Perioperative Care of Older People

Transcription

1 Perioperative Care of Older People Philip Braude, Consultant Geriatrician POPS Proactive care of Older People undergoing Surgery Guy s and St Thomas #AGM17conf

2 Prevalence surgical pathology increases with age Degenerative Vascular Neoplastic

3 Elective surgery

4 Emergency surgery Patients 0 1,000 2,000 3,000 4,000 5,000 < >90

5 Surgery rates not reflect incidence National Cancer Intelligence Network, UK 2010 Access All Ages, RCS 2012

6 Why might this be? Multimorbidity Cognitive impairment Polypharmacy Frailty Dependence Ageism?

7 Older people get more complications Systematic review 28 papers = 34,194 patients Outcomes in Older People Undergoing Operative Intervention for Colorectal Cancer. Patel, JAGS, 2001

8 Older people get more complications Systematic review 28 papers = 34,194 patients Outcomes in Older People Undergoing Operative Intervention for Colorectal Cancer. Patel, JAGS, 2001

9 Older people get more complications Systematic review 28 papers = 34,194 patients Outcomes in Older People Undergoing Operative Intervention for Colorectal Cancer. Patel, JAGS, 2001

10 Older people get more likely to die Death rate +/- complications with without 30day mortality 13% 1% 1 year mortality 28% 7% 5year mortality 58% 40% Temporal Patterns of Postoperative Complications. Thompson, Arch Surg, 2003

11 and have functional deterioration Never mind dying, how long before I get back to normal? Functional independence after major abdominal surgery in the elderly. Lawrence. J Am Coll Surg, 2004

12 (...plus cost more) Late cancellations Length of stay Readmissions Social care costs Informal care costs J Vasc Surg 1997;25:

13 Who is at high risk of adverse outcomes? Poor functional recovery Older people Deterioration in function persisting up to 6months Poor cognitive recovery Older people Delirium, postop cognitive dysfunction, dementia Common, serious, distressing Poor experience Older people NCEPOD An age old problem, Francis report

14 So, why do older patients do worse?

15 Age not an independent factor

16 Age not an independent factor

17 But you knew all that already "You don't make a pig fatter by weighing the pig Don Berwick

18 Traditional hospital model Assess risk factors Not fit for surgery vs Fit for surgery Discharge to community React to complications Admit to SAL/Sx ward

19 Traditional hospital model 74yo Joyce Pain Opiates Post-op ileus Hypovolaemic (AKI) Anaemia Peripheral oedema Depressed (delirium) On/off sliding scale Fluids Blood Diuretics Anti-depressants Endocrinology Nephrology Haematology Cardiology Psychiatry On Call Medical Registrar Functional decline Carers & Rehab Geriatrics

20 What we should be doing Assessment of risk Modification of risk Care in the right place Manage complications Shared decision making PREM PROM Long term health

21 A variety of novel approaches are being taken Who? Anaesthetist led and delivered Geriatrician led and delivered Hospitalist led and delivered When? Preoperative only Postoperative only Whole pathway Braude FHC Journal 2016

22 Emerging specialty of perioperative medicine 10 million having surgery/pa in UK 1.6 million as in-patients 250,000 defined as high risk Promote multidisciplinary, patient centred medical care from contemplation of surgery until full recovery

23 Emerging specialty of perioperative medicine Promote multidisciplinary, patient centred medical care from contemplation of surgery until full recovery

24 Emerging specialty of perioperative medicine Promote multidisciplinary, patient centred medical care from contemplation of surgery until full recovery

25 National guidelines

26 and the relevant preoperative guidelines Preoperative Assessment IHD/failure ACC/ESC Optimization Anaemia PBM Planning Diabetes NHS DiabeteS Prevention of AKI NICE Prevention of POD NICE

27 the intraoperative guidelines Intra-operative MAP/BIS/temp Fluid balance Analgesia

28 and the relevant postoperative guidelines Post-operative AKI Sepsis AF ACS POD

29 This is complicated Nutrition Manage comorbidity Cognition Clinical pathway Anaemia Cardioresp fitness Frailty

30 This is complicated Length of stay Resource limitations Interdisciplinary Investigations Nutrition Manage comorbidity Cognition Clinical pathway Anaemia Cardioresp fitness Frailty Waiting list targets Consent and capacity Cancer treatment targets

31 This is complicated Length of stay Resource limitations Interdisciplinary Investigations Nutrition Manage comorbidity Cognition Clinical pathway Anaemia Cardioresp fitness Frailty Waiting list targets Consent and capacity Cancer treatment targets

32 This is complicated Length of stay Resource limitations Interdisciplinary Investigations Nutrition Manage comorbidity Cognition Geriatrics Anaemia Cardioresp fitness Frailty Waiting list targets Consent and capacity Cancer treatment targets

33 and to geriatricians sounds like Comprehensive Geriatric Assessment 30% higher chance of being alive and in own home NNT 13

34 Comprehensive Geriatric Assessment Holistic, multidimensional, interdisciplinary Formulation of: a list of needs, wants and priorities issues to tackle tailored individualised care plan

35 works as it allows Risk assessment Recognise comorbidity Identify disability & frailty Assess functional reserve Optimisation Medical, functional, psychological & social Organ specific guidelines MDT interventions

36 and facilitates Collaborative decision making Harm vs benefit Consent, capacity, advance directives Communication

37 Traditional hospital model 74yo Joyce Pain Opiates Post-op ileus Hypovolaemic (AKI) Anaemia Peripheral oedema Depressed (delirium) On/off sliding scale Fluids Blood Diuretics Anti-depressants Endocrinology Nephrology Haematology Cardiology Psychiatry On Call Medical Registrar Functional decline Carers & Rehab Geriatrics

38 Traditional hospital model 74yo Joyce Pain Post-op ileus Hypovolaemic (AKI) Anaemia Peripheral oedema Depressed (delirium) Functional decline Opiates Unrecognised disease/syndromes On/off sliding scale Suboptimal control of comorbidity Fluids Unrecognised complications Blood Poor coordination of care Diuretics Anti-depressants Carers & Rehab Endocrinology Nephrology Haematology Cardiology Psychiatry Geriatrics On Call Medical Registrar

39 A typical not too complicated story 74yo Joyce Living alone No support Difficult historian OA Diabetes HTN SOB?cause Difficult historian

40 A typical not too complicated story 74yo Joyce Living alone No support Difficult historian OA Diabetes HTN SOB?cause Difficult historian Pain HbA1c 8.2% BP 170/88 Ischaemic ECG Anaemia Deconditioning MoCA 21/30 Social issues

41 The same patient with POPS input... 74yo Joyce OA Pain Analgesia/physio Living alone No support Diabetes HTN SOB?cause HbA1c 8.2% BP 170/88 Ischaemic ECG Treat/plan ABPM/treat Undiagnose Difficult historian Difficult historian Anaemia Deconditioning MoCA 21/30 Social issues IV iron and blood Exercise programme Delirium risk/mx Equipment/POC Psychological support Discharge planning

42 with clear communication Based on the history and cognitive testing Ms X has likely dementia. This raises the following issues; a) Capacity Displays capacity to consent to proposed procedure but requires adequate time and clear explanation b) Delirium risk Cognitive impairment and poor vision put Mrs X at risk of developing POD. Patient has been counselled about this. When admitted please ensure that; i) Trust delirium guideline is printed, filed in notes and followed ii) Deliriogenic drugs are avoided where possible iii) Adequate hydration is maintained iv) Falls risk is assessed (using STRATIFY) v) Day night routine is maintained vi) Sensory impairments are optimised (I have told Ms X to bring in her glasses c) Long term management Please could GP monitor and consider referral to memory assessment services.

43 Evidence? CGA in perioperative medicine 5 studies; 3 before and after, 2 RCT (not all really CGA) Conclusions; preop CGA may reduce postop comps Partridge, Anaesthesia 2014

44 Evidence? Observational cohort Harari, Age Ageing 2007; 36: 190

45 Evidence? Observational cohort Pre-POPS n=54 POPS n=54 Age Cardiac 33% 55% Diabetes 13% 20.4% Renal 3.7% 22.2% Hypertension 51.9% 80% Delirium 18.5% 5.6% Pneumonia 20% 4% ACS 7.4% 3.7% Arrhythmia 13% 7.4% Heart failure 3.7% 0% Thrombosis 11% 2% (1) Wound sepsis 22.2% 3.7% (2)* Harari, Age Ageing 2007

46 Evidence? Observational cohort Pre-POPS Post-POPS Uncontrolled pain 29.6% 1.9% NBM >4days 9.3% 0% Catheter>4/ % 7.4 % Dependent transfers 14.8% 0% Bedridden >3days 27.8 % 9.3% Pressure sores 18.5% 3.7% Length of stay 15.8 ± ± 5.2 Delayed discharge 70.4% 24.1% - medical problems 37% 13% - slow rehab n 13% 7.4% - wait for OT/equipment 20.4% 3.7%

47 Evidence? RCT

48 Evidence? RCT Percentage Patients Percentage aged of patients over with 65 complications years and undergoing delayed discharge by trial arm elective AAA or LEAR surgery, randomised to routine care versus CGA New diagnosis OT/Social worker referral Medication changes Planning with primary care Planning with ward team 0 Reduction in Median LOS 5.5 days to 3.3 days (p<0.001) Control Intervention Control Intervention Control Intervention Medical complications (p=0.002) Surgical complications (p=0.04) Delayed discharge (p=0.05) Partridge, British Journal of Surgery Jan 2017

49 Evidence? QIP - elective

50 Evidence? QIP - emergency Before February 1 st 11 Median After February1 st 7 Median Length of stay 4 days 30 day readmission rate 13.2% Times seen by non surgeon 18% Medication reviews 51% Coding complications Coding comorbidities Courtesy of Dr Vilches-Moraga, Salford

51 Is there an appetite for CGA? 70% describe inadequate training in complex older patients 68% difficulty in accessing medical support 8% no need for closer working Ideal components of a collaborative geriatric medicine-surgical service Medical Optimisation 79% Mental Capacity Assessment 71% Quantifying Medical Risks of Surgery 64% Managing Medical Complications 87% Communication with patients and families 38% Post-op rehab/ discharge planning 92% Do Surgical Trainees Believe They Are Adequately Trained to Manage the Ageing Population? A UK Survey of Knowledge and Beliefs in Surgical Trainees. Shipway. JSE, 2015.

52 But is yet to be translated into routine care Partridge, Age and Ageing 2014

53 and emergency care

54 however, this picture is already changing Oxford Belfast Salford Imperial Guildford Southmead Kings, London Portsmouth Edinburgh North Tees Nottingham Cambridge Chelmsford GSTT, London

55 The workforce challenge - not enough geriatricians! High number of unfilled posts Population 63 million 73.2 million Population million 16.8 million Number of geriatricians 1222* 1464** * current number of consultant geriatricians ** required number of consultant geriatricians Geriatric medicine workforce planning: a giant geriatric problem or has the tide turned? Fisher. Clinical Medicine, 2014.

56 Need to consider alternative workforce Specialty Primary care Anaesthetists Geriatricians General physicians (hospitalists) Discipline Nurses Occupational therapists Physiotherapists Pharmacists Physician associates

57 Many training resources available

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60 and training opportunities British Geriatrics Society POPS Special Interest Group POPS AAA conference: March 2018 ( POPS OOPE posts RCoA Perioperative medicine programme UCL Perioperative Medicine MSc EBPOM, NELA Age Anaesthesia Association

61 @DrPhilipBraude