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Mai Nguyen Mercer University COPHS Doctor of Pharmacy Candidate 2012 November 8, 2011 Preceptor: Dr. Ali Rahimi. Surgical Innovations in Geriatrics Medicine. Thomas R. Hornick, MD. Clinics in Geriatric Medicine. 2006;22: 499-513.
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Mai Nguyen Mercer University COPHSDoctor of Pharmacy Candidate 2012 November 8, 2011 Preceptor: Dr. Ali Rahimi Surgical Innovations in Geriatrics Medicine
Thomas R. Hornick, MD. Clinics in Geriatric Medicine. 2006;22: 499-513. Surgical Innovations: Impact on the Quality of Life of the Older Patient
Introduction • In the past, major surgery was rare in the elderly population. • But now, indications for surgery are being extended to include older patients for many major operations that were limited to younger patients not long ago. • In 1996, people >65 yo accounted for 35% of all operations in the US • In 2002-2003, there were 4.2 million hospital stays with at least one procedure done in those older than 75 years.
Risks of Surgery in Elderly Patients • Multiple chronic diseases • Susceptible to common in-hospital complications: • Adverse drug events • Delirium • Functional decline • Falls • Incontinence • Pressure ulcers
Health-Related QOL • Patients’ resultant comfort or sense of well being • Extent to which they were able to maintain reasonable physical, emotional, and intellectual function • Degree to which they retain their ability to participate in valued activities with the family, in the workplace and in the community
Health-Related QOL • Measured by questionnaires • Short-form-36 (SF-36) or its shortened version, short-form-12 (SF-12) • These scales measure areas of mental and physical health. • Physical health: physical functioning, problems with work or other daily activities as a result of physical problems, bodily pain, and general health perception. • Mental health: perceived mental health, problems with work or other daily activities as a result of emotional problems, social function, and vitality.
Health-Related QOL and Joint Replacement Therapy • HRQOL and joint replacements have been well studied. • Older individuals who have severe OA have poor SF-36 scores for pain, physical function, and problems with work or other daily activities as a result of physical health. • These scores improve remarkably after joint replacement, often reaching or exceeding scores of normal population after 6 months.
Health-Related QOL and Cardiac Surgery • Valve replacement surgery has greater risks and benefits in the elderly. • Rates for short-term mortality range from 8% to 20%, depending on valve and comorbidities. • QOL in those surviving valve replacement is greatly improved, with improvement in SF-36. • SF-36 improvement at 18 months was significant in almost all QOL areas and the mean scores were comparable to the scores of healthy elderly patients.
Health-Related QOL and Cataracts • Removal of cataracts improves vision and vision-related QOL with low risk. • 72% to 92% of patients reporting improvement in visual function after surgery • 89% of patients showing improvement on vision-specific HRQOL scales • Morbidity and mortality are low despite its use in the very elderly.
Summary • As surgery has been extended into the elderly population, HRQOL has been added as a parameter to evaluate surgical success. • Surgery remains of significant risk in older patients • Estimate of the type of outcome, including morbidity, mortality, and HRQOL can aid in that decision.
Selvon F. St. Clair, et al. Clinics in Geriatric Medicine. 2006;22: 515-533. Hip and Knee Arthroplasty in the Geriatric Population
Introduction • OA is a chronic widespread form of arthritis that affects all joint structures and commonly manifested in hip and knee. • Risk factors for OA: genetic origins, microtrauma, increased cytokine activity, lack of nutrients (antioxidants), and obesity. • Approximately 68% of total hip arthroplasties and 74% of total knee arthroplasties are performed on people over age 65.
Total Hip Arthroplasty • THA was developed in the 1960s and is considered the standard of care for severe end-stage OA of the hip in elderly patients • Typically takes approximately 1.5 hours to complete • Involves the surgical excision of the head and proximal neck of the femur and removal of the acetabular cartilage and subchondral bone • Replacement of hip joint with prosthetic implant.
Total Knee Arthroplasty • TKA is the treatment of choice in patients over 55 years who have progressive and painful OA and who have failed nonsurgical and less invasive treatments. • Replacement of diseased or damaged joint surfaces of the knee with different type of metals, polyethylene, or ceramics prosthesis.
Future Directions of Hip and Knee Arthroplasty • Minimally Invasive Surgery TKA • Involves using a limited incision (4-7 in.) down the midline of knee • Standard TKA involves 8-14 in. skin incision • Early retrospective results from other centers indicate positive results with this technique. • Computer-Assisted Navigation TKA • Increases the accuracy of implantation • Results in improved outcomes and faster return to normal functions
Vincent Conti, MD, and Scott D. Lick, MD Clinics in Geriatric Medicine. 2006;22: 559-574. Cardiac Surgery in the Elderly: Indications and Management Options to Optimize Outcomes
Introduction • Cardiovascular disease remains the most common cause of morbidity and mortality in the US • CAD and CHF most common in the elderly • Surgical procedures (CABG and cardiac valve repair and replacement) are the best options for many older patients to improve their QOL.
Indications for Operation • Primary Indication: Presence of symptoms that compromise the QOL when these symptoms are the result of the cardiac lesion to be corrected and likely to resolve or improve with successful operation • Other considerations: • Limited life expectancy • Dementia • Multisystem organ failure • Chronic liver failure • Severe pulmonary disease • Severe malnutrition
Coronary Artery Bypass Graft (CABG) • Coronary artery bypass operations traditionally have been performed using a median sternotomy incision. • Although recovery after median sternotomy in most patients is rapid and complete, the elderly tend to have more difficulties and recover more slowly. • Development of coronary artery bypass operations using a small anterolateral thoracotomy incision • Some studies showed did not improve outcomes and associated with more early postoperative pain
Aortic Valve Replacement • Valve replacement and repair have been done through smaller incisions • Aortic valve replacement partial sternotomy incisions • Mitral valve procedures right parasternal incisions • Mitral valve repair or replacement robotic techniques for minimal incisions • Transcatheter heart valve replacement • Valve replacement without open heart surgery • More studies needed
Acute Aortic Dissection • Aortic dissection occurs when a tear in the inner wall of the aorta causes blood to flow between the layers of the wall of the aorta and force the layers apart. • Patients who have acute ascending (type A) aortic dissection involving the ascending aorta should undergo urgent operation. • Patients who have dissections involving only the descending aorta (type B) are managed medically initially. • Operative risk increases with age in patients with Type A dissection and survival with medical therapy have improved. • More elderly patients are treated medically
Cardiac Transplantation • Occasionally is 0ffered to patients >70yo but rarely to those >75yo • Recipient age adversely affects 1-year survival after heart transplant • OR = 1 at age 55 (P<0.0001) • OR = 1.3 at age 65 (P<0.0001) • No valid data beyond 65 • All solid-organ transplants require lifelong medications to suppress the immune system • But they can cause neuropathy, osteoporosis, HTN, worsening DM, and renal dysfunction. • Recipient must not only survive the operation but also tolerate the side effects of postoperative medications.
Rishi P. Singh, MD, Hilel Lewis, MD Clinics in Geriatric Medicine. 2006;22: 659-675. Innovations in Eye Surgery
Introduction • Prevalence and disabling effects of eye-related illness increases as the population ages. • Recent research shows that vision impairment is associated with: • Decline in QOL • 2 or more falls in the elderly • Increased rate of hip fractures and decreased mobility
Cataract • Clouding of the lens caused by clumping of proteins due to inadequate delivery of nutrients to deeper lens fibers • Results in blurry vision • Primary Goal of Surgery: • To remove clouded lens
Glaucoma • Condition that causes damage to the optic nerve due to increased intraocular pressure • Caused by decreased or no drainage of aqueous humor • Glaucoma causes irreversible loss of peripheral vision early and central vision later in the disease development. • Primary goal of surgery: • To reduce intraocular pressure
Age-Related Macular Degeneration • Disease associated with aging that gradually destroys sharp, central vision. • Affects the macula, the part of the eye that allow you to see fine detail
Age-Related Macular Degeneration • Wet AMD • Occurs when abnormal blood vessels behind the retina start to grow under the macula • Loss of central vision occurs quickly • Early symptom: straight lines appear wavy • Dry AMD • Occurs when the light-sensitive cells in the macula slowly break down • Loss of central vision occurs gradually • Early symptom: slightly blurred vision
Diabetic Retinopathy • Diabetic retinopathy is a complication of diabetes that results from damage to the blood vessels of the retina. • Symptoms: blurred vision, floaters, trouble seeing at night, blindness eventually. • Many with early diabetic retinopathy have no symptoms before major bleeding occurs in the eye.
Diabetic Retinopathy • Surgical procedures for treatment: • Laser eye surgery (photocoagulation) • Creates small burns in the retina where there are abnormal blood vessels in order to stop or slow the leakage of blood and fluid in the eye • Vitrectomy • Removes some or all of the vitreous humor from the eye
References • Hornick TR. Surgical Innovations: Impact on the Quality of Life of the Older Patient. Clinics in Geriatric Medicine. 2006;22: 499-513. • St. Clair SF, et al. Hip and Knee Arthroplasty in the Geriatric Population. Clinics in Geriatric Medicine. 2006;22: 515-533. • Conti V. and Lick SD. Cardiac Surgery in the Elderly: Indications and Management Options to Optimize Outcomes. Clinics in Geriatric Medicine. 2006;22: 559-574. • Singh RP and Lewis H. Innovations in Eye Surgery. Clinics in Geriatric Medicine. 2006;22: 659-675. • www.ncbi.nlm.nih.gov