Perioperative care of the geriatric patient

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 patient’s 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 patient’s
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 (< 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 patient’s 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 don’t 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 > 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
 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

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 > 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

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 (< 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

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 < 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 > 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 (< 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
< 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
 BUN:creatinine 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 patient’s 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 > 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