PreOperative Assessment in the Older Adult

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Pre-Operative Assessment in the Older Adult

• Tomas L. Griebling, MD, FACS, FGSA
• Department of Urology
• The Landon Center on Aging

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Goals

• To review the most common physiologic changes in
  the elderly which may impair ability to
  compensate for operative stress
• To describe the purpose and components of the
  preoperative assessment
• To provide strategies to minimize operative and
  perioperative risks

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Cardiovascular System

• Changes in mechanics
• Decrease in myocytes, increase in collagen
  resulting in decreased compliance
• Autonomic tissue replaced by collagen resulting
  in conduction abnormalities
• Decreased compliance of vascular system leading
  to increased systolic blood pressure with
  resulting ventricular hypertrophy

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Cardiovascular System

• Changes in control mechanisms
• decreased responsiveness to catacholamines due
  probably to impaired receptor function
• decreased heart rate response to changes in
  circulatory volume may lead to congestive heart
  failure or hypotension (COSV x HR gtpreload
  dependency)

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Pulmonary System

• Reduced chest wall compliance resulting in
• increased work of breathing
• reduced maximal minute ventilation
• Reduced respiratory response to hypoxia by 50 (?
  May be due to impaired
• chemoreceptor function)
• Decreased ciliary function
• Reduced cough and swallowing function

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Neurologic Changes

• Decrease in cortical gray matter, neuronal
  volume, complexity of neuronal connections,
  synthesis of neurotransmitters
• Neuronal loss and demyelination occur in the
  spinal cord resulting in changes in reflexes and
  reductions in proprioception (may alter balance)
• Vision and hearing loss make information
  processing more difficult
• Decreased adrenoceptor responsiveness results in
  increased concentrations of circulating
  catacholamines

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Renal Changes

• Decline in renal blood flow--10 per decade after
  age 50
• Old kidney has difficulty
• maintaining circulating blood volume
• with sodium homeostasis
• removing excess acid
• adjusting to hypovolemia, hemorrhage, low cardiac
  output and hypotension
• Renal insufficiency may not be appreciated

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Adverse Drug Reactions (ADR)

• Decrease in lean body mass with increased
  proportion of body fat
• Decreased protein binding of certain drugs
• Alterations in renal, CV, hepatic function may
  change drug concentrations and their duration of
  action
• ADRs increase with number of drugs administered
  and linearly with age

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Preoperative Assessment--Purposes

• Not just for clearance
• To identify factors associated with increased
  risks of specific complications related to a
  procedure
• To recommend a management plan to minimize these
  risks

Cassel CK, Leipzig RM, Cohen HJ, et al. Geriatric
Medicine An Evidence Based Approach, 4th ed. New
York Springer 2003.
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Preoperative Assessment--Components

• Functional Assessment
• Cognitive Assessment
• Nutritional Assessment
• Review of advance directives
• whether and when to withhold or withdraw support
  involves patient, family, supports

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Functional Assessment

• American Society of Anesthesiologists (ASA) score
• Class I A normal healthy patient for elective
  operation
• Class II A patient with mild systemic disease
• Class III A patient with severe systemic
  disease that
• limits activity but is not
  incapacitating
• Class IV A patient with incapacitating systemic
  disease
• that is a constant threat
  to life
• Class V A moribund patient that is not expected
  to
• survive 24 hrs with or
  without the operation
• E Emergency case modifier

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Functional Assessment

• Exercise capacity
• inactive defined as inability to leave the home
  on ones own at least twice per week
• increased CV risk in patients unable to meet a
  4-MET demand during most daily activities
• Activities of Daily Living
• Correlated with post-op morbidity and mortality
• 60 older adults hospitalized lose independence
  of at least 1 ADL

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Cognitive Assessment

• Not done uniformly
• Dementia is a major predictor of post-op delirium
• Use of Mini-Mental State Exam (MMSE) or
  orientation and recall testing, mini-COG, etc.
• Much potential for future research

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Nutritional Assessment

• Poor nutrition is a risk factor for
• pneumonia
• poor wound-healing
• 30-day mortality
• Hypoalbuminemia (lt 3.3mg/dL)
• increased length of stay
• increased rates of readmission
• unfavorable disposition
• increased all-cause mortality

Corti M. Serum albumin level and physical
disability as predictors of mortality in older
persons.JAMA 1994 2721036.
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Strategies to Minimize Risk

• Routine screening is low yield
• Pre-op testing should be based on the type of
  surgery
• Manage hypertension
• lower blood pressure to under 180/110
• In patients with dementia, consider placement of
  epidural to control pain without sedation (may
  minimize risk for delirium)
• Avoid long periods without nutrition
• limited evidence, but should try to improve
  nutritional status prior to elective surgery

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Strategies to Minimize Risk

• Perioperative use of ß-blockers
• Mangano, et al., NEJM 1996
• In patients at with or at risk for CAD, does IV
  atenolol decrease peri-op CV morbidity and
  increase overall survival?
• Randomized, double-blind, placebo-controlled
• 200 pts enrolled IV atenolol 10 mg given 30 min
  prior to surgery, 50-100 mg bid POD 1-7
• 192 followed for 2 yrs

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Strategies to Minimize Risk
Event-free survival after hospital discharge at 2
years was 68 in the placebo group and 83 in the
atenolol group (p0.008). Cardiac risk factors
included age gt 65, hypertension, current
smoking, cholesterol gt 240, and diabetes. Not
clear yet if age alone is an indication for use
of ß-blockers in perioperative period (consider
exercise tolerance)
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Strategies to Minimize Risk

• Diabetic Postoperative Mortality and Morbidity
  (DIPOM) study
• Perioperative Ischemic Evaluation (POISE)
• Metoprolol after Vascular Surgery (MaVS)\
• Other clinical trials

Http//www.medscape.com/viewarticle/494679
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Reuben DB, et al. Geriatrics at Your Fingertips
2005, 7th edition. New York, American Geriatrics
Society, 2005.
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Summary

• Older adults have decreased reserves in multiple
  organ systems
• Disease burden and functional capacity outweigh
  age when assessing preoperative risk
• Collaboration among providers helps to identify
  functional, cognitive and nutritional deficits
  and to create management plans to minimize these
  deficits when possible
• Good planning helps optimize outcomes !!