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Preoperative Assessment in the Older Adult

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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


1
Preoperative Assessment in the Older Adult
  • Lisa Caruso, MD, MPH
  • Section of Geriatrics
  • Boston University Medical Center

2
Goals
  • 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
    assessment
  • To provide strategies to minimize operative risks

3
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

4
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
    dependency)

5
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

6
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

7
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

8
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
    action
  • ADRs increase with number of drugs administered
    and linearly with age

9
(No Transcript)
10
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.
11
Preoperative Assessment--Components
  • Functional Assessment
  • Cognitive Assessment
  • Nutritional Assessment
  • Review of advance directives
  • whether and when to withhold or withdraw support

12
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

13
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

14
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

15
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.
16
Strategies to Minimize Risk
  • Routine screening is low yield
  • preop testing should be based on the type of
    surgery
  • 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

17
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

18
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.
19
Strategies to Minimize Risk
  • Diabetic Postoperative Mortality and Morbidity
    (DIPOM) study
  • Perioperative Ischemic Evaluation (POISE) trial
  • Metoprolol after Vascular Surgery (MaVS) trial

Http//www.medscape.com/viewarticle/494679
20
Reuben DB, et al. Geriatrics at Your Fingertips
2005, 7th edition. New York, American Geriatrics
Society, 2005.
21
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
    and to create management plans to minimize these
    deficits when possible.
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