THE AMERICAN GERIATRICS SOCIETY Geriatrics Health Professionals. Leading change. Improving care for older adults.

1. POSTOPERATIVE CARE OF THE GERIATRIC PATIENTMaria-Karnina Iskandar, MDAmit Patel, MDKonstantin BalonovAnesthesiology ResidentsRuben J. Azocar, MD Associate Professor of Anesthesiology AGS THE AMERICAN GERIATRICS SOCIETY Geriatrics Health Professionals. Leading change. Improving care for older adults.

2. Objectives • Review the impact of postoperative complications in the elderly • Discuss the most common postoperative issues in the elderly • Review the issues related to postoperative delirium and postoperative cognitive dysfunction

3. Deviation from the routine • Geriatric patients compensate on a daily basis for physiological declines in every organ system • Periods of extreme stress, such as surgery and anesthesia, can decompensate the older adult • In 2005, patients over 65 years accounted for approximately 7 million surgeries/year(3.6 times more than patients <65)

4. EFFECT OF AGE AND DISEASE ON RISKOF PERIOPERATIVE COMPLICATIONS Number of Complicationsper 1000 Surgeries Number of Comorbidities Can Anaesth Soc J. 1986;33:336.

5. Preoperative visit • Review comorbidities and their current state • Assess functional, cognitive and nutritional status • Provide recommendations to prevent perioperative complications

6. IMPLICATIONS OF COMPLICATIONS 30-day mortality for 60-year-olds vs. patients 801 1.1% vs. 3.7% if no complications 15.1% vs. 26.1% if ≥1 complications 3-month mortality in patients 70 vs. nonsurgical controls2 2.9 hazard ratio if no complications 7.3 hazard ratio if ≥1 complications If survive 3 months, complications minimally increase subsequent mortality Diminished functional status/↑dependency compared to patients with no complications • 1. Hamel M et al. JAGS. 2005;53:424. • 2. Kawalpreet M et al. Anesth Analg. 2003;96:583.

7. WHICH COMPLICATIONS ARE SEVERE? Heart failure: incidence of 5% in some studies, with mortality as high as 65%1 Pulmonary: 2.4 hazard ratio for death2 Renal: 6.1 hazard ratio for death2 Infection: UTI just as likely to lead to death as deep surgical wound infection is3 CNS: stroke, delirium, post-op cognitive dysfunction • 1. Roche JJ et al. BMJ 2005;331:1374. • 2. Kawalpreet M et al. Anesth Analg. 2003;96:583. • 3. Hamel M et al. JAGS. 2005;53:424.

8. AGE ANDPERIOPERATIVE COMPLICATIONS Hamel M et al. JAGS. 2005;53:424.

9. CV complications (1 of 3) • Most frequent: hypertension or hypotension • Second most frequent: dysrhythmias • Third most frequent: ischemia

10. CV complications (2 of 3) • Common causes of hypotension • Chronic medications (eg, levodopa, bromocriptine, tricyclic antidepressants) • Altered pharmacodynamics and pharmacokinetics causing prolonged/residual effects • Common causes of dysrhythmias • Hypoxia, hypercarbia • Electrolyte imbalance, metabolic alkalosis/acidosis • Preexisting cardiac disease

11. CV complications (3 of 3) • HR and rhythm can have greater impact on BP than in younger patients • Treatment: • Be more cautious than in younger patients about administering IVF as first-line treatment • Consider increasing heart rate and peripheral vasoconstriction (alpha-adrenergics or mixedalpha/beta-agonists) • Utilize Trendelenburg position as adjuvant

12. Pulmonarycomplications (1 of 2) Why are geriatric patients more at risk of post-op pneumonia, hypoxemia, hypoventilation, and atelectasis? • Decline in pulmonary reserve, increased V/Q mismatch • Diminished hypoxic & hypercapnic ventilatory drive • Altered pharmacology of anesthetic drugs intraoperatively, causing residual/prolonged effects • Decrease in laryngeal reflexes makes them more prone to aspiration

13. Pulmonarycomplications (2 of 2) • Patients at most risk are those with: • CHF • Arrhythmias • Dementia • CVA • Seizure disorder • Emergency surgery • Inappropriate reversal of neuromuscular blockade: subclinical paralysis might interfere with respiratory muscles and lead to atelectasis

14. Renal complications • Geriatric patients are more at risk of post-op renal dysfunction • Aging process changes renal circulation and tubular function • Patient-related factors: HTN, DM, CRI • Intraoperative factors: prolonged hypotension, massive transfusions • Consider placing Foley in at-risk patients, to monitor urine output throughout perioperative period

15. TIME FRAME OF Delirium and POST-OP COGNITIVE DYSFUNCTION PACU = post-anesthesia care unit POD = post-op delirium POCD = post-op cognitive dysfunction Silverstein et al. Anesthesiology. 2007;106:622-628.

16. PostOperative Delirium (POD) DSM-MS IV: A change in mental status, characterized by: • A prominent disturbance of attention and reduced clarity of awareness of the environment • An acute onset, developing within hours to days, and tends to fluctuate during the course of the day

17. Main clinical features OF POD • Acute onset • Fluctuating course • Inattention • Disorganized thinking • Alteration in consciousness • Cognitive deficit (memory, orientation, executive functions) • Hallucinations • Psychomotor disturbances • Lethargy (hypoactive delirium) • Agitation (hyperactive delirium) • Alterations of sleep-wake cycle • Emotional disturbances

18. Patient-related Pain Hypoxemia Hypercarbia Hypotension Metabolic disorders Sepsis Substance abuse Preexisting disease (depression/dementia) Visual/hearing impairments Other Restraints Cardiac surgery CNS drugs Sleep deprivation RISK FACTORS FOR POD

19. PATHOPHYSIOLOGY OF POD (1 of 3) Mantz J. Anesthesiology. 2010;112(1):189-195.

20. PATHOPHYSIOLOGY OF POD (2 of3) • Multifactorial • Deficit in cholinergic transmission (“cholinergic hypothesis”) • Acetylcholine plays important roles in attention, consciousness, and memory, and it is critically affected in dementia • Anticholinergic intoxication produces a delirium that can be reversed by cholinesterase inhibitors and by the propensity of antimuscarinic drugs to induce delirium • Serum anticholinergic activity is associated with delirium • Cholinesterase inhibitors do not typically treat or prevent postoperative delirium

21. PATHOPHYSIOLOGY OF POD (3 of 3) • γ-aminobutyric acid • Many sedative/hypnotics, including inhaled anesthetics, propofol, and benzodiazepines, potentiate γ-aminobutyric acid-mediated transmission through γ-aminobutyric acid type A receptors in the CNS • The monoamine transmitters have prominent neuromodulatory roles in regulating cognitive function, arousal, sleep, and mood, and they are modulated by cholinergic pathways • Excess of dopaminergic transmission has been implicated in hyperactive delirium, which can respond to antipsychotic dopamine receptor antagonists such as haloperidol

22. Impact of POD • Morbidity • Risk of injury • CV/neurological events • ? Post-op cognitive dysfunction after ICU delirium • Mortality • Loss of autonomy • Longer hospital stay: 6.0 days vs. 4.6 days • Nursing home placement • Health care costs: average additional cost $2,947

23. Prevention andManagement OF POD • Identification of patients at risk • Baseline cognitive impairment • Mini-Mental State Exam • DEAR score (Age, cognition, ADLs, hearing/visual impairment, chemical use) • Dementia/depression • Consider geriatric consultation • Avoid/minimize/treat delirium-related factors • Hospital Elder Life Program • Cognitive impairment, sleep deprivation, immobility, visual/hearing impairment, and dehydration

24. BOSTON MEDICAL CENTER’S Delirium-free Passport • Multidisciplinary effort • Checklist at all stages of perioperative period • Pilot in total knee replacement patients • Education phase

25. PREVENTION AND MANAGEMENT OF POST-OP DELIRIUM

26. MORE ABOUTManagement OF POD • Seek/treat cause • Delirium is a medical emergency • Medical issues are a frequent cause of delirium • Hyperactive delirium • Haloperidol • Atypical antipsychotics • Avoid benzodiazepines

27. Postoperative Cognitive Dysfunction (POCD) • Deterioration of intellectual function presenting as impaired memory or concentration • Not detected until days or weeks after anesthesia • Duration of several weeks to permanent • Diagnosis is warranted only if: • Corroborated with neuropsychological testing • There is evidence of greater memory loss than one would expect due to normal aging

28. Implications of POCD Abrupt decline in cognitive function heralds: • Loss of independence • Withdrawal from society • Leaving the labor market prematurely • Dependency on social transfer payments • Death Steinmetz J. Anesthesiology. 2009:110;548-555.

29. Incidence OF POCD • ISPOCD collaborative research effort 19941996 • Members from 8 European countries and USA • 13 hospitals • Anesthesia and surgery were associated with POCD • 26% of patients at 1 week after surgery • 10% of patients at 3 months after surgery • Hypotension and/or hypoxemia not related to occurrence of POCD Moller et al. Lancet. 1998:351;857-861.

30. LONG-TERM FOLLOW-UPOF ISPOCD COHORT • Re-evaluated patients at 1 and 2 years • The rate of POCD decreased to approximately 1%, which was not statistically significant Abildstrom et al. Acta Anaesthesiol Scand. 2000;44:1246-1251.

31. Age and POCD (1 of 2) • Single site, University of Florida, 1999–2002 • 1200 patients undergoing elective surgery • Young — 18 to 39 years of age • Middle-aged — 40 to 59 years of age • Elderly — 60 years and older • Controls — primary family members • Study design identical to ISPOCD study • Same psychometric test battery • Outcome endpoints: POCD (primary) and mortality (secondary) Monk et al. Anesthesiology. 2008;108:18-30.

32. Age and POCD (2 of 2) • POCD was common in all age groups at hospital discharge (33%44%) • 3 months after surgery the incidence of POCD was: • 4%5% in those younger than 65 • 13% in adults older than 60 years, particularly those with less than high school education • Associated with increased 1-year mortality Monk et al. Anesthesiology. 2008;108:18-30.

33. POCD AND NONCARDIAC SURGERY • Systematic review • POCD affects a significant proportion of people in the early weeks after major noncardiac surgery, with the older adult being more at risk • Minimal evidence that patients continue to show POCD up to 6 months and beyond • Studies on regional versus general anesthesia have not found differences in POCD Newman S. Anesthesiology. 2007;106:572-590.

34. POCD • Is POCD a measurable deterioration in older patients shortly after surgery and anesthesia with gradual resolution such that the incidence declines to levels nearly indistinguishable from control subjects by approximately 1 year? • More research needed

35. Conclusions • Surgery and anesthesia have a great impact in the decreased physiological reserve of the elderly • The number of comorbidities plays an important role in the incidence of complications • CNS, cardiac, pulmonary and renal complications have the greatest impact in the older individual

36. Acknowledgments Supported by a grant from the Geriatric Education for Specialty Residents Program (GSR), which is administered by the American Geriatrics Society and funded by the John A. Hartford Foundation of New York City

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