Perioperative geriatrics. Guidelines, limits and beyond.

Camilla Wong MD FRCPC MHScOctober 29, 2016

#GeriUpdate16

A comprehensive geriatric assessment (CGA) is a multidimensional, interdisciplinary diagnostic process to determine the medical, psychological, and functional capabilities of a frail elderly person in order to develop a coordinated and integrated plan for treatment and long-term follow-up

Cochrane Database of Systematic Reviews 2011MDTea

CGA}geriatric assessment}

CGA}geriatric assessment}

Pre-operative Intra-operative Post-operative Discharge

PROACTIVE Comprehensive Geriatric Assessment

Values-based assessment

Surgical risk assessment

Geriatric risk assessment

Medical optimization

Geriatric optimization

Pre-habilitation

Anesthesia

PerioperativeAnalgesia

PerioperativeNausea

Delirium, pain, falls, nutrition, function,

catheter, pressure ulcer, pulmonary care bundles

Care Transitions



Determine goals and expectations.

Assess cognitive ability and capacity to understand anticipated surgery.

Screen for depression.

Identify and manage risk factors for delirium.

Screen for substance dependence.

Document functional status, mobility and falls.

Determine frailty.

Assess nutritional status and offer interventions.

Determine support system.

Order appropriate diagnostic tests.

Perform a preoperative cardiac evaluation.

Perform a preoperative pulmonary evaluation and implement optimization strategies.

Take a medication history and make any appropriate perioperative adjustments.

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PRE-OP

a) “understand” the information that is relevant to making a decision about

the treatment, and b) “appreciate” the reasonably foreseeable consequences of a

decision or lack of decision.

PRE-OPERATIVE HARMONIZATION

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VALUES BASED ASSESSMENT

JAMA. 2014;311(20):2110-2120.


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SURGICAL RISK ASSESSMENT

http://riskcalculator.facs.org/RiskCalculator/




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GERIATRIC RISK ASSESSMENT

Lancet. 2013;381(9868):752-62.

J Am Coll Surg. 2015 Dec;221(6):1083-92.

vs

P H E N OT Y P I C F R A I LT Y

J Gerontol A Biol Sci Med Sci 2001; 56:M146eM156.

ROBUST: 0-1

PRE-FRAIL: 2-3

FRAIL: 4-5

W E I G H T L O S Sunintentional > 10 pounds in prior year

W E A K N E S Sgrip strength in lower 20%

E X H A U S T I O Nself-report

S L O W N E S Sslowest 20% 15 feet walking time

L O W A C T I V I T Ylowest 20% kcals per week

Ann Surg 2013;258:582-588.

BMC Geriatrics (2016) 16:157


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2VALUES BASED ASSESSMENT




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P R E O P E R A T I V E T E S T I N G

Preoperative diagnostic tests should be performed selectively. Normal laboratory values obtained up to 4 months before surgery can be used if no substantial interval chance in clinical status.

Routine sets of preoperative screening tests are NOT recommended.3 exceptions: hemoglobin, renal function, albumin.

P U L M O N A R Y

Risk assessment for and strategies to reduce perioperative pulmonary complications for patients undergoing noncardiothoracic surgery. Ann Intern Med. 2006;144(8):575-80.

A N T I M I C R O B I A L

Clinical practice guidelines for antimicrobial prophylaxis in surgery. American Journal of Health-System Pharmacy 2013;70:195-283.

N U T R I T I O N

The European Society for Clinical Nutrition and Metabolism guidelines.http://www.espen.org/education/espen-guidelines

C A R D I O V A S C U L A R

2014 ACC/AHA Guideline on Perioperative Cardiovascular Evaluation and Management of Patients Undergoing Noncardiac Surgery. J Am Coll Cardiol. 2014;64(22):e77-e137.

T H R O M B O E M B O L I S M

Perioperative Management of Antithrombotic Therapy: Antithrombotic Therapy and Prevention of Thrombosis. Chest 2012; 141(2S):e326S-e350S.

D I A B E T E S

Canadian Diabetes Association Clinical Practice Guidelines Expert Committee. Can J Diabetes 2013;37(S1):S1-S212.

Cochrane Database Syst Rev. 2014;(3):CD002294.

Administer the CAGE Questionnaire.

If motivated, delay surgery for abstinence or detoxification.

If at risk, give perioperative prophylaxis for withdrawal syndromes.

In alcohol use disorder, give perioperative daily multivitamin and high-dose thiamine.

J Am Coll Surg. 2012;215(4):453-66.

J Am Coll Surg. 2016;222(5):930-47.

M E D I C AT I O N M A N A G E M E N T







T E S T.

Perform an assessment such as the Mini-Cog.

If abnormal, then further evaluation.

D O C U M E N T.

Documentation of pre-operative cognitive

status helps to quantify postoperative cognitive dysfunction.

I N Q U I R E .

Ask informants about any cognitive decline.

J Am Coll Surg. 2012;215(4):453-66.

C O G N I T I V E I M P A R I M E N T

IDENTIFY POST-OP DELIRIUM RISKAge > 65, cognitive impairment, severe illness, hearing or vision impairment, presence of infection, inadequately controlled pain, depression, alcohol use, sleep deprivation or disturbance, renal insufficiency, anemia, hypoxia or hypercarbia, poor nutrition, dehydration, electrolyte abnormalities, poor functional status, limited mobility, use of psychotropic medications, risk of urinary retention of constipation, presence of urinary catheter, aortic procedures.

J Am Geriatr Soc. 2015;63(1):142-50.

Age Ageing. 2012;41(5):629-34.

NNT = 13

DELIRIUM PREVENTION

J Am Geriatr Soc. 2015;63(1):142-50.

IF SCREEN IS POSITIVE, THEN FURTHER EVALUATION IS RECOMMENDED.

In the past 12 months, have you ever had a time when you felt sad, blue, depressed, or down for most of the time for at least 2 weeks?

In the past 12 months, have you ever had a time, lasting at least 2 weeks, when you didn’t care about the things that you usually cared about or when you didn’t enjoy the things that you usually enjoyed?

J Am Coll Surg. 2012;215(4):453-66.

Management of ADLs and IADLS

History of falls

Vision, hearing, swallowing

Gait and balance assessment

P E R F O R M A N C E S TAT U SDEFICITS SHOULD PROMPT PROACTIVE DISCHARGE PLANNING

AND REFERRALS TO ALLIED HEALTH

J Am Coll Surg. 2012;215(4):453-66.








increase functional capacity in anticipation of an upcoming stress

d e c r e a s e s p n e u m o n i aRR 0.45, 95% CI 0.24-0.83

d e c r e a s e s l e n g t h o f s t ay3.21 days, p=0.01

Cochrane Database of Systematic Reviews 2012 (11): CD010118.

Surg Endosc. 2013;27(4):1072-82.

PREHABIL ITAT IONA 1-month trimodal program improves post-op functional recovery.

Anesthesiology 2011;114:495-511.

Fasting from intake of clear liquids at least 2 hours before elective procedures requiring general anesthesia, regional anesthesia, or sedation/analgesia is recommended.

Fasting from intake of a light meal 6 hours of more before elective procedures requiring general anesthesia, regional anesthesia, or sedation/analgesia is recommended.

Anesthesiology 2011;114:495-511.








Pre-habilitation

J Am Coll Surg. 2016;222(5):930-47.

J Am Geriatr Soc. 2015;63(1):142-50.








Pre-habilitation

Anesthesia

J Am Coll Surg. 2016;222(5):930-47.

J Am Coll Surg. 2016;222(5):930-47.

J Am Coll Surg. 2016;222(5):930-47.








Pre-habilitation

Anesthesia


NauseaIn general, AVOID using:

corticosteroids scopolamine metoclopramide

promethazinedimenhydrinate

prochlorperazine

U S E 5 - H T 3 R E C E P T O R A N T A G O N I S T S

J Am Coll Surg. 2016;222(5):930-47.








Pre-habilitation

Anesthesia


PerioperativeNausea

Delirium prevention strategies

Multimodal, individualized acute pain control

Minimize pulmonary complications

Fall risk reduction

Maintain adequate nutrition

Urinary tract infection prevention

Prevent functional decline

Reduce pressure ulcers

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J Am Coll Surg. 2012;215(4):453-66.

POST-OP

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DELIRIUM PREVENTION

J Am Geriatr Soc. 2015;63(1):142-50.

orientation strategies vision and hearing aids sleep environment

family participation uncluttered hallways multimodal pain control

remove urinary catheters and other tethers

W H AT I S G O O D F O R D E L I R I U M ,

I S G O O D F O R FA L L S , I S G O O D

F O R F U N C T I O N A L D EC L I N E .

wound care: minimize pressure, friction,

humidity, shear force

avoid potentially inappropriate medications

resume diet early and provide dentures, if needed

chest physiotherapy and incentive spirometry

early, multidisciplinary involvement

nutritional supplement, if needed

early mobilization, using walking aids if needed scheduled toileting aspiration precautions








Pre-habilitation

Anesthesia


PerioperativeNausea



CO M M O N C O M P O N E N T S O F T R A N S I T I O N C A R E M O D E L S• Coordinated care with primary care physician• Engagement of patient, family, and/or caregiver• Patient-centered medical record • Post-discharge follow up plan• Medication management• Knowledge of important signs and symptoms

J Am Coll Surg. 2012;215(4):453-66.








Pre-habilitation

Anesthesia


PerioperativeNausea



Care Transitions








Pre-habilitation

Anesthesia


PerioperativeNausea



Care Transitions

Palliative Care

Family Doctor

Geriatrics

Surgery

Internist

Pain Service

Anesthesia

PT

RDPharmacy

Nursing

SW

OTSLP

ENHANCEDRECOVERYPROGRAMS

“ T H E I M M E D I AT E C H A L L E N G E T O I M P R O V I N G T H E Q U A L I T Y O F S U R G I C A L C A R E I S N O T D I S C O V E R I N G N E W K N O W L E D G E , B U T R AT H E R H O W T O I N T E G R AT E W H AT W E A L R E A D Y K N O W I N T O P R A C T I C E .”

17 systematic reviews and 12 additional showed Enhanced Recovery After Surgery (ERAS) programs may reduce hospital stays by 0.5–3.5 days compared with conventional care.

BMJ. 2005; 330(7505): 1401–1402.BMJ Open 2014;4:e005015.

13%16%13%4.5 days

less delirium

less pneumonia

less catheters

less days in hospital

Age and Ageing 2007; 36:190–196








Pre-habilitation

Anesthesia


PerioperativeNausea



Care Transitions

Perioperative geriatrics. Guidelines, limits and beyond.

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