Tessa Collins, MD Tessa.collins2@providence.orgMedical Director Perioperative Care ClinicProvidence Portland Medical CenterDirector of Perioperative Medicine, Oregon Anesthesiology Group

Perioperative Evaluation and Management of the Geriatric Surgical Patient

9/12/20

OGS 2020

No Financial Disclosures or conflicts of interestOGS 2020

Objectives

• Describe the essential tools and risk stratification methods for preoperative geriatric assessment

• Identify key factors in the assessment used to predict perioperative outcomes

• Describe several preoperative optimization strategies used for risk mitigation

OGS 2020

Algorithm to approach

your geriatric

patient with a condition potentiallyamenable to surgery

Step 1 Determine goals and priorities of patient

Step 2 Assess the role of surgery in satisfying patient’s goals and priorities

Step 3 Perform a geriatric focused preoperative assessment

Step 4 Formulate preoperative optimization plan

OGS 2020

Step 1 Determine goals and priorities of patient

Goals of Care documented in chart

– Life prolongation

– Function & Independence

– Maintenance of Cognition

– Comfort

– Consider this a good time to discuss ADVANCED DIRECTIVES and POLST

Oresanya et al, JAMA 2014

OGS 2020

• Shared clinical decision makingfully engages the patient in the process of making choices about treatment options and incorporates the patient’s wishes about what matters most to them into the decision

• Appropriateness of care is the responsibility of the physician to offer the right treatment options that make sense for a particular patient

OGS 2020

• 226 patients with limited life expectancy • Hypothetical scenarios assessed treatment preferences

according to three components of any given therapy:• Burden of treatment (LOS, major intervention, ICU, mech

vent)• Expected Outcome

- Return to current health- Death- Functional impairment- Cognitive impairment

• Likelihood of these outcomes

OGS 2020

Fried TR et al. N Engl J Med 2002;346:1061-1066.

Treatment Preferences According to the Burden and Outcome of Treatment.

OGS 2020

Patient Caregiver Agreement about acceptable outcomes• >80% for health states

- Current Health, mild memory impairment• 61-65% for severe pain

- patients/caregivers equally likely to rate as acceptable• 58-62% for severe functional impairment

- Caregiver more likely to rate as acceptable

OGS 2020

Step 2Assess the

role of surgery in satisfying

patient’s goals and priorities

Surgery Benefits

– Cure of disease

– Symptom relief

– Prolongation of life

– Improved function

Surgery Risks

– Premature death

– Cognitive Dysfunction

– Loss of function

– Loss of independence (eginstitutionalization)

OGS 2020

Many studies looking at Major Cancer surgery in the elderly and outcomes………OGS 2020

Multicenter prospective cohort study• 3322 pts, major digestive

surgery• Age > 65 independent risk

factor for mortality

Ann Surg. 2011 Aug;254(2):375-82.

OGS 2020

• ≥ 75 higher mortality and complication rate

• If ≥ 75 and had a complication, mortality twice as high

• Independent risk factors for severe complications and/or mortality

- albumin level of < 4 g/dl - lung disease- intraoperative transfusion- concurrent intra-abdominal operation- operative time of >240 min

OGS 2020

• 9,397 stage I–III colorectal cancer • 10 % excess mortality for elderly in first 1 year• Elderly colorectal cancer patients who survive the first year have

the same cancer-related survival as younger patients

OGS 2020

Emily Finlayson, Zhaohui Fan, John D. Birkmeyer

Journal of the American College of Surgeons, Volume 205, Issue 6, 2007, 729–734

Light gray bar, aged 65 to 69 years

Dark gray bar, aged 70 to 79 years

Black bar, aged 80+ years

Outcomes in Octogenarians Undergoing High-Risk

Cancer Operation: A National Study

30 day mortality rates

• National benchmark data• 30 day mortality after major

cancer surgery• 14,088 patients >65

OGS 2020

Mortality in minor operations…OGS 2020

GI surgery in Nursing Home residents

• National Medicare claims and Minimum Data Set (1999-2006) to look at 70,719 nursing home residents having surgery for bleeding duodenal ulcer, cholecystectomy, appendectomy, and colectomy

• Operative mortality compared with 1.1 million non-institutionalized Medicare patients undergoing same operations

Finlayson et al, Ann Surg 2011

OGS 2020

Finlayson et al, Ann Surg 2011

OGS 2020

Predicts Poor

Outcomes

• Preoperative Cognitive Impairment

• Functional Dependence

• Preoperative institutionalization

• Frailty

OGS 2020

Frailty

• Increased vulnerability to adverse outcomes

– Postoperative complications

– Increased LOS

– Discharge to institution

– Delirium

– Functional Dependence

– Mortality

– Falls

OGS 2020

What does the recovery period actually look like for older adults?Informed Decision making requires we

give patients accurate information about likely postoperative outcomes and potential complications!

OGS 2020

• Prospective Cohort study 372 patients >60 y

• Major Elective Abdominal Surgery

• Assessed levels of functional dependence

– Preop,1 wk, 3wk, 6 wk, 3m, 6m

• Utilized both self-report and performance-based instruments

Lawrence et al, J Am Coll Surg 2004

OGS 2020

Lawrence et al, J Am Coll Surg 2004

OGS 2020

Lawrence et al, J Am Coll Surg 2004

OGS 2020

Results

• Max functional decline occurs at 1 week

• Protracted disability at 6 months after operation was substantial

• Preoperative Depression was an independent predictor of recovery and longer time to recovery in IADL

• Better preoperative physical performance status and serious postoperative complications consistently predicted recovery.

OGS 2020

Useful Tools for Understanding Prognosis

Geriatric Prognosis Indices

• Eprognosis.ucsf.edu

Surgical Prognosis

• ACS NSQIP Surgical Risk Calculator

– https://riskcalculator.facs.org

OGS 2020

Eprognosis.ucsf.edu

Impact of comorbidities on Prognosis

OGS 2020

OGS 2020

OGS 2020

OGS 2020

OGS 2020

Geriatric Specific Outcomes

OGS 2020

OGS 2020

Step 3

Perform comprehensive

geriatric preoperative assessment

Recommended for patients >75 having major inpatient surgery (LOS > 2 days)

Goal: Identify modifiable risk factors that may benefit from preoperative intervention.

OGS 2020

Cognition

Comorbidities

Function & Mobility

Nutrition

Goals of Care

OGS 2020

Tools used for CGA in Preoperative Clinic

• Mini-Cog or MOCA or SLUMS (depends on surgery and situation)

• ADL/IADL screen

• TUGT

• Nutrition risk/Weight loss

• PHQ-2

• Substance use screen

• Frailty Screen

OGS 2020

OGS 2020

Frailty Score

• Fried – 3 or more of the following

– Weight loss ≥ 10 lbs in the last year

– Decreased grip strength

– Exhaustion

– Low physical activity

– Slow gait speed

• Modified: Grip strength and weight loss

OGS 2020

Frailty Screen for

Preoperative Clinic

FRAIL SCALE:

Fatigue

Resistance (ability to climb one FOS)

Ambulation (ability to walk one block)

Illnesses (Greater than 5)

Loss of weight (>5% in last 12 months)

Total score: 0 = Robust, 1-2 = pre-frail, >2 = frail

J Clin Anesth. 2018;47:33-42

OGS 2020

OGS 2020

OGS 2020

Step 4Preoperative Optimization

Plan

• Medical comorbidities

• Cognition- delirium prevention & post-op disposition plan

• Substance Use- detox plan

• Function/Mobility-Prehabilitation

OGS 2020

Medical Comorbidities

• DM -A1C<8 %

• COPD – no active wheezing, inhaler compliance

• OSA- frequently diagnosed in clinic, needs to be treated for major surgery

• HTN – well-controlled?

• CAD- stable? Medically managed?

• CHF- compensated/stable? BNP or echo needed?

• Cirrhosis- calculate MELD/Childs-pugh

• CKD- stable? Stop NSAIDS etc, AKI prevention

OGS 2020

Cognition

Mini-Cog Screen

– Discuss with patient and family

– Primary focus is delirium prevention

• Bring assistive devices- glasses, hearing aids, dentures

• Family at Bedside!

• Recs in consult for perioperative care to support delirium reduction (decreased use of opioids, avoid benzos multimodal anesthesia, only melatonin for sleep, etc)

OGS 2020

Substance Use

• Alcohol cessation support- serial serum ETOH levels and BH referral

• Smoking cessation- medication supported, BH, serial testing

OGS 2020

Prehabilitation• Refer to PT for strength

and gait training, aerobic conditioning

• OT as needed, especially for home safety evaluation if patient returning home alone or will need assistive devices after surgery

• Nutrition referral if needed

• 5 days Protein drinks for major surgery

OGS 2020

• Geriatric surgery patients have increased mortality that extends out to 1 year, largely due to an increased complication rate and inability to tolerate complications when they occur

• Goal is to identify the at risk subset, optimize if possible and at very least improve informed consent with shared clinical decision making

• Don’t deny patients potentially curative operations based on age alone, many of these patients will tolerate surgery well and have good outcomes

ConclusionOGS 2020

https://www.facs.org/quality-programs/geriatric-surgery

OGS 2020