Five Practical Tips for the Older Surgical Patient:

From a Geriatrician’s Perspective

G. Paul Eleazer, MD,FACP,AGSF

University of South Carolina School of Medicine

Visualize a patient who is 80 years old. What does

he or she look like ?

Tip One

• All Older People Are Not Alike! Don’t Base Judgments On Age Alone Don’t Deny Surgery Unnecessarily

(Agism) Don’t Press For Surgery If Benefit Is

Minimal

Aging Heterogeneity

Source: Solomon, UCLA Review Course 2002

Why Is There So Much Variance In Older Adults?

• Genetic Differences• Environmental Stresses Differ

Tobacco Alcohol Exercise

• Aging Dependant Diseases

Aging Changes from the Geriatric Perspective

• Disease Versus Normal Aging• Decreased Reserve Capacity

Varies Between and Within Individuals After Age 30, most “typical” declines

are 5-10% declines in Physiologic Function

Aging Changes from the Geriatric Perspective

• Homeostenosis Impaired Response To Physical,

Emotional, And Environmental Stresses

Example: Fluid Challenge of 1000cc:

35 year old70 year old

35 Year Old with 1000 cc Fluid Bolus

• Excess of 500 cc What are the

likely Consequences?

80 Year Old with 1000 cc Fluid Bolus

• Excess of 500 cc What are the

likely Consequences?

Relevant Changes That Occur With Aging

• Physiology Pulmonary Cardiac Pharmacologic Wound Healing Immune function

• Anatomic• Functional • Social

Age Related Changes in Pulmonary Function

Heath 1981;

Lakatta,1993

Impact of Training on VO2Max with Age

Heath 1981;

Lakatta,1993

Impact of Training on VO2Max with Age

Heath 1981;

Lakatta,1993

Impact of Training on VO2Max with Age

Pulmonary Changes with Aging

Declines In: Alveolar Surface

Area Diffusion

Capacity Hypoxic Drive Arterial PO2

Arterial PO2 Correction for

Age (Room Air)

Expected PaO2 = 100 – (Age/3) • For a 20 year old = 93 mmHg

• For a 90 year old = 70 mmHg

Airway Changes

• Swallowing Changes Predispose to Aspiration

• Decreased Numbers and Function of Cilia

• Diminished Cough• Pneumonia More Common

Cardiac Changes with Aging

Changes in Conduction

• Multiple Changes, Net Results: Decline in Maximum Heart Rate

220 minus Age [or other formula]

• Decreased Beta-2 Receptors Decreased Response to Beta

Agonists

Heart Rate And Age

•Rounds on Two Post Op Patients: 20 year old with HR of 100 95 Year old with HR of 100

•What is your Level of Concern for Each?

CalculatePredicted Maximum Heart

Rate•20 year old = 220 – 20 =

200•95 Year old =220 - 95 =

125

20 Year Old with Heart Rate of 100

• Percent of Maximum HR= Actual/Predicted x 100

• 100/200 = 50% Maximum Predicted HR

95 Year old with Heart Rate of 100

Percent of Maximum HR= Actual/Predicted x 100

100/125 = 80% Maximum Predicted HR

Each Patient has Heart Rate of 100

• 20 year old = 100/200 = 50% Maximum Predicted HR

• 95 Year old =100/125 = 80% Maximum Predicted HR

Equivalent to an ongoing Cardiac Stress Test!

Functional Cardiac (Pump) Changes

• Resting Cardiac Output - Little Change

• Maximum Cardiac Output - Declines

Functional Cardiac (Pump) Changes

• Decreased LV Compliance• Increased Diastolic Dysfunction• Increased Importance of Atrial

Contraction Decreased Tolerance for Atrial

Fibrillation

From Swinn,1989

Increased Importance of Atrial “Kick” with Age

Atrial Fibrillation Less Well Tolerated

Age Associated Declines in GFR and Renal Plasma Flow

Based on Data from Davis JCI 29:496-507 (1950)

Tip Two

Be Gentle•In Relationship•In Caring• In Doing Anything !

Tip Three

• Medications are Dangerous in Older Adults Start Low, Go Slow Avoid all Medications, if Possible Particularly Avoid Certain Medications

Tip Three:Medications are

Dangerous in Older Adults Start Low, Go Slow Avoid all Medications, if

Possible Particularly Avoid Certain

Medications

Medications in Older Adults

• Older People Take More Medications• Drug-drug Interactions More Likely• Adverse Drug Reactions More Serious

Two Patients, Both Get 1mg Lorazepam for Agitation

• 20 Year Old• 80 Year Old

Unsteady Gait Fall

Two Patients, Both Get 1mg Lorazepam for Agitation

• 20 Year Old• 80 Year Old

Unsteady Gait Fall

No Injury

Hip Fracture

Delirium

• In Post Operative Patients Often Due to Medications May be Due to Other

• Hypoxia• Pain• Infection• Sleep Deprivation• Others

Delirium

• Adding a Medication to Treat Delirium May Be Hazardous More Drug Interactions More Adverse Reactions Often Does Not Help the Patient !

• If you “must” – low dose Haloperidol (0.5 mg)

Mortality of Delirium

•Mortality of in-hospital delirium 25-33%

• Unrecognized by Physicians 30-50% of the Time !

Inouye SK et al, American Journal of Medicine May 1999

Diagnosing Delirium Confusion Assessment Method

1. Acute Onset & Fluctuating CoursePlus

2. InattentionAnd One Of The Following:

3. Disorganized Thinking4. Altered Level of Consciousness

Inouye SK, et al. Ann Intern Med 1990; 113:941-8

Commonly Used Drugs That Should Be Avoided In Older

People• Propoxyphene ( Darvon, Darvocet)• Meperidine (Demerol)• NSAID’s – (Indocin, Toradol) • Diphenhydramine (Benadryl)• Muscle Relaxants (Flexeril, Robaxin)• Benzo’s -especially Valium, Dalmane

Beers, MA Archives IM 1997,157:1531-1536), Updated 2002

Start Low,Go Slow ...

Tip Four

•Function is Most Important Pre Op Post Op Long Term

Function is Most Important

• Pre Operatively Baseline Function Predicts

Morbidity and Mortality•4 MET Equivalent

Consider “Prehab” Realistic Goal Setting Planning for Post Operative Care

Function is Most Important

•Post Operatively Early Mobilization Rehabilitation

Function is Most Important

•Long Term Prevention of Functional Decline

Planning, Ethical Issues

Tip Five

There are no “Benign Procedures” in Older Adults!

Where I First Learned About Iatrogenesis

• Summer of 1979 Mr. Monroe H. 76 Year Old Admitted with Diarrhea

and Weight Loss Admission U/A showed 10-20 WBC’s

and many epithelial cells

Where I First Learned About Iatrogenesis

• 76 Year Old Admitted with Diarrhea and Weight Loss

“To Catheterize or Not To Catheterize” for a repeat U/A - ????

“It’s a Benign Procedure”

Where I First Learned About Iatrogenesis

• Catheterized Vagal Reaction Unresponsive Code Called Right Central Line Placed “for access” Moved to the ICU

Where I First Learned about Iatrogenesis

• Post Central Line CXR Pneumothorax Chest Tube Placed SBFT Placed Long, Tortuous, Hospital Course Death about 1 month after admission.

Conclusion

There are NO Benign Procedures in Someone

over Age 65 !

Summary of Tips from the Geriatrician’s Perspective

1. All Older People Are Not Alike!2. Be Gentle3. Medications are Dangerous in

Older Adults4. Function is Most Important5. There are No Benign Procedures

in Older Adult