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 Misconception that surgery is too dangerous for older adults Patients and families Professionals

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

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

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

Preoperative Care Capacity to Consent Discussion of Goals of Care Pulmonary Evaluation Cardiovascular Evaluation Diabetes Evaluation Delirium Risk Factor Assessment

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..

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.

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

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

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

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..

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.

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

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

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

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

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..

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.

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

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

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.

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

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

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..

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

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

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

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

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.

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

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

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

Perioperative Care Prevention of Surgical Site Infection Perioperative Beta-blockade Anticoagulation for Hip Fracture and Replacement

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..

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.

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

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

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.

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

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

Perioperative Beta-blockade Meta-analysis of 22 RCTs showed no reduction in total mortality, cardiovascular 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

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

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..

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.

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

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

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

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

Postoperative Care Mobilization Diabetes Control Screen for Postoperative Delirium Cognition and Function at Discharge

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 ..

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.

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

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

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 postoperative days (or the chart should reflect attempts to achieve this)..

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

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

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

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.

Screen for Postoperative Delirium Daily screening with validated screening tools after surgery Increases rates of early detection of postoperative delirium Enhances ability to intervene Leads to improved clinical outcomes and decreased morbidity / mortality

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

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

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)

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

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.

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

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

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

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

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

Documents

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