GI Surgery in the Elderly: Demographics and Special Considerations

1. GI Surgery in the Elderly: Demographics and Special Considerations Karen Hall, M.D., Ph.D. Associate Professor University of Michigan Health System GRECC, Ann Arbor VA Healthcare System www.sitemaker.umich.edu/kehall

2. Increase in the Number of Persons Aged 65+ Years in the United States 72 (20%) 55 (17%) Number (millions) Percent of population 40 (13%) Population 35 (12%) 31 (13%) 26 (11%) 20 (10%) 17 (9%) 12 (8%) 9 (7%) 7 (5%) 5 (5%) 4 (4%) 3 (4%) Year US Population Demographics Etzioni et al. Ann Surg 2003; 238:170-177

3. 65+ are the fasting growing group Etzioni et al. Ann Surg 2003; 238:170-177

4. Proportion of Surgeries by Age Etzioni et al. Ann Surg 2003; 238:170-177

5. Etzioni et al. Ann Surg 2003; 238:170-177

6. National Demographic and Health Survey (NDHS): Diverticulitis 1996-2002 • Hospital admissions increased by 14% to 261,180 yearly • Office visits increased by 14% to 1,493,865 yearly • Emergency department visits increased by 49% to 161,364 yearly • And….Surgery increased by 17% to 18,951 yearly Hall et al. Gastroenterology 2005; 129:1305-1338

7. But, there are fewer general surgeons now • 1000 new graduates, average age 33 years • Average age is 43 years • Average practice lifetime is 30 years • Average age of retirement is 62 years • 30% of surgeons are within 10 years of retirement • 25% reduction in general surgeons in the US between 1995 and 2005 • Anticipate a shortfall of 3,000 surgeons by 2010 Jonasson and Kwakawa Ann Surg 1996; 24:574-82; Lynge DC et al. Arch Surg 2008; 143:345-50

8. Why the decrease in surgeon numbers? • Reduced hours (lifestyle), health decline • Between 1992 and 2005 retirement because of dissatisfaction with changes in surgical practice increased from 28% to 56% Jonasson and Kwakawa Ann Surg 1996; 24:574-82; Lynge DC et al. Arch Surg 2008; 143:345-50

9. What will General Surgeons be doing in the next 10 years? • Will surgical procedures change? (NOTES) • Will other people be doing “surgery”? • Will more surgery be performed as part of a multi-specialty team of proceduralists? Jonasson and Kwakawa Ann Surg 1996; 24:574-82; Lynge DC et al. Arch Surg 2008; 143:345-50

10. What impact will an increased number of geriatric patients have on surgical practice? • Increased workload • Increased time required to see individual patients • Will outcomes be worse? • Do surgical studies measure meaningful outcomes?

11. Surgery-specific and disease-specific risk factors that predict poor outcome with CRC resection • 2,533 new diagnosed colorectal cancer patients undergoing resection in 79 hospitals in the UK, between April 2000 and March 2002 • Colorectal cancer (CRC) resection in patients over 80 with 30 day mortality as the endpoint • 15.6% 30 day mortality • Factors predicting mortality: Increasing age, high ASA grade, emergent procedure, no resection, presence of metastatic disease • But is mortality the most important outcome for geriatric patients? Heriot et al. Dis Colon Rectum 2006; 49:816-24

12. What are important outcomes for geriatric patients? • In addition to mortality, patients care about “Function, Function, Function” • Disability may result in nursing home placement, poor quality of life, and increase the risk of additional complications • Geriatric syndromes and impairment in Activities of Daily Living (ADLs) are more accurate predictors of disability and dependency than standard measures based on surgical procedure or disease

13. What are important predictors for disability in geriatric patients? • 11,093 respondents in the Health and Retirement Study (HRS) surveyed in 2000 – Risk Ratio (RR) for dependency: • Chronic diseases predicting disability (cancer, heart, lung, diabetes, MSK, stroke, psychiatric): • RR 1.0-3.0 • Geriatric syndromes (cognitive impairment, falls, incontinence, low BMI, low vision) were much more potent predictors of disability than chronic disease: • 1 syndrome RR of ADL impairment = 3.0 • 2 syndrome RR = 7.3 • >3 syndromes RR = 16.9 Cigolle et al. Ann Int Med 2007; 147:156-164

14. Factors that predict Post-Hospitalization Functional Decline and Poor Quality of Life Pre-Operative • Age > 70 years • Comorbid conditions • Diabetes, CHF, neoplasia • Functional Impairment in > 2 ADLs • Decubitus Ulcer (poor mobility and nutrition) • Cognitive impairment (dementia) • Low level Social Activity (mobility or depression) Post-Operative • Poorly controlled pain • Delirium Arora VM et al. J Am Geriatr Soc 2007; 55:1705-1711; Manku and Leung Anesth Analg 2003; 96:590-594

15. Pre-Operative Screening for Vulnerable Elderly Expert panel of surgeons, anesthesiologists, internists, geriatricians, rehab medicine • Identified 76 quality indicators in 7 domains for elderly patients undergoing abdominal operations: • Cardiopulmonary • Elderly Issues (e.g. mobility, cognition) • Medications • Patient-provider discussion (e.g. DNR) • Intra-operative care (e.g. hypothermia) • Post Op management (e.g. delirium prevention) • Discharge Planning • Many not routinely assessed in pre-op screening McGory et al. J Am Coll Surg 2005; 201:870-883

16. Measures assess process, not outcomes • Recommendation 16: • If an elderly patient 75 years or older is undergoing a major abdominal operation THEN an objective cognitive assessment (such as the “3-Item Recall”) should be performed within 8 weeks prior to the operation McGory et al. J Am Coll Surg 2005; 201:870-883

17. Geriatric-specific Pre-Operative Assessment • Comorbidity Assessment • Cardiopulmonary, Cr Clearance • Elderly Issues • Screen nutrition, cognition, mobility, vision, hearing • Medications • bowel prep, polypharmacy, Beers criteria for medications to avoid because of adverse effects in the elderly • Patient-Provider Discussion • decision-making capacity, expected functional outcomes, preference for life-sustaining measures • Post-Operative • Prevent malnutrition, delirium, deconditioning, pressure ulcers, eyeglasses, hearing aid, early Foley catheter removal, assessment of lines and early removal of lines • Discharge Planning • Medications, Social Support, ADL dependency, nutrition, cognition, ambulation McGory et al. J Am Coll Surg 2005; 201:870-883

18. Vulnerable Elderly Surgical Pre-Operative Assessment (VESPA) • Joint pilot project between Gynecology (Kathy Diehl), General Surgery (Emily Finlayson) and Geriatric Medicine (Karen Hall) • Based in General Surgery and Gynecology pre-operative clinic • Focused pre-operative assessment protocol of patients 65 years and older undergoing elective surgery • Performed by physician assistants • Protocol includes screening questions and rapid assessments to discover impairments prior to elective surgery • Data collection started July 2008 • Goal is to follow outcomes and develop early alert for at-risk patients prior to admission

19. Practical application of recommendations • Ask about social situation and support • Check bowel function and urine for infection • Brief cognitive assessment (Mini-Cog or MMSE particularly assessment of short term recall and orientation) • Review medications • Functional assessment (test mobility with “Timed Up and Go”, ability to do ADLs) • Review any “tubes” (catheters, lines) – are they necessary? • Address nutrition early

20. Delirium • Most common complication of hospitalized patients over 65 years • Highest risk: hip fracture (>50%), vascular surgery (80%) • Mortality increased 2x compared to non-delirious, LOS 8 days, impaired cognition at 1 and 6 months post hospitalization, increased institutionalization at one year Young and Inouye 2007; McCusker and Marcantonio 1994; Millar 1981; Dasgupta 2006; Bickel 2008; Kat 2008

21. Age Cognitive status Medical comorbidities Fecal Impaction Pain Functional impairment Sensory impairment Drugs Long-term care resident Risk Factors for Delirium Siddiqi et al. Cochrane Systematic Review 2007; Desgupta 2006; Inouye 1993

22. Prevention Because once the patient is delirious, it will take days to resolve Management of Delirium

23. Ensure adequate oxygen delivery Fluid/electrolyte balance Bowel/bladder regimen Nutrition Pain management Maintain sleep-wake cycle Early mobilization Prevention and treatment of major medical complications Environmental stimuli Manage agitation Aspiration precautions Prevention and Management of Delirium Marcantonio 2001

24. Strategies that have been shown to Reduce Incidence of Delirium • Proactive geriatric team consultation • (Medication review – eliminate culprits on Beer’s list (Arch Int Med 2003, 163:2716-24) • Prophylactic medications to decrease post-operative delirium: haloperidol; gabapentin • Multidisciplinary team management of vulnerable patients • Yale Delirium Prevention Program Siddiqi et al. Cochrane Systematic Review 2007

25. Delirium Prevention Program • Yale Geriatric Care Program (“Delirium Prevention Program”) • Twice-daily interventions by trained volunteers in patients at risk • Assist with eating, mobilization • Re-orientation to place, date • Socialization • University of Michigan (“Elder Life Program”) • Significant decrease in falls, restraint use (physical and chemical), improved ADL performance, decreased length of stay Inouye et al. 1993; Young and Inouye 2007

26. Conclusions • Demographic changes are likely to affect current surgical practice and workload • New, less invasive procedures might result in fewer open procedures and more non-surgical providers performing surgery • Pre-operative screening of geriatric patients for ADL impairment and common geriatric syndromes can improve post-operative outcomes • www.sitemaker.umich.edu/kehall