Practical Tips for Older Surgical Patients: A Geriatrician's Perspective

1. Five Practical Tips for the Older Surgical Patient:From a Geriatrician’s Perspective G. Paul Eleazer, MD,FACP,AGSF University of South Carolina School of Medicine

2. Visualize a patient who is 80 years old. What does he or she look like ?

5. Tip One • All Older People Are Not Alike! • Don’t Base Judgments On Age Alone • Don’t Deny Surgery Unnecessarily (Agism) • Don’t Press For Surgery If Benefit Is Minimal

6. Aging Heterogeneity Source: Solomon, UCLA Review Course 2002

7. Why Is There So Much Variance In Older Adults? • Genetic Differences • Environmental Stresses Differ • Tobacco • Alcohol • Exercise • Aging Dependant Diseases

8. Aging Changes from the Geriatric Perspective • Disease Versus Normal Aging • Decreased Reserve Capacity • Varies Between and Within Individuals • After Age 30, most “typical” declines are 5-10% declines in Physiologic Function

9. Aging Changes from the Geriatric Perspective • Homeostenosis • Impaired Response To Physical, Emotional, And Environmental Stresses • Example: Fluid Challenge of 1000cc: 35 year old 70 year old

10. 35 Year Old with 1000 cc Fluid Bolus • Excess of 500 cc • What are the likely Consequences?

11. 80 Year Old with 1000 cc Fluid Bolus • Excess of 500 cc • What are the likely Consequences?

12. Relevant Changes That Occur With Aging • Physiology • Pulmonary • Cardiac • Pharmacologic • Wound Healing • Immune function • Anatomic • Functional • Social

13. Age Related Changes in Pulmonary Function

14. Impact of Training on VO2Max with Age Heath 1981; Lakatta,1993

15. Impact of Training on VO2Max with Age Heath 1981; Lakatta,1993

16. Impact of Training on VO2Max with Age Heath 1981; Lakatta,1993

17. Pulmonary Changes with Aging • Declines In: • Alveolar Surface Area • Diffusion Capacity • Hypoxic Drive • Arterial PO2

18. Arterial PO2 Correction for Age (Room Air) Expected PaO2 = 100 – (Age/3) For a 20 year old = 93 mmHg For a 90 year old = 70 mmHg

19. Airway Changes • Swallowing Changes Predispose to Aspiration • Decreased Numbers and Function of Cilia • Diminished Cough • Pneumonia More Common

20. Cardiac Changes with Aging

21. Changes in Conduction • Multiple Changes, Net Results: • Decline in Maximum Heart Rate 220 minus Age [or other formula] • Decreased Beta-2 Receptors • Decreased Response to Beta Agonists

22. Heart Rate And Age • Rounds on Two Post Op Patients: • 20 year old with HR of 100 • 95 Year old with HR of 100 • What is your Level of Concern for Each?

23. CalculatePredicted Maximum Heart Rate • 20 year old = 220 – 20 = 200 • 95 Year old =220 - 95 = 125

24. 20 Year Old with Heart Rate of 100 • Percent of Maximum HR= Actual/Predicted x 100 • 100/200 = 50% Maximum Predicted HR

25. 95 Year old with Heart Rate of 100 Percent of Maximum HR= Actual/Predicted x 100 100/125 = 80% Maximum Predicted HR

26. Each Patient has Heart Rate of 100 • 20 year old = 100/200 = 50% Maximum Predicted HR • 95 Year old =100/125 = 80% Maximum Predicted HR Equivalent to an ongoing Cardiac Stress Test!

27. Functional Cardiac (Pump) Changes • Resting Cardiac Output - Little Change • Maximum Cardiac Output - Declines

28. Functional Cardiac (Pump) Changes • Decreased LV Compliance • Increased Diastolic Dysfunction • Increased Importance of Atrial Contraction • Decreased Tolerance for Atrial Fibrillation

29. Increased Importance of Atrial “Kick” with Age Atrial Fibrillation Less Well Tolerated From Swinn,1989

30. Age Associated Declines in GFR and Renal Plasma Flow Based on Data from Davis JCI 29:496-507 (1950)

31. Tip Two • Be Gentle • In Relationship • In Caring • In Doing Anything !

32. Tip Three • Medications are Dangerous in Older Adults • Start Low, Go Slow • Avoid all Medications, if Possible • Particularly Avoid Certain Medications

33. Tip Three: Medications are Dangerous in Older Adults • Start Low, Go Slow • Avoid all Medications, if Possible • Particularly Avoid Certain Medications

34. Medications in Older Adults • Older People Take More Medications • Drug-drug Interactions More Likely • Adverse Drug Reactions More Serious

35. Two Patients, Both Get 1mg Lorazepam for Agitation • 20 Year Old • 80 Year Old Unsteady Gait Fall

36. Two Patients, Both Get 1mg Lorazepam for Agitation • 20 Year Old • 80 Year Old Unsteady Gait Fall No Injury Hip Fracture

37. Delirium • In Post Operative Patients • Often Due to Medications • May be Due to Other • Hypoxia • Pain • Infection • Sleep Deprivation • Others

38. Delirium • Adding a Medication to Treat Delirium May Be Hazardous • More Drug Interactions • More Adverse Reactions • Often Does Not Help the Patient ! • If you “must” – low dose Haloperidol (0.5 mg)

39. Mortality of Delirium • Mortality of in-hospital delirium 25-33% • Unrecognized by Physicians 30-50% of the Time ! Inouye SK et al, American Journal of Medicine May 1999

40. Diagnosing Delirium Confusion Assessment Method • Acute Onset & Fluctuating Course Plus 2. Inattention And One Of The Following: 3. Disorganized Thinking 4. Altered Level of Consciousness Inouye SK, et al. Ann Intern Med 1990; 113:941-8

41. Commonly Used Drugs That Should Be Avoided In Older People • Propoxyphene ( Darvon, Darvocet) • Meperidine (Demerol) • NSAID’s – (Indocin, Toradol) • Diphenhydramine (Benadryl) • Muscle Relaxants (Flexeril, Robaxin) • Benzo’s -especially Valium, Dalmane Beers, MA Archives IM 1997,157:1531-1536), Updated 2002

42. Start Low,Go Slow ...

43. Tip Four • Function is Most Important • Pre Op • Post Op • Long Term

44. Function is Most Important • Pre Operatively • Baseline Function Predicts Morbidity and Mortality • 4 MET Equivalent • Consider “Prehab” • Realistic Goal Setting • Planning for Post Operative Care

45. Function is Most Important • Post Operatively • Early Mobilization • Rehabilitation

46. Function is Most Important • Long Term • Prevention of Functional Decline • Planning, Ethical Issues

47. Tip Five There are no “Benign Procedures” in Older Adults!

48. Where I First Learned About Iatrogenesis • Summer of 1979 Mr. Monroe H. • 76 Year Old Admitted with Diarrhea and Weight Loss • Admission U/A showed 10-20 WBC’s and many epithelial cells

49. Where I First Learned About Iatrogenesis • 76 Year Old Admitted with Diarrhea and Weight Loss • “To Catheterize or Not To Catheterize” for a repeat U/A - ???? • “It’s a Benign Procedure”

50. Where I First Learned About Iatrogenesis • Catheterized • Vagal Reaction • Unresponsive • Code Called • Right Central Line Placed “for access” • Moved to the ICU