Objectives

UMMS CRITPreoperative Assessment in the Older Adult

Erika Oleson, DO, MSDivision of Geriatric MedicineUniversity of Massachusetts

UMMS CRIT 2012 Module I: Preoperative Assessment in the Older Adult

Advancing Geriatrics Education (AGE) A UMMS initiative funded by the Donald W. Reynolds Foundation

By the end of this lecture, the participant should be able to identify and describe:

• The purpose of preoperative assessment• How age-related physiologic changes influence perioperative care• Components of preoperative assessment • How to minimize perioperative risks

Objectives



• Identify specific patient related factors which may increase risk for complications

• Identify procedural risks and how they can impact recovery• To recommend treatment plans to minimize complications during

and after the procedure

Why do a Preoperative Assessment?



• Type of surgery (elective, urgent, emergent)• Functional status at baseline• Life expectancy• Co-morbid conditions• Expected outcomes and complications

Key determinants of preoperative risk



• Diminished organ reserves

• Decreased thermoregulation may increase risk of perioperative

hypothermia

• Cardiac and vascular stiffening may complicate fluid management

• Decreased hepatic blood flow and number of functional nephrons

may alter metabolism and clearance of several medications

• Sarcopenia may prolong functional recovery

• Altered sensory perception may increase risk of postoperative

delirium

Physiological changes associated with aging



• Cardiac events• Infection• Delirium• Pressure ulcers• Functional decline• Malnutrition• Inadequate pain control• Deep vein thrombosis

Perioperative complications in the geriatric patient



• Detailed review of clinical history and physical examination• Functional/Physical activity assessment• Cognitive evaluation• Nutritional assessment• Social support• Goals of Care• Advance directives

Components of preoperative assessment



Functional/Physical Activity Assessment

Metabolic Equivalents Examples

1 Watching televisionEating, dressing, cooking, using toiletWalking 1-2 blocks at 2-3 miles per hourLight housework

4 Climbing flight of stairsWalking on ground level at 4 mphRunning a short distanceDoing heavy chores (eg scrubbing floors, lifting furniture)Playing moderately strenuous sports (eg golf, dance,

bowling)>10 Playing strenuous sports (eg tennis, basketball)

Holt NF Perioperative Cardiac Risk Assessment Am Fam Physician 2012; 85(3):239-246Fleisher LA, Beckman JA, Borwn KA, et al. ACC/AHA 2007 guidelines on perioperative cardiovascular evaluation and care for noncardiac surgery

J Am Coll Cardiol. 2007; 50 (17)



American Society of Anesthesiologists (ASA) score:

Class I: normal healthy patient for elective surgery

Class II: patient with mild systemic disease

Class III: patient with severe systemic disease that limits activity but is not incapacitating

Class IV: patient with incapacitating systemic disease that is constant threat to life

Class V: moribund patient who is not expected to survive 24hrs with or without surgery

ASA Scores



• Evaluate baseline cognitive function (Mini-cog, MOCA, MMSE, etc.)

• Dementia and history of delirium increase the risk of postoperative delirium

• Post-operative delirium associated with predisposing risk factors:– Age ≥ 70, cognitive impairment, limited physical function,

history of alcohol abuse, abnormal serum sodium, potassium or glucose, and intraoperative blood loss

• Confusion Assessment Method (CAM) is a useful screening tool for delirium

Cognitive Assessment



Instant Nutritional Assessment

• Hypoalbuminemia (<3.5mg/dl) increases risk of: - Systemic sepsis and pneumonia- Superficial and deep wound infection- Poor wound healing- Pulmonary edema and failure to wean from ventilation- All-cause mortality rate- Increased hospital length of stay and readmission rates

Nutritional Assessment

Gibbs J, Cull W, Henderson W, Daley J, Hur K, Khuri SF. Preoperative serum albumin level as a predictor of operative mortality and morbidity: results from the National VA Surgical Risk Study. Arch Surg. 1999;134:36-42.

Corti M. Serum albumin level and physical disability as predictors of mortality in older persons. JAMA 1994; 272:1036-1042Gastroenterol Clin North Am. 2007; 36:1-22

No malnourishment Serum albumin >=3.5g/dl and TLC >=1,500 cells/mm3

Severe malnourishment Serum albumin <3.5g/dl and TLC < 1,500 cells/mm3



• Manage hypertension- Peri-operative β-blockers for major surgery, if not contraindicated

• Manage diabetes appropriately• Treat reversible factors (anemia, infection, electrolyte imbalance etc.)• Avoid prolonged periods without nutrition• Pre-operative testing, based on clinical predictors and type of surgery

Strategies to Minimize Risk: Pre-operatively



Assessing Cardiac Risk in Non-cardiac Surgery

Emergency Surgery?

Are of major risk factors present?

Proceed to Surgery

Proceed to surgery

Proceed to surgery

Cancel or postpone surgery; correct acute cardiac conditions

Assess for clinical risk factors: Hx of ischemic heart disease, prior or compensated heart failure, history of cerbrovascular disease,

diabetes mellitus, renal insufficiency

Is patient able to do light housework, climb a flight of steps, walk up a hill,

or run a short distance?

Is procedure low risk?

High risk surgery Intermediate risk surgery

Proceed to surgery with perioperative B-blockade; consider stress testing

if it will change managementProceed to surgery

Strongly consider stress testing if it will change management; if not, proceed to surgery with perioperative B-blockade

Yes

Yes

Yes

Yes

No

No

No

≥3 risk factors

No or unknown

1 or 2 risk factors0 risk factors

Fleisher LA, Beckman JA, Borwn KA, et al. ACC/AHA 2007 guidelines on perioperative cardiovascular evaluation and care for noncardiac surgery J Am Coll Cardiol. 2007; 50 (17)



• Manage hypertension and monitor volume status• Control blood sugars appropriately in your diabetic pts• Adequate analgesia, avoid prn orders for patients with cognitive

impairment• Early mobilization/Avoid prolonged bed rest• DVT prophylaxis

• Avoid/Remove catheters if possible• Regularly review medications• Address nutritional needs• Communicate with proxy/family

Strategies to Minimize Risk: Postoperatively



• Elderly patients have decreased reserves in multiple organ systems which increases their risk for several perioperative complications

• Preoperative assessment should be individualized, comprehensive, and multidisciplinary

• Comprehensive perioperative management minimizes complications in older patients, especially those with chronic medical problems and functional impairments

Summary

Documents

Objectives