PREOPERATIVE AND PERIOPERATIVE ISSUES IN THE

ELDERLY

Sarah M. McGee, MD, MPHDirector of Education Division of Geriatrics

November 7, 2008August 5, 2009

THE AMERICAN GERIATRICS SOCIETY

Geriatrics Health Professionals.

Leading change. Improving care for older adults.

AGS

SOME OF THE FACTS

• Increasing numbers of older adults are having surgery • Half of elderly will require surgery at least once• Elective surgery has become more common• Severity of initial presentation of surgical problem is increased in older

adults• Emergent surgery is more common in older adults• Older adults are more likely than younger patients• to have surgery cancelled or postponed because of comorbid conditions• Post-op mortality for ages 85+ is twice that for ages 6569

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WHY IS IT IMPORTANT TO EVALUATEPERIOPERATIVE RISK?

• Careful and thorough preoperative assessment should help with anticipation, recognition, and management of postoperative issues

• Physiological changes associated with normal aging, superimposed upon pre-existing comorbidities, place the older adult at higher risk for complications compared with younger patients

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PHYSIOLOGICAL CHANGESWITH NORMAL AGING

• Decreased functional reserve physiologic decrease in vital organ function Cardiac Pulmonary Renal

• Pharmacokinetics affected• Decreased ability to deal with perioperative

physiological stress

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FACTORS THAT AFFECT RECOGNITION OF DISEASE

IN OLDER ADULTS

• Underreporting of symptoms• Decreased physical activity• Increased prevalence of atypical

presentations• Increased prevalence of silent ischemia

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• An 84-year-old man with mild dementia, living at an assisted care facility, is found on the floor complaining of severe left hip and groin pain

• Has been able to ambulate independently but is physically inactive

• Needs min assistance with ADLs• In the ED is found to have an intertrochanteric hip

fracture• Past medical history: CAD with CABG 15 years

prior, HTN, CRI, and dementia

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CASE (1 of 3)

CASE (2 of 3)

• The orthopedic service requests preoperative clearance and co-management by the medical service

• Despite his mild dementia, the patient is felt to be competent

• He wishes to proceed with surgery and signs the consent form

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CASE (3 of 3)

• Although the patient had CABG years ago: No recent chest pain No syncope No SOB, DOE or PND No evidence of CHF on exam • Exercise tolerance is poor by report• Baseline creatinine is 2.2 • Albumin is 2.8

• Does he need further cardiac testing? Should surgery be delayed? What are some possible predictors of negative outcome?

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PREOPERATIVE ASSESSMENT: COMPLETE MEDICAL HISTORY

• Medical problems• Past surgical history, including any post-op

problems, especially delirium• Medications• Allergies/intolerances to pain medication• Baseline functional status

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OTHER PREOPERATIVE FACTORSTO CONSIDER

• Prior functional status• Dementia• Nutritional status

Significant predictor of 30-day mortality Marker for frailty

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CARDIAC RISK AND HIP FRACTURES

• Perioperative myocardial ischemia may occur in up to 35% of elderly patients undergoing hip fracture surgery

• Studies of patients undergoing noncardiac surgery suggest that:

Only 15% with perioperative MI have chest pain Only 53% have any clinical symptoms

• Up to 50% of patients with perioperative ischemia go unrecognized Symptoms hidden with analgesia Symptoms (ie, increased HR, decreased oxygen, increased

RR) attributed to other causes?

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REVISED CARDIAC RISK INDEX

Each risk factor is assigned 1 point•Ischemic heart disease (hx of MI, Q-waves, hx of + exercise test, current ischemic-type chest pain, use of SL NTG; does not include prior CABG/PCI unless those features are present)•CHF (hx CHF, pulmonary edema, PND, rales, S3, cxr edema)•Cerebrovascular disease (CVA or TIA)•DM treated with insulin•Creatinine > 2•High-risk surgery (peritoneal, thoracic, vascular)

Risk of CV event (MI, pulm edema, v-fib, cardiac arrest)• 0 points: 0.4%0.5%• 1 point: 0.9%1.3%• 2 points: 4%6.6%• 3 points: 9%11%

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PREOP CARDIAC TESTING

Big question:

Will results of test change management?

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PERIOPERATIVE CARDIAC ISSUES

• Beta blockers prior to surgery decrease risk of CV events/death in patients at moderate or high risk Higher-risk patients = higher number of events = more likely

to see benefit

• Theory: decrease catecholamine surge

• Risk of bradycardia may outweigh benefit in lower-risk patients with low risk of events

• Risk stratify by clinical criteria; high-risk patients need more intense monitoring for silent ischemia

• All patients need optimization of medical management (fluid status, renal function, meds)

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WHAT ABOUT STATINS?

• In retrospective trials, use of statins was associated with decrease in perioperative CV events

• Small randomized, controlled trial with 100 patients Atorvastatin vs placebo prior to major vascular surgery (14 days

prior, continued for 45 days after) Combined outcome of CV death/MI/stroke found in 8% of patients

with treatment, 26% of patients with placebo

• May be of benefit

• Benefit not clear during urgent procedures

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PREOPERATIVE MANAGEMENT: DIABETES

• Metabolic control

• Hyperglycemia without prior diagnosis of DM in elderly with acute event = bad predictor

• Discontinue oral agents initially

• May need to cover with insulin; usually will need some amount of baseline insulin to avoid extreme fluctuations

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OTHER PREOPERATIVE NEEDS

• Review and discontinue medications that are not needed/potentially harmful

• Be attentive to medications that need to be restarted postoperatively (eg, antidepressants, antihypertensives)

• Watch for medications that may cause problems during withdrawal (eg, benzodiazepines, SSRIs)

• Think about possible alcohol and smoking withdrawal

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TIMING OF SURGERY

• Several studies show that early surgery (first 2448 hours after fracture) is associated with decreased mortality, pressure ulcers, delirium

• General consensus: the earlier the better, once stable

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PREVENTION OF DVT AND PE

Clear guidelines from 7th Conference on Antithrombotic and Thrombolytic Therapy, 2004

•Hip fracture patients are at high risk of VTE Risk of DVT is 50% without prophylaxis Risk of proximal DVT is 27% Risk of fatal PE is 1.4%7.5%

•Factors that increase risk of VTE: advanced age, delayed surgery, general anesthesia

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SUMMARY OF VTE PREVENTION GUIDELINES

• Routine use of low-molecular-weight heparin

• Can use warfarin (INR 23)

• ASA alone is not sufficient

• Continue anticoagulation for at least 2835 days after surgery, possibly longer

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CONSIDER THE CASE AGAIN

• What analgesia should the patient be given?• Should he be monitored for a perioperative

cardiac event?• What is his risk of delirium? How can this be

prevented or managed? • What other complications is he at risk of

developing?• What would be an appropriate level of

discharge care?

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POSTOPERATIVE COMPLICATIONS

Although patients and families worry about intraoperative complications and death, the vast majority of adverse events occur in the postoperative period

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POSTOPERATIVE ANALGESIA

Epidural vs PCA vs intermittent administered morphine:

•No clear sweeping differences

•Some data indicate that epidural route may provide better pain relief; no clear difference in time to recover physical independence

•Elderly patients with dementia or delirium may have difficulty with PCA

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PAIN ASSESSMENT

• Should be based on patient’s perception of pain (pain scale)

• May be difficult in very demented patients, although direct questioning may still work

• Nonverbal cues: agitation, tachycardia, facial expressions

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PAIN MANAGEMENT

• Consider nonpharmacologic treatments

• Use scheduled dosing of pharmacologic agents

• When adding pharmacologic agents, choose those with the fewest side effects Morphine is most predictable and probably less likely

than other agents to increase confusion Avoid propoxyphene, meperidine

• Use PRN dosing for breakthrough pain

• Reevaluate pain control regimen frequently

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PAIN RELIEF PYRAMID

NONPHARMACOLOGIC

ACETAMINOPHEN

NARCOTICS

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NONPHARMACOLOGIC OPTIONS

Temperature• Cold for acute pain• Heat/cold for chronic

pain

Positioning

Physical therapy• Use early

Massage • Engage nursing, family

Education • To reduce fears, explain

cause or mechanism of pain

• Engage cooperation and “partner” in management

Relaxation techniquesBiofeedback

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ACETAMINOPHEN

• P.O. 6501000 mg QID (or Tylenol ER: 2 gelcaps, 650 mg each, q8h)

• Compatible with NSAIDs and opiates

• Keep total dose less than 4 g/24 hours

• Patients on scheduled dose of acetaminophen must avoid acetaminophen/narcotic combinations (eg, Vicodin is hydrocodone with acetaminophen)

  

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CONSTIPATION: PREDISPOSING FACTORS

• Prior history• Bed rest/inactivity• Change in diet• Narcotics• Diminished fluid intake

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CONSTIPATION: PREVENTION

When prescribing narcotics for the elderly:• Order scheduled and PRN bowel hygiene• Stool softeners are usually not enough • Consider:Senna beginning at 12 tablets per dayMiralax

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POSTOPERATIVECARDIAC RISK

• Elderly patients undergoing emergent/urgent hip fracture surgery are at high risk of CV event

• 50% of ischemic events in the postoperative period are silent

• Highest risk is within first 3 days after fracture

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POSTOPERATIVE CARDIAC SURVEILLANCE

• Have a high index of suspicion

• Consider CK-MB and troponin testing, as well as surveillance EKG, immediately postoperatively on all hip fracture patients

• Continue monitoring if any changes seen

• Continue to optimize medical treatment (ie, statin, ASA, beta-blocker, fluid status)

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POSTOPERATIVE ISSUES:GENITOURINARY

• Overall incidence of UTI after hip fracture: 25%• Best to remove Foley catheter as soon as

possible • May be complicated if patient receiving epidural

anesthesia• Urinary retention

Straight catheterizations restore bladder function earlier

D/C medications that can increase retention (sedatives, anticholinergics)

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POSTOPERATIVE ISSUES: PULMONARY

• Pneumonia Accounts for 25%50% of all hospital deaths after

hip fracture surgery Significant cause of later deaths (after hospital

discharge) after hip fracture surgery Risk may be decreased with regional anesthesia,

early weight bearing, pulmonary hygiene, incentive spirometry

• Pulmonary embolism causes 15% of deaths after hip fracture surgery

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POSTOPERATIVE DELIRIUM

• Most common medical complication following hip fracture

• Marker of bad outcome Increased mortality (25%33%) Increased risk of needing skilled nursing facility Increased length of hospital stay Interferes with rehab and functional status recovery

• Goes unrecognized 30%50% of the time• Prevention is key

Multiple studies demonstrate targeted interventions significantly prevent delirium, but have no significant impact once delirium develops

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DELIRIUM:PATIENT-RELATED RISK FACTORS

• Advanced age• Underlying cognitive impairment• Prior delirium• Alcohol abuse• Malnutrition• Depression• Type of surgery

Hip fracture surgery: 30% risk

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DELIRIUM:IATROGENIC RISK FACTORS

• Conventional restraints• Other restraints/tethers:

Oxygen tubing Telemetry boxes IV lines

• Medications• Poor pain control• Foley catheters• Environmental: noise, disturbance of sleep• Lack of hearing and visual aids

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DELIRIUM:HIGH-RISK MEDICATIONS

• Anticholinergics• Antipsychotics• Antibiotics such as quinolones• H2 blockers, especially cimetidine• Narcotics• Sleep aids/sedatives

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DELIRIUM: PREVENTION

• Identify high-risk patients• Confusion Assessment Method (next slide)• Decrease sleep interruptions, improve environment• Family, orientation, sitter if needed• Avoid restraints and tethers• Avoid polypharmacy, no anticholinergics (no Benadryl)• Monitor for ischemia, oxygen status, infection• Remove Foley catheter ASAP• Provide adequate analgesia• Provide adequate bowel regimen• Monitor for urinary retention, I/O catheters when needed

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DIAGNOSING DELIRIUM: CONFUSION ASSESSMENT METHOD

Acute onset and fluctuating course

plus

Inattention

and one of the following:

Disorganized thinking

Altered level of consciousness

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DELIRIUM: MANAGEMENT

• Search for predisposing factors• Reevaluate medications• Avoid benzodiazepines (eg, lorazepam)

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DELIRIUM AND ANTIPSYCHOTICS

• No data that antipsychotics improve outcomes; they probably just make delirious patients more sedated

• Not approved for this indication• Increased use of atypical antipsychotic

agents for management of patients with delirium

• Agents and dosing in older patients Haldol 0.250.5 mg starting dose Risperidone 0.250.5 mg starting dose

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DELIRIUM AND ANTIPSYCHOTICS: THE DOWNSIDES

• Side effects Sedation Orthostasis Increased delirium CV risks, QT interval prolongation Edema

• FDA black-box warning, April 2005 Observation in multiple studies of increased risk

of sudden death and stroke in elderly patients

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OTHER COMPLICATIONS: MALNUTRITION

• Poor nutritional status is independently associated with increased morbidity and mortality

• Enteral supplements may decrease postoperative complications, length of hospital stay

• Postoperative parenteral nutrition: increased complications in elderly

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OTHER COMPLICATIONS:PRESSURE SORES

• Incidence after hip fracture surgery 10%40% • Risk decreases with:

Frequent turning Early out-of-bed status Weight bearing as tolerated Removal of Foley catheter and other lines

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OTHER COMPLICATIONS:ANEMIA

• Anemia and worsening anemia are common in ill elderly and during postoperative period

• There is evidence that liberal transfusion to keep Hgb at 1012 may worsen outcome

• Data unclear in elderly in postoperative period May not tolerate as low a Hgb Lower Hgb is associated with worse outcome, but

not clear whether the association is causal

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TRANSFUSION GUIDELINES

Recommend moderately restrictive transfusion guidelines:•Keep Hgb at 79, likely closer to 89 range, especially if underlying myocardial ischemia•No real evidence to support keeping Hbg over 10

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POSSIBLE HOSPITAL COURSE 1

• A post-op patient receives PRN analgesia• Because he is restless and physically

agitated, trying to get out of bed and pull out his Foley, he is restrained and given 5 mg Haldol

• He develops a fever and hematuria and is started on an oral antibiotic for UTI

• He develops diarrhea and sacral breakdown• PO intake declines and he is unable to

participate in rehab

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POSSIBLE HOSPITAL COURSE 2

• A post-op patient receives scheduled and PRN morphine on POD 1 and 2

• Analgesia is changed to scheduled Vicodin on POD 3

• The Foley is removed on POD 2• Though the patient is more confused than at

baseline, according to his family, he is able to participate actively in rehab and is able to be discharged to subacute care on POD #4

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DISCHARGE PLANNING

• Rehab possible at multiple sites• No clear benefit to one over another

Home Inpatient rehab Subacute rehab/skilled nursing facility

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PREDICTORS OF DISCHARGETO INSTITUTION

• Age > 85• Inability to ambulate• Dementia• Inability to transfer• Fecal incontinence• Pressure sores• Poor social support

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TRANSITIONS CAN BE DANGEROUS

Guard against incomplete transfer of information• Discharge summaries and PDI need to be consistent

and complete• Include most recent events, labs, and meds• Be especially cautious if facilities do not have the

same computer system

We are on the same team!

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ADDITIONAL CONSIDERATIONSAT THE TIME OF DISCHARGE

• Treatment of osteoporosis• Prevention of falls• Prevention of fall-related injuries

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RISK OF OSTEOPOROSIS

• 70% patients over age 80 have osteoporosis• Hip fracture without major trauma: diagnosis of

osteoporosis• More than BMD: older patient is more likely to have

fracture than younger patient with same BMD (falls risk, brittle bones, cognition, visual impairment, etiology of fall, etc)

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OSTEOPOROSIS:TREATMENT AT DISCHARGE

• 5%6% patients admitted with hip fracture are adequately treated for osteoporosis at discharge Only 12% at 5 years Only 20% have any prescription treatment over 2 years

• Patients over age 74 (at highest risk) are least likely to receive treatment

• Discharge medications carry weight!• No significant contraindication in most to treating

at time of discharge

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OSTEOPOROSIS:SUPPLEMENTS

• Calcium Fewer than half of adults take adequate amount 12001500 mg/day Calcium and Vitamin D decrease risk of hip fracture

• Vitamin D 400800 IU/day Frail older patients with limited sun exposure may need

at least 800 IU/day Concern that many elders and institutionalized adults

are at risk of Vitamin D deficiency; most frail adults need calcium and Vitamin D supplements

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OSTEOPOROSIS: BISPHOSPHONATES

• Decrease bone resorption• Decrease in hip and vertebral fractures• Alendronate, risedronate• Ibandronate (Boniva): once monthly• Those at highest risk of fracture shown to have

greatest benefit

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PREVENTION OF FALLS

• Home assessment• Rehab• Strengthening and gait assessment• Assistive devices• Cognitive assessment• Urinary incontinence• Medication review• Peripheral neuropathy• Visual impairment• Alcohol use• Prior falls: fear of falling cycle

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RISK FACTORS FORHIP FRACTURE

• Age over 65• Any prior fracture• Benzodiazepine/anticonvulsant use• High resting heart rate• Inability to rise from chair without using arms• Low weight• Not walking for exercise• Poor depth perception/vision• Poor health perception

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FRACTURE REDUCTION:HIP PROTECTORS

• Used most often in long-term-care settings with at-risk elders

• Multiple barriers: Patient concern Forgetting to put them on Incontinence Questionable efficacy

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SUMMARY (1 of 2)

• Preoperative assessment: cardiac risk assessment, capacity, delirium risk, nutritional and functional assessment

• Noninvasive testing for cardiac assessment usually not needed except for high-risk patients

• Surgery should proceed as quickly as possible (2448 hr)• Perioperative beta-blockers, beginning prior to surgery,

are reasonable in patients at moderate or high risk • Treat pain aggressively with scheduled analgesics and

reassess frequently

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SUMMARY (2 of 2)

• Postoperative care: weight bearing as tolerated immediately, removal of Foley catheter after 24 hours, I/O catheter for urinary retention, prevention of pressure sores, removal of lines/boxes as soon as possible, surveillance for pulmonary cardiac issues

• Watch for delirium; avoid medications such as anticholinergic agents; try to avoid restraints and antipsychotics

• Transfuse if unstable, cardiac ischemia, or Hgb < 79 range

• Discontinue all unnecessary medications; stop meds that increase risk of falls

• Follow nutritional status and use supplements

• Treat underlying osteoporosis aggressively: calcium, Vitamin D, consider bisphosphonate

• Take steps to reduce the risk of falls

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