Preoperative Assessment Guidelines in the Elderly

Preoperative Assessment Guidelines in the Elderly How Are They Helping? Mark R. Katlic, M.D., M.M.M. Chairman, Department of Surgery Director, Center for Geriatric Surgery Sinai Hospital Baltimore, Maryland

Nothing to Disclose

Rectal Cancer Resection in the Elderly n=612 Law WL. World J Surg 2006;30:598-604.

Esophagectomy (n=739) Ruol A. J Thorac Cardiovasc Surg 2007;133:1186-1192.

Isolated CABG in Octogenarians Nissinen J. Ann Thorac Surg 2010;89:1119-24.

Resected Gastric Cancer (n=1465) Biondi A. J Am Coll Surg 2012;215:858-867.

Pancreatectomy for Cancer n=517 Hatzaras I. J Am Coll Surg 2011;212:373-377.

Major Hepatectomy <70 yrs vs. 70 years (n=517) Menon KV. J Am Coll Surg 2006;203:677-683.

Elective Thoracic Aneurysm Repair and QOL, n=110 Zierer A. Ann Thorac Surg 2006;82:573-578.

Physical and Mental Health-Related Quality of Life Over age 70 yrs vs. Younger (n=249) Moller A. World J Surg 2010;34:684-691.

Gastric Cancer Surgery (n=363) Gretschel S. World J Surg 2006;30:1468-1474.

High-Risk Cancer Operations Finlayson E. J Am Coll Surg 2007;205:729-734.

Colorectal Surgery in the Elderly NSQIP Database,2005-2007 (n=30,900) Kiran RP. Ann Surg 2013;257:905-908.

How do we do better? 1.More comprehensive preoperative evaluation a. more informed selection/denial of individual patient for surgery b. modify procedure to individual patient c. entire care team better informed about individual patient 2. More compulsive perioperative care

Age 80 Functional Age vs Chronological Age

Surgery Comprehensive Geriatric Assessment Geriatrics

Chow WB. J Am Coll Surg 2012;215:453-466.

Chow WB. J Am Coll Surg 2012;215:453-466

Mini-Cog Test of Cognition

Screening for Depression Patient Health Questionnaire-2 (PHQ-2) 27 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? 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 cared about or when you didn t enjoy the things that you usually enjoyed? Interpretation of PHQ-2 Depression If the patient answers YES to either question, then further evaluation is needed. Note: This screening test has not been validated in extremely frail elderly patients, those with severe concurrent medical illnesses, are suffering from medication side effects, or those with impaired communication skills.

Frailty Standardized Definition (3 or more of following criteria) 50 Criteria Definition Shrinkage Unintentional weight loss 10 pounds in past year Weakness Decreased grip strength lowest 20% at baseline, adjusted for gender and body mass index. Exhaustion Self-reported poor energy and endurance Low physical activity Frailty Weekly energy expenditure in the lowest 20 th percentile by gender. Slowness Walking speed in the lowest 20 th percentile by gender and height.

Nutrition Risk Factors Screening for Severe Nutritional Risk 54 Weight loss > 10 15% within 6 months BMI < 18.5 kg/m 2 Serum albumin <30 g/l (with no evidence of hepatic or renal dysfunction) Interpretation of Nutritional Screening If YES to any above criterion, then they are at severe nutritional risk.

How Are These Guidelines Helping? 1. Identify patients at risk 2. What to do when issues are identified

Sinai CGS New Data 100 100.0% 100.0% 90 90 90.0% 80 80.0% 70 70.0% Number of patients 60 50 40 30 35.3% 28 51.9% 31 48.1% 60.0% 50.0% 40.0% 30.0% n % Cumulative % 20 10 0 22 20.3% 16.6% 12 15.0% 11.8% 8.6% 4 6.4% 2.1% 2.1% 0 1 2 3 4 5 20.0% 10.0% 0.0% Mini Cog Score

Association Between Geriatric Conditions and Adverse Outcomes after Surgery Oresanya LB. JAMA 2014;311:2110-2120

Frailty as a Predictor of Postoperative Complications and Discharge to Facility Makary MA. J Am Coll Surg 2010;210:901-908.

Frailty as a Predictor of Discharge to Facility Robinson TN. J Am Coll Surg 2011;213:37-44..

Association Between Geriatric Conditions and Mortality after Surgery Oresanya LB. JAMA 2014;311:2110-2120.

Timed Up and Go as Predictor of Postoperative Mortality and Morbidity Robinson TN. Ann Surg 2013;258:582-590.

Frailty as a Predictor of Mortality after TAVR Green P. J Am Coll Cardiol Intv 2012;5:974-81.

How Are These Guidelines Helping? 1. Identify patients at risk 2. What to do when issues are identified

What To Do About Problems Identified Polypharmacy medication review Pharmacist consult Cognitive Geriatrician consult assistive devices (e.g., glasses, hearing aid) medication review alert the care team non-pharmacologic prophylaxis for delirium Nutritional Dietician consult supplements?

What To Do About Problems Identified Functional Physical Therapist consult assistive devices alert the care team Social Service consult (early discharge planning) prehabilitation? Frailty modify the operation alert the care team Social Service consult (early discharge planning) nutritional supplements? prehabilitation?

Options for Your Hospital Complete Center for Geriatric Surgery Ala Carte Choices Location of evaluation Who does the evaluation? More limited dataset (tests) Where will data reside?

Location of Evaluation Preoperative Testing Area Each surgeon s office/clinic Pilot project: specific specialty (e.g., Ortho, Gen Surg) Pilot project: certain large surgery group or division (e.g., private practice group, Surgical Oncology, Orthopedics)

Who Does the Evaluation Dedicated Geriatric Surgery Coordinator Nurse Practitioner or Physician Assistant Registered Nurse Nursing Assistant Surgeons themselves Surgical Resident/Fellow Medical Student

Limited Dataset (Tests) Frailty Mini-cog Timed up-and-go Gait speed Activities of daily living (ADL) Performance status Common already: medication reconciliation, falls risk

Hand-Grip Dynamometer

Limited Dataset (Tests) Frailty Mini-cog Timed up-and-go Gait speed Activities of daily living (ADL) Performance status Common already: medication reconciliation, falls risk

Timed Get Up and Go Test Person sits in a standard arm chair Begin timing: Rises from standard arm chair Walks to line on floor A 10 foot length Turns and walks back to chair Sits in chair

Limited Dataset (Tests) Frailty Mini-cog Timed up-and-go Gait speed Activities of daily living (ADL) Performance status Common already: medication reconciliation, falls risk

Limited Dataset (Tests) ---e.g., one from each domain--- Cognition: Mini-Cog MMSE Frailty: 5-point phenotype TUG Gait Speed Stair Climbing Function: ECOG ADL IADL

Summary Many centers have proven surgical results in the elderly equal to those in the general population, but overall age remains a risk factor Development of ACS NSQIP/AGS Best Practices How does geriatric assessment help Identify patients at risk Do something about problems identified Sinai Center for Geriatric Surgery How to operationalize at your hospital (options)