To appreciate the unique problems of older surgical patients. To describe the differential and management

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2 To appreciate the unique problems of older surgical patients. t To describe the differential and management of acute abdomen in the older. To recognize and tend to hospital complications in olderpatients. To be familiar with options for recovery after discharge from the hospital.

3 CC: Upset stomach. HPI: A 78 year-old male with history of DM and BPH presents to his PMD at the VA with an upset stomach. He complains of vague abdominal pain since last night, after going out to dinner with his wife. She reports that t he was okay until this happened and was able to drive them to the hospital. He does not feel like eating and has vomited small amounts of green stuff several times. He admits to some diarrhea yesterday and has been passing gas.

4 What other information about his HPI would you want to know?

5 Non-insulin dependent diabetes Benign prostatic hypertrophy Hypertension Anxiety S/p appendectomy, age 22 (no complications)

6 Lopressor (metoprolol), 50 mg bid Glyburide, 5 mg qd Flomax (tamsulosin ER), 0.4 mg qd Ativan (lorazepam) 1 mg q4-6 hrs prn anxiety NKDA

7 Why are the social and psychiatric history particularly important in older patients?

8 Married 45 years, 2 children Worked as a carpenter. Retired about ten years ago. Tobacco: 2 ppd 35 yrs, quit 25 years ago. EtOH: denies

9 What are some of the challenges in assessing an older adult with abdominal pain? Wh l f h h i l i i What elements of the physical examination are important for this case?

10 VS: BP 108/71, P 84, T 98.2F, R 20 General: older gentleman, no apparent distress HEENT: dry mucous membranes CV: RRR with no M/R/G, normal pulses, no edema Resp: lungs clear to auscultation Abd: tympanic with diffuse tenderness to palpation; guarding in LLQ Neuro: non-focal, alert, oriented to person, place and time, attentive Psych: mildly anxious

11 What is the differential diagnosis of acute abdomen in the general population? What conditions i or diseases may be added d to the list, considering that our patient is an older adult?

12 During your examination, the patient has multiple spontaneous episode of large-volume bilious emesis. He begins to seem restless and confused. Repeat vitals, taken a few minutes later, reveal BP 82/50, P 124, T 98.3F, R 24.

13 What are your next steps in management? What labs, tests and imaging might be useful for this patient?

14 Albumin

15 In the ED, he is fluid resuscitated with NS. A nasogastric tube is placed, which yields 500cc of bilious, nonbloody material. After fluid resuscitation, his hemoglobin drops to 12.8; however, his vital signs remain normal while his mentation is waxing and waning. A kidney-ureter-bladder (KUB) film is obtained:

16 Nicolaou S et al. AJR 2005;185:

17 A following CT scan shows no passage of contrast into the large bowel. As a member of the surgical team, you approach the patient and his wife to discuss an exploratory laparotomy.

18 What are some of the special considerations when surgical and anesthetic interventions are being offered to older patients?

19 The patient is highly functional (he is independent of his BADLs and IADLs), and he and his wife agree to surgery. The surgeon finds and lyses adhesions that have caused the complete small bowel obstruction.

20 What are some of the other post-operative complications and hospital risks relevant to older patients?

21 On POD #1, he becomes agitated and rips out his IV line. He attempts to take a swing at his nurse. Haldol (haloperidol), 1 mg is administered.

22 What are some of the common causes of delirium in the geriatric population? Wh di i h ld d h ld b What medications should and should not be used for agitation in older patients?

23 ments/beers/2012beerscriteria_jags.pdf

24 On POD #2, he is unable to get out of bed or transfer to a chair. He is not eating well and you are concerned. You notice a wound on his heel.

25 Picture credit: Thompson, EG. Healthwise Staff.

26 On POD #5, he is able to ambulate to a chair, but he is very weak and needs assistance. Hi if h k h h His wife approaches you to ask what the next steps are.

27 What are some of the available discharge options for older patients who still need assistance after surgery?

28 Skilled Nursing Facility (SNF) Nursing Home Area Aging Agency Philadelphia hl l h Corporation for Aging (PCA) Assisted Living Facility Continuing-care Retirement Community Program of All-inclusive care for the Elderly (PACE) Living Independently for Elders (LIFE) Adult Protective Services

29 The patient is discharged to a nursing home setting for rehabilitation. You see him in the office four weeks later for his post-op visit. He is doing well, with no residual symptoms. His strength and independence have returned, and he plans to return home soon.

30 Appelbaum, Paul. Assessment of Patients Competence to Consent to Treatment. N Engl J Med 2007; 357: Caesar, R. Acute geriatric abdomen. In: The textbook of primary and acute care medicine, part VI: Gastrointestinal disease (Bosker G, ed.). Thomson American Health Consultants, Hustey FM, et al. The use of abdominal computed tomography in older ED patients with acute abdominal pain. Am J Emerg Med 2005; 23: Kiser KW, Vassar MJ. Emergency department diagnosis of abdominal disorders in the elderly. Am J Emerg Med 1998; 16: McGory ML, et al. Developing quality indicators for elderly surgical patients. Ann Surg Aug; 250(2): Podnos et al. Intra-abdominal sepsis in elderly persons. Clin Infect Dis 2002; 35: Sieber FE, Barnett SR. Preventing postoperative complications in the elderly. Anesthesiol Clin 2011; 29(1): van Geloven AA, et al. Hospital admissions of patients aged over 80 with acute abdominal complaints. Eur J Surg 2000; 166: