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Five Practical Tips for the Older Surgical Patient: From a Geriatrician’s Perspective G. Paul Eleazer, MD,FACP,AGSF University of South Carolina School of Medicine Visualize a patient who is 80 years old. What does he or she look like ? Tip One • All Older People Are Not Alike! Don’t Base Judgments On Age Alone Don’t Deny Surgery Unnecessarily (Agism) Don’t Press For Surgery If Benefit Is Minimal Aging Heterogeneity Source: Solomon, UCLA Review Course 2002 Why Is There So Much Variance In Older Adults? • Genetic Differences • Environmental Stresses Differ Tobacco Alcohol Exercise • Aging Dependant Diseases Aging Changes from the Geriatric Perspective • Disease Versus Normal Aging • Decreased Reserve Capacity Varies Between and Within Individuals After Age 30, most “typical” declines are 510% declines in Physiologic Function Aging Changes from the Geriatric Perspective • Homeostenosis Impaired Response To Physical, Emotional, And Environmental Stresses Example: Fluid Challenge of 1000cc: 35 year old 70 year old 35 Year Old with 1000 cc Fluid Bolus • Excess of 500 cc What are the likely Consequences? 80 Year Old with 1000 cc Fluid Bolus • Excess of 500 cc What are the likely Consequences? Relevant Changes That Occur With Aging • Physiology Pulmonary Cardiac Pharmacologic Wound Healing Immune function • Anatomic • Functional • Social Age Related Changes in Pulmonary Function Impact of Training on VO2Max with Age Heath 1981; Lakatta,1993 Impact of Training on VO2Max with Age Heath 1981; Lakatta,1993 Impact of Training on VO2Max with Age Heath 1981; Lakatta,1993 Pulmonary Changes with Aging Declines In: Alveolar Surface Area Diffusion Capacity Hypoxic Drive Arterial PO2 Arterial PO2 Correction for Age (Room Air) Expected PaO2 = 100 – (Age/3) • For a 20 year old = 93 mmHg • For a 90 year old = 70 mmHg Airway Changes • Swallowing Changes Predispose to Aspiration • Decreased Numbers and Function of Cilia • Diminished Cough • Pneumonia More Common Cardiac Changes with Aging Changes in Conduction • Multiple Changes, Net Results: Decline in Maximum Heart Rate 220 minus Age [or other formula] • Decreased Beta-2 Receptors Decreased Response to Beta Agonists Heart Rate And Age • Rounds on Two Post Op Patients: 20 year old with HR of 100 95 Year old with HR of 100 • What is your Level of Concern for Each? Calculate Predicted Maximum Heart Rate • 20 year old = 220 – 20 = 200 • 95 Year old =220 - 95 = 125 20 Year Old with Heart Rate of 100 • Percent of Maximum HR= Actual/Predicted x 100 • 100/200 = 50% Maximum Predicted HR 95 Year old with Heart Rate of 100 Percent of Maximum HR= Actual/Predicted x 100 100/125 = 80% Maximum Predicted HR Each Patient has Heart Rate of 100 • 20 year old = 100/200 = 50% Maximum Predicted HR • 95 Year old =100/125 = 80% Maximum Predicted HR Equivalent to an ongoing Cardiac Stress Test! Functional Cardiac (Pump) Changes • Resting Cardiac Output - Little Change • Maximum Cardiac Output - Declines Functional Cardiac (Pump) Changes • Decreased LV Compliance • Increased Diastolic Dysfunction • Increased Importance of Atrial Contraction Decreased Tolerance for Atrial Fibrillation Increased Importance of Atrial “Kick” with Age Atrial Fibrillation Less Well Tolerated From Swinn,1989 Age Associated Declines in GFR and Renal Plasma Flow Based on Data from Davis JCI 29:496-507 (1950) Tip Two Be Gentle • In Relationship • In Caring • In Doing Anything ! Tip Three • Medications are Dangerous in Older Adults Start Low, Go Slow Avoid all Medications, if Possible Particularly Avoid Certain Medications Tip Three: Medications are Dangerous in Older Adults Start Low, Go Slow Avoid all Medications, if Possible Particularly Avoid Certain Medications Medications in Older Adults • Older People Take More Medications • Drug-drug Interactions More Likely • Adverse Drug Reactions More Serious Two Patients, Both Get 1mg Lorazepam for Agitation • 20 Year Old • 80 Year Old Unsteady Gait Fall Two Patients, Both Get 1mg Lorazepam for Agitation • 20 Year Old • 80 Year Old Unsteady Gait No Injury Fall Hip Fracture Delirium • In Post Operative Patients Often Due to Medications May be Due to Other • • • • • Hypoxia Pain Infection Sleep Deprivation Others Delirium • Adding a Medication to Treat Delirium May Be Hazardous More Drug Interactions More Adverse Reactions Often Does Not Help the Patient ! • If you “must” – low dose Haloperidol (0.5 mg) Mortality of Delirium • Mortality of in-hospital delirium 25-33% • Unrecognized by Physicians 30-50% of the Time ! Inouye SK et al, American Journal of Medicine May 1999 Diagnosing Delirium Confusion Assessment Method 1. Acute Onset & Fluctuating Course Plus 2. Inattention And One Of The Following: 3. Disorganized Thinking 4. Altered Level of Consciousness Inouye SK, et al. Ann Intern Med 1990; 113:941-8 Commonly Used Drugs That Should Be Avoided In Older People • • • • • • Propoxyphene ( Darvon, Darvocet) Meperidine (Demerol) NSAID’s – (Indocin, Toradol) Diphenhydramine (Benadryl) Muscle Relaxants (Flexeril, Robaxin) Benzo’s -especially Valium, Dalmane Beers, MA Archives IM 1997,157:15311536), Updated 2002 Start Low, Go Slow ... Tip Four • Function is Most Important Pre Op Post Op Long Term Function is Most Important • Pre Operatively Baseline Function Predicts Morbidity and Mortality • 4 MET Equivalent Consider “Prehab” Realistic Goal Setting Planning for Post Operative Care Function is Most Important • Post Operatively Early Mobilization Rehabilitation Function is Most Important • Long Term Prevention of Functional Decline Planning, Ethical Issues Tip Five There are no “Benign Procedures” in Older Adults! Where I First Learned About Iatrogenesis • Summer of 1979 Mr. Monroe H. 76 Year Old Admitted with Diarrhea and Weight Loss Admission U/A showed 10-20 WBC’s and many epithelial cells Where I First Learned About Iatrogenesis • 76 Year Old Admitted with Diarrhea and Weight Loss “To Catheterize or Not To Catheterize” for a repeat U/A - ???? “It’s a Benign Procedure” Where I First Learned About Iatrogenesis • Catheterized Vagal Reaction Unresponsive Code Called Right Central Line Placed “for access” Moved to the ICU Where I First Learned about Iatrogenesis • Post Central Line CXR Pneumothorax Chest Tube Placed SBFT Placed Long, Tortuous, Hospital Course Death about 1 month after admission. Conclusion There are NO Benign Procedures in Someone over Age 65 ! Summary of Tips from the Geriatrician’s Perspective 1. All Older People Are Not Alike! 2. Be Gentle 3. Medications are Dangerous in Older Adults 4. Function is Most Important 5. There are No Benign Procedures in Older Adult