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Perioperative Care in Geriatrics

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Title: Perioperative Care in Geriatrics


1
Perioperative Care in Geriatrics
  • Tomas L. Griebling, MD, FACS, FGSA
  • Department of Urology
  • The Landon Center on Aging

2
Surgical Care in Older Adults
  • Conditions which can be treated surgically are
    common in older adults
  • Surgery may be a good treatment option for some
    geriatric patients
  • Misconception that surgery is too dangerous for
    older adults
  • Patients and families
  • Professionals

3
Surgical Care in Older Adults
  • Careful perioperative evaluation and management
    can help reduce both morbidity and mortality
  • Increased attention and research related to
    surgical care in older adults
  • Cross-disciplinary principles
  • Interaction between surgical and non-surgical
    specialties is critical in this process

4
ACOVE Surgical Indicators
  • Assessing Care of Vulnerable Elders
  • Quality indicators designed to examine delivery
    of care and help improve clinical outcomes
  • Measures regarding surgical care included in
    ACOVE-III
  • Evidence-based design

J Am Geriatr Soc 55 s347-s358, 2007
5
ACOVE Surgical Indicators
  • Organized by timing of service
  • Preoperative
  • Perioperative
  • Postoperative
  • Spectrum of care is important
  • Consider and begin planning all aspects of care
    preoperatively

6
Preoperative Care
  • Capacity to Consent
  • Discussion of Goals of Care
  • Pulmonary Evaluation
  • Cardiovascular Evaluation
  • Diabetes Evaluation
  • Delirium Risk Factor Assessment

7
Capacity to Consent
  • IF a vulnerable elder is to have inpatient or
    outpatient elective surgery, THEN there should be
    documentation of the patients capacity to
    understand the risks and benefits of the proposed
    procedure before the operative consent form is
    presented for signature..

8
Capacity to Consent
  • .. BECAUSE failure to document this information
    may result in a surgical procedure and surgical
    outcomes that are not consistent with the
    patients goals of care.

9
Capacity to Consent
  • Informed consent
  • Critical to planning and delivery of quality
    surgical care
  • Important aspect of clinical communication
  • Potential target of liability
  • Ethical obligation
  • AMA Code of Ethics
  • Legislation all 50 states mandate this

10
Capacity to Consent
  • Risk factors that impair or prevent adequate
    informed consent
  • Older age
  • Fewer years of formal education
  • Delirium
  • Surrogate consent may be necessary
  • Cognitive assessment rare even in delirious
    subjects in prior studies (lt 4 cases)

Am J Med 103 410-418, 1997
11
Capacity to Consent
  • Independent risk factors for failure to obtain
    informed consent
  • Delirium (OR 2.7, 95 CI 1.3 5.3)
  • Less invasive procedure
  • (OR 5.0, 95 CI 2.0 12.8)
  • Not without risks
  • Need to match with goals of therapy
  • Potential for liability

Am J Med 103 410-418, 1997
12
Discussion of Goals of Care
  • IF a vulnerable elder is to have elective major
    surgery, THEN patient priorities and preferences
    regarding treatment options, operative risks,
    anticipated postoperative functional outcome, and
    advance directive and designated surrogate
    decision maker should be discussed
    preoperatively..

13
Discussion of Goals of Care
  • .. BECAUSE preoperative discussions regarding
    surgical options, including risks and outcomes,
    life-sustaining preferences, and presence of an
    advance directive, may improve the correlation
    between the patients wishes and administered
    care.

14
Discussion of Goals of Care
  • Needed information
  • Complications
  • Likelihood for survival
  • Likelihood for functional decline
  • Providers often misunderstand patient preferences
    or dont discuss
  • Poor documentation about goals complicates this
    issue

J Am Geriatr Soc 48 s44-s51, 2000
15
Discussion of Goals of Care
  • Hospitalized Elderly Longitudinal Project
  • 63 of patients gt 80 years old received at least
    1 life-sustaining intervention before death
    despite voicing a desire for less-aggressive care
  • Written advance directives
  • Only documented in about 25 cases
  • 1990 Patient Self-Determination Act

J Am Geriatr Soc 50 930-934, 2002 Arch Intern
Med 164 1501-1506, 2004
16
Discussion of Goals of Care
  • Patients prediction of functional status
  • Self-predictions and current level of function
    often provides the most accurate information
    about future outcomes
  • Factors influencing treatment choice
  • Burden of treatment
  • Possible outcomes
  • Likelihood of possible outcomes

New Engl J Med 346 1061-1066, 2002
17
Discussion of Goals of Care
  • Low-burden treatments
  • Likelihood of poor outcome is strongly correlated
    with decision to decline even low-burden
    treatments among older adults
  • Discussions of goals important
  • Help maintain patient autonomy
  • Prevent unnecessary treatments

18
Preoperative Pulmonary Evaluation
  • IF a vulnerable elder is to have elective major
    surgery, THEN a pulmonary review of systems
    (i.e., history of smoking, baseline exercise
    tolerance, history of chronic obstructive
    pulmonary disease (COPD), or asthma) and chest
    auscultation should be performed preoperatively..

19
Preoperative Pulmonary Evaluation
  • .. BECAUSE vulnerable elders may possess risk
    factors for the development of postoperative
    pneumonia, and a pulmonary history and
    examination can aid in identifying the risk of
    postoperative pneumonia.

20
Preoperative Pulmonary Evaluation
  • Prospective cohort gt 160,000 elderly VA patients
  • Independent risk factors for post-op pneumonia
  • Increased age (gt 60 years)
  • Recent smoking
  • History of COPD or stroke
  • Impaired cognitive or functional status
  • Weight loss

Ann Intern Med 135 847-857, 2001
21
Preoperative Pulmonary Evaluation
  • Many risk factors are non-modifiable
  • Interventions target post-operative risk
    reduction in high-risk patients
  • Incentive spirometry
  • Intermittent positive-pressure breathing
  • Minimum pre-operative assessment
  • Examination of airway, lungs, heart
  • Exercise tolerance testing if indicated

Circulation 100 1464-1480, 1999
22
Preoperative Cardiovascular Evaluation
  • IF a vulnerable elder is to have elective major
    surgery, THEN an assessment of cardiovascular
    risk should be performed preoperatively, BECAUSE
    cardiovascular disease causes a significant
    amount of postoperative morbidity and mortality.

23
Preoperative Cardiovascular Evaluation
  • Risk stratification tools
  • Many different options available
  • Self-reported exercise tolerance is very
    important and a major predictor of outcome
  • Poor exercise tolerance (lt 4 blocks walking or lt
    2 flights stairs) associated with more cardiac,
    neurologic complications and transfers to ICU or
    telemetry

Arch Intern Med 159 2185-2192, 1999
24
Preoperative Cardiovascular Evaluation
  • Formal cardiac stress testing used selectively
    based on risk stratification
  • Exercise tolerance
  • 1 MET improvement mortality reduction of 17 in
    men and 12 in women
  • Overall tolerance lt 5 METs
  • 2x increase in postoperative death in men
  • 3x increase in postoperative death in women

Circulation 108 1554-1559, 2003 N Engl J Med
346 793-801, 2002
25
Preoperative Diabetes Evaluation
  • IF a vulnerable elder is to have elective major
    surgery, THEN the presence or absence of diabetes
    mellitus should be documented preoperatively
    AND
  • IF a vulnerable elder with diabetes mellitus is
    to have elective major surgery, THEN the diabetes
    regimen and adequacy of diabetes control should
    be documented preoperatively..

26
Preoperative Diabetes Evaluation
  • .. BECAUSE diabetes mellitus affects
    perioperative cardiovascular risk and is a major
    risk factor for wound infection.

27
Preoperative Diabetes Evaluation
  • Hyperglycemia impairs wound healing
  • Blood sugar gt 250 mg/dL
  • Impairs leukocyte function
  • Prevents immunoglobulin from fixing complement
    correctly
  • Increases risk of mortality
  • Associated with increased length of hospital stays

Int Anesthesiol Clin 38 31-67, 2000 Anesthsiol
Clin North Am 22 93-123, 2004
28
Preoperative Diabetes Evaluation
  • Duration of diabetes
  • Long-standing diabetes (lt 10 years)
  • Increases risk of end-organ disease
  • Increased risk of associated postoperative
    complications
  • Stroke
  • Myocardial infarction
  • Deterioration in renal function

29
Preoperative Diabetes Evaluation
  • Mechanism of diabetes control
  • Important to know what patient uses
  • Influences choices on pre- and post-operative
    managements
  • Diet
  • Oral hypoglycemic agents
  • Insulin
  • Goal of serum glucose on day of surgery of
  • lt 200 mg/dL
  • Consider delaying elective surgery if necessary
    until glucose control improved
  • Discussion continued in Post-operative care
    section

30
Preoperative Delirium Risk Factor Assessment
  • IF a vulnerable elder is to have elective major
    surgery, THEN he or she should be screened for
    risk factors for the development of postoperative
    delirium within 8 weeks before surgery, BECAUSE
    delirium is common in elderly patients, and
    identification of patients at risk for delirium
    may allow prevention or earlier diagnosis and
    treatment of postoperative delirium.

31
Preoperative Delirium Risk Factor Assessment
  • Post-operative delirium is common in older adults
  • Incidence varies widely in literature
  • However, associated morbidity and mortality can
    be significant
  • Studies suggest increased 2-3 fold increase in
    mortality in those with post-op delirium
  • Increases length of stay and need for
    post-discharge care

32
Preoperative Delirium Risk Factor Assessment
  • Predictive models identify risk factors
  • Visual impairment
  • Severe illness
  • Cognitive impairment
  • Poor functional status
  • Self-reported alcohol abuse
  • Electrolyte abnormalities
  • BUNcreatinine ratio 18

Ann Intern Med 119 474-481, 1993 JAMA 271
134-139, 1994
33
Preoperative Delirium Risk Factor Assessment
  • Prior episodes of delirium are also highly
    predictive of future delirium
  • Prevention is key
  • Preoperative planning can help reduce the
    incidence of post-operative delirium
  • Discussion continued in Post-operative care
    section

34
Perioperative Care
  • Prevention of Surgical Site Infection
  • Perioperative Beta-blockade
  • Anticoagulation for Hip Fracture and Replacement

35
Prevention of Surgical Site Infection
  • IF a vulnerable elderly has elective major
    surgery, THEN prophylactic antibiotics should be
    administered within 1 hour before incision (2
    hours for vancomycin or fluoroquinolone) and
    discontinued within 24 hours after the end of
    surgery..

36
Prevention of Surgical Site Infection
  • .. BECAUSE studies show a marked reduction in
    the relative risk of surgical site infections
    with the appropriate timing and duration of
    antibiotic prophylaxis.

37
Prevention of Surgical Site Infection
  • National Surgical Infection Prevention Project
    (NSIPP)
  • Prospective, randomized, double-blind RCT
  • Elective GI surgery
  • If no antibiotics 4x increase in wound
    infection or systemic sepsis
  • Infection rates significantly reduced if
    antibiotics administered within 1 hour of start
    of surgical case
  • Multiple studies support this recommendation

Surgery 66 97-103, 1967
38
Prevention of Surgical Site Infection
  • Stopping antibiotics after surgery
  • Prolonged antibiotic use increases the risk of
    colonization or infection with antibiotic
    resistant organisms
  • NSIPP guidelines recommend routine antibiotics be
    stopped within 24 hours after surgery
  • Dependent on multiple patient factors
  • Tailored to the patients needs

Clin Infect Dis 38 1706-1715, 2004
39
Perioperative Beta-blockade
  • IF a vulnerable elder with coronary artery
    disease has elective major surgery, THEN
    preoperative beta blockade should be considered,
    and if initiated, it should be continued until
    discharge, BECAUSE perioperative beta blockade
    appears to decrease the risk of cardiovascular
    morbidity and mortality.

40
Perioperative Beta-blockade
  • Somewhat controversial
  • Several studies support this
  • More recent studies raise questions about safety
    and possible adverse outcomes
  • Depends on specific population and individual
    patient characteristics
  • Suggests therapy should be tailored by
    cardiovascular risk status

41
Perioperative Beta-blockade
  • Underlying cardiovascular risk important
  • Retrospective study 780,000 patients in 326
    hospitals
  • Outcomes varied by risk status
  • Low-risk no benefit or possible harm
  • Adjusted OR death 1.36 (95 CI 1.27 1.45)
  • High-risk survival benefit
  • Adjusted OR death 0.58 0.88 (dependent on
    risk status)

N Engl J Med 353 349-361, 2005
42
Perioperative Beta-blockade
  • Meta-analysis of 22 RCTs showed no reduction in
    total mortality, cardio-vascular mortality,
    nonfatal MI, nonfatal cardiac arrest (considered
    separately)
  • However, the composite risk of all of these
    events (combined) was reduced during the first 30
    days post-op

BMJ 331 313-321, 2005
43
Perioperative Beta-blockade
  • Potential complications
  • Increased risk hypotension (RR 1.27)
  • Increased risk of bradycardia (RR 2.27)
  • Overall, the American College of Cardiology and
    American College of Physicians recommend
    beta-blockade in selected surgical patients
    (based on the cardiovascular risk status)

J Am Coll Cardiol 39 542-553, 2002
44
Anticoagulation for Hip Fracture and Replacement
  • IF a vulnerable elder has sustained a hop
    fracture, THEN an anticoagulant regimen should be
    started and
  • IF a vulnerable elder is to have a total hip
    replacement, THEN an anticoagulation regimen
    should be started preoperatively or on the
    evening after surgery..

45
Anticoagulation for Hip Fracture and Replacement
  • .. BECAUSE studies suggest that DVT prophylaxis
    reduces the incidence of DVT and pulmonary
    embolism (PE) in elderly patients with hip
    fracture and undergoing total hip replacement.

46
Anticoagulation for Hip Fracture and Replacement
  • Prevalence of DVT in elderly hip fracture
    patients undergoing arthroplasty ranges from 42
    57 if no given anti-coagulation prophylaxis
  • Meta-analysis of RCTs showed that subcutaneous
    heparin administration yielded a 56 reduction in
    odds of proximal DVT

Chest 126(suppl) 338s-400s, 2004 New Engl J Med
318 1162-1173, 1988
47
Anticoagulation for Hip Fracture and Replacement
  • Comparison trials of various forms of
    anti-coagulation therapy have yielded mixed
    results
  • Low-molecular weight heparins
  • Warfarin
  • Other agents (enoxaparin, fondaparinux)
  • Standard heparin
  • Intermittent pneumatic compression leggings
  • Graduated compression stockings

48
Anticoagulation for Hip Fracture and Replacement
  • If surgical delay occurs, recommend heparin-based
    therapy
  • Surgical delay is associated with decreased
    mobility, bedrest
  • Pain may also limit mobility and increase DVT
    risk
  • American Geriatrics Society (AGS) recommends all
    elderly patients undergoing major surgery

49
Anticoagulation Prophylaxis in Other Surgical
Cases
  • American Geriatrics Society (AGS) recommends all
    elderly patients undergoing major surgery receive
    some form of DVT prophylaxis
  • Graduated compression stockings
  • Intermittent pneumatic compression leggings
  • Must be operational prior to induction of
    anesthesia for maximum effect
  • Low-molecular weight heparins or regular heparin
  • Oral warfarin is NOT recommended (harder to
    control and adjust around time of surgery)

J Am Geriatr Soc 49 664-672, 2004
50
Postoperative Care
  • Mobilization
  • Diabetes Control
  • Screen for Postoperative Delirium
  • Cognition and Function at Discharge

51
Mobilization
  • If a vulnerable elder who was ambulatory as an
    outpatient has major surgery and is not in
    intensive care, THEN ambulation should be
    performed by postoperative day 2 ..

52
Mobilization
  • .. BECAUSE early ambulation as a major component
    of a multimodal intervention program, is
    associated with better functional recovery and
    shorter length of hospital stay in postoperative
    patients.

53
Mobilization
  • Prolonged bedrest is associated with increased
    risk of DVT, pulmonary embolism, and
    deconditioning in elderly
  • Multiple studies support that early mobilization
    yield benefits
  • Decreased length of hospital stay
  • Faster attainment of functional recovery
  • ACC/AHA guidelines support this also

Circulation 100 1464-1480, 1999
54
Mobilization
  • Mobilization includes multiple components
  • Up to chair
  • Toilet transfers
  • Ambulation
  • Remove tethers (catheters, tubes, drains, etc.)
    as soon as feasible
  • Utilize physiotherapy and devices to aide
    mobility as needed

55
Diabetes Control
  • If a vulnerable elder with diabetes mellitus has
    major surgery, THEN blood sugar should be dept
    below 200 on day of surgery and the first two
    post-operative days (or the chart should reflect
    attempts to achieve this)..

56
Diabetes Control
  • .. BECAUSE diabetes mellitus affects
    perioperative cardiovascular risk and is a major
    risk factor for wound infection.

57
Diabetes Control
  • Blood glucose gt 250 mg/dL impairs wound healing
    after surgery
  • Intensive insulin therapy
  • Goal blood glucose 80 110 mg/dL
  • Reduces morbidity and mortality in critically ill
    surgical patients
  • Compared to standard blood glucose range of 180
    200 mg/dL)

J Thorac Cardiovasc Surg 125 1007-1021, 2003
58
Diabetes Control
  • American College of Endocrinology
  • Position Statement on diabetes control in elderly
    hospitalized patients
  • Blood sugar targets
  • 110 mg/dL intensive care unit patients
  • 110 mg/dL preprandial, non-intensive care
  • 180 mg/dL random, non-intensive care

59
Screen for Postoperative Delirium
  • If a vulnerable elder has major surgery, THEN a
    daily screening examination for delirium should
    be performed for the first 3 days after surgery,
    BECAUSE daily screening for delirium will improve
    recognition of delirium and allow earlier
    intervention.

60
Screen for Postoperative Delirium
  • Daily screening with validated screening tools
    after surgery
  • Increases rates of early detection of
    post-operative delirium
  • Enhances ability to intervene
  • Leads to improved clinical outcomes and decreased
    morbidity / mortality

61
Screen for Postoperative Delirium
  • Confusion Assessment Method (CAM)
  • Validated screening tool
  • Easy to administer
  • Acute onset and fluctuating course (required)
  • Inattention (required)
  • AND either
  • Disorganized thinking OR
  • Altered level of consciousness
  • Sensitivity 81, Specificity 84

Ann Intern Med 113 941-948, 1990
62
Screen for Postoperative Delirium
  • CAM is a useful screening tool
  • Confirmation of diagnosis using the DSM-IV
    criteria
  • Primary goal is to prevent onset
  • Treat potential causative factors
  • Consider psychiatric consultation in patients
    with persistent delirium not responsive to therapy

63
Screen for Postoperative Delirium
  • Treatment
  • Improve environment
  • Involve family, other caregivers
  • Avoid restraints (physical chemical) as
    possible (balance risk/benefit)
  • Correct underlying factors
  • Electrolytes and hydration
  • Inappropriate medications (doses, types)

64
Screen for Postoperative Delirium
  • Treatment
  • Scheduled haloperiodol (0.5 2.0 mg)
  • Titrate to clinical response
  • May require total of 2.0 5.0 mg over time
  • Decrease dosing once improving
  • Remember to start low and go slow
  • Avoid PRN dosing may worsen symptoms

65
Cognition and Function at Discharge
  • If a vulnerable elder has major surgery, THEN
    assessment of cognition and functional status
    before discharge, in comparison with preoperative
    levels, should be performed, BECAUSE it may
    identify discharge-planning needs.

66
Cognition and Function at Discharge
  • Approximately 60 of all older adults will loose
    complete independence of at least on Activity of
    Daily Living (ADL) during an acute
    hospitalization
  • May require additional care after discharge
  • Home health nursing
  • Rehabilitation / therapy services
  • Skilled nursing facility placement
  • Temporary vs. permanent

67
Cognition and Function at Discharge
  • 97 of older adults report one or more additional
    care needs at the time of hospital discharge
  • 33 report that at least one of these needs were
    not being met
  • Failure to screen for decline in cognitive or
    functional status
  • Need to understand baseline function
  • Understand available services

Health Serv Res 27 155-175, 1992
68
Cognition and Function at Discharge
  • Baseline assessment must be performed and
    documented (changes in status)
  • Involve patient, family, other caregivers
  • Begin planning for discharge prior to admission
    or surgery if possible
  • Understand coverage and services available in
    your practice community

69
Summary
  • Some elderly patients may be good candidates for
    surgical therapy
  • Careful perioperative care can help optimize
    outcomes
  • Preoperative assessment
  • Selection for surgery
  • Recommended preoperative evaluations
  • Perioperative care
  • Postoperative care

70
Summary
  • Multidisciplinary cooperation is vital
  • Coordination of the overall plan of care
  • Transitions of care important
  • Between services
  • Changes in environment and care location
  • Successful outcomes can be achieved
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