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Preoperative Assessment in the Older Adult


Preoperative Assessment in the Older Adult Lisa Caruso, MD, MPH Section of Geriatrics Boston University Medical Center Goals To review the most common physiologic ... – PowerPoint PPT presentation

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Title: Preoperative Assessment in the Older Adult

Preoperative Assessment in the Older Adult
  • Lisa Caruso, MD, MPH
  • Section of Geriatrics
  • Boston University Medical Center

  • To review the most common physiologic changes in
    the elderly which may impair ones ability to
    compensate for operative stress
  • To describe the purpose of the preoperative
  • To provide strategies to minimize operative risks

Cardiovascular System
  • Changes in mechanics
  • Decrease in myocytes, increase in collagen
    resulting in decreased compliance
  • Autonomic tissue replaced by collagen resulting
    in conduction abnormalities
  • Decreased compliance of vascular system leading
    to increased systolic blood pressure with
    resulting ventricular hypertrophy

Cardiovascular System
  • Changes in control mechanisms
  • decreased responsiveness to catacholamines due
    probably to impaired receptor function
  • decreased heart rate response to changes in
    circulatory volume may lead to congestive heart
    failure or hypotension (COSV x HR gtpreload

Pulmonary System
  • Reduced chest wall compliance resulting in
  • increased work of breathing
  • reduced maximal minute ventilation
  • Reduced respiratory response to hypoxia by 50 (?
    Due to impaired chemoreceptor function)
  • Decreased ciliary function
  • Reduced cough and swallowing function

Neurologic Changes
  • Decrease in cortical gray matter, neuronal
    volume, complexity of neuronal connections,
    synthesis of neurotransmitters
  • Neuronal loss and demyelination occur in the
    spinal cord resulting in changes in reflexes and
    reductions in proprioception
  • Vision and hearing loss make information
    processing more difficult

Renal Changes
  • Decline in renal blood flow--10 per decade after
    age 50
  • Old kidney has difficulty
  • maintaining circulating blood volume
  • with sodium homeostasis
  • removing excess acid
  • adjusting to hypovolemia, hemorrhage, low cardiac
    output and hypotension
  • Renal insufficiency may not be appreciated

Adverse Drug Reactions (ADR)
  • Decrease in lean body mass with increased
    proportion of body fat
  • Decreased protein binding of certain drugs
  • Alterations in renal, CV, hepatic function may
    change drug concentrations and their duration of
  • ADRs increase with number of drugs administered
    and linearly with age

(No Transcript)
Preoperative Assessment--Purposes
  • Not just for clearance
  • To identify factors associated with increased
    risks of specific complications related to a
  • To recommend a management plan to minimize these

Cassel CK, Leipzig RM, Cohen HJ, et al. Geriatric
Medicine An Evidence Based Approach, 4th ed. New
York Springer 2003.
Preoperative Assessment--Components
  • Functional Assessment
  • Cognitive Assessment
  • Nutritional Assessment
  • Review of advance directives
  • whether and when to withhold or withdraw support

Functional Assessment
  • American Society of Anesthesiologists (ASA) score
  • Class I A normal healthy patient for elective
  • 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

Functional Assessment
  • Exercise capacity
  • inactive defined as inability to leave the home
    on ones own at least twice per week
  • increased CV risk in patients unable to meet a
    4-MET demand during most daily activities
  • Activities of Daily Living
  • Correlated with post-op morbidity and mortality

Cognitive Assessment
  • Not done uniformly
  • Dementia is a major predictor of post-op delirium
  • Use of Mini-Mental State Exam or orientation and
    recall testing
  • Much potential for future research

Nutritional Assessment
  • Poor nutrition is a risk factor for
  • pneumonia
  • poor wound-healing
  • 30-day mortality
  • Hypoalbuminemia (lt3.3mg/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.JAMA 19942721036.
Strategies to Minimize Risk
  • Routine screening is low yield
  • preop testing should be based on the type of
  • Manage hypertension
  • lower blood pressure to under 180/110
  • In patients with dementia, consider placement of
    epidural to control pain without sedation thus
    minimizing risk for delirium
  • Avoid long periods without nutrition
  • little evidence, but should try to improve
    nutritional status prior to elective surgery

Strategies to Minimize Risk
  • Perioperative use of ß-blockers
  • Mangano, et al., NEJM 1996, RDBPCT
  • In patients with or at risk for CAD, does IV
    atenolol decrease periop CV morbidity and
    increase overall survival?
  • Cardiac RF included age gt 65, hypertension,
    smoking, cholesterol gt 240, and diabetes.
  • 200 pts enrolled IV atenolol 10 mg given 30 min
    prior to surgery, 50-100 mg bid POD 1-7
  • 192 followed for 2 yrs

Strategies to Minimize Risk
Event-free survival after hospital discharge at 2
years was 68 in the placebo group and 83 in the
atenolol group (p0.008). Not clear yet if age
alone is an indication for use of ß-blockers in
perioperative period.
Strategies to Minimize Risk
  • Diabetic Postoperative Mortality and Morbidity
    (DIPOM) study
  • Perioperative Ischemic Evaluation (POISE) trial
  • Metoprolol after Vascular Surgery (MaVS) trial

Reuben DB, et al. Geriatrics at Your Fingertips
2005, 7th edition. New York, American Geriatrics
Society, 2005.
  • 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
    and to create management plans to minimize these
    deficits when possible.