Transcript Dementia

PREOPERATIVE AND
PERIOPERATIVE
ISSUES IN THE
ELDERLY
AGS
Sarah M. McGee, MD, MPH
Director of Education
Division of Geriatrics
November 7, 2008
August 5, 2009
THE AMERICAN GERIATRICS SOCIETY
Geriatrics Health Professionals.
Leading change. Improving care for older adults.
SOME OF THE FACTS
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Increasing numbers of older adults are having surgery
Half of elderly will require surgery at least once
Elective surgery has become more common
Severity of initial presentation of surgical problem is
increased in older adults
Emergent surgery is more common in older adults
Older adults are more likely than younger patients
to have surgery cancelled or postponed because of
comorbid conditions
Post-op mortality for ages 85+ is twice that for ages 6569
Slide 2
WHY IS IT IMPORTANT TO EVALUATE
PERIOPERATIVE RISK?
• Careful and thorough preoperative
assessment should help with anticipation,
recognition, and management of
postoperative issues
• Physiological changes associated with normal
aging, superimposed upon pre-existing
comorbidities, place the older adult at higher
risk for complications compared with younger
patients
Slide 3
PHYSIOLOGICAL CHANGES
WITH NORMAL AGING
• Decreased functional reserve  physiologic
decrease in vital organ function
 Cardiac
 Pulmonary
 Renal
• Pharmacokinetics affected
• Decreased ability to deal with perioperative
physiological stress
Slide 4
FACTORS THAT AFFECT
RECOGNITION OF DISEASE
IN OLDER ADULTS
• Underreporting of symptoms
• Decreased physical activity
• Increased prevalence of atypical
presentations
• Increased prevalence of silent ischemia
Slide 5
CASE (1 of 3)
• An 84-year-old man with mild dementia, living at
an assisted care facility, is found on the floor
complaining of severe left hip and groin pain
• Has been able to ambulate independently but is
physically inactive
• Needs min assistance with ADLs
• In the ED is found to have an intertrochanteric hip
fracture
• Past medical history: CAD with CABG 15 years
prior, HTN, CRI, and dementia
Slide 6
CASE (2 of 3)
• The orthopedic service requests preoperative
clearance and co-management by the
medical service
• Despite his mild dementia, the patient is felt
to be competent
• He wishes to proceed with surgery and signs
the consent form
Slide 7
CASE (3 of 3)
• Although the patient had CABG years ago:
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No recent chest pain
No syncope
No SOB, DOE or PND
No evidence of CHF on exam
Exercise tolerance is poor by report
Baseline creatinine is 2.2
Albumin is 2.8
Does he need further cardiac testing? Should
surgery be delayed? What are some possible
predictors of negative outcome?
Slide 8
PREOPERATIVE ASSESSMENT:
COMPLETE MEDICAL HISTORY
• Medical problems
• Past surgical history, including any post-op
problems, especially delirium
• Medications
• Allergies/intolerances to pain medication
• Baseline functional status
Slide 9
OTHER PREOPERATIVE FACTORS
TO CONSIDER
• Prior functional status
• Dementia
• Nutritional status
 Significant predictor of 30-day mortality
 Marker for frailty
Slide 10
CARDIAC RISK AND HIP FRACTURES
• Perioperative myocardial ischemia may occur in up to
35% of elderly patients undergoing hip fracture
surgery
• Studies of patients undergoing noncardiac surgery
suggest that:
 Only 15% with perioperative MI have chest pain
 Only 53% have any clinical symptoms
• Up to 50% of patients with perioperative ischemia go
unrecognized
 Symptoms hidden with analgesia
 Symptoms (ie, increased HR, decreased oxygen, increased
RR) attributed to other causes?
Slide 11
REVISED CARDIAC RISK INDEX
Each risk factor is assigned 1 point
• Ischemic heart disease (hx of MI, Q-waves, hx of + exercise
test, current ischemic-type chest pain, use of SL NTG; does not
include prior CABG/PCI unless those features are present)
• CHF (hx CHF, pulmonary edema, PND, rales, S3, cxr edema)
• Cerebrovascular disease (CVA or TIA)
• DM treated with insulin
• Creatinine > 2
• High-risk surgery (peritoneal, thoracic, vascular)
Risk of CV event (MI, pulm edema, v-fib, cardiac arrest)
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0 points: 0.4%0.5%
1 point: 0.9%1.3%
2 points: 4%6.6%
3 points: 9%11%
Slide 12
PREOP CARDIAC TESTING
Big question:
Will results of test change management?
Slide 13
PERIOPERATIVE CARDIAC ISSUES
• Beta blockers prior to surgery decrease risk of CV
events/death in patients at moderate or high risk
 Higher-risk patients = higher number of events = more likely to
see benefit
• Theory: decrease catecholamine surge
• Risk of bradycardia may outweigh benefit in lower-risk
patients with low risk of events
• Risk stratify by clinical criteria; high-risk patients need
more intense monitoring for silent ischemia
• All patients need optimization of medical management
(fluid status, renal function, meds)
Slide 14
WHAT ABOUT STATINS?
• In retrospective trials, use of statins was associated
with decrease in perioperative CV events
• Small randomized, controlled trial with 100 patients
 Atorvastatin vs placebo prior to major vascular surgery (14
days prior, continued for 45 days after)
 Combined outcome of CV death/MI/stroke found in 8% of
patients with treatment, 26% of patients with placebo
• May be of benefit
• Benefit not clear during urgent procedures
Slide 15
PREOPERATIVE MANAGEMENT:
DIABETES
• Metabolic control
• Hyperglycemia without prior diagnosis of DM in
elderly with acute event = bad predictor
• Discontinue oral agents initially
• May need to cover with insulin; usually will need
some amount of baseline insulin to avoid
extreme fluctuations
Slide 16
OTHER PREOPERATIVE NEEDS
• Review and discontinue medications that are not
needed/potentially harmful
• Be attentive to medications that need to be
restarted postoperatively (eg, antidepressants,
antihypertensives)
• Watch for medications that may cause problems
during withdrawal (eg, benzodiazepines, SSRIs)
• Think about possible alcohol and smoking
withdrawal
Slide 17
TIMING OF SURGERY
• Several studies show that early surgery (first
2448 hours after fracture) is associated with
decreased mortality, pressure ulcers,
delirium
• General consensus: the earlier the better,
once stable
Slide 18
PREVENTION OF DVT AND PE
Clear guidelines from 7th Conference on
Antithrombotic and Thrombolytic Therapy, 2004
• Hip fracture patients are at high risk of VTE
 Risk of DVT is 50% without prophylaxis
 Risk of proximal DVT is 27%
 Risk of fatal PE is 1.4%7.5%
• Factors that increase risk of VTE: advanced
age, delayed surgery, general anesthesia
Slide 19
SUMMARY OF VTE PREVENTION
GUIDELINES
• Routine use of low-molecular-weight heparin
• Can use warfarin (INR 23)
• ASA alone is not sufficient
• Continue anticoagulation for at least 2835
days after surgery, possibly longer
Slide 20
CONSIDER THE CASE AGAIN
• What analgesia should the patient be given?
• Should he be monitored for a perioperative
cardiac event?
• What is his risk of delirium? How can this be
prevented or managed?
• What other complications is he at risk of
developing?
• What would be an appropriate level of
discharge care?
Slide 21
POSTOPERATIVE COMPLICATIONS
Although patients and families worry about
intraoperative complications and death, the
vast majority of adverse events occur in the
postoperative period
Slide 22
POSTOPERATIVE ANALGESIA
Epidural vs PCA vs intermittent administered
morphine:
• No clear sweeping differences
• Some data indicate that epidural route may provide
better pain relief; no clear difference in time to
recover physical independence
• Elderly patients with dementia or delirium may have
difficulty with PCA
Slide 23
PAIN ASSESSMENT
• Should be based on patient’s perception of
pain (pain scale)
• May be difficult in very demented patients,
although direct questioning may still work
• Nonverbal cues: agitation, tachycardia, facial
expressions
Slide 24
PAIN MANAGEMENT
• Consider nonpharmacologic treatments
• Use scheduled dosing of pharmacologic agents
• When adding pharmacologic agents, choose
those with the fewest side effects
 Morphine is most predictable and probably less likely
than other agents to increase confusion
 Avoid propoxyphene, meperidine
• Use PRN dosing for breakthrough pain
• Reevaluate pain control regimen frequently
Slide 25
PAIN RELIEF PYRAMID
NARCOTICS
ACETAMINOPHEN
NONPHARMACOLOGIC
Slide 26
NONPHARMACOLOGIC OPTIONS
Temperature
Education
• Cold for acute pain
• Heat/cold for chronic
pain
• To reduce fears, explain
cause or mechanism of
pain
• Engage cooperation and
“partner” in management
Positioning
Physical therapy
• Use early
Relaxation techniques
Biofeedback
Massage
• Engage nursing, family
Slide 27
ACETAMINOPHEN
• P.O. 6501000 mg QID
(or Tylenol ER: 2 gelcaps, 650 mg each, q8h)
• Compatible with NSAIDs and opiates
• Keep total dose less than 4 g/24 hours
• Patients on scheduled dose of
acetaminophen must avoid
acetaminophen/narcotic combinations (eg,
Vicodin is hydrocodone with acetaminophen)
Slide 28
CONSTIPATION:
PREDISPOSING FACTORS
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Prior history
Bed rest/inactivity
Change in diet
Narcotics
Diminished fluid intake
Slide 29
CONSTIPATION: PREVENTION
When prescribing narcotics for the elderly:
• Order scheduled and PRN bowel hygiene
• Stool softeners are usually not enough
• Consider:
 Senna beginning at 12 tablets per day
 Miralax
Slide 30
POSTOPERATIVE
CARDIAC RISK
• Elderly patients undergoing emergent/urgent
hip fracture surgery are at high risk of CV
event
• 50% of ischemic events in the postoperative
period are silent
• Highest risk is within first 3 days after fracture
Slide 31
POSTOPERATIVE CARDIAC
SURVEILLANCE
• Have a high index of suspicion
• Consider CK-MB and troponin testing, as well as
surveillance EKG, immediately postoperatively on all
hip fracture patients
• Continue monitoring if any changes seen
• Continue to optimize medical treatment (ie, statin,
ASA, beta-blocker, fluid status)
Slide 32
POSTOPERATIVE ISSUES:
GENITOURINARY
• Overall incidence of UTI after hip fracture: 25%
• Best to remove Foley catheter as soon as
possible
• May be complicated if patient receiving epidural
anesthesia
• Urinary retention
 Straight catheterizations restore bladder function
earlier
 D/C medications that can increase retention
(sedatives, anticholinergics)
Slide 33
POSTOPERATIVE ISSUES:
PULMONARY
• Pneumonia
 Accounts for 25%50% of all hospital deaths after
hip fracture surgery
 Significant cause of later deaths (after hospital
discharge) after hip fracture surgery
 Risk may be decreased with regional anesthesia,
early weight bearing, pulmonary hygiene,
incentive spirometry
• Pulmonary embolism causes 15% of deaths
after hip fracture surgery
Slide 34
POSTOPERATIVE DELIRIUM
• Most common medical complication following hip
fracture
• Marker of bad outcome
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Increased mortality (25%33%)
Increased risk of needing skilled nursing facility
Increased length of hospital stay
Interferes with rehab and functional status recovery
• Goes unrecognized 30%50% of the time
• Prevention is key
 Multiple studies demonstrate targeted interventions
significantly prevent delirium, but have no significant impact
once delirium develops
Slide 35
DELIRIUM:
PATIENT-RELATED RISK FACTORS
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Advanced age
Underlying cognitive impairment
Prior delirium
Alcohol abuse
Malnutrition
Depression
Type of surgery
 Hip fracture surgery: 30% risk
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DELIRIUM:
IATROGENIC RISK FACTORS
• Conventional restraints
• Other restraints/tethers:
 Oxygen tubing
 Telemetry boxes
 IV lines
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Medications
Poor pain control
Foley catheters
Environmental: noise, disturbance of sleep
Lack of hearing and visual aids
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DELIRIUM:
HIGH-RISK MEDICATIONS
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Anticholinergics
Antipsychotics
Antibiotics such as quinolones
H2 blockers, especially cimetidine
Narcotics
Sleep aids/sedatives
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DELIRIUM: PREVENTION
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Identify high-risk patients
Confusion Assessment Method (next slide)
Decrease sleep interruptions, improve environment
Family, orientation, sitter if needed
Avoid restraints and tethers
Avoid polypharmacy, no anticholinergics (no Benadryl)
Monitor for ischemia, oxygen status, infection
Remove Foley catheter ASAP
Provide adequate analgesia
Provide adequate bowel regimen
Monitor for urinary retention, I/O catheters when needed
Slide 39
DIAGNOSING DELIRIUM:
CONFUSION ASSESSMENT METHOD
Acute onset and fluctuating course
plus
Inattention
and one of the following:
Disorganized thinking
Altered level of consciousness
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DELIRIUM: MANAGEMENT
• Search for predisposing factors
• Reevaluate medications
• Avoid benzodiazepines (eg, lorazepam)
Slide 41
DELIRIUM AND ANTIPSYCHOTICS
• No data that antipsychotics improve
outcomes; they probably just make delirious
patients more sedated
• Not approved for this indication
• Increased use of atypical antipsychotic
agents for management of patients with
delirium
• Agents and dosing in older patients
 Haldol 0.250.5 mg starting dose
 Risperidone 0.250.5 mg starting dose
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DELIRIUM AND ANTIPSYCHOTICS:
THE DOWNSIDES
• Side effects
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Sedation
Orthostasis
Increased delirium
CV risks, QT interval prolongation
Edema
• FDA black-box warning, April 2005
 Observation in multiple studies of increased risk
of sudden death and stroke in elderly patients
Slide 43
OTHER COMPLICATIONS:
MALNUTRITION
• Poor nutritional status is independently
associated with increased morbidity and
mortality
• Enteral supplements may decrease
postoperative complications, length of
hospital stay
• Postoperative parenteral nutrition: increased
complications in elderly
Slide 44
OTHER COMPLICATIONS:
PRESSURE SORES
• Incidence after hip fracture surgery 10%40%
• Risk decreases with:
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Frequent turning
Early out-of-bed status
Weight bearing as tolerated
Removal of Foley catheter and other lines
Slide 45
OTHER COMPLICATIONS:
ANEMIA
• Anemia and worsening anemia are common in ill
elderly and during postoperative period
• There is evidence that liberal transfusion to keep
Hgb at 1012 may worsen outcome
• Data unclear in elderly in postoperative period
 May not tolerate as low a Hgb
 Lower Hgb is associated with worse outcome, but
not clear whether the association is causal
Slide 46
TRANSFUSION GUIDELINES
Recommend moderately restrictive transfusion
guidelines:
• Keep Hgb at 79, likely closer to 89 range,
especially if underlying myocardial ischemia
• No real evidence to support keeping Hbg over 10
Slide 47
POSSIBLE HOSPITAL COURSE 1
• A post-op patient receives PRN analgesia
• Because he is restless and physically
agitated, trying to get out of bed and pull out
his Foley, he is restrained and given 5 mg
Haldol
• He develops a fever and hematuria and is
started on an oral antibiotic for UTI
• He develops diarrhea and sacral breakdown
• PO intake declines and he is unable to
participate in rehab
Slide 48
POSSIBLE HOSPITAL COURSE 2
• A post-op patient receives scheduled and
PRN morphine on POD 1 and 2
• Analgesia is changed to scheduled Vicodin
on POD 3
• The Foley is removed on POD 2
• Though the patient is more confused than at
baseline, according to his family, he is able to
participate actively in rehab and is able to be
discharged to subacute care on POD #4
Slide 49
DISCHARGE PLANNING
• Rehab possible at multiple sites
• No clear benefit to one over another
 Home
 Inpatient rehab
 Subacute rehab/skilled nursing facility
Slide 50
PREDICTORS OF DISCHARGE
TO INSTITUTION
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Age > 85
Inability to ambulate
Dementia
Inability to transfer
Fecal incontinence
Pressure sores
Poor social support
Slide 51
TRANSITIONS CAN BE DANGEROUS
Guard against incomplete transfer of information
• Discharge summaries and PDI need to be consistent
and complete
• Include most recent events, labs, and meds
• Be especially cautious if facilities do not have the
same computer system
We are on the same team!
Slide 52
ADDITIONAL CONSIDERATIONS
AT THE TIME OF DISCHARGE
• Treatment of osteoporosis
• Prevention of falls
• Prevention of fall-related injuries
Slide 53
RISK OF OSTEOPOROSIS
• 70% patients over age 80 have osteoporosis
• Hip fracture without major trauma: diagnosis of
osteoporosis
• More than BMD: older patient is more likely to have
fracture than younger patient with same BMD (falls
risk, brittle bones, cognition, visual impairment,
etiology of fall, etc)
Slide 54
OSTEOPOROSIS:
TREATMENT AT DISCHARGE
• 5%6% patients admitted with hip fracture are
adequately treated for osteoporosis at discharge
 Only 12% at 5 years
 Only 20% have any prescription treatment over 2 years
• Patients over age 74 (at highest risk) are least
likely to receive treatment
• Discharge medications carry weight!
• No significant contraindication in most to treating
at time of discharge
Slide 55
OSTEOPOROSIS:
SUPPLEMENTS
• Calcium
 Fewer than half of adults take adequate amount
 12001500 mg/day
 Calcium and Vitamin D decrease risk of hip fracture
• Vitamin D
 400800 IU/day
 Frail older patients with limited sun exposure may need
at least 800 IU/day
 Concern that many elders and institutionalized adults
are at risk of Vitamin D deficiency; most frail adults
need calcium and Vitamin D supplements
Slide 56
OSTEOPOROSIS:
BISPHOSPHONATES
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Decrease bone resorption
Decrease in hip and vertebral fractures
Alendronate, risedronate
Ibandronate (Boniva): once monthly
Those at highest risk of fracture shown to have
greatest benefit
Slide 57
PREVENTION OF FALLS
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Home assessment
Rehab
Strengthening and gait assessment
Assistive devices
Cognitive assessment
Urinary incontinence
Medication review
Peripheral neuropathy
Visual impairment
Alcohol use
Prior falls: fear of falling cycle
Slide 58
RISK FACTORS FOR
HIP FRACTURE
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Age over 65
Any prior fracture
Benzodiazepine/anticonvulsant use
High resting heart rate
Inability to rise from chair without using arms
Low weight
Not walking for exercise
Poor depth perception/vision
Poor health perception
Slide 59
FRACTURE REDUCTION:
HIP PROTECTORS
• Used most often in long-term-care settings with
at-risk elders
• Multiple barriers:
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Patient concern
Forgetting to put them on
Incontinence
Questionable efficacy
Slide 60
SUMMARY (1 of 2)
• Preoperative assessment: cardiac risk assessment,
capacity, delirium risk, nutritional and functional
assessment
• Noninvasive testing for cardiac assessment usually not
needed except for high-risk patients
• Surgery should proceed as quickly as possible (2448 hr)
• Perioperative beta-blockers, beginning prior to surgery,
are reasonable in patients at moderate or high risk
• Treat pain aggressively with scheduled analgesics and
reassess frequently
Slide 61
SUMMARY (2 of 2)
• Postoperative care: weight bearing as tolerated immediately,
removal of Foley catheter after 24 hours, I/O catheter for urinary
retention, prevention of pressure sores, removal of lines/boxes as
soon as possible, surveillance for pulmonary cardiac issues
• Watch for delirium; avoid medications such as anticholinergic
agents; try to avoid restraints and antipsychotics
• Transfuse if unstable, cardiac ischemia, or Hgb < 79 range
• Discontinue all unnecessary medications; stop meds that increase
risk of falls
• Follow nutritional status and use supplements
• Treat underlying osteoporosis aggressively: calcium, Vitamin D,
consider bisphosphonate
• Take steps to reduce the risk of falls
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