1. Geriatrics Perioperative Care Beth A. Barron, MD Columbia University Associate Program Director of Internal Medicine Allen Hospitalist Co-Director (no disclosures)

2. Objectives 1. Review the effects of aging on organ systems and consider how this effects the perioperative evaluation 2. Consider interventions to predict and reduce complications 3. Review the approach to perioperative evaluation in the elderly

3. CASE Mrs. G is a 90 yo female with past medical history of hypertension, osteoporosis, and hyperlipidemia who presents with L sided hip fracture after slip and fall. Meds: Lisinopril, Cardizem, Lipitor, Raloxifene, and Benadryl prn sleep Exam: 180/100 HR 92

4. What is the most important predictor of postoperative complications in the elderly?  Age  Comorbidities  Functional Status  Thallium Stress Testing

5. Principle # 1 Chronological age alone should not lead to refusal to clear for surgery Understand the effects of aging on all organ systems.

6. Chronological age as surgery determinant Geriatric assessment and severity of illness are better predictors of postoperative morbidity than age Complications are beyond mortality and CV events. Loss of function, independence and cognitive status are of great importance to the patients.

7. Evidence Effects of Age and Severity of Illness on Outcome and Length of Stay in Geriatric Surgical Patients William E. Dunlop, MD, THE AMERICAN JOURNAL OF SURGERY VOLUME 165 MAY 1993 Early and long-term outcomes of carotid endarterectomy in the very elderly: an 18-year single-center study. Ballotta E; Journal of Vasc Surg 2009; 50(3) 518-25.

8. What are the effects of aging on the cardiac system?  Increased risk of atrial fibrillation  CHF  Hypotension  All of the above

9. Effect of aging on cardiac system Conduction system disorders  Delays in conduction  Increasing risk of atrial fibrillation Blood pressure  Increasing systolic pressure  Increasing risk of orthostasis Ventricular hypertrophy and stiffness Reduced heart rate variability

11. Current Recommendations

12. What are the effects of aging on the pulmonary system?  Decreased cough  Decreased FEV1  Decreased response to hypercapnia  All of the above

13. Effects of aging on pulmonary system Clin Interv Aging 2006 September; 1(3) 253-260.

14. Other effects of aging important in the perioperative period  Trend towards more hypercoagulable  Decreased immune system response  Decreased kidney function

15. When reviewing this patients medications (Lisinopril, Cardizem, Lipitor, Raloxifene, and Benadryl prn sleep)….  Continue all medications  Continue all but Benadryl  Discontinue Lipitor  Discontinue Lisinopril, Raloxifene and Benadryl

16. Principle # 2 Review all medications preoperatively and eliminate the unnecessary and potentially harmful.

17. Polypharmacy Discontinue all nonessential meds Avoid any medications predisposing to delirium  Anticholinergics  Benzodiazepines  Opiates  Tricyclic antidepressants  Benadryl Hold any medications with potential harm in the periop period  ACE (hypotension, renal)  Hormones (thrombosis)

18. Principle # 3 Determine cognitive ability, competency, functional status and availability of supports. Determine advance directives, health care proxy, and goals of care

19. Informed consent/Capacity to Consent Understand the risks vs benefits Goals of Care Complications Likelihood for survival Likelihood for functional decline

20. The day after the operation she becomes confused and agitated.  This could have been prevented with preoperative Haldol  Give a stat dose of Ativan and observe  This could have been prevented with a geriatrics consult

21. Principle #4 Be aware of preoperative risks of delirium Consider ways to minimize the development of delirium Be alert to the occurrence of postoperative delirium

22. Dementia Mini mental state examination Ask patient and family about memory loss Review ability to complete ADL’s, IADL’s Major post op mortality predictor: increase up to 50%

23. Post operative cognitive dysfunction Separate from transient delirium from anesthetics or post operative complications May be related to sensitivity of neurologic tissue to hypoxia and hypotension

24. Evidence Monk, TG. Predictors of cognitive dysfunction after noncardiac surgery. Anesthesiology 2008; 108:18- 30 Discharge cognitive dysfunction  36.6% age 18-39  30.4% age 40-59  41.4% age > 60 Cognitive dysfunction at 3mo  5.6% less than age 60  12.7% greater than age 60

25. Predicting delirium Severe illness (complicated infection) Baseline dementia Dehydration Sensory impairment (visual*) Risk of delirium  4% if none  11% if 1 or 2  37% if 3 or more Kalisvaart KJ. Risk factors and prediction of postoperative delirium in elderly hip-surgery patients. J Am Geriatr Soc 2001: 49:516-522.

26. Predicting delirium Marcantonio ER, A clinical prediction rule for delirium after elective noncardiac surgery. JAMA 1994: 271: 134-139. One point:  Age >70  History of etoh abuse  Baseline cognitive impairment  Severe physical impairment (ADL’s)  Abnormal electrolytes or glucose  Noncardiac thoracic surgery  Abdominal aortic aneurysm (2 pts)

27. Consequences of delirium Can be prolonged Occurs in 15% of elderly surgical patients (even higher in ortho – 41% in hip fracture) Increases mortality and SNF placement Increases length of stay Marcantonio, J Am Geriatr Soc 2000 Jun; 48(6): 618-24

28. Preventing delirium Risk factor assessment:  Alcohol  Dementia Discontinue high risk medications Consider hydration and nutritional state Environment:  Day/night  Reorientation  Bring visual and hearing aides and walking assist devices for patient use Avoid hypotension, hypoxia Minimize anesthesia time or consider local/regional

29. Preventing delirium Low dose Haldol  Kalisvaart, KJ. Haloperidol prophylaxis for elderly hip-surgery patients at risk for delirium. J Am Geriatr Soc. Oct 2005; 53(10): 1658-66  Patients > 70 with risk factors for delirium given 1.5mg daily pre and post op  Decreased LOS and severity of delirium but not incidence

30. Prevention of delirium Geriatric consult  Decreases rate from 50 to 32%  Orientation, lighting, Hearing aides, glasses  Avoid restraints  Minimize medications  Prevent hypoxia, dehydration, malnutrition  Encourage ambulation Marcantonio, J Am Geriatr Soc 2001 May; 49(5):516-22

31. Principle # 5 Assess volume status and nutrition pre and post operatively. Monitor hemodynamics in high-risk patients and maintain adequate intake

32. Nutrition Complications associated with poor outcomes:  Delayed wound healing Markers of poor nutrition that predict outcomes  Albumin < 3.2 g/dL  Cholesterol < 160mg/d:L  Body mass index < 20 kg/m 2 Evidence supporting supplemental nutrition improving outcomes is weak at best

33. Cochrane Database 2005

34. Important things to consider when treating pain in the geriatric patients include  Patients may be more sensitive to these medications  Pain may be undertreated in this population  Hydration and nutrition influence the dosing needed  All of the above

35. Principle # 6 Pain control continues to be essential in the elderly population. May be more sensitive to both the effects and side effects of these medications.

36. Pain management in the elderly Risks of under treatment – cognitive difficulties requesting Drug-drug interactions More vulnerable to side effects and over medication  Changes in renal and hepatic clearance  Reduced lean body mass and total water  Poor nutrition or hydration

37. Determining preoperative frailty can help determine  LOS  Discharge disposition  Post operative complications  All of the above

38. Principle # 7 Functional status, fall risk and frailty are important to consider when estimating a patients ability to recover from surgery. Frailty is likely the most predictive measure of postoperative mortality.

39. Functional Status, Mobility, Frailty Assessing functional status Fall risk Frailty  Markers can predict post-op complications, LOS and d/c To SNF Gait/Mobility  TUGT (timed up and go test)

40. Frailty is predictive of postoperative complications Frailty risk score  Weakness (grip strength)  Weight loss (>10lb in 1 year)  Exhaustion (everything is an effort, could not get going)  Low physical activity (M  Slowed walking speed (measured 15ft speed) Frailty as a Predictor of Surgical Outcomes in Older Patients Makary J AM Coll Surg 2010

41. Summary: Geriatric Preoperative Checklist: Complete history and physical examination. Assess the patient’s cognitive ability and capacity to understand the anticipated surgery. Identify the patient’s risk factors for developing postoperative delirium Consider all current medical issues and their effects on the perioperative period. Review ways to reduce cardiac and pulmonary complications.

42. Summary: Geriatric Preoperative Checklist Document functional status and history of falls. Determine baseline frailty score. Assess patient’s nutritional status and consider preoperative interventions if the patient is at severe nutritional risk. Medication reconciliation and consider appropriate perioperative adjustments. Consider risk of polypharmacy. Determine patient’s family and social support system.

43. Future research opportunities Preoperative predictions:  Usable risk predictors  What laboratory and radiology tests are necessary?  Multidisciplinary team assessments Preoperative optimization:  Explore the effects on preoperative interventions: anemia, nutrition, mobility, strength Postoperative management:  Pain control  Multidisciplinary Teams