Assessment of the Elderly Pa2ent. Irwin Foo Western General Hospital Edinburgh

Transcription

1 Assessment of the Elderly Pa2ent Irwin Foo Western General Hospital Edinburgh

2 UK Demographics Fastest increase in the oldest old million age > 85 years ?3.5 million Life Expectancy Males 6.6 yrs Females 7.5 yrs Office for National Statistics

3 What do we mean by the Elderly? Anaesthe2sts Geriatricians Young Old 65-75yrs Old 75-85yrs Oldest Old over 85yrs Chronological vs Biological Ageing Elderly > 80 yrs old

4 Increasing Workload 50% of elderly will require anaesthesia for surgical interven2on in their life2me Surgical/anaesthe2c advances Laparoscopic techniques Improved anaesthe2c techniques Etzioni ei al. Ann Surg 2003; 238:170

5 Etzioni ei al. Ann Surg 2003; 238:170

6 How are we Doing? NCEPOD Report 2010 Launched 11th November, 2010: patients > 80yrs dying within 30 days postop over 3 month period

7 This report makes depressing reading. Too often it suggests a pattern of one size fits all medicine being applied to a heterogenous population with varying needs and falling short in ways which are both predictable and preventable. The thrust is encapsulated in the finding that only 36% of patients received care that our Advisors classed as good (Fig. 1.4). That does not mean that the care provided to that minority was exceptionally brilliant, merely that it was what the Advisors would accept as appropriate from themselves or their teams. Mr Bertie Leigh - Chair of NCEPOD

8 Content of Talk Recogni2on that elderly surgical pa2ents are not merely Older Adults Elderly specific issues Accurate assessment of func2onal reserve including frailty Involvement of Medicine of the Elderly Preven2on of postopera2ve complica2ons Iden2fica2on of pa2ents at high risk of delirium Prehabilita2on Management of expecta2ons

9 Why are Elderly Surgical Pa2ents not merely Older Adults?

10 Recogni2on that Elderly Surgical Pa2ents are not merely Older Adults Founded in 1987 to promote the art and science of anaesthesia for elderly patients

11 Variable Physiological Ageing % ORGAN FUNCTION YOUNG AVERAGE OLD AGE (YEARS)

12 FRCA answer Aeer age 40yrs - 1% reduc2on in GFR /yr Bal2more Longitudinal Study of Ageing (Lindeman, 1985) Average decline 0.8% per year Unexpected varia2on in healthy individuals Renal Func2on 30% showed no change in creatinine clearance for yrs 10% nearer 1.5-2% decline

13 Rate of Physiological Ageing in Different Systems

14 Mul2ple Comorbidi2es

15 Mul2ple Comorbidi2es No preoperative problems (20%) % of patients n = CVS RS CNS Vaz FG and Seymour DG Age and Ageing 1989; 18:

16 Comorbidi2es NCEPOD 2010 CVS > RS > Renal > CNS

17 Developing Quality Indicators for Elderly Surgical Pa2ents Process- based quality indicator defined as a process measure that, if performed, results in or signifies higher quality 91 candidate indicators rated as valid by an expert panel 71 (78%) of indicators rated as valid address processes of care NOT ROUTINELY performed in younger surgical popula2ons Developing Quality Indicators for Elderly Patients Undergoing Abdominal Operations. McGory et al J Am Coll Surg 2005; 201: 870

18 Process Measures More Applicable to the Elderly Surgical Pa2ent Elderly Pa2ents All Pa2ents Comorbidity Assessment CVS risk evaluation per ACC/AHA guidelines Estimation of Creatinine Clearance Evaluation of Elderly Issues Medication Use polypharmacy Patient -to- provider discussions decision making capacity, advanced directives Postoperative Management prevent malnutrition, delirium, deconditioning etc Discharge Planning social support, home health care, assess ADL

19 Elderly Specific Issues Cogni2ve impairment Delirium risk Nutri2on Pressure ulcer risk Func2onal status Ambula2on Vision/hearing impairments ADLs/IADLs Polypharmacy Developing Quality Indicators for Elderly Patients Undergoing Abdominal Operations. McGory et al J Am Coll Surg 2005; 201: 870

20 Frailty Frail easily broken or destroyed What is frailty? Geriatric syndrome physiological reserve across mul2ple organ systems Iden2fies pa2ents with a diminished capacity to effec2vely compensate for external stressors, who are at greater risk of adverse outcomes Prolonged hospital stay Ins2tu2onalisa2on Worsening disability Death Frailty is linked with inflamma2on? Causal ;? Compensatory;? Epiphenomenon

21 Frailty Opera2ng elec2vely on someone who seems to be very frail but stable carries the highest risk of adverse outcomes

22 Frailty Frailty identified by the end of the bed test in majority But Recognised as independent marker of outcome An Age Old Problem NCEPOD 2010

23 Type of surgery Extent of Surgical Stress (pa2ents > 90 yrs; n = 301) Mortality after 2 days (%) Mortality after 30 days (%) Major vascular Thoracotomy Biliary, liver Bowel, rectal, anal Hip TURP, eye Warner et al, Ann Surg 1988; 207:

24 Elderly Surgical Pa2ent Outcome Physiological Ageing Comorbidities Patient Outcome Elderly Specific Issues + Frailty Extent of Surgical Stress

25 Preopera2ve Assessment Process in the Elderly Serves two broad purposes: Risk stra2fica2on Inform doctors, pa2ents and their rela2ves/carers about risks and benefits of having (or not having) surgery Proac2ve iden2fica2on and op2miza2on of modifiable risk factors before surgery Oral nutri2on and supplementa2on Prehabilita2on Strategies to minimise postopera2ve delirium

26 Minimum Components of Preopera2ve Elderly Assessment (AAGBI 2014 guidelines, in prepara2on) Domain Items to be assessed Appropriate assessment tools Medical Comorbidity/severity e.g. cardiovascular Previous anaesthesia Anaesthesia - specific Alcohol intake (Pain intensity) Presen2ng Pathology Vital signs, ECG, (echocardiography), Shuple (CPEX) CAGE ques2onnaire (VAS score) Radiological

27 Domain Items to be assessed Appropriate assessment tools Medica2on Medica2on review NSQIP preop assessment An2coagulant therapy Relevant allergies Cogni2ve Mental Capacity AMTS Decision- making capacity Communica2on Risk factors for postop delirium Coagula2on screen Vision, hearing, speech NSQIP preop assessment Func2onal Capacity Gait and Balance 6 metre walk Mobility Walks unaided/ housebound Use of func2onal aids Visual/hearing/dentures Glasses etc Risk Score Pathology- specific Norngham hip fracture score Frailty NSQIP preop assessment

28 NSQIP preopera2ve assessment Chow et al. Journal of the American College of Surgeons 2012;215:

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30 Accurate Assessment of Func2onal Reserve

31 Most Consistent Feature of the Elderly Surgical Pa2ent? Patient Heterogeneity Physiological Ageing Co-morbidities Frailty Organ Functional Reserve

32 Effect of Ageing on Func2onal Reserve Progressive loss of func2onal reserve invisible loss un2l 70-80% of reserve lost! Anaesthesia/surgical insult oeen u2lises 50% or more of func2onal reserve % Maximal Organ Function Maximal Functional Reserve Basal

33 Elderly Pa2ents may not be Reliable Historians McGlade et al (2001) compared reliability of pa2ents Questionnaire: as historians tendency to overestimate Ques2onnaire abilities Pa2ent Next of kin Simple exercise test Stairs: 15% who claimed they could climb stairs Climbing 2 flights of stairs declined to do so Anaesth Intensive Care 2001; 29:520-6

34 Dynamic tes2ng of Func2onal Reserve Cardiopulmonary Exercise Testing Anaerobic Threshold Older, P. et al. Chest 1999;116: Aerobic Metabolism Anaerobic Contribution To Metabolism

35 Clinical History cannot be used to select pa2ents for CPET Need to test all older pa2ents?

36 Incremental Shuple Walk Test A more prac2cal alterna2ve? Correlates well with measured peak O 2 consump2on Cut- off distance: 250m in colorectal pa2ents predicted postop complica2ons Specificity = 0.88; Sensi2vity = 0.58 (Nup and Russell Anaesthesia 2012; 67: 839) Equipment needed CD player and shuple CD with incremental beeps 2 cones 9 metres apart Wrist pulse oximeter Willing helper to supervise walk

37 Frailty Assessment End of the Bed Test Who Is Frail? Hubbard et al J Gerontol A Biol Sci Med Sci 2010;65: 377

38 Frailty Assessment Frailty Scoring System 5 domains Shrinking (weight loss > 4 Kg in last year) Decreased grip strength (adjusted by gender and BMI) Men <30Kg Women < 17.5Kg Exhaus2on (ques2ons about effort and mo2va2on) Low Physical Ac2vity (ques2ons about leisure 2me ac2vi2es) Slowed walking speed (2me to walk 15 feet ) 0-1 Not Frail 2-3 Intermediate Frail 4-5 Frail Fried et al. Journal of Gerontology 2001;56:

39 Frailty as a Predictor of Surgical Outcomes in Older Pa2ents Independently predicts: Postopera2ve complica2ons Length of stay Discharge to a skilled/ assisted- living facility Enhances conven2onal risk models Frailty + ASA better predictor of outcomes Makary MA et al. J Am Coll Surg 2010; 210: 901-8

40 Is There a Gold Standard? Components of CGA CGA Multidimensional interdisciplinary diagnostic process focused on determining a frail elderly person s medical, psychological and functional capability in order to develop a coordinated and integrated plan for treatment and long-term follow-up

41 Surgical OutpaBents/PAC ProacBve referral of pabents aged 65 or over MulBmorbidity FuncBonal dependency PaBents diagnosed as unfit Post Discharge Intermediate Care Links with primary care / social care Specialist clinic follow up (falls etc) The POPS model Hospital Admission Post- op consultant geriatrician / specialist nurse intervenbon / liaison Therapy liaison Discharge planning Teaching / training Pre- operabve CGA Consultant Clinical Nurse Specialist Physiotherapy OccupaBonal therapist Social worker PaBent educabon Liaison Surgical team AnaestheBsts GP Community services PaBent

42 So Does it Work? Pre- POPS n=54 Post- POPS n=54 Age Cardiac 33% (18) 55% (27) Diabetes 13% (7) 20.4% (11) Renal 3.7% (2) 22.2% (12) Hypertension 51.9% (28) 80% (43) Post- POPS Length of Stay Reduc2on of 4.5 days!! Delirium 18.5% (10) 5.6% (3)* Pneumonia 20% (11) 4% (2)* ACS 7.4% (4) 3.7% (2 Arrhythmia 13% (7) 7.4% (4) Heart failure 3.7% (2) 0 Thrombosis 11% (6) 2% (1) Wound sepsis 22.2% (12) 3.7% (2)* Harari et al, Age Ageing 2007; 36:

43 Enhanced Recovery Pathway

44 Enhanced Recovery Plus Clinic Surgical Clinic Form Any elderly patient (>75 yrs) with any of the factors below is suitable for referral to the Enhanced Recovery Plus Clinic Recent history of MI (past year) Previous stroke Unstable Currently Angina taking warfarin Undergoing Chronic lung treatment disease with for heart shortness failure of breath at less than Uncontrolled 100 yards hypertension (BP > 160/90) Poor nutritional status (BMI < 20, or weight loss of 5 kg or more over 6 months) Two or more falls from standing height in the past year Significant memory problems or history of confusion or known dementia Needs personal help with (prior to admission): Getting to the toilet Moving from bed to chair Standing up Dressing Walking Appears Frail Mul2disciplinary nurse led clinic Timed Up and Go test Incremental Shuple Walk Test Detailed Cogni2ve Assessment Frailty Screen Nutri2onal Screen Input from Anaesthe2st MOE Consultant MDT Discussion and individualised preop plan

45 Survival and Postopera2ve Complica2ons NSQIP data > 1 million patients Khuri et al. Annals of Surgery 2005; 242:

46 What is Delirium? Acute change in cogni2on and apen2on Clinical features abrupt onset fluctua2ons with lucid intervals altered consciousness inability to sustain focus/ apen2on disturbed cogni2on delusions and hallucina2ons bewilderment and fear Mixed Hypoactive Hyperactive Unclassified Easily Missed up to 2/3 rd of cases by staff

47 Affects All Surgical Special2es Surgical Procedure Incidence Lung transplant 73% Hip fracture repair 62% Elec2ve abdominal aor2c surgery 33% Cardiac 21% Open In comparison general surgery with other complica2ons 17% 0.1% fatal PE in 3 months following hip fracture surgery Elec2ve 1% significant hip replacement wound infec2on following 15% elec2ve Elec2ve THR/TKR knee replacement 11% Urological surgery 6% Sieber Anesthesiology Clin 2009;451

48 Delirium Not just a nuisance! O Regan et al Int J of Surg 2013: 136

49 Iden2fica2on of Risk Factors Predisposing Factors Age > 65yrs Cogni2ve Impairment or Demen2a Depression Func2onal Impairment Mul2ple medical comorbidi2es/ Severe Illness Marked abnormal lab results Polypharmacy and psychotropic drug usage (benzodiazepines, an2cholinergics, an2histamines) Alcohol abuse Sensory impairments Nursing Home residence Current hip fracture PrecipitaBng Factors High- risk surgery Periopera2ve drugs Poorly controlled pain Anaemia Blood loss Dehydra2on Postopera2ve complica2ons Instrumenta2on (bladder catheters etc) Use of restraints Impaired oxygena2on

50 Simple Periopera2ve Tool Abbreviated Mental Test Age Time (to the nearest hour) Address - to recall at the end of the test: 42 West Street (ask pa2ent to repeat the address to ensure it has been heard correctly) Year Name of hospital Recogni2on of two persons (e.g. doctor, nurse) Date of birth Year of start of the first world war Name of monarch Count backwards from 20 to 1 Decline of AMT score of 2 or more = Diagnosis of Delirium Chonchubhair et al BJA 1995: Sensi2vity 93% Specificity 84% Comparable to CAM and NuDESC Sensi2vity 96-98% Specificity % O Regan et al Int J Surg 2013:136 Need Preoperative Baseline Score!!

51 Why Recovery Room Delirium Tes2ng? Brain already stressed by surgical and anaesthe2c drugs insults Dynamic test of brain func2onal reserve Strong predictor of postop delirium Allows early interven2on Proac2ve geriatric consulta2on Prophylac2c drug therapy

52 Proac2ve Geriatric Consulta2on Proac2ve geriatric consulta2on in hip fracture pa2ents (Marcantonio, 2001) Delirium incidence Interven2on group 32% Normal care 50% (NNT = 5.6) Delirium severity 60% risk reduc2on for severe delirium Consulta2on Recommenda2ons adequate CNS oxygen delivery fluid/electrolyte treat pain eliminate unnecessary medica2ons bowel/bladder func2on nutri2on early mobilisa2on preven2on/detec2on major postop complica2ons appropriate environmental s2muli treatment of agitated delirium Marcantonio et al JAGS 2001; 49:

53 Prophylac2c Drug Therapy Haloperidol prophylaxis in cri2cally ill elderly pa2ents admiped to ICU aeer non- cardiac surgery (n = 457) 0.5mg bolus followed by 0.1mg/hr i.v. for 12 hours Wang et al. Crit Care Med 2012; 40:731-39

54 Prehabilita2on Process of enhancing the func2onal capacity of an individual in an2cipa2on of a forthcoming physiological stressor Form of strength training Effect of preop inspiratory muscle training on postoperative pulmonary complications after cardiac or abdominal surgery Valkenet K et al Clinical Rehabilitation 2011; 25:99

55 Prehabilita2on Implementa2on of pre- surgical exercise programme Preop inspiratory muscle training Dronkers et al (2008) Small pilot study Interven2on group developed less atelectasis than control Inspiratory Muscle Strength Dronkers et al. Clin Rehab 2008;22:134

56 Preop Exercise aeer Neoadjuvant Chemoradia2on in Rectal Cancer Pa2ents Decline with NACRT (n = 28) Improvement with exercise regimen (n=18) Adjusted Predictions of week with 95% CIs VO2 LT week West et al 2013

57 Too Enthusias2cally Pursued

58 Informa2on Giving and Educa2on Impact of abdominal surgery on func2onal recovery Measured self- reported ADL and IADL Planned programme with goals useful for family and carers Lawrence et al J Am Coll Surg 2004;199:

59 Informa2on Giving and Educa2on Pa2ent s expecta2ons influence treatment preferences Survey of pa2ents >60yrs with limited life expectancy 98.7% would accept low- burden treatment to restore current health 88.8% would reject treatment if it resulted in cogni2ve impairment Postopera2ve Cogni2ve Dysfunc2on (POCD) Cogni2on Normal ageing Surgery Anaesthesia Loss of independence Fried TR et al N Engl J Med 2002;346: Time (years)

60 Improve Communica2on with Older Pa2ents.. Tradi2onal role of the Stethoscope Reverse Stethoscope Technique for the hard of hearing

61 Summary Elderly specific issues need to be addressed at preassessment Accurate assessment of func2onal reserve including frailty necessary for proac2ve management Requires involvement of Medicine of the Elderly Prehabilita2on Iden2fica2on of pa2ents at high risk of delirium allows strategies to be put in place Informa2on giving and management of expecta2ons important in this age group

62 Thank You AAA Mee2ng May 2014 Edinburgh You do not heal old age, you protect it and you extend it Sir James Sterling Ross And you preserve quality of life AAA Mee2ng May 22 nd - 23 rd, 2014 Edinburgh