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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. 1 9/21/2015 Surgery in the elderly • Approximately 50% of patients over 65 will require surgery during their lifetime • > 33% of inpatient procedures in 2007 were performed on patients aged 65+ Expected to double by 2020 • Cancer is the leading cause of mortality in patients over 65 years Suboptimal management may decrease quality of life and increased dependency • 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 2 9/21/2015 Case discussion • 89-year-old man with invasive squamous cell carcinoma scheduled for maxillectomy, radical neck dissection, and right thigh free flap. • PMH: • 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: 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? • Not happening! Case cancelled. • Discuss surgical indications and alternative treatment options with the surgeon • Seek input from a cardiologist • Proceed with the case 3 9/21/2015 Outline • Decision making in the perioperative period • Preoperative risk and risk stratification in geriatric surgical patients • Functional status Cognition Frailty Scoring systems Preoperative evaluation of geriatric surgical patients Medical testing Geriatric-specific assessments • Preoperative optimization Surgical decisionmaking 4 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 5 9/21/2015 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. 6 9/21/2015 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. 7 9/21/2015 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. 8 9/21/2015 Preoperative risk stratification Traditional risk stratification tools • Revised cardiac index • Comorbidities • Exercise tolerance (METs) • Basic laboratory studies • ASA classification 9 9/21/2015 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. • Propensity-matched cohorts from ACS NSQIP database • Propensity-matched cohorts from ACS NSQIP database • Patients with preoperative impaired sensorium had higher rates of: • Complex vascular or general surgery • Functionally dependent patients had higher rates of: Pneumonia Ventilator dependence Renal failure Urinary tract infection Stroke Venous thromboembolism Death 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) 10 9/21/2015 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 • • • Composite phenotype of functional and physiologic decline Reflects a state of reduced physiologic reserve Associated with increased susceptibility to poor outcomes • Clinical domains of frailty: Cognition Activity Nutrition Mobility Strength Energy Mood Robinson TN, et al. Ann Surg. 2009. 250(3):449. 11 9/21/2015 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) 12 9/21/2015 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. 13 9/21/2015 J Am Coll Surg. 2013. 217:665. 14 9/21/2015 2015 15 9/21/2015 Defining frailty • Cognition • Mini-cog < 3 Impaired cognitive function Delirium risk factors Recent falls Up and go test • • Activity Functional dependence Daily activity level • Nutrition Recent weight loss Albumin < 3.3 g/dL Low BMI Mobility Strength Grip strength • Mood Depressed mood • Comorbidity Hematocrit < 35% Charlson Comorbidity Index > 3 Robinson TN, et al. Ann Surg. 2009. 250(3):449. 16 9/21/2015 Frailty, in summary • Predictor of postoperative complications, discharge to institution, hospital readmission, mortality • Spans multiple surgical subspecialties • No consensus definition exists • Further study needed to determine most important elements of frailty Surgical risk calculators • American College of Surgeons: NsQip www.riskcalculator.facs.org • Cardiothoracic specific: Euroscore www.euroscore.org STS risk calculator www.sts.org/quality-research-patient-safety/quality/risk-calculator-andmodels/risk-calculator • UCSF: eprognosis.org 17 9/21/2015 Riskcalculator.facs.org 18 9/21/2015 J Am Coll Surgeons. 2013. 217: 833. Observed rate Observed rate 19 9/21/2015 eprognosis.org Preoperative evaluation of geriatric patients 20 9/21/2015 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. • • Chen CL, et al. NEJM. 2015. 372(16):1530. Data collected from large surveys conducted by the CDC and NCHS yearly from 1997 – 2010. • Before and after release of new ASA and ACC/AHA guidelines for preop testing in 2002 • 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 • Routine EKG was the only test to decrease • Testing patterns varied widely between practice settings • UA, CXR, Hgb, stress testing patterns did not change • No change in testing practices compared with 20 years ago 21 9/21/2015 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. 22 9/21/2015 Cognition: Mini-cog Risk factors for delirium • Age > 65 years • Poor nutrition • Cognitive decline or dementia • Alcohol or substance use • Poor vision or hearing • • Severe illness or comorbities Electrolyte or metabolic abnormalities • Infection • Sleep disturbance or deprivation • Functional dependence • Depression • Immobility • Polypharmacy Am Geriatrics Society Expert Panel. J Am Coll Surgeons. 2015. 220(2):136. 23 9/21/2015 Functional assessment: Fall history • 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. 24 9/21/2015 25 9/21/2015 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. 26 9/21/2015 Preoperative optimization Comprehensive Geriatric Assessment • Well-established evaluation and intervention process • Patient-specific plan for treatment and follow up developed • Domains involved: • 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. 27 9/21/2015 Clinicians involved in CGA • Geriatricians • Pharmacists • Internists/hospitalists • Nurse specialists • Physical therapists • Dieticians • Occupational therapists • Social workers CGA predicts adverse outcomes in elderly surgical patients Kim K, et al. Arch Geront Geriatrics. 2013. 56:507. 28 9/21/2015 CGA may improve postoperative outcomes • 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 • Frailty is difficult to treat! • Interventions are better established in community, long-term care, and medical inpatient setting • Limited evidence in surgical population • 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. 29 9/21/2015 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. 30 9/21/2015 geriatric.surgery.ucsf.edu Case discussion revisited • To OR for 15 hour surgery, uneventful intraoperative course • Reintubated on POD0 for airway obstruction • Extubated POD1 • ICU course complicated by hypoxemia and delirium • Started on antibiotics for PNA • Discharged to step down POD7 31 9/21/2015 Case discussion revisited • Started on therapeutic anticoagulation for extensive LUE and LIJ thrombus on POD9 • Taken urgently back to OR for nasopharyngeal bleeding POD10 • PEA arrest on transfer back to ICU, ROSC after 5 rounds of CPR • L chest tube placed for PTX sustained during code • Extubated POD11 • ICU course marked by significant delirium, difficult to manage pain • RUE US showed extensive DVT on POD17 • Discharged to step down POD18 • Intensive rehab ongoing 32 9/21/2015 Conclusions • Surgical decision-making should depend on patient’s physiologic age and goals • Reduced physiologic reserve places the geriatric patient at risk during the perioperative period Medical comorbidities Functional dependence Cognitive impairment Malnutrition Frailty • Frailty is associated with poor surgical outcomes • Preoperative assessment of the elderly patient should include evaluation of these risk factors • Optimization should occur prior to surgery when possible • Assessment by multidisciplinary geriatrics team may improve outcomes Questions? 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