PREOPERATIVE ASSESSMENT OF THE GERIATRIC PATIENT

Cheryl Hinners M.D.

CASE

– MR. PREOP IS A 75YO WM WITH THE PMH OF COPD(NO MEDS, CONTINUES TO SMOKE), DM-2, OA, HTN, AND CAD WITH AN MI 5 YRS AGO. HE HAS BEEN DIAGNOSED WITH PROSTATE CA AND AN OPEN PROSTATECTOMY IS PLANNED.

– LIVES INDEPENDENTLY, SWING DANCES 2X /WEEK. MEDS; ASA, IBPROFEN, NPH BID, FELODIPINE

• MORE THAN 50% OF OLDER AMERICANS WILL HAVE A SURGICAL PROCEDURE AFTER

AGE 65

• ASA CLASSIFICATIONS

• DECREASED SURGICAL MORTALITY

PREOP ASSESSMENT

• IDENTIFY INCREASE RISK FOR COMPLICATIONS

• MAKE RECOMMENDATIONS– COMORBID CONDITIONS– PHARMACOLOGIC TX– FUNCTIONAL/PSYCHOLOGIC STATES

ASSESSING RISK OF CARDIAC COMPLICATIONS

• MOST COMMON AND SERIOUS

• STRONGEST PREDICTORS OF ADVERSE CARDIAC OUTCOMES– RECENT MI– UNCOMPENSATED CHF– USA– ARRYTHMIAS

PRACTICE GUIDELINES

MAJOR CLINICAL PREDICTORS• USA, CHF, ARRYTHMIAS, SEVERE

VALVULAR DZ

INTERMEDIATE• MILD ANGINA, PRIOR MI,

COMPENSATED CHF, DM

• MINOR CLINICAL PREDICTORS– ADVANCED AGE– ABNORMAL EKG– ABNORMAL RHYTHM– LOW FUNCTIONAL CAPACITY(METS)– H/O STROKE– UNCONTROLLED HTN

PROCEDURE RISK

• HIGH– EMERGENT– MAJOR VESSEL PROCEDURE– PVD PROCEDURE– PROLONGED PROCEDURE

• INTERMEDIATE RISK– CAROTID ENDARTECTOMY– HEAD AND NECK PROCEDURES– INTRAPERITONEAL/INTRATHORACIC– ORTHOPEDIC– PROSTATE

• LOW RISK PROCEDURES– BREAST– CATARACT– ENDOSCOPIC

MANAGEMENT OF SELECTED PROBLEMS

• HTN– DIASTOLIC BP >110 OR MAJOR

FLUCTUATIONS IN BP– ELEVATED BP

• REVIEW MEDS, CONSIDER AGE-RELATED CHANGES, VOLUME STATUS, PAIN, FULL BLADDER.

• CHF– SIGNIFICANT RF FOR CARDIAC

COMPLICATIONS– TX OF SYSTOLIC DYSFUNCTION– MANAGEMENT INTRAOP

• PULMONARY DISEASE– POSTOP MORBIDITY IN 40% ELDERLY

FROM RESPIRATORY PROBLEMS– AGE-RELATED CHANGES– ANESTHESIA– SURGICAL PROCEDURE– POSTOP PAIN MEDS

****PREOP FUNCTIONAL LEVEL IS A RELIABLE PREDICTOR OF PULMONARY COMPLICATIONS******

• INTERVENTIONS– SMOKING CESSATION– COPD CONSIDERATIONS

• DIABETES– MEDICATION CONSIDERATIONS

• THROMBOEMBOLIC DZ– OCCUR IN 20-30% OF PATIENTS

UNDERGOING GENERAL SURGERY– HIGHER INCIDENCE , >40%

• HIP/KNEE

• GYN CA/ OPEN PROSTATECTOMY

• NEUROSURG

• NEUROPSYCHIATRIC DISORDERS– DEMENTIA– DELIRIUM– DEPRESSION EXACERBATION– ALCOHOLISM

POSTOP PAIN

• PAIN SCALE

• MEDICATIONS

• LAXATIVES

PREDICTORS OF POOR OUTCOME

• ADVANCED AGE

• POOR FUNCTIONAL STATUS

• IMPAIRED COGNITION

• LIMITED SOCIAL SUPPORT

IATROGENIC ILLNESS

• DVT

• DOSING DRUGS

• DRUG-DRUG INTERATIONS

• PRESSURE ULCERS

• DEHYDRATION