Geriatrics Perioperative Care

1. Geriatrics Perioperative Care Beth A. Barron, MD Columbia University Associate Program Director of Internal Medicine Allen Hospitalist Co-Director (no disclosures)

2. 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

3. 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

4. What is the most important predictor of postoperative complications in the elderly? • Age • Comorbidities • Functional Status • Thallium Stress Testing

5. Principle # 1 • Chronological age alone should not lead to refusal to clear for surgery • Understand the effects of aging on all organ systems.

6. 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.

7. 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.

8. What are the effects of aging on the cardiac system? • Increased risk of atrial fibrillation • CHF • Hypotension • All of the above

9. 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

11. Current Recommendations

12. What are the effects of aging on the pulmonary system? • Decreased cough • Decreased FEV1 • Decreased response to hypercapnia • All of the above

13. Effects of aging on pulmonary system Clin Interv Aging 2006 September; 1(3) 253-260.

14. Other effects of aging important in the perioperative period • Trend towards more hypercoagulable • Decreased immune system response • Decreased kidney function

15. When reviewing this patients medications (Lisinopril, Cardizem, Lipitor, Raloxifene, and Benadryl prn sleep)…. • Continue all medications • Continue all but Benadryl • Discontinue Lipitor • Discontinue Lisinopril, Raloxifene and Benadryl

16. Principle # 2 • Review all medications preoperatively and eliminate the unnecessary and potentially harmful.

17. 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)

18. Principle # 3 • Determine cognitive ability, competency, functional status and availability of supports. • Determine advance directives, health care proxy, and goals of care

19. Informed consent/Capacity to Consent • Understand the risks vs benefits • Goals of Care • Complications • Likelihood for survival • Likelihood for functional decline

20. The day after the operation she becomes confused and agitated. • 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

21. 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

22. 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%

23. 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

24. 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

25. 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.

26. 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)

27. 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

28. 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

29. 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

30. 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

31. Principle # 5 • Assess volume status and nutrition pre and post operatively. • Monitor hemodynamics in high-risk patients and maintain adequate intake

32. 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

33. Cochrane Database 2005

34. Important things to consider when treating pain in the geriatric patients include • 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

35. 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.

36. 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

37. Determining preoperative frailty can help determine • LOS • Discharge disposition • Post operative complications • All of the above

38. 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.

39. 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)

40. 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

41. 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.

42. 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.

43. 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