Goals

2. Goals • To describe the purpose of the preoperative assessment • To provide strategies to minimize operative risks

3. The Big Question:Should this patient go for surgery? - goal of surgery - urgency of surgery (elective, urgent, emergent) - patient’s/family’s goals and wishes - baseline function, co-morbidities - life expectancy - anticipated outcomes/complications

4. Preoperative Assessment -Purposes • Not just for “clearance” • To identify factors associated with increased risks of specific complications related to a procedure • To recommend a management plan to minimize these risks Cassel CK, Leipzig RM, Cohen HJ, et al. Geriatric Medicine: An Evidence Based Approach, 4th ed. New York: Springer; 2003.

5. What Do Geriatricians Worry About? • Delirium • Infection • Pressure sores • Malnutrition • Functional decline • increased mortality • poorer quality of life • need for increased care/change of place of living

6. Common Sense Geriatric “Rules” • Organ reserves are diminished • Complications are more likely • Less is often more • Test only what you are able and prepared to correct and what will improve outcome • You minimize complications, if you prevent prolonged bed rest (pre- and post-op)

7. Preoperative Assessment - Components • Functional Assessment • Cognitive Assessment • Nutritional Assessment • Review of advance directives

8. Functional Assessment • American Society of Anesthesiologists (ASA) score • Class I A normal healthy patient for elective operation • Class II A patient with mild systemic disease • Class III A patient with severe systemic disease that limits activity but is not incapacitating • Class IV A patient with incapacitating systemic disease that is a constant threat to life • Class V A moribund patient that is not expected to survive 24 hrs with or without the operation

9. Cognitive Assessment • Dementia and Hx of delirium are major predictor of post-op delirium • Patients with delirium have higher mortality • Know your patient’s baseline cognitive function (Mini-Cog, CAM, etc.)

10. Nutritional Assessment • Poor nutrition is a risk factor for • pneumonia • poor wound-healing • 30-day mortality • Hypoalbuminemia (<3.3mg/dL) • increased length of stay • increased rates of readmission • unfavorable disposition • increased all-cause mortality Corti M. Serum albumin level and physical disability as predictors of mortality in older persons. JAMA1994;272:1036.

11. Strategies to Minimize Risk - pre-operative • Routine screening is low yield • Pre-op testing should be based on the type and urgency of surgery • Manage hypertension • lower blood pressure to under 180/110 • Avoid long periods without nutrition • Treat easily reversible factors (anemia, infection, etc) • Use ß-blockers peri-operatively for major surgery, if not contra-indicated

12. Strategies to Minimize Risk - post operative • Control diabetes without causing hypoglycemia • Pay attention to constipation/urination • Mobilize early/DVT prophylaxis • Minimize use of psycho-active medication • Control pain (your dementia patient won’t do PRN well) • Avoid prolonged periods without nutrition • Involve the families

13. Summary • Older adults have decreased reserves in multiple organ systems • Disease burden and functional capacity outweigh age when assessing preoperative risk • Collaboration among providers helps to identify functional, cognitive and nutritional deficits/risks and to create management plans to minimize these deficits/risks when possible