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

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Perioperative Care in Geriatrics

Tomas L. Griebling, MD, FACS, FGSA

Department of Urology

The Landon Center on Aging


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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


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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


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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


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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


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Preoperative Care

  • Capacity to Consent

  • Discussion of Goals of Care

  • Pulmonary Evaluation

  • Cardiovascular Evaluation

  • Diabetes Evaluation

  • Delirium Risk Factor Assessment


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Capacity to Consent

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


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Capacity to Consent

….. BECAUSE failure to document this information may result in a surgical procedure and surgical outcomes that are not consistent with the patient’s goals of care.


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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


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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 (< 4% cases)

Am J Med 103: 410-418, 1997


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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


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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…..


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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 patient’s wishes and administered care.


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Discussion of Goals of Care

  • Needed information

    • Complications

    • Likelihood for survival

    • Likelihood for functional decline

  • Providers often misunderstand patient preferences or don’t discuss

  • Poor documentation about goals complicates this issue

J Am Geriatr Soc 48: s44-s51, 2000


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Discussion of Goals of Care

  • Hospitalized Elderly Longitudinal Project

    • 63% of patients > 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


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Discussion of Goals of Care

  • Patient’s 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


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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


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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…..


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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.


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Preoperative Pulmonary Evaluation

  • Prospective cohort > 160,000 elderly VA patients

  • Independent risk factors for post-op pneumonia

    • Increased age (> 60 years)

    • Recent smoking

    • History of COPD or stroke

    • Impaired cognitive or functional status

    • Weight loss

Ann Intern Med 135: 847-857, 2001


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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


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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.


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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 (< 4 blocks walking or < 2 flights stairs) associated with more cardiac, neurologic complications and transfers to ICU or telemetry

Arch Intern Med 159: 2185-2192, 1999


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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 < 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


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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…..


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Preoperative Diabetes Evaluation

….. BECAUSE diabetes mellitus affects perioperative cardiovascular risk and is a major risk factor for wound infection.


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Preoperative Diabetes Evaluation

  • Hyperglycemia impairs wound healing

    • Blood sugar > 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


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Preoperative Diabetes Evaluation

  • Duration of diabetes

    • Long-standing diabetes (< 10 years)

      • Increases risk of end-organ disease

      • Increased risk of associated postoperative complications

        • Stroke

        • Myocardial infarction

        • Deterioration in renal function


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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

    < 200 mg/dL

    Consider delaying elective surgery if necessary until glucose control improved

  • Discussion continued in Post-operative care section


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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.


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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


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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

    • BUN:creatinine ratio ≥ 18

Ann Intern Med 119: 474-481, 1993

JAMA 271: 134-139, 1994


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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


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Perioperative Care

  • Prevention of Surgical Site Infection

  • Perioperative Beta-blockade

  • Anticoagulation for Hip Fracture and Replacement


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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…..


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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.


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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


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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 patient’s needs

Clin Infect Dis 38: 1706-1715, 2004


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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.


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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


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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


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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


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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


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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…..


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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.


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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


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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


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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


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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


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Postoperative Care

  • Mobilization

  • Diabetes Control

  • Screen for Postoperative Delirium

  • Cognition and Function at Discharge


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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 …..


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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.


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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


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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


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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)…..


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Diabetes Control

….. BECAUSE diabetes mellitus affects perioperative cardiovascular risk and is a major risk factor for wound infection.


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Diabetes Control

  • Blood glucose > 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


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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


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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.


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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


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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


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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


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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)


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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


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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.


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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


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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


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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


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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


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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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