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POSTOPERATIVE CARE OF THE GERIATRIC PATIENTMaria-Karnina Iskandar, MDAmit Patel, MDKonstantin BalonovAnesthesiology ResidentsRuben J. Azocar, MD Associate Professor of Anesthesiology AGS THE AMERICAN GERIATRICS SOCIETY Geriatrics Health Professionals. Leading change. Improving care for older adults.
Objectives • Review the impact of postoperative complications in the elderly • Discuss the most common postoperative issues in the elderly • Review the issues related to postoperative delirium and postoperative cognitive dysfunction
Deviation from the routine • Geriatric patients compensate on a daily basis for physiological declines in every organ system • Periods of extreme stress, such as surgery and anesthesia, can decompensate the older adult • In 2005, patients over 65 years accounted for approximately 7 million surgeries/year(3.6 times more than patients <65)
EFFECT OF AGE AND DISEASE ON RISKOF PERIOPERATIVE COMPLICATIONS Number of Complicationsper 1000 Surgeries Number of Comorbidities Can Anaesth Soc J. 1986;33:336.
Preoperative visit • Review comorbidities and their current state • Assess functional, cognitive and nutritional status • Provide recommendations to prevent perioperative complications
IMPLICATIONS OF COMPLICATIONS 30-day mortality for 60-year-olds vs. patients 801 1.1% vs. 3.7% if no complications 15.1% vs. 26.1% if ≥1 complications 3-month mortality in patients 70 vs. nonsurgical controls2 2.9 hazard ratio if no complications 7.3 hazard ratio if ≥1 complications If survive 3 months, complications minimally increase subsequent mortality Diminished functional status/↑dependency compared to patients with no complications • 1. Hamel M et al. JAGS. 2005;53:424. • 2. Kawalpreet M et al. Anesth Analg. 2003;96:583.
WHICH COMPLICATIONS ARE SEVERE? Heart failure: incidence of 5% in some studies, with mortality as high as 65%1 Pulmonary: 2.4 hazard ratio for death2 Renal: 6.1 hazard ratio for death2 Infection: UTI just as likely to lead to death as deep surgical wound infection is3 CNS: stroke, delirium, post-op cognitive dysfunction • 1. Roche JJ et al. BMJ 2005;331:1374. • 2. Kawalpreet M et al. Anesth Analg. 2003;96:583. • 3. Hamel M et al. JAGS. 2005;53:424.
AGE ANDPERIOPERATIVE COMPLICATIONS Hamel M et al. JAGS. 2005;53:424.
CV complications (1 of 3) • Most frequent: hypertension or hypotension • Second most frequent: dysrhythmias • Third most frequent: ischemia
CV complications (2 of 3) • Common causes of hypotension • Chronic medications (eg, levodopa, bromocriptine, tricyclic antidepressants) • Altered pharmacodynamics and pharmacokinetics causing prolonged/residual effects • Common causes of dysrhythmias • Hypoxia, hypercarbia • Electrolyte imbalance, metabolic alkalosis/acidosis • Preexisting cardiac disease
CV complications (3 of 3) • HR and rhythm can have greater impact on BP than in younger patients • Treatment: • Be more cautious than in younger patients about administering IVF as first-line treatment • Consider increasing heart rate and peripheral vasoconstriction (alpha-adrenergics or mixedalpha/beta-agonists) • Utilize Trendelenburg position as adjuvant
Pulmonarycomplications (1 of 2) Why are geriatric patients more at risk of post-op pneumonia, hypoxemia, hypoventilation, and atelectasis? • Decline in pulmonary reserve, increased V/Q mismatch • Diminished hypoxic & hypercapnic ventilatory drive • Altered pharmacology of anesthetic drugs intraoperatively, causing residual/prolonged effects • Decrease in laryngeal reflexes makes them more prone to aspiration
Pulmonarycomplications (2 of 2) • Patients at most risk are those with: • CHF • Arrhythmias • Dementia • CVA • Seizure disorder • Emergency surgery • Inappropriate reversal of neuromuscular blockade: subclinical paralysis might interfere with respiratory muscles and lead to atelectasis
Renal complications • Geriatric patients are more at risk of post-op renal dysfunction • Aging process changes renal circulation and tubular function • Patient-related factors: HTN, DM, CRI • Intraoperative factors: prolonged hypotension, massive transfusions • Consider placing Foley in at-risk patients, to monitor urine output throughout perioperative period
TIME FRAME OF Delirium and POST-OP COGNITIVE DYSFUNCTION PACU = post-anesthesia care unit POD = post-op delirium POCD = post-op cognitive dysfunction Silverstein et al. Anesthesiology. 2007;106:622-628.
PostOperative Delirium (POD) DSM-MS IV: A change in mental status, characterized by: • A prominent disturbance of attention and reduced clarity of awareness of the environment • An acute onset, developing within hours to days, and tends to fluctuate during the course of the day
Main clinical features OF POD • Acute onset • Fluctuating course • Inattention • Disorganized thinking • Alteration in consciousness • Cognitive deficit (memory, orientation, executive functions) • Hallucinations • Psychomotor disturbances • Lethargy (hypoactive delirium) • Agitation (hyperactive delirium) • Alterations of sleep-wake cycle • Emotional disturbances
Patient-related Pain Hypoxemia Hypercarbia Hypotension Metabolic disorders Sepsis Substance abuse Preexisting disease (depression/dementia) Visual/hearing impairments Other Restraints Cardiac surgery CNS drugs Sleep deprivation RISK FACTORS FOR POD
PATHOPHYSIOLOGY OF POD (1 of 3) Mantz J. Anesthesiology. 2010;112(1):189-195.
PATHOPHYSIOLOGY OF POD (2 of3) • Multifactorial • Deficit in cholinergic transmission (“cholinergic hypothesis”) • Acetylcholine plays important roles in attention, consciousness, and memory, and it is critically affected in dementia • Anticholinergic intoxication produces a delirium that can be reversed by cholinesterase inhibitors and by the propensity of antimuscarinic drugs to induce delirium • Serum anticholinergic activity is associated with delirium • Cholinesterase inhibitors do not typically treat or prevent postoperative delirium
PATHOPHYSIOLOGY OF POD (3 of 3) • γ-aminobutyric acid • Many sedative/hypnotics, including inhaled anesthetics, propofol, and benzodiazepines, potentiate γ-aminobutyric acid-mediated transmission through γ-aminobutyric acid type A receptors in the CNS • The monoamine transmitters have prominent neuromodulatory roles in regulating cognitive function, arousal, sleep, and mood, and they are modulated by cholinergic pathways • Excess of dopaminergic transmission has been implicated in hyperactive delirium, which can respond to antipsychotic dopamine receptor antagonists such as haloperidol
Impact of POD • Morbidity • Risk of injury • CV/neurological events • ? Post-op cognitive dysfunction after ICU delirium • Mortality • Loss of autonomy • Longer hospital stay: 6.0 days vs. 4.6 days • Nursing home placement • Health care costs: average additional cost $2,947
Prevention andManagement OF POD • Identification of patients at risk • Baseline cognitive impairment • Mini-Mental State Exam • DEAR score (Age, cognition, ADLs, hearing/visual impairment, chemical use) • Dementia/depression • Consider geriatric consultation • Avoid/minimize/treat delirium-related factors • Hospital Elder Life Program • Cognitive impairment, sleep deprivation, immobility, visual/hearing impairment, and dehydration
BOSTON MEDICAL CENTER’S Delirium-free Passport • Multidisciplinary effort • Checklist at all stages of perioperative period • Pilot in total knee replacement patients • Education phase
PREVENTION AND MANAGEMENT OF POST-OP DELIRIUM
MORE ABOUTManagement OF POD • Seek/treat cause • Delirium is a medical emergency • Medical issues are a frequent cause of delirium • Hyperactive delirium • Haloperidol • Atypical antipsychotics • Avoid benzodiazepines
Postoperative Cognitive Dysfunction (POCD) • Deterioration of intellectual function presenting as impaired memory or concentration • Not detected until days or weeks after anesthesia • Duration of several weeks to permanent • Diagnosis is warranted only if: • Corroborated with neuropsychological testing • There is evidence of greater memory loss than one would expect due to normal aging
Implications of POCD Abrupt decline in cognitive function heralds: • Loss of independence • Withdrawal from society • Leaving the labor market prematurely • Dependency on social transfer payments • Death Steinmetz J. Anesthesiology. 2009:110;548-555.
Incidence OF POCD • ISPOCD collaborative research effort 19941996 • Members from 8 European countries and USA • 13 hospitals • Anesthesia and surgery were associated with POCD • 26% of patients at 1 week after surgery • 10% of patients at 3 months after surgery • Hypotension and/or hypoxemia not related to occurrence of POCD Moller et al. Lancet. 1998:351;857-861.
LONG-TERM FOLLOW-UPOF ISPOCD COHORT • Re-evaluated patients at 1 and 2 years • The rate of POCD decreased to approximately 1%, which was not statistically significant Abildstrom et al. Acta Anaesthesiol Scand. 2000;44:1246-1251.
Age and POCD (1 of 2) • Single site, University of Florida, 1999–2002 • 1200 patients undergoing elective surgery • Young — 18 to 39 years of age • Middle-aged — 40 to 59 years of age • Elderly — 60 years and older • Controls — primary family members • Study design identical to ISPOCD study • Same psychometric test battery • Outcome endpoints: POCD (primary) and mortality (secondary) Monk et al. Anesthesiology. 2008;108:18-30.
Age and POCD (2 of 2) • POCD was common in all age groups at hospital discharge (33%44%) • 3 months after surgery the incidence of POCD was: • 4%5% in those younger than 65 • 13% in adults older than 60 years, particularly those with less than high school education • Associated with increased 1-year mortality Monk et al. Anesthesiology. 2008;108:18-30.
POCD AND NONCARDIAC SURGERY • Systematic review • POCD affects a significant proportion of people in the early weeks after major noncardiac surgery, with the older adult being more at risk • Minimal evidence that patients continue to show POCD up to 6 months and beyond • Studies on regional versus general anesthesia have not found differences in POCD Newman S. Anesthesiology. 2007;106:572-590.
POCD • Is POCD a measurable deterioration in older patients shortly after surgery and anesthesia with gradual resolution such that the incidence declines to levels nearly indistinguishable from control subjects by approximately 1 year? • More research needed
Conclusions • Surgery and anesthesia have a great impact in the decreased physiological reserve of the elderly • The number of comorbidities plays an important role in the incidence of complications • CNS, cardiac, pulmonary and renal complications have the greatest impact in the older individual
Acknowledgments Supported by a grant from the Geriatric Education for Specialty Residents Program (GSR), which is administered by the American Geriatrics Society and funded by the John A. Hartford Foundation of New York City
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