Preoperative Assessment of the Geriatric Patient in the Office

Transcription

1 Preoperative Assessment of the Geriatric Patient in the Office R. Terry Martin M.D. Program Director Sacred Heart Hospital Geriatric Fellowship Disclaimer Dr. R. Terry Martin has no conflict of interest, financial agreement, or working affiliation with any group or organization. Objectives 1. To be able to assess the risk factors of postoperative delirium based upon cognitive assessment, depression screening and functional assessment of the patient preoperatively. 2. To preform an appropriate preoperative assessment through history, physical, labs and diagnostic tests based on the cardiopulmonary risk preoperatively and during hospitalization. 3. To optimize the patient s status preoperatively to reduce hospital complications, length of stay and nursing home admissions for rehabilitation 4. To optimize patient medications by review utilizing the Beer s list (AGS 2015) to reduce delirium and complication postoperatively 1

2 The highest rate of postoperative complications in the older patient undergoing surgery is: A. Cardiac complications B. Delirium C. Pulmonary complications D. Falls E. Infections Stopping tobacco abuse preoperatively reduces the risk of postoperative complications by which of the following percentages: A. 0% B. 5% C. 10% D. 13% E. 15% Which one of the following list is given a level of evidence rating of A : A. CBC is indicted for all preoperative assessments in all surgeries. B. BMP should be completed to assess for electrolyte and renal function preoperatively in all surgeries. C. Patient with S & S of cardiovascular disease should undergo an EKG. D. Patients in their usual state of health undergoing cataract surgery do not require preoperative testing. E. Random glucose or A1C measurement should be done if abnormal result would change perioperative management. 2

3 Importance of Preoperative Assessment of Elderly Elderly numbers will nearly double from 2010 to 2050 to 20% Baby Boomers started 2011 Fastest growing segment of elderly is > > 65 =37% of hospital discharges but 43% of hospital days of care % of inpatient and 32.1% of outpatient procedures Approach to Elderly Adult Risks are different pre and post-op(multi-organ involvement) More co-morbid diseases compounded with physiologic deteriorating organ function (less able to handle stress) Less cognitive reserve capacity(more delirium) Polypharmacy and adverse drug reactions(more delirium) Potential for post-op complications are greater Require more preoperative preparation for surgery Less functional capacity and more require placement for rehab Approach to Elderly Cognitive ability and Capacity for surgery Can patient under stand the consent for surgery and risks of surgical complications? Must document baseline mental status Must have family member to confirm mental status and history Assessment: Mini-Cog test = 3 object recall and clock draw 3

4 Mini-Cog Test 3 Item Recall and Clock Draw 1. GET THE PATIENT S ATTENTION, THEN SAY: I am going to say three words that I want you to remember now and later. The words are: Banana Sunrise Chair Please say them for me now. Give the patient 3 tries to repeat the words. If unable after 3 tries, go to next item. Mini- Cog Test 2. SAY ALL THE FOLLOWING PHRASES IN THE ORDER INDICATED: Please draw a clock in the space below. Start by drawing a large circle. Put all the numbers in the circle and set the hands to show 11:10 (10 past 11). If not completed after 3 minutes terminated the test. 3. SAY: What were the three words I asked you to remember? Mini Cog Scoring 3 item RECALL (0 3 points) 1 point for each correct word CLOCK DRAW (CDT): Clock draw (0 or 2 points): 0 points for abnormal clock 2 points for normal clock Number 1 12 in correct order and placement inside circle 2 hands one point to 11 and other to 2 4

5 Mini-Cog Interpretation Positive for Cognitive Impairment Negative for Cognitive Impairment 0 recall 1-2 recall + Abnormal CDT 1 2 recall + normal CDT 3 recall (CDT not required) Mini-Cog vs MMSE Sensitivity Specificity Time to completion Mini-Cog 76% 89% 2-4 min. MMSE 24 cut point 71% 94% 5-12 min. Depression Screening PHQ-2 Risk Factors: Female Disability Sleep Disturbance Prior depression Cognitive Impairment Living alone New medical illness Multiple co-morbidities 5

6 SCREENING FOR DEPRESSION Patient Health Questionnaire-2 (PHQ-2) 1. 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 two weeks? MOOD 2. In the past 12 months, have you ever had a time, lasting at least two weeks, when you didn t care about the things that you usually care about or when you didn t enjoy the things that you usually enjoy? ANHEDONIA One positive response requires full depression evaluation Assessment of Depression with Positive PHQ 2 GDS - Geriatric Depression Scale for non demented patients 15 minutes to administered for 30 item form 8 minutes for 15 item form 3 minutes for 5 item for that has Sensitivity 94% Specificity 81% Cornell Scale for Depression in Dementia 20 minutes to administered for 19 items Sensitivity 93% and Specificity 97% Same questions are asked to patient and informant(2 separate) Based on Assessor direct rating rather than informant and patient GDS 5 item II. Criteria: Questions (abnormal or positive answers in parentheses) Are you basically satisfied with your life? (No) Do you often get bored? (Yes) Do you often feel helpless? (Yes) Do you prefer to stay at home rather than going out and doing new things? (Yes) Do you feel pretty worthless the way you are now? (Yes) Two positive answers suggests depression 6

7 Consequences of depression Increase Discharge to TCF/SNF for rehab Prolonged LOS Decreased Motivation for rehab Post-op delirium + complications Increase pain perception Increase analgesic use CARDIAC RISK STRATIFICATION FOR NONCARDIAC SURGICAL PROCEDURES (BASED ON REVISED CARDIAC RISK INDEX) Risk Low (< 1%) Examples Endoscopic procedures, superficial surgery, cataract surgery, breast surgery, ambulatory surgery Intermediate (1-5%) Intraperitoneal and intrathoracic surgery, cardiac endarterectomy, head and neck surgery, orthopedic surgery, prostate surgery Vascular (>5%) Aortic/other major vascular surgery, peripheral vascular surgery Reprinted from Journal of the American College of Cardiology, Vol 54(22), Fleischmann KE, Beckman JA, Buller CE, et al., 2009 ACCF/AHA Focused Update on Perioperative Beta Blockade, p , 2009, with permission from Elsevier. ACC/AHA Guidelines 7

8 ESTIMATING ENERGY REQUIREMENTS FOR VARIOUS ACTIVITIES 52 Metabolic Equivalents (METs) Can you 1 MET Take care of yourself? Eat, dress, and use the toilet? Walk indoors around the house? Walk a block or two on level ground at 2 to 3 mph (3.2 to 4.8 kph)? 4 METs Do light work around the house like dusting or washing dishes? Climb a flight of stairs or walk up a hill? Walk on level ground at 4 mph (8.4 kph)? Run a short distance? Move heavy furniture? Participate in moderate recreational activity like golf, bowling, dancing, doubles tennis, or throwing a baseball or football? >10 METs Participate in strenuous sports like swimming, singles tennis, football, basketball, or skiing? Reprinted from Journal of the American College of Cardiology, Vol 54(22), Fleischmann KE, Beckman JA, Buller CE, et al., 2009 ACCF/AHA Focused Update on Perioperative Beta Blockade, p , 2009, with permission from Elsevier. EKGs Not Recommended for low risk procedure if asymptomatic Recommended Intermediate or vascular surgery Known ischemic heart disease, PVD, CVA, HF, arrhythmias, CKD, COPD Noninvasive Stress Test Not recommended Intermediate risk surgery if no CVD clinical risk factors All low-risk surgeries Recommended for Intermediate and Vascular Surgeries 3 or more CVD clinical risk factors Functional capacity < 4 METs 1-2 clinical risk factors + < 4 METs 8

9 Pulmonary Complications Pulmonary Complications appear Day 4 vs Day 1 Cardiac Similar prevalence to cardiac adverse events. In elective abdominal procedures, pulmonary complications occurred > cardiac adverse events and longer LOS. Highest total hospital costs compared with post-op infectious, thromboembolic, and cardiac adverse events, and required the longest median LOS Pulmonary vs. Cardiac Complications ORIF hip with either general or spinal anesthesia Cardiac complications 8% Pulmonary complications 4% OVERALL MORTALITY CARDIAC COMPLICATIONS PULMONARY COMPLICATIONS 30 days 22% 17% 1 Year 36% 44% Pulmonary Risk factors Age > 60 Functional dependence ADL s > IADL s HF OSA Pulmonary HTN Delirium ( hip fracture 26 % pre-op and 40% overall in hospital) Creatinine > 1.5 mg/dl Weight Loss > 10 lbs. in 6 months Serum albumin < 3.5 mg/dl 9

10 Pre-Op Recommendations for Preventing Pulmonary Complications Optimization of pulmonary function in COPD and Asthma (delay surgery if necessary) Smoking cessation (conflicting studies) May increase pulmonary complications < 8 weeks of cessation Meta-analysis smoking cessation = no increase in pulmonary complications Pre-op Inspiratory Muscle training for thoracic surgery Select Chest x-rays and PFT s Pulmonary Complications Atelectasis Rx: out of bed Day 1 and incentive spirometry Bronchitis/Pneumonia Exacerbation of preexisting pulmonary disease Bronchospasm PE ARDS Prolonged Mechanical Ventilation Chest X-ray PFT s and Chest X-Ray 14,650 pts. - 23% abnormal - changed management 3% of time Abnormal chest x-ray was predicted from H&P Chest x-ray should be obtain with known cardiopulmonary disease If >50 yrs. undergoing upper abdominal, thoracic or AAA surgery PFT s H&P superior for non-thoracic surgeries at predicting complications 10

11 Medication Review/Elimination 50% of > 60 yrs. have 5 or more meds/supplements predicting % chance of drug-drug interactions Beer s List Medication (potential inappropriate)- AGS 2015 Many drugs renal cleared but egfr on lab slips do not reflect renal function in Elderly due to loss of muscle mass and organ deterioration( liver and renal) Calculate egfr with Cockcroft-Gault Formula > Modification of Diet in Renal Disease Study Equation (MDRD) egfr= (140-Age) x Body wt. (kgs.) / 72x Cr = Male (X.85 female) Cockcroft Gault Calculation 82 years female for elective cholecystectomy with weight of 130 lbs. and serum creatinine 1.3. LAB slip states egfr (nomogram) = 49 ml/min(ckd 3) By Cockcroft Gault calculation ml/min ( CKD 4) Reduce dosages: Antibiotics Novel Oral Anticoagulants (NOAC shouldn t be used) Fluids Digoxin, etc. Pre-op Testing Geriatric Patients Test Recommendations Indication Hemoglobin All Except Cataracts Particularly >80 BUN/Cr All Major surgery DM, CAD, ACE/ARB, NSAIDS WBC Platelet Count NO NO Myeloproliferative disorders Splenomegaly, Lymphadenopathy, Infections Spontaneous bleeding, easy bruising, myeloproliferative disorders 11

12 Pre-op Testing Geriatric Patients Test PT/INR PTT Recommendations NO Indication Vascular Procedures, Cardiac, Cancer surgery, Neurosurgery, Spinal procedures Electrolytes NO CKD, HF, Diuretics, digoxin, ACE/ARBs Glucose NO DM, Obesity Medication to Hold Pre-0p DM Sulfonylureas - Midnight (fasting) Metformin - 2 days before and after Thiazolindinedones - 3 days before GLP 1 Agonists - Midnight DPP 4 Inhibitors Midnight Long acting Insulin regular dose substitute U/Kg/Day + Geriatric sliding scale Medication to Hold Pre-Op CVS ASA High risk CVD continue Low risk CVD Hold 7 days before Clopidigril 5 days NSAIDS 2 days Coumadin 5 days NOAC (Dabigatran, Rivaroxaban, Apixaban) 2 days all are renal cleared Don t use GFR < 30 ml/min. (CKD 4 & 5) Cockcroft-Gault formula Loop Diuretics Midnight (NPO) 12

13 Meds to Continue β Blockers TX Goal is resting HR as optimal DO NOT START new β blocker Pre-op ACE and ARB continued All inhalers continued Smoker advise continue to smoke until after surgery as Risk Stopping Clearance Should be a communication to Surgeon and Anesthesiologist 72 years old obese male with COPD, OSA, DM, CAD and PVD which are well controlled. He has been evaluated with EKG, Stress test, chest x-ray CBC, CMP which are within normal limits (Attached). His functional capacity is 4 METs. Cognitively he is intact on Mini-Cog with 5/5. He was instructed to hold his ASA for 7 days, metformin for 2 days before surgery. He is to take 30 U of Lantus SQ in AM on the day of surgery (approx. ½ of usual dosage). Patient will bring and use his CPAP setting of 12 for 7 hours nightly. I would recommend Incentive Spirometry, out of bed and ambulate Day 1, O₂ saturation of % and VTE prophylaxis and utilization of a low dose Geriatric Sliding Scale for his DM. Clearance Do not hesitate to cancel elective surgery if the patient has not been optimized with his chronic diseases Don t write cleared for surgery due to medical/legal issues 13

14 egfr per calculation is the best representation of a geriatric patient renal function if the following is given: A. Age, weight and Height B. BMI and serum creatinine C. Serum creatinine, BUN and age D. Height, weight and serum Creatinine E. Age, weight and serum creatinine Which of the following medication should not be held in a high risk surgery A. Clopidigril B. Aspirin C. Glyburide D. Metformin E. Furosemide When utilizing the Mini Cog test for cognition, which of the following indicates normal cognitive function: A. 3/3 recall and 2/2 clock draw B. 2/3 recall and 0/2 clock draw C. 0/3 recall and 2/2 clock draw D. 1/3 recall and 0/2 clock draw 14

15 Major References 1. Fleischer LA, Fleischmann KE, Auerbach AD, et al ACC/AHA Guideline on Perioperative Cardiovascular Evaluation and Management of Patients Undergoing Noncardiac Surgery. J AM Coll Cardiol. 2014; 64(22): Chow WB, Rosenthal RA, Merkow RP, Ko CY, Esnaola NF. Optimal Preoperative Assessment of the Geriatric Surgical Patient: Best practice Guidelines: ACS NSQIP/AGS JACS. 2012: 215(4): Preoperative Cardiac Risk Assessment. BMJ Best Practices: BMJ update June 16,