PREOPERATIVE EVALUATION OF THE OLDER ADULT Carlos Guzman, MD Kamesiau Premmer, MD Ileana Ramirez, MD Anesthesiology Residents Mauricio Gonzalez, MD Associate Professor of Anesthesiology AGS THE AMERICAN GERIATRICS SOCIETY Geriatrics Health Professionals. Leading change. Improving care for older adults. Topic

Objectives To review the impact of anesthesia and surgery on older adults To describe the purpose of the preoperative assessment To describe key areas of assessment for the geriatric patient presenting for surgery and anesthesia

Elderly population in the US The US Census Bureau projects that in the next few decades the total US population will grow at a relatively stable rate, whereas there will be a more rapid growth in the portions of the population older than 65 years and older than 75 years.

Health Care FOR THE ELDERLY, 2005 Of 165,925,000 short-term hospital days, 44% involve patients >65 Under 65: 0.36 hospital days/person/year Over 65: 1.99 hospital days/person/year (3.31/person for patients >85) Approximately 7 million surgeries/year (3.6 times more than patients <65) http://www.cdc.gov/nchs/data/series/sr_13/sr13_165.pdf Topic

anesthesia-related deathS US, 1999–2005, per million population Li Guohua, MD. Anesth. 2009; Vol.110, Iss.4: 759-65.

30-day Surgical Mortality Thoracotomy mortality in patients >70: 17% Emergency abdominal surgery mortality in patients >80: 10% Major procedure mortality in patients >90: 20% Jin F, Chung F. Br J Anaesth 2001; 87: 608-24.

EFFECT OF AGE AND DISEASE ON RISK OF PERIOPERATIVE COMPLICATIONS Number of Complications per 1000 Surgeries This slide illustrates the interaction of age and disease to influence the risk of surgery. For any age bracket, risk increases as more chronic disease is present. By connecting points of constant disease, the effect of age becomes more apparent. At low disease level (0 or 10), age increases risk only modestly. When significant chronic disease is present, age markedly increases risk. Number of Comorbidities Can Anaesth Soc J. 1986;33:336.

Preoperative Assessment: Purposes Not just for “clearance” To identify factors associated with increased risks of specific complications related to a procedure To recommend a management plan to minimize these risks Cassel CK, Leipzig RM, Cohen HJ, et al, eds. Geriatric Medicine: An Evidence-Based Approach. 4th ed. New York: Springer; 2003.

Preoperative Evaluation Difficult to assess based on age alone or even by presence of comorbidities, as chronological age correlates poorly with physiological age Complete ROS and review of medications Functional assessment might be the best way to assess Cognitive assessment Nutritional assessment Education Review advance directives to decide whether and when to withhold or withdraw support Topic

Functional Assessment ASA classification Activities of daily living Correlated with post-op morbidity and mortality Frailty Topic

Frailty AND SURGICAL OUTCOMES (1 of 3) 5 frailty criteria were measured: Unintentional weight loss > 10 pounds in the last year Decreased grip strength, adjusted for gender and BMI Exhaustion, ascertained by questions about effort and motivation Low physical activity Slow walking speed Score of 2 or 3 = intermediately frail Score of 4 or 5 = frail J Am Coll Surg. 2010;210:901-908. Topic

Frailty AND SURGICAL OUTCOMES (2 of 3) Preoperative frailty was associated with increased risk of: Postoperative complications (intermediately frail, OR = 2.06; frail, OR = 2.54) Increased length of stay (intermediately frail, incidence rate ratio = 1.49; frail: incidence rate ratio = 1.69) Discharge to a skilled or assisted-living facility after previously living at home (intermediately frail, OR = 3.16; frail, OR = 20.48) J Am Coll Surg. 2010;210:901-908. Topic

Frailty AND SURGICAL OUTCOMES (3 of 3) Frailty improved the predictive power (P < .01) of each risk index considered: American Society of Anesthesiologists Lee Eagle J Am Coll Surg. 2010;210:901-908. Topic

Cognitive Assessment Increased risk of central nervous system dysfunction in the elderly Postoperative delirium Postoperative cognitive dysfunction Assessment not done uniformly Much potential for future research

TIME FRAME OF Delirium and POST-OP COGNITIVE DYSFUNCTION PACU Emergence Delirium 24- 72 hrs. POD Weeks/ Months POCD Persistent Dementia PACU = post-anesthesia care unit POD = post-op delirium POCD = post-op cognitive dysfunction Silverstein et al. Anesthesiology. 2007;106:622-628. Topic

Pathophysiology of POD DELIRIUM  Cortisol/Stress GABAergic Transmission  Dopaminergic Transmission  Cholinergic Transmission  Serotonergic Transmission Cytokines/Inflammation  Noradrenergic transmission Adapted from: Mantz J. Anesthesiology. 2010;112(1):189-195.

RISK FACTORS FOR POST-OP DELIRIUM Patient-related Substance abuse Preexisting disease (depression/dementia) Visual/hearing impairments Pain Hypoxemia Hypercarbia Hypotension Metabolic disorders Sepsis Other Restraints Cardiac surgery CNS drugs Sleep deprivation Topic

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 Preoperative Clinic Preoperative Area Intraoperative PACU Postoperative Assess for risk DEAR score Mini-Cog score Medical consult Patient/family education (verbal, brochure Review delirium assessment Counseling Regional anesthesia Avoid benzos Assess hydration status Monitor depth of anesthesia Maintain euvolemia Monitor/treat potential causes of delirium Avoid delirium- causing drugs Order set Assessment of patients CAM score R/O causes of delirium Family at bedside Remove Foley Return dentures, hearing aids, glasses Medical consult Postoperative interventions Return dentures, hearing aids, glasses Reorientation Avoid dehydration Medication reconciliation Pain control Avoid delirium-causing drugs Facilitate normal sleep cycle Mobility/avoid restraints Azocar: Geriatric Perioperative Passport ©. Reprinted with permission. Topic

DELIRIUM ELDERLY AT-RISK (DEAR) INSTRUMENT 5 criteria: Age 80 Poor hearing and/or vision Impairment in 1 activities of daily living MMSE < 24 or previous post-op delirium Alcohol >3 drinks/week or benzodiazepines >3 times/week, or other psychotropic medication >3 times/week (BMC Addition) 1 point per finding Score of 1 = mild risk, recommend strict adherence to good geriatric practices Score of 2 = significant risk, recommend good geriatric practices plus more aggressive monitoring and intervention Age Ageing. 2005;34:169-171.  Topic

Nutritional Assessment Poor nutrition is a risk factor for: Pneumonia Poor wound healing 30-day mortality Hypoalbuminemia (<3.3 mg/dL) is associated with: Increased length of stay Increased rates of readmission Unfavorable disposition Increased all-cause mortality JAMA. 1994;272:1036.

Summary Older adults have decreased reserves in multiple organ systems Disease burden and functional capacity outweigh age when assessing preoperative risk Collaboration among providers helps to identify functional, cognitive, and nutritional deficits and to create management plans to minimize these deficits when possible

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 Our gratitude to Dr. Alec Rooke for his assistance with many of these slides Topic

www.americangeriatrics.org Thank you for your time! Visit us at: Facebook.com/AmericanGeriatricsSociety Twitter.com/AmerGeriatrics linkedin.com/company/american-geriatrics-society