1. UMMS CRIT Module I: Preoperative Assessment in the Older Adult Petra Flock, MD, MSc, CMD Division of Geriatrics University of Massachusetts Medical School

2. UMMS CRIT 2010 Module I: Pre-Operative Assessment Advancing Geriatrics Education (AGE) A UMMS initiative funded by the Donald W. Reynolds Foundation To describe the purpose of the preoperative assessment To provide strategies to minimize operative risks Goals

3. UMMS CRIT 2010 Module I: Pre-Operative Assessment Advancing Geriatrics Education (AGE) A UMMS initiative funded by the Donald W. Reynolds Foundation - goal of surgery - urgency of surgery ( elective, urgent, emergent) - patient’s/family’s goals and wishes - baseline function, co-morbidities - life expectancy - anticipated outcomes/complications The Big Question: Should this patient go for surgery?

4. UMMS CRIT 2010 Module I: Pre-Operative Assessment Advancing Geriatrics Education (AGE) A UMMS initiative funded by the Donald W. Reynolds Foundation 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 Preoperative Assessment -Purposes Cassel CK, Leipzig RM, Cohen HJ, et al. Geriatric Medicine: An Evidence Based Approach, 4th ed. New York: Springer; 2003.

5. UMMS CRIT 2010 Module I: Pre-Operative Assessment Advancing Geriatrics Education (AGE) A UMMS initiative funded by the Donald W. Reynolds Foundation Delirium Infection Pressure sores Malnutrition Functional decline  increased mortality  poorer quality of life  need for increased care/change of place of living What Do Geriatricians Worry About?

6. UMMS CRIT 2010 Module I: Pre-Operative Assessment Advancing Geriatrics Education (AGE) A UMMS initiative funded by the Donald W. Reynolds Foundation Organ reserves are diminished Complications are more likely Less is often more Test only what you are able and prepared to correct and what will improve outcome You minimize complications, if you prevent prolonged bed rest (pre- and post-op) Common Sense Geriatric “Rules”

7. UMMS CRIT 2010 Module I: Pre-Operative Assessment Advancing Geriatrics Education (AGE) A UMMS initiative funded by the Donald W. Reynolds Foundation Functional Assessment Cognitive Assessment Nutritional Assessment Review of advance directives Preoperative Assessment - Components

8. UMMS CRIT 2010 Module I: Pre-Operative Assessment Advancing Geriatrics Education (AGE) A UMMS initiative funded by the Donald W. Reynolds Foundation American Society of Anesthesiologists (ASA) score –Class I A normal healthy patient for elective operation –Class II A patient with mild systemic disease –Class III A patient with severe systemic disease that limits activity but is not incapacitating –Class IV A patient with incapacitating systemic disease that is a constant threat to life –Class V A moribund patient that is not expected to survive 24 hrs with or without the operation Functional Assessment

9. UMMS CRIT 2010 Module I: Pre-Operative Assessment Advancing Geriatrics Education (AGE) A UMMS initiative funded by the Donald W. Reynolds Foundation Dementia and Hx of delirium are major predictor of post-op delirium Patients with delirium have higher mortality Know your patient’s baseline cognitive function (Mini-Cog, CAM, etc.) Cognitive Assessment

10. UMMS CRIT 2010 Module I: Pre-Operative Assessment Advancing Geriatrics Education (AGE) A UMMS initiative funded by the Donald W. Reynolds Foundation Poor nutrition is a risk factor for –pneumonia –poor wound-healing –30-day mortality Hypoalbuminemia (<3.3mg/dL) –increased length of stay –increased rates of readmission –unfavorable disposition –increased all-cause mortality Nutritional Assessment Corti M. Serum albumin level and physical disability as predictors of mortality in older persons. JAMA 1994;272:1036.

11. UMMS CRIT 2010 Module I: Pre-Operative Assessment Advancing Geriatrics Education (AGE) A UMMS initiative funded by the Donald W. Reynolds Foundation Routine screening is low yield –Pre-op testing should be based on the type and urgency of surgery Manage hypertension –lower blood pressure to under 180/110 Avoid long periods without nutrition Treat easily reversible factors (anemia, infection, etc) Use ß-blockers peri-operatively for major surgery, if not contra- indicated Strategies to Minimize Risk - pre-operative

12. UMMS CRIT 2010 Module I: Pre-Operative Assessment Advancing Geriatrics Education (AGE) A UMMS initiative funded by the Donald W. Reynolds Foundation Control diabetes without causing hypoglycemia Pay attention to constipation/urination Mobilize early/DVT prophylaxis Minimize use of psycho-active medication Control pain (your dementia patient won’t do PRN well) Avoid prolonged periods without nutrition Involve the families Strategies to Minimize Risk - post operative

13. UMMS CRIT 2010 Module I: Pre-Operative Assessment Advancing Geriatrics Education (AGE) A UMMS initiative funded by the Donald W. Reynolds Foundation 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/risks and to create management plans to minimize these deficits/risks when possible Summary