Transcript Implementation of the Competencies

Geriatrics Perioperative Care
Beth A. Barron, MD
Columbia University
Associate Program Director of Internal Medicine
Allen Hospitalist Co-Director
(no disclosures)
Objectives
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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
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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?
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Age
Comorbidities
Functional Status
Thallium Stress Testing
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Principle # 1
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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
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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
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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
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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?
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Increased risk of atrial
fibrillation
CHF
Hypotension
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Effect of aging on cardiac system
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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?
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Decreased cough
Decreased FEV1
Decreased response to
hypercapnia
All of the above
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Effects of aging on pulmonary system
Clin Interv Aging 2006 September;
1(3) 253-260.
Other effects of aging important in the
perioperative period
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Trend towards more hypercoagulable
Decreased immune system response
Decreased kidney function
When reviewing this patients medications (Lisinopril,
Cardizem, Lipitor, Raloxifene, and Benadryl prn
sleep)….
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Continue all medications
Continue all but Benadryl
Discontinue Lipitor
Discontinue Lisinopril,
Raloxifene and Benadryl
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Principle # 2
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Review all medications preoperatively and eliminate
the unnecessary and potentially harmful.
Polypharmacy
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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
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Determine cognitive ability, competency, functional
status and availability of supports.
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Determine advance directives, health care proxy, and
goals of care
Informed consent/Capacity to Consent
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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.
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This could have been
prevented with
preoperative Haldol
Give a stat dose of Ativan
and observe
This could have been
prevented with a geriatrics
consult
Th
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Principle #4
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Be aware of preoperative risks of delirium
Consider ways to minimize the development of
delirium
Be alert to the occurrence of postoperative delirium
Dementia
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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
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Separate from transient delirium from anesthetics or
post operative complications
May be related to sensitivity of neurologic tissue to
hypoxia and hypotension
Evidence
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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
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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
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Marcantonio ER, A clinical prediction rule for delirium after elective
noncardiac surgery. JAMA 1994: 271: 134-139.
One point:
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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
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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
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Risk factor assessment:
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Alcohol
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Dementia
Discontinue high risk medications
Consider hydration and nutritional state
Environment:
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Day/night
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Reorientation
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Bring visual and hearing aides and walking assist devices for patient use
Avoid hypotension, hypoxia
Minimize anesthesia time or consider local/regional
Preventing delirium
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Low dose Haldol
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Kalisvaart, KJ. Haloperidol prophylaxis for elderly hipsurgery 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
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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
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Assess volume status and nutrition pre and post
operatively.
Monitor hemodynamics in high-risk patients and
maintain adequate intake
Nutrition
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Complications associated with poor outcomes:
 Delayed wound healing
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Markers of poor nutrition that predict outcomes
 Albumin < 3.2 g/dL
 Cholesterol < 160mg/d:L
 Body mass index < 20 kg/m2
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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
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Patients may be more
sensitive to these
medications
Pain may be undertreated
in this population
Hydration and nutrition
influence the dosing
needed
All of the above
Pa
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Principle # 6
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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
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Risks of under treatment – cognitive difficulties
requesting
Drug-drug interactions
More vulnerable to side effects and over medication
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Changes in renal and hepatic clearance
Reduced lean body mass and total water
Poor nutrition or hydration
Determining preoperative frailty can
help determine
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LOS
Discharge disposition
Post operative
complications
All of the above
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Principle # 7
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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
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Assessing functional status
Fall risk
Frailty
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Markers can predict post-op complications, LOS and d/c
To SNF
Gait/Mobility
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TUGT (timed up and go test)
Frailty is predictive of postoperative complications
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Frailty risk score
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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:
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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
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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
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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