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