Five Practical Tips for the Older Surgical Patient: From a Geriatrician’s Perspective
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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
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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! - PowerPoint PPT Presentation
Transcript of Five Practical Tips for the Older Surgical Patient: From a Geriatrician’s Perspective
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
