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Geriatrics Perioperative Care
Beth A. Barron, MDColumbia University
Associate Program Director of Internal Medicine
Allen Hospitalist Co-Director(no disclosures)
Objectives
1. Review the effects of aging on organ systems and consider how this effects the perioperative evaluation
2. Consider interventions to predict and reduce complications
3. Review the approach to perioperative evaluation in the elderly
CASE
Mrs. G is a 90 yo female with past medical history of hypertension, osteoporosis, and hyperlipidemia who presents with L sided hip fracture after slip and fall.
Meds: Lisinopril, Cardizem, Lipitor, Raloxifene, and Benadryl prn sleep
Exam: 180/100 HR 92
What is the most important predictor of postoperative complications in the elderly?
A. AgeB. ComorbiditiesC. Functional
StatusD. Thallium Stress
Testing
Age
Comorbiditi
es
Functi
onal Statu
s
Thallium Stre
ss Testi
ng
0% 0%0%0%
Principle # 1
Chronological age alone should not lead to refusal to clear for surgery
Understand the effects of aging on all organ systems.
Chronological age as surgery determinant
Geriatric assessment and severity of illness are better predictors of postoperative morbidity than age
Complications are beyond mortality and CV events. Loss of function, independence and cognitive status are of great importance to the patients.
Evidence Effects of Age and Severity of Illness on
Outcome and Length of Stay in Geriatric Surgical Patients William E. Dunlop, MD, THE AMERICAN JOURNAL OF SURGERY VOLUME 165 MAY 1993
Early and long-term outcomes of carotid endarterectomy in the very elderly: an 18-year single-center study. Ballotta E; Journal of Vasc Surg 2009; 50(3) 518-25.
What are the effects of aging on the cardiac system?
A. Increased risk of atrial fibrillation
B. CHFC. HypotensionD. All of the above
Increase
d risk o
f atri
al fib... CHF
Hypotension
All of t
he above
0% 0%0%0%
Effect of aging on cardiac system
Conduction system disorders Delays in conduction Increasing risk of atrial fibrillation
Blood pressure Increasing systolic pressure Increasing risk of orthostasis
Ventricular hypertrophy and stiffness Reduced heart rate variability
Current Recommendations
What are the effects of aging on the pulmonary system?
A. Decreased cough
B. Decreased FEV1C. Decreased
response to hypercapnia
D. All of the aboveDecre
ased co
ugh
Decreas
ed FEV1
Decreas
ed resp
onse to
h...
All of t
he above
0% 0%0%0%
Effects of aging on pulmonary system
Clin Interv Aging 2006 September; 1(3) 253-260.
Other effects of aging important in the perioperative period
Trend towards more hypercoagulable
Decreased immune system response
Decreased kidney function
When reviewing this patients medications (Lisinopril, Cardizem, Lipitor, Raloxifene, and Benadryl prn sleep)….
A. Continue all medications
B. Continue all but Benadryl
C. Discontinue LipitorD. Discontinue
Lisinopril, Raloxifene and Benadryl
Continue all medica
tions
Continue all but B
enadryl
Discontinue Li
pitor
Discontinue Li
sinopril
, Ra...
0% 0%0%0%
Principle # 2
Review all medications preoperatively and eliminate the unnecessary and potentially harmful.
Polypharmacy
Discontinue all nonessential meds Avoid any medications predisposing to delirium
Anticholinergics Benzodiazepines Opiates Tricyclic antidepressants Benadryl
Hold any medications with potential harm in the periop period ACE (hypotension, renal) Hormones (thrombosis)
Principle # 3
Determine cognitive ability, competency, functional status and availability of supports.
Determine advance directives, health care proxy, and goals of care
Informed consent/Capacity to Consent
Understand the risks vs benefits Goals of Care Complications Likelihood for survival Likelihood for functional decline
The day after the operation she becomes confused and agitated.
A. This could have been prevented with preoperative Haldol
B. Give a stat dose of Ativan and observe
C. This could have been prevented with a geriatrics consult
This could have
been pr...
Give a stat d
ose of A
tiva...
This could have
been pr...
0% 0%0%
Principle #4
Be aware of preoperative risks of delirium
Consider ways to minimize the development of delirium
Be alert to the occurrence of postoperative delirium
Dementia
Mini mental state examination Ask patient and family about
memory loss Review ability to complete ADL’s,
IADL’s Major post op mortality predictor:
increase up to 50%
Post operative cognitive dysfunction
Separate from transient delirium from anesthetics or post operative complications
May be related to sensitivity of neurologic tissue to hypoxia and hypotension
Evidence
Monk, TG. Predictors of cognitive dysfunction after noncardiac surgery. Anesthesiology 2008; 108:18-30
Discharge cognitive dysfunction 36.6% age 18-39 30.4% age 40-59 41.4% age > 60
Cognitive dysfunction at 3mo 5.6% less than age 60 12.7% greater than age 60
Predicting delirium Severe illness (complicated infection) Baseline dementia Dehydration Sensory impairment (visual*) Risk of delirium
4% if none 11% if 1 or 2 37% if 3 or more
Kalisvaart KJ. Risk factors and prediction of postoperative delirium in elderly hip-surgery patients. J Am Geriatr Soc 2001: 49:516-522.
Predicting delirium
Marcantonio ER, A clinical prediction rule for delirium after elective noncardiac surgery. JAMA 1994: 271: 134-139.
One point: Age >70 History of etoh abuse Baseline cognitive impairment Severe physical impairment (ADL’s) Abnormal electrolytes or glucose Noncardiac thoracic surgery Abdominal aortic aneurysm (2 pts)
Consequences of delirium
Can be prolonged Occurs in 15% of elderly surgical
patients (even higher in ortho – 41% in hip fracture)
Increases mortality and SNF placement
Increases length of stay
Marcantonio, J Am Geriatr Soc 2000 Jun; 48(6): 618-24
Preventing delirium
Risk factor assessment: Alcohol Dementia
Discontinue high risk medications Consider hydration and nutritional state
Environment: Day/night Reorientation Bring visual and hearing aides and walking assist
devices for patient use Avoid hypotension, hypoxia Minimize anesthesia time or consider local/regional
Preventing delirium
Low dose Haldol Kalisvaart, KJ. Haloperidol prophylaxis
for elderly hip-surgery patients at risk for delirium. J Am Geriatr Soc. Oct 2005; 53(10): 1658-66
Patients > 70 with risk factors for delirium given 1.5mg daily pre and post op
Decreased LOS and severity of delirium but not incidence
Prevention of delirium
Geriatric consult Decreases rate from 50 to 32% Orientation, lighting, Hearing aides,
glasses Avoid restraints Minimize medications Prevent hypoxia, dehydration, malnutrition Encourage ambulation
Marcantonio, J Am Geriatr Soc 2001 May; 49(5):516-22
Principle # 5
Assess volume status and nutrition pre and post operatively.
Monitor hemodynamics in high-risk patients and maintain adequate intake
Nutrition
Complications associated with poor outcomes: Delayed wound healing
Markers of poor nutrition that predict outcomes Albumin < 3.2 g/dL Cholesterol < 160mg/d:L Body mass index < 20 kg/m2
Evidence supporting supplemental nutrition improving outcomes is weak at best
Cochrane Database 2005
Important things to consider when treating pain in the geriatric patients include
A. Patients may be more sensitive to these medications
B. Pain may be undertreated in this population
C. Hydration and nutrition influence the dosing needed
D. All of the above
Patients
may be more
sen...
Pain m
ay be undertr
eate...
Hydration and nutri
tion i...
All of t
he above
0% 0%0%0%
Principle # 6
Pain control continues to be essential in the elderly population.
May be more sensitive to both the effects and side effects of these medications.
Pain management in the elderly
Risks of under treatment – cognitive difficulties requesting
Drug-drug interactions More vulnerable to side effects and
over medication Changes in renal and hepatic clearance Reduced lean body mass and total water Poor nutrition or hydration
Determining preoperative frailty can help determine
A. LOSB. Discharge
dispositionC. Post operative
complicationsD. All of the above
LOS
Discharge disp
osition
Post opera
tive complic
at...
All of t
he above
0% 0%0%0%
Principle # 7
Functional status, fall risk and frailty are important to consider when estimating a patients ability to recover from surgery.
Frailty is likely the most predictive measure of postoperative mortality.
Functional Status, Mobility, Frailty
Assessing functional status Fall risk Frailty
Markers can predict post-op complications, LOS and d/c To SNF
Gait/Mobility TUGT (timed up and go test)
Frailty is predictive of postoperative complications
Frailty risk score Weakness (grip strength) Weight loss (>10lb in 1 year) Exhaustion (everything is an effort, could not
get going) Low physical activity (M Slowed walking speed (measured 15ft speed)
Frailty as a Predictor of Surgical Outcomes in Older Patients Makary J AM Coll Surg 2010
Summary: Geriatric Preoperative Checklist:
Complete history and physical examination. Assess the patient’s cognitive ability and
capacity to understand the anticipated surgery.
Identify the patient’s risk factors for developing postoperative delirium
Consider all current medical issues and their effects on the perioperative period.
Review ways to reduce cardiac and pulmonary complications.
Summary: Geriatric Preoperative Checklist
Document functional status and history of falls. Determine baseline frailty score.
Assess patient’s nutritional status and consider preoperative interventions if the patient is at severe nutritional risk.
Medication reconciliation and consider appropriate perioperative adjustments. Consider risk of polypharmacy.
Determine patient’s family and social support system.
Future research opportunities
Preoperative predictions: Usable risk predictors What laboratory and radiology tests are
necessary? Multidisciplinary team assessments
Preoperative optimization: Explore the effects on preoperative interventions:
anemia, nutrition, mobility, strength Postoperative management:
Pain control Multidisciplinary Teams