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