Preoperative Assessment of Older Adults

1
Preoperative Assessment of Older Adults

• Seki Balogun, MD
• Core Curriculum in Geriatric Medicine
• February 16, 2004

2

• The role of the medical consultant is to
  identify the problems, correct the correctable,
  and then point out the uncorrectable to the
  unsuspecting
• - G.E. McElwain, Jr.

3
Introduction

• Preoperative assessment in older patients is
  important as
• Surgical procedures are more frequent in the
  elderly
• Surgical rates are 55 higher in persons over the
  age of 65
• 40 of admissions of older patients to general
  hospitals are admissions to surgical services

4
Introduction

• Studies evaluating surgical mortality show that
  older patients have a higher mortality rate than
  younger patients
• Older patients account for 75 of all
  postoperative deaths, increasing nearly linearly
  with each decade of age

5
Introduction

• Preop assessment in the elderly is very complex
  and sometimes difficult, due to factors like
• Frequent coexistence of multisystem diseases
• Heterogeneity of the geriatric population,
  requiring individualized approach for older
  patient undergoing surgery
• As such , there is no simple algorithmic
  guideline

6
Epidemiology of surgical risk

• In the past, higher surgical risk created a
  reluctance to operate on most older patients
• As late as 1980, continued reluctance to
  recommend surgery in geriatric patients was
  common
• Surgery was often delayed until it was the only
  option available, as such it was often performed
  urgently or emergently, leading to even poorer
  outcome

7
Epidemiology

• Changes in attitude toward the estimation of
  surgical risk have occurred over the years
• Decline in overall surgical mortality in the
  elderly
• In the 1950s, surgical mortality ranged from 9.2
  in patients younger than 55 years with cardiac
  disease to 18 in patients older than 75 years
• More recently, mortality in patients with cardiac
  disease is about 0.9 2.4
• This change in mortality is attributable
  primarily to improvements in anesthesia and
  surgical expertise

8
Epidemiology

• Hence, from the standpoint of risk, surgery can
  longer be denied solely on the basis of age
• Increase in life expectancy over the years also
  has had a profound impact on evaluating the
  benefit of surgery
• Prognosis of older patients who survive surgery
  is often better than age matched controls

9
Individual risk factors

• Patient-specific risk factors
• Age and life expectancy
• Functional Status Activities of Daily Living
  (ADL) scales predict surgical complications
• Complications have been found to be more frequent
  in inactive patients
• Medication Use (include Herbal and OTC)
• Obesity
• Not found to be risk factor for adverse postop
  outcomes
• Relationship to postop pulmonary complications-
  controversial

10
Individual risk factors

• Neuropsychological Status
• Psychological factors predict surgical outcome
• Social support systems and the will to live,
  though difficult to quantify are important
  predictors of surgical outcome
• Assessment of preoperative mental status is
  critical to understanding the etiology of
  postoperative cognitive status
• Dementia is a predictor of poor outcome, with
  increased mortality compared to nondemented
  patients
• Postoperative complications also occur more
  frequently in these patients i.e. delirium

11
Specific organ system disease factors

• Most post operative mortality occur as a result
  of
• Cardiac complications
• Pulmonary complications
• Infectious complications

12
Cardiac Disease

• Cardiovascular Disease
• the single best predictor of postoperative
  cardiac complications is the presence of ischemic
  heart disease
• Myocardial infarction (MI) within 3 months of
  surgery carries a risk of recurrent infarction or
  death of 8 30 perioperatively, the risk
  decreases to 3.5 5 after about 6 months
• Clinical evidence of heart failure and
  arrhythmia powerful predictor of adverse cardiac
  event
• Best strategy for assessment of preoperative
  cardiac risk remains controversial
• Prevention of bacterial endocarditis should be
  addressed for susceptible patients using standard
  protocol

13
Cardiac testing in PAD prior to noncardiac surgery

• Resting Echocardiogram
• Quantify valvular dysfunction in pts with
  significant murmur
• Evaluate ventricular dysfunction in poorly
  controlled CHF or CHF of unknown cause
• EKG
• Useful in detecting silent ischemia in pts with
  CAD
• Arrhythmias complex ventricular arrhythmias
  predict future cardiac events

14
Recommendations for Preop Resting EKG

• Class I
• Recent chest pain or ischemic equivalent in
  moderate to high risk patients scheduled for
  moderate to high risk surgery
• Class IIA
• Asymptomatic with DM
• Class IIB
• Prior coronary revascularization
• Asymptomatic male gt 45 yrs or female gt55 yrs with
  two or atherosclerotic risk factors
• Prior hospital admission for cardiac disease
• Class III
• Routine test in asymptomatic subjects undergoing
  low risk procedures

Eagle KA, Berger PB et al. J Am Coll Cardiology
39542, 2002
15
Cardiac testing in PAD prior to noncardiac surgery

• Stress testing (Exercise or pharmacologic)
• Useful in
• New, unexplained chest pain
• Status of CAD uncertain
• Moderate risk for perioperative cardiac
  complication (Eagle Class I or II)
• C reactive Protein
• Risk factor for cardiovascular disease
• Prognostic importance in CAD
• Data from larger studies needed

16
Estimation of Coronary Risk before noncardiac
surgery

• Revised Goldman Cardiac Risk Index
• Six independent predictors
• High risk surgery
• Hx of ischemic heart disease
• Hx of heart failure
• Hx of cerebrovascular disease
• DM with insulin therapy
• Preop serum creatinine gt2mg/dl

17
Revised Goldman Cardiac Risk Index

• Risk factor
• 0
• 1
• 2
• 3 or more

• Major complication Rate
• 0.4
• 0.9
• 7
• 11

Lee TH, Marcantonio ER et al. Circ 1001043 1999
18
Pulmonary Diseases

• Increases the risk of postoperative complications
• Accounts for 40of total complications and 20 of
  deaths
• Risk factors include
• Obesity (controversial)
• cough,
• smoking,
• history of lung disease,
• site of surgery (more complications when surgery
  is in upper abdomen, close to the diaphragm)
• prolonged duration of anesthesia (gt3 hours)
• repeat surgery within one year
• Respiratory Infection
• Type of anesthesia (general gt epidural or spinal
  )
• Clinical findings (wheezes, rales, rhonchi,
  decreased breath sounds) predict postop pulmonary
  complications

19
Chest X-ray

• Add little to clinical evaluation in identifying
  periop risks
• May be useful in patients with suspected
  pulmonary disease or cardiac disease

20
Pulmonary Function Test

• Indicated in lung resection surgery
• In unexplained dyspnea
• Maybe used in COPD or Asthma if unable to
  determine patients best baseline
• Arterial blood gas analysis- indicated in
• Pts undergoing CABG or upper abdominal surgery
  with a history of tobacco use or dyspnea
• lung resection surgery

21
Strategies To Reduce Postoperative Pulmonary
Complications

• Complications include
• Atelectasis
• Infections
• Prolonged mechanical ventilation and respiratory
  failure
• Exacerbation of underlying chronic lung disease
• Bronchospasm

22
Strategies To Reduce Postoperative Pulmonary
Complications

• Preoperative strategies
• Smoking Cessation
• At least 8 weeks before surgery
• Adequate treatment of COPD and Asthma (inhaled
  ipratropium, inhaled beta agonists,
  corticosteriods)
• Delay elective surgery with respiratory
  infections
• Treat respiratory infections
• Patient education on lung expansion maneuvers
  (coughing, incentive spirometry)
• Intraoperative
• Minimize duration of anesthesia and surgery (when
  possible)
• Choose laparoscopic rather than open abdominal
  surgery
• Choose regional, epidural or spinal anesthesia
  (when possible)
• Postoperative
• Deep breathing exercises
• Epidural anesthesia in lieu of parenteral opioids
  

23
Renal Disease

• Important impact on morbidity and postop course
• Adjust CrCl for age and decrease in muscle mass
• The dosing of medications should be adjusted
  appropriately
• Preoperative renal status is the best universal
  predictor of postop renal failure
• Risk of renal deterioration postop higher in
  patients with serum creatinine greater than
  1.2mg/dl ( 2.9 vs. 14.4)

24
Renal Disease

• Other Risk factors for postoperative renal
  failure
• rising serum creatinine
• LV dysfunction
• advanced age
• decreased serum albumin
• Malignancy
• emergency surgery
• vascular surgery,
• Preop diuretic,
• hypotension
• Poor prognostic indicators
• oliguria,
• urine sediment abnormalities,
• severity of renal failure
• Attention should be paid to volume status
• Avoid use of nephrotoxic medications when possible

25
Type of surgery

• Important in determining risk
• Elective or emergent
• Inside or outside body cavity

26
Emergency versus Elective Surgery

• Older adults undergo 50 of all emergency
  procedures
• Surgical risk increases tremendously, especially
  in the elderly
• Mortality rate 20 in older adults undergoing
  emergency surgery, compared to 1.9 in patients
  who had elective surgery
• Post-op complications and morbidity were also
  higher

27
Emergency versus Elective Surgery

• Possible reasons
• Surgical disease may have a more sudden onset in
  the elderly or may be more difficult to diagnose
  because of atypical presentation
• Surgeons are reluctant to operate electively in
  older patients
• Older patients are sometimes reluctant to undergo
  any invasive procedure, and wait until option of
  last resort

28
Body Cavity versus Non-Body Cavity Surgery

• Surgical mortality increases dramatically in
  thoracic and abdominal procedures

29
Common surgical procedures in older adults

• Most common surgical procedures are
  prostatectomy, coronary artery bypass grafting,
  pacemaker implantation
• Others are angioplasty, cholecystectomy, eye
  surgeries, orthopedic, operations on the nervous
  system and abdominal

30
Relatively Safe Procedures

• TURP - mortality about 0.2
• Mortality can increase up to 6.3 in patients
  older than 80 years or otherwise at high risk
• Eye Surgeries Cataract very safe, likelihood
  of life threatening postop complication is about
  1.2

31
Relatively risky Procedures

• Biliary surgery In patients older than 70, 30
  50 of cholecystectomies are performed emergently
  resulting in up to a 5-fold increase in mortality
  compared to elective surgery
• Other abdominal surgery older patients have an
  incidence of perforation

32
Relatively risky Procedures

• Cardiovascular Surgery
• PTCA mortality 2 6 in patients 60 and above
  (higher mortality with age)
• CABG increased mortality can be predicted from
  the following emergency surgery, renal
  insufficency, severe LV dysfunction, preop hct
  less than 34, COPD, advanced age, MVR, DM, Body
  weight less 65kg, Aortic stenosis, Stroke

33
Relatively risky Procedures

• Orthopedic surgery
• Hip surgery, especially after falls one of the
  most common in older adults
• In-hospital mortality in about 4, 1-year
  mortality of about 14 17
• Frequent complications DVT (40 60 of
  patients), Pulmonary embolism (20), pressure
  ulcer (20 70), Urinary retention (28 52)
• Total knee replacement relatively safe,
  mortality rates of about 1.5

34
Perioperative Medication Management

• Consultants often must decide if chronic
  medications should be continued in perioperative
  period

35
Perioperative Medication Management

• In general
• Medications associated with known adverse effects
  if withdrawn abruptly should be continued
  (consider alternative route when appropriate)
• Medications that can increase surgical
  complications or not essential for short term
  improvement in QOL should be held
• Medications not meeting either criterion will
  depend on individual physician judgment

36
Perioperative Medication Management

• Cardiovascular Medications
• Beta-blockers
• Beneficial effects
• Recommended in patients at high risk for
  cardiovascular disease
• Reduce ischemia by decreasing myocardial oxygen
  demand due to increased stress and catecholamine
  release
• Reduce risk of perioperative myocardial
  infarction and death
• Should be continued in perioperative period

37
Centrally acting antihypertensives Alpha 2
agonists

• Clonidine
• May improve outcomes
• Data less conclusive
• Decrease in stress response to surgery
• Has sedative, anxiolytic and analgesic properties
• Reduce anesthetic requirement
• Abrupt withdrawal can precipitate rebound
  hypertension
• Should be continued in perioperative period
• Transdermal clonidine for patients who may not be
  able to resume oral medications by 12hrs after
  surgery

38
Calcium Channel Blockers

• Limited data regarding benefits and risks of CCB
• Acute withdrawal symptoms not typical, though
  reported severe vasospasm in patients undergoing
  revascularization
• No serious interactions with anesthetic agents
• Possible association with increased bleeding risk
  (Conflicting data)
• Can be safely administered in perioperative period

39
ACE Inhibitors and ARBs

• Controversial
• Can blunt the compensatory activation of the
  renin-angoiotensin system during surgery, leading
  to prolonged hypotension
• Possibly, reduces incidence of postoperative
  hypertension
• Recommendations continue ACEI/ARB in patients
  with HTN
• Can withhold in pts with CHF, who also have low
  BP

40
Diuretics

• Possible adverse effects
• Hypokalemia
• Can theoretically increase perioperative
  arrhythmia (not found in observational studies)
• Hypovolemia
• Anesthetic agents can induce vasodilatation,
  leading to hypotension in pts who are volume
  depleted
• Most recommend withholding diuretics on the
  morning of surgery in some pts

41
Gastrointestinal Agents

• H2 blockers/PPI
• Decrease stress related mucosal damage
• Decrease gastric volume and increase gastric pH
• Reduces risk of chemical pneumonitis
• Should be continued in the perioperative period

42
Pulmonary agents

• Inhaled beta agonists and anticholinergics
• Reduces postoperative pulmonary complications in
  patients with COPD and asthma
• Should be continued in perioperative period
• Theophylline
• Potential for serious toxicity
• No data on benefits
• Recommendation discontinue the evening before
  surgery

43
Pulmonary agents

• Corticosteriod
• Chronic use in COPD should continued in periop
• Maintains optimal lung function
• Minimizes risk of adrenal insufficiency
• Leukotriene Inhibitors
• Effect on asthma symptoms and pulmonary function
  lasts up to 3 weeks
• No adverse interactions with anesthetic agents
• Rec continue in periop

44
Endocrine Agents

• Insulin and oral hypoglycemics
• Generally can continue with subcutaneous insulin
  perioperatively (rather than an insulin infusion)
  for procedures that are not long and complex
• Can switch patients taking long-acting insulin
  (Ultralente or glargine) to an intermediate-acting
  insulin one to two days prior to surgery because
  of a potential increased risk for hypoglycemia
• May also reduce the night time (supper or HS)
  intermediate-acting insulin on the night prior to
  surgery to prevent hypoglycemia if the patient
  has borderline hypoglycemia or tight control of
  the fasting blood glucose.
• Sliding scale may be used in place of oral
  hypoglycemics on morning of surgery

45
Endocrine Agents

• HRT/SERM
• Recommendation Stop 4 -6 weeks before surgery at
  moderate to high risk for thromboembolism
• Can be continued in surgeries at low risk for
  thromboembolism
• If on SERM for Breast Cancer recommend
  consultation with oncologist

46
Endocrine Agents

• Lipid Lowering agents
• May cause myopathy and rhabdomyolysis
• Statins may prevent vascular events and reduce
  perioperative mortality
• Recommendation continue statins, discontinue
  niacin, fibric acid derivative and cholestyramine
  at least one day before surgery

47
Endocrine Agents

• Thyroid agents
• Should be continued
• IV or IM administration if oral intake cannot be
  resumed in 5 7 days after surgery

48
Medications that affect hemostasis

• Aspirin
• Optimal periop management uncertain
• Inhibits platelet cyclooxygenase
• Increases intraop blood loss and hemorhagic
  complications
• May prevent vascular complications in cardiac
  surgeries (CABG, PVD surgery)
• Recommendations depends on pt risk factors and
  surgical procedure
• 2004 ACC/AHA Continue CABG after ST elevation MI
• Should be withheld in procedures with high
  hemorrhagic risk (CNS surgery)
• 5- 10 days before procedure (for new platelets to
  be formed)
• Plavix, dipyridamole
• Stop 7 10 days before surgery
• NSAIDS
• Stop 3 days before surgery

49
Warfarin

• Patients at low risk for perioperative bleeding,
  anticoagulation can be maintained at or below the
  low end of the therapeutic range (INR 2.0).
• Patients with a high risk of bleeding, INR should
  be 1.5. or less
• Stop warfarin two to five days preop in those at
  low risk for thrombosis
• Stop warfarin in pts at high risk for thrombosis,
  but treat with intravenous or subcutaneous
  heparin when the INR is subtherapeutic.
• Can be restarted postop when there is no
  contraindication to anticoagulation.

50
Psychotropic Agents

• TCA
• Withdrawal symptoms insomnia, headache,
  increased salivation
• Recommend Continue
• SSRIs
• May increase need for blood transfusions
• Inhibits platelet aggregation
• Recommend Weigh benefits vs. risks

51
Chronic Opioid Therapy

• Abrupt discontinuation may result in withdrawal
  symptoms
• Continue in periop period
• If oral intake not possible, consider alternative
  routes
• Higher doses may be required