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Anne Donovan, MDAssistant Clinical ProfessorUCSF Anesthesia and Critical Care Medicine

Preoperative evaluation of the elderly patient:

It’s not just about age anymore!

https://www.census.gov/prod/cen2010/briefs/c2010br-03.pdf. Accessed 9.1.15.

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Surgery in the elderlySurgery in the elderly

• Approximately 50% of patients over 65 will require surgery during their lifetime

• > 33% of inpatient procedures in 2007 were performed on patients aged 65+ Expected to double by 2020

• Cancer is the leading cause of mortality in patients over 65 years Suboptimal management may decrease quality of life and increased dependency

• Age (by itself) is no longer an acceptable exclusion criterion for surgery

Kim S, et al. Clin Int Aging. 2015. 10:13-27Yang R, et al. Ger Ortho Surg & Rehab. 2(2):56-64

Ploussard G, et al. World J Urol. 2014. 32:299

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Case discussionCase discussion

• 89-year-old man with invasive squamous cell carcinoma scheduled for maxillectomy, radical neck dissection, and right thigh free flap.

• PMH: Severe aortic stenosis (valve area 0.9 cm2, peak/mean gradients 56/35) CAD s/p 4 vessel CABG in 2000 Carotid artery stenosis (60% L, < 50% R) Third degree heart block, s/p dual chamber pacemaker placement Hypertension

• SH: Lives at home, partially dependent on care from his nephew Ambulates with walker No problems with oral intake Cognitive function and decision making capacity intact

What would you do?What would you do?

• Not happening! Case cancelled.

• Discuss surgical indications and alternative treatment options with the surgeon

• Seek input from a cardiologist

• Proceed with the case

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OutlineOutline

• Decision making in the perioperative period

• Preoperative risk and risk stratification in geriatric surgical patients Functional status Cognition Frailty Scoring systems

• Preoperative evaluation of geriatric surgical patients Medical testing Geriatric-specific assessments

• Preoperative optimization

Surgical decision-making

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Focusing on patient goalsFocusing on patient goals

Technique Description

Best case/worst case Decision-making tool allowing presentation of multiple treatment options and range of outcomes

Eliciting patients’ care goals, concerns, triggers for consideringtransition to palliative care

- What is the most important to you right now? (lifeprolongation, maintaining independence, pain control, etc)- What makes life worth living?- Can you imagine anything that would be worse than death?- Would you be willing to go through anything to achieve this goal?- Can you imaging a scenario where you would just want to be kept comfortable?

Advance directives Establishing alternate decision makers

Kruser JM, et al. J Am Ger Soc. 2015. Epub ahead of printOresanya LB, et al. JAMA. 2014. (311);20: 2111

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Perioperative risk in geriatric surgical patients

Physiologic changes in the elderlyOrgan System Age related changes (not inclusive)

Neurologic Loss of brain mass, < cerebral blood flow, < cerebral oxygen consumption, < neurotransmitters, cognitive decline, behavioral variability, < PNS conduction velocity, loss of peripheral neurons, denervation

Cardiovascular CAD, < CO, < LV compliance, autonomic dysfunction, < baroreceptor response, conduction system changes, valvular disease, < vascular compliance

Pulmonary > parenchymal compliance, < chest wall compliance, > V/Q mismatch, < respiratory muscle mass, rapid shallow breathing, > RV and FRC, < FVC and FEV1, < central response to hypoxia and hypercapnia, < ciliary function

Gastrointestinal Protein malnourishment, < hepatic blood flow, < hepatic microsomal enzyme function, < drug metabolism, < plasma protein concentration

Renal < renal mass, < renal blood flow, < GFR, < urine concentrating ability, < response to plasma hormones

Hematologic Anemia, < blood volume, < bone marrow cellularity

Immunologic < immune system function

Endocrine Insulin resistance, < hormone (free T3, GH, aldosterone) production

Musculoskeletal Decreased muscle mass, increased fat mass, impaired thermoregulation, skin fragility

Yang R, et al. Ger Ortho Surg & Rehab. 2(2):56-64.

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Additional considerations in the elderly

Additional considerations in the elderly

• Comorbidities

• Polypharmacy Altered drug metabolism

• Functional status

• Nutritional status

• Communication and comprehension issues

• Frailty

• Social needs

Geriatric syndromes

Jones TS et al. JAMA Surg. 2013. 148(12):1132.

Physiologic decline

Pressure ulcers

Incontinence

Functional declineFalls

Delirium

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Perioperative stress in the elderlyPerioperative stress in the elderly

Surgical stress

response

Decreased physiologic

reserve

Poor outcomes

“… Age per se should not be considered an exclusion criterion for surgery.

Biological age, which is the result of pathophysiologicaging processes, comorbidity, and genetic factors, seems to be more predictive than chronological age in defining the degree of fitness and performance of a given individual

when facing health problems.”

“… Age per se should not be considered an exclusion criterion for surgery.

Biological age, which is the result of pathophysiologicaging processes, comorbidity, and genetic factors, seems to be more predictive than chronological age in defining the degree of fitness and performance of a given individual

when facing health problems.”

Bettelli G. Minerva Anes. 2011. 77(6):637.

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Preoperative risk stratification

Traditional risk stratification toolsTraditional risk stratification tools

• Revised cardiac index

• Comorbidities

• Exercise tolerance (METs)

• Basic laboratory studies

• ASA classification

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Factors associated with poor surgical outcomes in the elderly

Outcome Condition

Mortality Cognitive impairmentFunctional dependenceMalnutrition (?)Frailty

Delirium Cognitive impairmentFrailty

Discharge to a facility Cognitive impairmentFrailtyAdmitted from care facility

Functional decline Cognitive impairmentPreoperative functional decline

Oresanya LB, et al. JAMA. 2014. (311);20: 2111.

Impaired sensorium and functional dependence are predictors of poor outcomes after surgery

Impaired sensorium and functional dependence are predictors of poor outcomes after surgery

Gajdos, et al. JAMA Surg. 2015. 150(1):36.

• Propensity-matched cohorts from ACS NSQIP database

• Patients with preoperative impaired sensorium had higher rates of: Pneumonia Ventilator dependence Renal failure Urinary tract infection Stroke Venous thromboembolism Death

Scarborough JE, et al. Ann Surg. 2015. 261(3): 432.

• Propensity-matched cohorts from ACS NSQIP database

• Complex vascular or general surgery

• Functionally dependent patients had higher rates of: Mortality (OR 1.75, 95% CI 1.54 – 1.98) Major morbidity (OR 1.51, CI 1.41 – 1.62) Minor morbidity (OR 1.28, CI 1.18 – 1.39) Reoperation (OR 1.40, CI 1.13 – 2.06)

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Predictor Odds ratio* (95% CI) P value

Mini-cog < 4 4.2 (1.2 – 13.8) 0.02

Albumin ≤ 3.3 g/dL 8.6 (2.5 – 29.3) 0.0006

Falls ≥ 1 5.1 (1.7 – 22.4) 0.004

Hematocrit < 35% 10.7 (3.3 – 34.9) < 0.0001

ADLs < 6 13.9 (3.0 – 65.4) 0.0008

Charlson ≥ 3 3.9 (1.0 – 14.6) 0.04

* Mortality at 6 months

Ann Surg. 2009. 250(3):449.

FrailtyFrailty

• Composite phenotype of functional and physiologic decline

• Reflects a state of reduced physiologic reserve

• Associated with increased susceptibility to poor outcomes

• Clinical domains of frailty: Cognition Activity Nutrition Mobility Strength Energy Mood

Robinson TN, et al. Ann Surg. 2009. 250(3):449.

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Makary MA, et al. J Am Coll Surg. 2010. 210(6): 901.

Non-frail (Frailty score 0-1)

Intermediately frail (Frailty score 2-3)

Frail(Frailty score 4-5)

Postoperativecomplications

Overall 3.9% 7.3% 11.4%

Major procedure

19.5% 33.7% 43.5%

Adjusted OR (95% CI)

2.06(1.18 – 3.06)

2.54(1.12 – 5.77)

Length of stay Overall 0.7 1.2 1.5

Major procedure

4.2 6.2 7.7

Discharge to institution

Overall 0.8% 0% 17.4%

Major procedure

2.9% 12.2% 42.1%

Adjusted OR (95% CI)

3.16(1 – 9.99)

20.48(5.54 – 75.68)

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Comparison of frailty scoring systems

Hopkins Frailty Score

Shrinking Unintentional weight loss ≥ 10 lb in 1 year

Weakness Grip strength measurement

Exhaustion Questions about effort and motivation

Low activity Questions about leisure time activity

Slowed walking speed

Time to walk 15 feet

Multidimensional Frailty ScoreItem 0 1 2

Malignancy No Yes NA

Charlson Comorbitiy Index 0 1-2 >2

Albumin (g/dL) ≥ 3.9 3.5 – 3.9 < 3.5

ADLs Independent Partially dependent

Dependent

IADLs Independent Partially dependent

Dependent

MMSE Normal MCI Dementia

Risk of delirium (Nu-Desc) 0-1 ≥ 2 NA

Mini Nutritional assessment Normal Risk of malnutrition

Malnutrition

Midarm circumference (cm) ≥ 27 24.6 – 27 < 24.5

Scored 0 or 1 for each domain0-1 = non-frail; 1-2 = intermediate; 4-5 = frail

Makary MA, et al. J Am Coll Surgeons. 2010. 210(6):901.

Kim S, et al. JAMA Surg. 2014. 149(7):633.

Low risk = 0-5, High risk = 6+

Frailty is a better predictor than comorbidities!

Adjusted OR per increase in 1 point in MFS

Adjusted OR for MFS ≥ 7

Postoperative complications

1.14p = 0.42

8.54p = 0.002

Discharge to institution

1.38p = 0.1

1.29p = 0.7

Increased hospital lengh of stay

1.41p = 0.038

Choi JY, et al. J Am Coll Surgeons. 2015. Epub ahead of print.

Frailty is a predictor of poor outcomes even in otherwise “low-

risk” elderly patients!

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J Am Coll Surg. 2013. 217:665.

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2015

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Defining frailtyDefining frailty

• Cognition Mini-cog < 3 Impaired cognitive function Delirium risk factors

• Activity Functional dependence Daily activity level

• Nutrition Recent weight loss Albumin < 3.3 g/dL Low BMI

• Mobility Recent falls Up and go test

• Strength Grip strength

• Mood Depressed mood

• Comorbidity Hematocrit < 35% Charlson Comorbidity Index > 3

Robinson TN, et al. Ann Surg. 2009. 250(3):449.

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Frailty, in summaryFrailty, in summary

• Predictor of postoperative complications, discharge to institution, hospital readmission, mortality

• Spans multiple surgical subspecialties

• No consensus definition exists

• Further study needed to determine most important elements of frailty

Surgical risk calculatorsSurgical risk calculators

• American College of Surgeons: NsQip www.riskcalculator.facs.org

• Cardiothoracic specific:

Euroscore www.euroscore.org

STS risk calculator www.sts.org/quality-research-patient-safety/quality/risk-calculator-and-

models/risk-calculator

• UCSF: eprognosis.org

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Riskcalculator.facs.org

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Observed rate Observed rate

J Am Coll Surgeons. 2013. 217: 833.

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eprognosis.org

Preoperative evaluation of geriatric patients

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Preoperative medical testingStudy Possible indications

EKG Cardiocirculatory or respiratory disease, CV risk factors, type and invasiveness of surgery

Other cardiac testing Cardiovascular risk factors, type of surger

CXR Smoking, recent URI, COPD

Pulmonary evaluation Type of surgery, interval from prior evaluation, treated or symptomatic asthma, symptomatic COPD, scoliosis with restrictive lung disease

Hemoglobin or hematocrit

Extremes of age, liver disease, history of anemia, bleeding, hematologic disease, type of surgery

Coagulation studies Bleeding disorders, liver or renal dysfunction, type of surgery

Serum chemistry Renal or liver disease, endocrine disorder, use of certain medications, perioperative therapies

Urinalysis Presence of UTI symptoms, specific procedures

Pregnancy Offer to patients of childbearing age where result would affect decision

“Preoperative tests should not be ordered routinely. Preoperative tests may be ordered,

required, or performed on a selective basis

for purposes of guiding or optimizing perioperative

management.”

ASA Practice Advisory for Preanesthesia Evaluation. Anesth & Analg. 2012. 116(3)

Routine preop medical testing: Still happening (and costing a lot of money)!

Routine preop medical testing: Still happening (and costing a lot of money)!

Sigmund AE, et al. JAMA IM. 2015. 175(8):1352.

• Data collected from large surveys conducted by the CDC and NCHS yearly from 1997 – 2010.

• Before and after release of new ASA and ACC/AHA guidelines for preoptesting in 2002

• Routine EKG was the only test to decrease

• UA, CXR, Hgb, stress testing patterns did not change

Chen CL, et al. NEJM. 2015. 372(16):1530.

• Observational cohort of 440,000 patients having cataract surgery in 2011

• In the month before surgery: 53% had at least one preop test $4.8 million in testing $12.4 million in office visits

• Testing patterns varied widely between practice settings

• No change in testing practices compared with 20 years ago

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Date of download: 8/27/2015 Copyright © The American College of Cardiology. All rights reserved.

From: 2014 ACC/AHA Guideline on Perioperative Cardiovascular Evaluation and Management of Patients Undergoing Noncardiac Surgery: A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines

J Am Coll Cardiol. 2014;64(22):e77-e137. doi:10.1016/j.jacc.2014.07.944

Evaluation of geriatric-specific conditions

Condition Evaluation tool

Cognition Mini-cogMMSERisk factors for delirium

Function Ability to perform ADL’s and IADL’sHistory of fallsTimed up and go test

Nutrition BMIAlbumin and prealbuminUnintentional weight lossMini nutritional assessment

Polypharmacy Medication reconciliation

Frailty Comprehensive geriatric assessment

Oresanya LB, et al. JAMA. 2014. (311);20: 2111.

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Cognition: M

ini-cog

Risk factors for deliriumRisk factors for delirium

• Age > 65 years

• Cognitive decline or dementia

• Poor vision or hearing

• Severe illness or comorbities

• Infection

• Functional dependence

• Immobility

• Poor nutrition

• Alcohol or substance use

• Electrolyte or metabolic abnormalities

• Sleep disturbance or deprivation

• Depression

• Polypharmacy

Am Geriatrics Society Expert Panel. J Am Coll Surgeons. 2015. 220(2):136.

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Functional assessment: Fall historyFunctional assessment: Fall history

• Prospective cohort study: 235 patients asked about fall history in 6 months preceding elective colorectal or cardiac surgery

33% of patients with fall Tended to be older, sicker, lower albumin and hct

Falls associated with: More postoperative complications Higher 30-day readmission Discharge to institution

Results were independent of age

Jones TS et al. JAMA Surg. 2013. 148(12):1132.

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Nutritional assessment

Parameter Criteria for severe malnourishment

Recent weight loss ≥ 10-15% in last year

BMI ≤ 18.5 kg/m2

Hyopalbuminemia ≤ 3 g/dL

Mid-arm muscle circumference < 21 cm (male), < 19 cm (female)

Decubitus ulcers Present

Mini-nutritional assessment 0-7 points

Chow WB, et al. J Am Coll Surg. 2012. 215(4): 453.Dudrick SJ. Surg Clin N Am. 2011. 91:877.

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Preoperative optimization

Comprehensive Geriatric AssessmentComprehensive Geriatric Assessment

• Well-established evaluation and intervention process

• Patient-specific plan for treatment and follow up developed

• Domains involved: Medical Physical/functional Psychological Social Environmental

• Shown in medical inpatients and community-dwelling patients to: Improve mortality Increase chance of living independently Improve physical function

Partridge JSL, et al. Anaesthesia. 2014. 69(Suppl 1): 8-16.

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Clinicians involved in CGAClinicians involved in CGA

• Geriatricians

• Internists/hospitalists

• Physical therapists

• Occupational therapists

• Pharmacists

• Nurse specialists

• Dieticians

• Social workers

CGA predicts adverse outcomes in elderly surgical patients

CGA predicts adverse outcomes in elderly surgical patients

Kim K, et al. Arch Geront Geriatrics. 2013. 56:507.

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CGA may improve postoperative outcomes

CGA may improve postoperative outcomes

• Patients receiving targeted optimization prior to surgery based on multidisciplinary CGA assessments had:

Lower rates of Pneumonia

Delirium

Pressure sores

Inappropriate catheter usage

Improved Pain control

Mobilization

Hospital LOS

Discharge coordination

Harari D, et al. Age and Ageing. 2007. 36:190.Indrakusuma R. Eur J Surgical Oncol. 2015. 41:21.

Evidence-based preoperative interventionsEvidence-based preoperative interventions

• Frailty is difficult to treat!

• Interventions are better established in community, long-term care, and medical inpatient setting

• Limited evidence in surgical population

• Other interventions with limited evidence in surgical patients Testosterone Growth hormone Vitamin D

Amrock LG and Deiner S. Curr Op Anes. 2014. 27(3):330.Fairhall N, et al. BMC Med. 2011. 9:83.

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How can we best minimize perioperative risk?Assessment Tools Intervention

Cognitive impairment, dementia

- Mini-cog (or other formal tool)- History from caretakers

- Refer to PMD, geriatrician, mental health specialist

Depression - Validated questionnaires - None suggested

Risk factors for delirium - Avoid deliriogenic medications

Alcohol and substance use - CAGE exam - Perioperative multivitamins, thiamine- Cessation

Cardiac and pulmonary evaluation

- ACC/AHA guidelines- ACS NSQIP PPC guidelines

- Appropriate assessment and perioperativemanagement

Functional status, mobility, fall risk

- ADL/IADL assessment- Fall history- TUG

- Referral to PT/OT preoperatively- Begin appropriate discharge planning

Frailty - Various definitions - None suggested

Nutritional status - Height, weight, BMI- Serum albumin, prealbumin- Unintentional weight loss

- Full nutritional assessment by dietitian with supplementation plan if severe risk identified

Medication review - Titrate, substitute, discontinue drugs- Avoid polypharmacy

Social -Advance directives discussion- Goals and expectations

- Discuss expected postop course- Discharge planning

Chow WB, et al. J Am Coll Surg. 2012. 215(4): 453.

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geriatric.surgery.ucsf.edu

Case discussion revisitedCase discussion revisited

• To OR for 15 hour surgery, uneventful intraoperative course

• Reintubated on POD0 for airway obstruction

• Extubated POD1

• ICU course complicated by hypoxemia and delirium

• Started on antibiotics for PNA

• Discharged to step down POD7

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Case discussion revisitedCase discussion revisited

• Started on therapeutic anticoagulation for extensive LUE and LIJ thrombus on POD9

• Taken urgently back to OR for nasopharyngeal bleeding POD10

• PEA arrest on transfer back to ICU, ROSC after 5 rounds of CPR

• L chest tube placed for PTX sustained during code

• Extubated POD11

• ICU course marked by significant delirium, difficult to manage pain

• RUE US showed extensive DVT on POD17

• Discharged to step down POD18

• Intensive rehab ongoing

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ConclusionsConclusions

• Surgical decision-making should depend on patient’s physiologic age and goals

• Reduced physiologic reserve places the geriatric patient at risk during the perioperative period

Medical comorbidities Functional dependence Cognitive impairment Malnutrition Frailty

• Frailty is associated with poor surgical outcomes

• Preoperative assessment of the elderly patient should include evaluation of these risk factors

• Optimization should occur prior to surgery when possible

• Assessment by multidisciplinary geriatrics team may improve outcomes

Questions?anne.donovan@ucsf.edu