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

UMMS CRIT Module I: Preoperative Assessment in the Older Adult

Petra Flock, MD, MSc, CMDDivision of GeriatricsUniversity of MassachusettsMedical School

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



- 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?



• 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.



• 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?



• 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”



• Functional Assessment

• Cognitive Assessment

• Nutritional Assessment

• Review of advance directives

Preoperative Assessment - Components



• 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



• 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



• 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.



• 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



• 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



• 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

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

Documents

umms initiative

umms crit module

preoperative assessment

geriatrics education

reynolds foundation

reynolds foundation

operative risks goals

moribund patient