1. 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.
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2. 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

3. 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.

4. Health Care FOR THE ELDERLY, 2005
Of 165,925,000 short-term hospital days, 44% involve patients >65
Under 65: hospital days/person/year
Over 65: hospital days/person/year (3.31/person for patients >85)
Approximately 7 million surgeries/year (3.6 times more than patients <65)
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5. anesthesia-related deathS
US, 1999–2005, per million population
Li Guohua, MD. Anesth. 2009; Vol.110, Iss.4:

6. 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:

7. 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.

8. 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;

9. 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
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10. Functional Assessment
ASA classification
Activities of daily living
Correlated with post-op morbidity and mortality
Frailty
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11. 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:
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12. 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:
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13. 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:
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14. 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

15. TIME FRAME OF Delirium and POST-OP COGNITIVE DYSFUNCTION
PACU
Emergence Delirium
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:
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16. 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):

17. 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
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18. BOSTON MEDICAL CENTER’S Delirium-free Passport
Multidisciplinary effort
Checklist at all stages of perioperative period
Pilot in total knee replacement patients
Education phase

19. 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.
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20. 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:  
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21. 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.

22. 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

23. 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
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