR 1.40, CI 1.13 – 2.06)
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Predictor
Odds ratio* (95% CI)
P value
Mini-cog < 4
4.2 (1.2 – 13.8)
0.02
Albumin ≤ 3.3 g/dL
8.6 (2.5 – 29.3)
0.0006
Falls ≥ 1
5.1 (1.7 – 22.4)
0.004
Hematocrit < 35%
10.7 (3.3 – 34.9)
< 0.0001
ADLs < 6
13.9 (3.0 – 65.4)
0.0008
Charlson ≥ 3
3.9 (1.0 – 14.6)
0.04
* Mortality at 6 months
Ann Surg. 2009. 250(3):449.
Frailty
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Composite phenotype of
functional and physiologic
decline
Reflects a state of reduced
physiologic reserve
Associated with increased
susceptibility to poor
outcomes
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Clinical domains of frailty:
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Cognition
Activity
Nutrition
Mobility
Strength
Energy
Mood
Robinson TN, et al. Ann Surg. 2009. 250(3):449.
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Makary MA, et al. J Am Coll Surg. 2010. 210(6): 901.
Postoperative
complications
Non-frail
(Frailty score 0-1)
Intermediately frail
(Frailty score 2-3)
Frail
(Frailty score 4-5)
Overall
3.9%
7.3%
11.4%
Major
procedure
19.5%
33.7%
43.5%
2.06
(1.18 – 3.06)
2.54
(1.12 – 5.77)
Adjusted OR
(95% CI)
Length of stay
Discharge to
institution
Overall
0.7
1.2
1.5
Major
procedure
4.2
6.2
7.7
Overall
0.8%
0%
17.4%
Major
procedure
2.9%
12.2%
42.1%
3.16
(1 – 9.99)
20.48
(5.54 – 75.68)
Adjusted OR
(95% CI)
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Comparison of frailty scoring systems
Multidimensional Frailty Score
Hopkins Frailty Score
Item
Malignancy
Shrinking
Unintentional weight loss ≥
10 lb in 1 year
Charlson Comorbitiy Index
0
1
2
No
Yes
NA
0
1-2
>2
≥ 3.9
3.5 – 3.9
< 3.5
Weakness
Grip strength measurement
Albumin (g/dL)
Exhaustion
Questions about effort and
motivation
ADLs
Independent
Partially
dependent
Dependent
Low activity
Questions about leisure
time activity
IADLs
Independent
Partially
dependent
Dependent
MMSE
Normal
MCI
Dementia
Slowed walking
speed
Time to walk 15 feet
Scored 0 or 1 for each domain
0-1 = non-frail; 1-2 = intermediate; 4-5 = frail
Makary MA, et al. J Am Coll Surgeons. 2010. 210(6):901.
Risk of delirium (Nu-Desc)
0-1
≥2
NA
Mini Nutritional assessment
Normal
Risk of
malnutrition
Malnutrition
Midarm circumference (cm)
≥ 27
24.6 – 27
< 24.5
Low risk = 0-5, High risk = 6+
Kim S, et al. JAMA Surg. 2014. 149(7):633.
Frailty is a better predictor than
comorbidities!
Adjusted OR per
Frailty is a Adjusted OR
increase in 1
for MFS ≥ 7
predictor
of poor
point in MFS
Postoperative
complications
Discharge to
institution
Increased hospital
lengh of stay
outcomes
1.14 even in
otherwise
p = 0.42 “lowrisk”
elderly
1.38
p = 0.1
patients!
8.54
p = 0.002
1.29
p = 0.7
1.41
p = 0.038
Choi JY, et al. J Am Coll Surgeons. 2015. Epub ahead of print.
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J Am Coll Surg. 2013. 217:665.
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2015
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Defining frailty
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Cognition
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 Mini-cog < 3
 Impaired cognitive function
 Delirium risk factors
 Recent falls
 Up and go test
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Activity
 Functional dependence
 Daily activity level
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Nutrition
 Recent weight loss
 Albumin < 3.3 g/dL
 Low BMI
Mobility
Strength
 Grip strength
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Mood
 Depressed mood
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Comorbidity
 Hematocrit < 35%
 Charlson Comorbidity Index > 3
Robinson TN, et al. Ann Surg. 2009. 250(3):449.
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Frailty, in summary
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Predictor of postoperative complications, discharge to
institution, hospital readmission, mortality
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Spans multiple surgical subspecialties
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No consensus definition exists
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Further study needed to determine most important
elements of frailty
Surgical risk calculators
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American College of Surgeons: NsQip
 www.riskcalculator.facs.org
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Cardiothoracic specific:
 Euroscore
 www.euroscore.org
 STS risk calculator
 www.sts.org/quality-research-patient-safety/quality/risk-calculator-andmodels/risk-calculator
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UCSF: eprognosis.org
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Riskcalculator.facs.org
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J Am Coll Surgeons. 2013. 217: 833.
Observed rate
Observed rate
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eprognosis.org
Preoperative
evaluation of geriatric
patients
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Preoperative medical testing
Study
EKG
Other cardiac testing
CXR
Pulmonary evaluation
“Preoperative tests
should not be ordered
routinely. Preoperative
Possible indications
tests may be ordered,
Cardiocirculatory or respiratory disease, CV risk factors, type andrequired, or performed
invasiveness of surgery
on a selective basis
Cardiovascular risk factors, type of surger
for purposes of guiding
Smoking, recent URI, COPD
or optimizing
Type of surgery, interval from prior evaluation, treated or symptomatic perioperative
asthma, symptomatic COPD, scoliosis with restrictive lung disease
management.”
Hemoglobin or
hematocrit
Extremes of age, liver disease, history of anemia, bleeding, hematologic
disease, type of surgery
Coagulation studies
Bleeding disorders, liver or renal dysfunction, type of surgery
Serum chemistry
Renal or liver disease, endocrine disorder, use of certain medications,
perioperative therapies
Urinalysis
Presence of UTI symptoms, specific procedures
Pregnancy
Offer to patients of childbearing age where result would affect decision
ASA Practice Advisory for Preanesthesia Evaluation. Anesth & Analg. 2012. 116(3)
Routine preop medical testing:
Still happening (and costing a lot of money)!
Sigmund AE, et al. JAMA IM.
2015. 175(8):1352.
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Chen CL, et al. NEJM. 2015.
372(16):1530.
Data collected from large surveys
conducted by the CDC and NCHS
yearly from 1997 – 2010.
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Before and after release of new ASA
and ACC/AHA guidelines for preop
testing in 2002
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Observational cohort of 440,000
patients having cataract surgery in
2011
In the month before surgery:
 53% had at least one preop test
 $4.8 million in testing
 $12.4 million in office visits
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Routine EKG was the only test to
decrease
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Testing patterns varied widely
between practice settings
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UA, CXR, Hgb, stress testing patterns
did not change
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No change in testing practices
compared with 20 years ago
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From: 2014 ACC/AHA Guideline on Perioperative Cardiovascular Evaluation and Management of Patients Undergoing Noncardiac
Surgery: A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines
J Am Coll Cardiol. 2014;64(22):e77-e137. doi:10.1016/j.jacc.2014.07.944
Copyright © The American College of Cardiology. All rights reserved.
Date of download: 8/27/2015
Evaluation of geriatric-specific
conditions
Condition
Evaluation tool
Cognition
Mini-cog
MMSE
Risk factors for delirium
Function
Ability to perform ADL’s and IADL’s
History of falls
Timed up and go test
Nutrition
BMI
Albumin and prealbumin
Unintentional weight loss
Mini nutritional assessment
Polypharmacy
Medication reconciliation
Frailty
Comprehensive geriatric assessment
Oresanya LB, et al. JAMA. 2014. (311);20: 2111.
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Cognition: Mini-cog
Risk factors for delirium
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Age > 65 years
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Poor nutrition
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Cognitive decline or dementia
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Alcohol or substance use
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Poor vision or hearing
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Severe illness or comorbities
Electrolyte or metabolic
abnormalities
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Infection
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Sleep disturbance or
deprivation
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Functional dependence
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Depression
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Immobility
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Polypharmacy
Am Geriatrics Society Expert Panel. J Am Coll Surgeons. 2015. 220(2):136.
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Functional assessment: Fall history
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Prospective cohort study: 235 patients asked about fall
history in 6 months preceding elective colorectal or
cardiac surgery
 33% of patients with fall
 Tended to be older, sicker, lower albumin and hct
 Falls associated with:
 More postoperative complications
 Higher 30-day readmission
 Discharge to institution
 Results were independent of age
Jones TS et al. JAMA Surg. 2013. 148(12):1132.
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Nutritional assessment
Parameter
Criteria for severe
malnourishment
Recent weight loss
≥ 10-15% in last year
BMI
≤ 18.5 kg/m2
Hyopalbuminemia
≤ 3 g/dL
Mid-arm muscle circumference
< 21 cm (male), < 19 cm (female)
Decubitus ulcers
Present
Mini-nutritional assessment
0-7 points
Chow WB, et al. J Am Coll Surg. 2012. 215(4): 453.
Dudrick SJ. Surg Clin N Am. 2011. 91:877.
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Preoperative
optimization
Comprehensive Geriatric Assessment
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Well-established evaluation and intervention process
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Patient-specific plan for treatment and follow up developed
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Domains involved:
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Medical
Physical/functional
Psychological
Social
Environmental
Shown in medical inpatients and community-dwelling patients to:
 Improve mortality
 Increase chance of living independently
 Improve physical function
Partridge JSL, et al. Anaesthesia. 2014. 69(Suppl 1): 8-16.
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Clinicians involved in CGA
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Geriatricians
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Pharmacists
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Internists/hospitalists
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Nurse specialists
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Physical therapists
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Dieticians
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Occupational therapists
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Social workers
CGA predicts adverse outcomes in
elderly surgical patients
Kim K, et al. Arch Geront Geriatrics. 2013. 56:507.
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CGA may improve postoperative
outcomes
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Patients receiving targeted optimization prior to surgery based on
multidisciplinary CGA assessments had:
 Lower rates of
 Pneumonia
 Delirium
 Pressure sores
 Inappropriate catheter usage
 Improved
 Pain control
 Mobilization
 Hospital LOS
 Discharge coordination
Harari D, et al. Age and Ageing. 2007. 36:190.
Indrakusuma R. Eur J Surgical Oncol. 2015. 41:21.
Evidence-based preoperative interventions
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Frailty is difficult to treat!
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Interventions are better established in community, long-term
care, and medical inpatient setting
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Limited evidence in surgical population
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Other interventions with limited evidence in surgical patients
 Testosterone
 Growth hormone
 Vitamin D
Amrock LG and Deiner S. Curr Op Anes. 2014. 27(3):330.
Fairhall N, et al. BMC Med. 2011. 9:83.
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How can we best minimize perioperative risk?
Assessment
Tools
Intervention
Cognitive impairment,
dementia
- Mini-cog (or other formal tool)
- History from caretakers
- Refer to PMD, geriatrician, mental health specialist
Depression
- Validated questionnaires
- None suggested
Risk factors for delirium
- Avoid deliriogenic medications
Alcohol and substance use
- CAGE exam
- Perioperative multivitamins, thiamine
- Cessation
Cardiac and pulmonary
evaluation
- ACC/AHA guidelines
- ACS NSQIP PPC guidelines
- Appropriate assessment and perioperative
management
Functional status,
mobility, fall risk
- ADL/IADL assessment
- Fall history
- TUG
- Referral to PT/OT preoperatively
- Begin appropriate discharge planning
Frailty
- Various definitions
- None suggested
Nutritional status
- Height, weight, BMI
- Serum albumin, prealbumin
- Unintentional weight loss
- Full nutritional assessment by dietitian with
supplementation plan if severe risk identified
Medication review
Social
- Titrate, substitute, discontinue drugs
- Avoid polypharmacy
-Advance directives discussion
- Goals and expectations
- Discuss expected postop course
- Discharge planning
Chow WB, et al. J Am Coll Surg. 2012. 215(4): 453.
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geriatric.surgery.ucsf.edu
Case discussion revisited
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To OR for 15 hour surgery, uneventful intraoperative course
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Reintubated on POD0 for airway obstruction
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Extubated POD1
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ICU course complicated by hypoxemia and delirium
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Started on antibiotics for PNA
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Discharged to step down POD7
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Case discussion revisited
•
Started on therapeutic anticoagulation for extensive LUE and LIJ
thrombus on POD9
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Taken urgently back to OR for nasopharyngeal bleeding POD10
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PEA arrest on transfer back to ICU, ROSC after 5 rounds of CPR
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L chest tube placed for PTX sustained during code
•
Extubated POD11
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ICU course marked by significant delirium, difficult to manage pain
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RUE US showed extensive DVT on POD17
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Discharged to step down POD18
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Intensive rehab ongoing
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Conclusions
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Surgical decision-making should depend on patient’s physiologic age and goals
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Reduced physiologic reserve places the geriatric patient at risk during the
perioperative period
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Medical comorbidities
Functional dependence
Cognitive impairment
Malnutrition
Frailty
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Frailty is associated with poor surgical outcomes
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Preoperative assessment of the elderly patient should include evaluation of these
risk factors
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Optimization should occur prior to surgery when possible
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Assessment by multidisciplinary geriatrics team may improve outcomes
Questions?
[email protected]
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