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Surgical Innovations in Geriatrics Medicine

Mai Nguyen Mercer University COPHS Doctor of Pharmacy Candidate 2012 November 8, 2011 Preceptor: Dr. Ali Rahimi. Surgical Innovations in Geriatrics Medicine. Thomas R. Hornick, MD. Clinics in Geriatric Medicine. 2006;22: 499-513.

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Surgical Innovations in Geriatrics Medicine

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  1. Mai Nguyen Mercer University COPHSDoctor of Pharmacy Candidate 2012 November 8, 2011 Preceptor: Dr. Ali Rahimi Surgical Innovations in Geriatrics Medicine

  2. Thomas R. Hornick, MD. Clinics in Geriatric Medicine. 2006;22: 499-513. Surgical Innovations: Impact on the Quality of Life of the Older Patient

  3. Introduction • In the past, major surgery was rare in the elderly population. • But now, indications for surgery are being extended to include older patients for many major operations that were limited to younger patients not long ago. • In 1996, people >65 yo accounted for 35% of all operations in the US • In 2002-2003, there were 4.2 million hospital stays with at least one procedure done in those older than 75 years.

  4. Risks of Surgery in Elderly Patients • Multiple chronic diseases • Susceptible to common in-hospital complications: • Adverse drug events • Delirium • Functional decline • Falls • Incontinence • Pressure ulcers

  5. Health-Related QOL • Patients’ resultant comfort or sense of well being • Extent to which they were able to maintain reasonable physical, emotional, and intellectual function • Degree to which they retain their ability to participate in valued activities with the family, in the workplace and in the community

  6. Health-Related QOL • Measured by questionnaires • Short-form-36 (SF-36) or its shortened version, short-form-12 (SF-12) • These scales measure areas of mental and physical health. • Physical health: physical functioning, problems with work or other daily activities as a result of physical problems, bodily pain, and general health perception. • Mental health: perceived mental health, problems with work or other daily activities as a result of emotional problems, social function, and vitality.

  7. Health-Related QOL and Joint Replacement Therapy • HRQOL and joint replacements have been well studied. • Older individuals who have severe OA have poor SF-36 scores for pain, physical function, and problems with work or other daily activities as a result of physical health. • These scores improve remarkably after joint replacement, often reaching or exceeding scores of normal population after 6 months.

  8. Health-Related QOL and Cardiac Surgery • Valve replacement surgery has greater risks and benefits in the elderly. • Rates for short-term mortality range from 8% to 20%, depending on valve and comorbidities. • QOL in those surviving valve replacement is greatly improved, with improvement in SF-36. • SF-36 improvement at 18 months was significant in almost all QOL areas and the mean scores were comparable to the scores of healthy elderly patients.

  9. Health-Related QOL and Cataracts • Removal of cataracts improves vision and vision-related QOL with low risk. • 72% to 92% of patients reporting improvement in visual function after surgery • 89% of patients showing improvement on vision-specific HRQOL scales • Morbidity and mortality are low despite its use in the very elderly.

  10. Summary • As surgery has been extended into the elderly population, HRQOL has been added as a parameter to evaluate surgical success. • Surgery remains of significant risk in older patients • Estimate of the type of outcome, including morbidity, mortality, and HRQOL can aid in that decision.

  11. Selvon F. St. Clair, et al. Clinics in Geriatric Medicine. 2006;22: 515-533. Hip and Knee Arthroplasty in the Geriatric Population

  12. Introduction • OA is a chronic widespread form of arthritis that affects all joint structures and commonly manifested in hip and knee. • Risk factors for OA: genetic origins, microtrauma, increased cytokine activity, lack of nutrients (antioxidants), and obesity. • Approximately 68% of total hip arthroplasties and 74% of total knee arthroplasties are performed on people over age 65.

  13. Total Hip Arthroplasty • THA was developed in the 1960s and is considered the standard of care for severe end-stage OA of the hip in elderly patients • Typically takes approximately 1.5 hours to complete • Involves the surgical excision of the head and proximal neck of the femur and removal of the acetabular cartilage and subchondral bone • Replacement of hip joint with prosthetic implant.

  14. Total Knee Arthroplasty • TKA is the treatment of choice in patients over 55 years who have progressive and painful OA and who have failed nonsurgical and less invasive treatments. • Replacement of diseased or damaged joint surfaces of the knee with different type of metals, polyethylene, or ceramics prosthesis.

  15. Complications of Hip and Knee Arthroplasty

  16. Future Directions of Hip and Knee Arthroplasty • Minimally Invasive Surgery TKA • Involves using a limited incision (4-7 in.) down the midline of knee • Standard TKA involves 8-14 in. skin incision • Early retrospective results from other centers indicate positive results with this technique. • Computer-Assisted Navigation TKA • Increases the accuracy of implantation • Results in improved outcomes and faster return to normal functions

  17. Vincent Conti, MD, and Scott D. Lick, MD Clinics in Geriatric Medicine. 2006;22: 559-574. Cardiac Surgery in the Elderly: Indications and Management Options to Optimize Outcomes

  18. Introduction • Cardiovascular disease remains the most common cause of morbidity and mortality in the US • CAD and CHF most common in the elderly • Surgical procedures (CABG and cardiac valve repair and replacement) are the best options for many older patients to improve their QOL.

  19. Indications for Operation • Primary Indication: Presence of symptoms that compromise the QOL when these symptoms are the result of the cardiac lesion to be corrected and likely to resolve or improve with successful operation • Other considerations: • Limited life expectancy • Dementia • Multisystem organ failure • Chronic liver failure • Severe pulmonary disease • Severe malnutrition

  20. Coronary Artery Bypass Graft (CABG) • Coronary artery bypass operations traditionally have been performed using a median sternotomy incision. • Although recovery after median sternotomy in most patients is rapid and complete, the elderly tend to have more difficulties and recover more slowly. • Development of coronary artery bypass operations using a small anterolateral thoracotomy incision • Some studies showed did not improve outcomes and associated with more early postoperative pain

  21. Aortic Valve Replacement • Valve replacement and repair have been done through smaller incisions • Aortic valve replacement  partial sternotomy incisions • Mitral valve procedures right parasternal incisions • Mitral valve repair or replacement  robotic techniques for minimal incisions • Transcatheter heart valve replacement • Valve replacement without open heart surgery • More studies needed

  22. Acute Aortic Dissection • Aortic dissection occurs when a tear in the inner wall of the aorta causes blood to flow between the layers of the wall of the aorta and force the layers apart. • Patients who have acute ascending (type A) aortic dissection involving the ascending aorta should undergo urgent operation. • Patients who have dissections involving only the descending aorta (type B) are managed medically initially. • Operative risk increases with age in patients with Type A dissection and survival with medical therapy have improved. • More elderly patients are treated medically

  23. Cardiac Transplantation • Occasionally is 0ffered to patients >70yo but rarely to those >75yo • Recipient age adversely affects 1-year survival after heart transplant • OR = 1 at age 55 (P<0.0001) • OR = 1.3 at age 65 (P<0.0001) • No valid data beyond 65 • All solid-organ transplants require lifelong medications to suppress the immune system • But they can cause neuropathy, osteoporosis, HTN, worsening DM, and renal dysfunction. • Recipient must not only survive the operation but also tolerate the side effects of postoperative medications.

  24. Rishi P. Singh, MD, Hilel Lewis, MD Clinics in Geriatric Medicine. 2006;22: 659-675. Innovations in Eye Surgery

  25. Introduction • Prevalence and disabling effects of eye-related illness increases as the population ages. • Recent research shows that vision impairment is associated with: • Decline in QOL • 2 or more falls in the elderly • Increased rate of hip fractures and decreased mobility

  26. Cataract • Clouding of the lens caused by clumping of proteins due to inadequate delivery of nutrients to deeper lens fibers • Results in blurry vision • Primary Goal of Surgery: • To remove clouded lens

  27. Cataract

  28. Glaucoma • Condition that causes damage to the optic nerve due to increased intraocular pressure • Caused by decreased or no drainage of aqueous humor • Glaucoma causes irreversible loss of peripheral vision early and central vision later in the disease development. • Primary goal of surgery: • To reduce intraocular pressure

  29. Glaucoma

  30. Age-Related Macular Degeneration • Disease associated with aging that gradually destroys sharp, central vision. • Affects the macula, the part of the eye that allow you to see fine detail

  31. Age-Related Macular Degeneration • Wet AMD • Occurs when abnormal blood vessels behind the retina start to grow under the macula • Loss of central vision occurs quickly • Early symptom: straight lines appear wavy • Dry AMD • Occurs when the light-sensitive cells in the macula slowly break down • Loss of central vision occurs gradually • Early symptom: slightly blurred vision

  32. Age-Related Macular Degeneration

  33. Diabetic Retinopathy • Diabetic retinopathy is a complication of diabetes that results from damage to the blood vessels of the retina. • Symptoms: blurred vision, floaters, trouble seeing at night, blindness eventually. • Many with early diabetic retinopathy have no symptoms before major bleeding occurs in the eye.

  34. Diabetic Retinopathy • Surgical procedures for treatment: • Laser eye surgery (photocoagulation) • Creates small burns in the retina where there are abnormal blood vessels in order to stop or slow the leakage of blood and fluid in the eye • Vitrectomy • Removes some or all of the vitreous humor from the eye

  35. Diabetic Retinopathy

  36. References • Hornick TR. Surgical Innovations: Impact on the Quality of Life of the Older Patient. Clinics in Geriatric Medicine. 2006;22: 499-513. • St. Clair SF, et al. Hip and Knee Arthroplasty in the Geriatric Population. Clinics in Geriatric Medicine. 2006;22: 515-533. • Conti V. and Lick SD. Cardiac Surgery in the Elderly: Indications and Management Options to Optimize Outcomes. Clinics in Geriatric Medicine. 2006;22: 559-574. • Singh RP and Lewis H. Innovations in Eye Surgery. Clinics in Geriatric Medicine. 2006;22: 659-675. • www.ncbi.nlm.nih.gov

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