1 8/7/2014 Specific Problems in Surgery in the Elderly TAN Kok-Yang MMed(Surg), FRCSE, FAMS Head & Senior Consultant, Department of Surgery Clinical Director, Geriatric Surgery Service KhooTeckPuatHospital KTPH Surgery. To deliver progressive and collaborative surgical care with a passion for safety and culture of compassion. • Elderly population in Singapore growing • 6.3% aged above 65 currently • 25% by year 2030 (more than 1 million individuals) Background Problem with Elderly Surgical Patients • High incidence of co- morbidities • Limited functional reserves • Frequent acute surgical problems resulting in emergency situations • Old Paris Hilton Department of General Surgery Physiological Issues in Elderly Surgical Patients Old Brad Pitt
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One must have 3 or more of the following criteria to be frail
Male Female
Weight Loss Greater than 10lbs or 5% weight loss in the last year
15 foot Walk Time Height < 173
cm
>7 seconds Height < 159
cm
>7 seconds
Height >173 cm > 6 seconds Height >159 cm > 6 seconds
Grip Strength BMI < 24 < 29 BMI < 23 < 17
BMI 24.1 - 26 < 30 BMI 23.1 - 26 < 17.3
BMI 26.1 - 28 < 30 BMI 26.1 - 29 < 18
BMI > 28 < 32 BMI > 29 < 21
Physical Activity
(MLTA)
< 383 kcal / wk < 270 kcal / wk
Exhausation A score of 2 or 3 on either question on the CES-D*
*How often in the last week did you feel this way?
a) I felt that everything I did was an effort.
b) I could not get going.
0 = 1 day; 1 = 1–2 days; 2 = 3–4 days; 3 = more than 4 days
BMI = Body Mass Index;
MLTA = Minnesota Leisure Time Activity Questionnaire;
CES-D = Center for Epidemiologic Studies Depression Scale.
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M.R.C.P.Correlation with Major Complication
Risk 95% CI p
ASA > 3 1.048 0.323-3.400 0.938
WCIS > 5 1.424 0.426-4.759 0.564
Frail 3.467 1.113 – 10.795 <0.001
Major complication Yes No p
Mean Pred Mort 11.58 8.00 0.055
Department of General Surgery
Physical phenotype of frailty may reflect
reduced functional reserves and thus
intolerance to the trauma of major surgery
Health status at the time of
assessment
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Department of Surgery, Khoo Teck
Puat Hospital
Assessment
Patient 2
Patient 1
Cancer
Patient 3
time
Health status
Treatment
Tan KY Ed. Colorectal Cancer in the Elderly, 2012
Retonaz et al in
Delivering Surgical Care to the Complex
Geriatric Patient
Comorbidity
FrailADL
dependent
• Identification of high risk patients
• Shift towards elective surgery
• Optimize comorbidities
through prehabilitation
• Transdisciplinary approach
• Attention to details
Getting Round These ProblemsTransdisciplinary Geriatric Surgery Service
• Surgeons
• Anaesthetists
• Geriatric Medicine Physicians
• Cardiologist
• Nurse Clinician
• Physiotherapist
• Dietitian
• Medical Social Worker
• Pharmacist
• Befriender
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DIETITIAN
SURGEON
PATIENT
Multidisciplinary Approach
Adhoc, uncoordinated care rendered to patients
not managed by Geriatric Surgery Service.
MSW PHYSIOTHERAPIST
ANAESTHETISTCARDIOLOGISTGERIATRICIAN
Department of Surgery, Khoo Teck
Puat Hospital
Dr. Tan Kok YangSurgeon Dr. Lawrence Tan
Geriatrician
Ms Adeline WeePharmacist
Dr. Naville ChiaAnaesthetist
WeilingBefriender
Tan Pei PeiMedical Social Worker
Dr. Edwin SeetAnaesthetist
Dr. Ong Hean YeeCardiologist
Amy VongDietitian
Dispenses of hierarchyHeightened communicationPatient-centricRole extension (improve one’s own discipline)
Role enrichment (understand other disciplines)Role expansion (interdisciplinary education)Role release (blurred boundaries)Role support (constant feedback and quality improvement)
1• Consolidation of data of risk stratification and disease pathology
2• Patient education process on disease pathology
3• Transdisciplinary patient and family conference
4• Exploration of treatment goals in accordance to patient
5• Exploration of treatment options and setting treatment aims, risks and benefits
6• Obtain consensus on treatment strategy between patient, surgical team and family
7• Clear documentation of discussions
Department of Surgery, Khoo Teck
Puat Hospital
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8/7/2014
Components of Prehabilitation
• Education
• Optimisation of lung
function
• Mobilisation
• Muscle strengthening
• Nutrition
Prehabilitation
Selection Criteria
Prehabilitation Post Rehabilitation
Criteria Day
Rehabilitation
Centre
Home
Prehabilitation
Criteria Home
Rehabilitation
Inpatient
Rehabilitation
(AMKCH)
Charlson
Comorbidity
Index
>3 >3 Charlson
Comorbidity
Index
>3 >3
Frailty
Syndrome
Positive Positive Frailty
Syndrome
Positive Positive
Mobility Moderate Poor to
moderate
Peri-operative
complication(s)
requiring more
specific care
Negative Positive
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Patient Education Materials
Prehab Education
Twice per week home visit
Barthels Index after 2 weeks
of prehabilitation :
71/100 from 65/100
Satisfied patient and family
reported overall improvement in functional
status.
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Component Initial
Assessment
One Week after prehabilitation Two Weeks after
prehabilitation
Target
Education and
Compliance
Understand
disease and
indication for
surgery
Patient
understands
disease and
indication for
surgery
Yes � No � Patient
understands
disease and
indication for
surgery
Yes
�
No
�
Patient understands
disease and indication
for surgery
Knows what to
expect
Patient knows
what to expect
Yes � No � Patient knows
what to expect
Yes
�
No
�
Patient knows what to
expect
Preparation of
Operation
Patient knows
what to do
Yes � No � Patient knows
what to do
Yes
�
No
�
Patient knows what to
do
Weight Change
Current Weight: No Weight Loss � No Weight Loss � No Weight Loss Over
past 2 weeks
Weight Loss <5% � Weight Loss <5% �
Weight Loss >5�
Weight Loss >5�
Dietary Intake
Usual Intake: Achieved 100%
of dietary
requirement 5 in
7days
Yes � No � Achieved 100%
of dietary
requirement 5 in
7days
Yes
�
No
�
Achieved 100% of
dietary requirement 5
in 7days
050
100150200250300350400450500
Pre op 1st postop 2nd post op 3rd post op 4th post op 5th post op discharge
Dis
tan
ce (
m)
2/ 6MWT 2mwt 6mwt
05
101520253035404550
Fo
rce (
kg
)
Ankle Dorsiflexion ankle dorsiflexion Left
ankle dorsiflexion Right
02468
101214161820
no
. o
f re
ps
Chair riseChair rise
0
10
20
30
40
Pre op 1st postop 2nd post op 3rd post op 4th post op 5th post op discharge
Dis
tan
ce (
cm
)
Forward reachForward reach
0
5
10
15
20
Pre op 1st postop 2nd post op 3rd post op 4th post op 5th post op discharge
no
. o
f re
ps
Step Test Left step up Right step up
0
5
10
15
20
25
30
Pre op 1st postop 2nd post op 3rd post op 4th post op 5th post op discharge
Tim
e (
s)
TUG TUG
Department of Surgery, Khoo Teck
Puat Hospital
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Intraoperative Care Planning
Anaesthesia
Hypothermia
Fluids
Tubes
Department of Surgery, Khoo Teck
Puat Hospital
01565605
Endoscopic Submucosal Dissection for Early Cancers
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Postoperative
Department of Surgery, Khoo Teck
Puat Hospital
Post-operative
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Early Mobilisation POD1 Anterior Resection and Partial
Cystectomy
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Geriatric Surgery Service continue to provide home based rehabilitation after discharge to ensure preservation of functional state and quality of life as per premorbid.