UMMS CRIT
Preoperative Assessment in the Older Adult
Erika Oleson, DO, MS
Division of Geriatric Medicine
University of Massachusetts
Objectives
By the end of this lecture, the participant should be able to identify and
describe:
• The purpose of preoperative assessment
• How age-related physiologic changes influence perioperative care
• Components of preoperative assessment
• How to minimize perioperative risks
UMMS CRIT 2012 Module I: Preoperative Assessment in the Older Adult
Advancing Geriatrics Education (AGE) A UMMS initiative funded by the Donald W. Reynolds Foundation
Why do a Preoperative Assessment?
• Identify specific patient related factors which may increase risk for
complications
• Identify procedural risks and how they can impact recovery
• To recommend treatment plans to minimize complications during
and after the procedure
UMMS CRIT 2012 Module I: Preoperative Assessment in the Older Adult
Advancing Geriatrics Education (AGE) A UMMS initiative funded by the Donald W. Reynolds Foundation
Key determinants of preoperative risk
• Type of surgery (elective, urgent, emergent)
• Functional status at baseline
• Life expectancy
• Co-morbid conditions
• Expected outcomes and complications
UMMS CRIT 2012 Module I: Preoperative Assessment in the Older Adult
Advancing Geriatrics Education (AGE) A UMMS initiative funded by the Donald W. Reynolds Foundation
Physiological changes associated with aging
• Diminished organ reserves
• Decreased thermoregulation may increase risk of perioperative
hypothermia
• Cardiac and vascular stiffening may complicate fluid management
• Decreased hepatic blood flow and number of functional nephrons
may alter metabolism and clearance of several medications
• Sarcopenia may prolong functional recovery
• Altered sensory perception may increase risk of postoperative
delirium
UMMS CRIT 2012 Module I: Preoperative Assessment in the Older Adult
Advancing Geriatrics Education (AGE) A UMMS initiative funded by the Donald W. Reynolds Foundation
Perioperative complications in the geriatric patient
• Cardiac events
• Infection
• Delirium
• Pressure ulcers
• Functional decline
• Malnutrition
• Inadequate pain control
• Deep vein thrombosis
UMMS CRIT 2012 Module I: Preoperative Assessment in the Older Adult
Advancing Geriatrics Education (AGE) A UMMS initiative funded by the Donald W. Reynolds Foundation
Components of preoperative assessment
• Detailed review of clinical history and physical examination
• Functional/Physical activity assessment
• Cognitive evaluation
• Nutritional assessment
• Social support
• Goals of Care
• Advance directives
UMMS CRIT 2012 Module I: Preoperative Assessment in the Older Adult
Advancing Geriatrics Education (AGE) A UMMS initiative funded by the Donald W. Reynolds Foundation
Functional/Physical Activity Assessment
Metabolic Equivalents
1
Examples
Watching television
Eating, dressing, cooking, using toilet
Walking 1-2 blocks at 2-3 miles per hour
Light housework
4
Climbing flight of stairs
Walking on ground level at 4 mph
Running a short distance
Doing heavy chores (eg scrubbing floors, lifting furniture)
>10
Playing moderately strenuous sports (eg golf, dance, bowling)
Playing strenuous sports (eg tennis, basketball)
Holt NF Perioperative Cardiac Risk Assessment Am Fam Physician 2012; 85(3):239-246
Fleisher LA, Beckman JA, Borwn KA, et al. ACC/AHA 2007 guidelines on perioperative cardiovascular evaluation and care for noncardiac
surgery J Am Coll Cardiol. 2007; 50 (17)
UMMS CRIT 2012 Module I: Preoperative Assessment in the Older Adult
Advancing Geriatrics Education (AGE) A UMMS initiative funded by the Donald W. Reynolds Foundation
ASA Scores
American Society of Anesthesiologists (ASA) score:
Class I: normal healthy patient for elective surgery
Class II: patient with mild systemic disease
Class III: patient with severe systemic disease that limits activity but is not
incapacitating
Class IV: patient with incapacitating systemic disease that is constant threat to
life
Class V: moribund patient who is not expected to survive 24hrs with or
without surgery
UMMS CRIT 2012 Module I: Preoperative Assessment in the Older Adult
Advancing Geriatrics Education (AGE) A UMMS initiative funded by the Donald W. Reynolds Foundation
Cognitive Assessment
• Evaluate baseline cognitive function (Mini-cog, MOCA, MMSE,
etc.)
• Dementia and history of delirium increase the risk of postoperative
delirium
• Post-operative delirium associated with predisposing risk factors:
– Age ≥ 70, cognitive impairment, limited physical function,
history of alcohol abuse, abnormal serum sodium, potassium or
glucose, and intraoperative blood loss
• Confusion Assessment Method (CAM) is a useful screening tool for
delirium
UMMS CRIT 2012 Module I: Preoperative Assessment in the Older Adult
Advancing Geriatrics Education (AGE) A UMMS initiative funded by the Donald W. Reynolds Foundation
Nutritional Assessment
Instant Nutritional Assessment
•
No malnourishment
Serum albumin >=3.5g/dl and TLC >=1,500 cells/mm3
Severe malnourishment
Serum albumin <3.5g/dl and TLC < 1,500 cells/mm3
Hypoalbuminemia (<3.5mg/dl) increases risk of:
- Systemic sepsis and pneumonia
- Superficial and deep wound infection
- Poor wound healing
- Pulmonary edema and failure to wean from ventilation
- All-cause mortality rate
- Increased hospital length of stay and readmission rates
Gibbs J, Cull W, Henderson W, Daley J, Hur K, Khuri SF. Preoperative serum albumin level as a predictor of operative mortality and morbidity: results from the National VA Surgical Risk Study.
Arch Surg. 1999;134:36-42.
Corti M. Serum albumin level and physical disability as predictors of mortality in older persons. JAMA 1994; 272:1036-1042
Gastroenterol Clin North Am. 2007; 36:1-22
UMMS CRIT 2012 Module I: Preoperative Assessment in the Older Adult
Advancing Geriatrics Education (AGE) A UMMS initiative funded by the Donald W. Reynolds Foundation
Strategies to Minimize Risk:
Pre-operatively
• Manage hypertension
- Peri-operative β-blockers for major surgery, if not contraindicated
• Manage diabetes appropriately
• Treat reversible factors (anemia, infection, electrolyte imbalance etc.)
• Avoid prolonged periods without nutrition
• Pre-operative testing, based on clinical predictors and type of surgery
UMMS CRIT 2012 Module I: Preoperative Assessment in the Older Adult
Advancing Geriatrics Education (AGE) A UMMS initiative funded by the Donald W. Reynolds Foundation
Assessing Cardiac Risk in Non-cardiac Surgery
Emergency Surgery?
Yes
Proceed to Surgery
Yes
Cancel or postpone surgery;
correct acute cardiac conditions
Yes
Proceed to surgery
Yes
Proceed to surgery
No
Are of major risk factors present?
No
Is procedure low risk?
No
Is patient able to do light housework,
climb a flight of steps, walk up a hill,
or run a short distance?
No or unknown
Assess for clinical risk factors: Hx of ischemic heart disease,
prior or compensated heart failure, history of cerbrovascular disease,
diabetes mellitus, renal insufficiency
≥3 risk factors
High risk surgery
Intermediate
risk surgery
Strongly consider stress testing if it will
change management; if not, proceed to
surgery with perioperative B-blockade
1 or 2 risk factors
0 risk factors
Proceed to surgery with perioperative
B-blockade; consider stress testing
if it will change management
Proceed to surgery
Fleisher LA, Beckman JA, Borwn KA, et al. ACC/AHA 2007 guidelines on perioperative
cardiovascular evaluation and care for noncardiac surgery J Am Coll Cardiol. 2007; 50 (17)
UMMS CRIT 2012 Module I: Preoperative Assessment in the Older Adult
Advancing Geriatrics Education (AGE) A UMMS initiative funded by the Donald W. Reynolds Foundation
Strategies to Minimize Risk: Postoperatively
• Manage hypertension and monitor volume status
• Control blood sugars appropriately in your diabetic pts
• Adequate analgesia, avoid prn orders for patients with cognitive
impairment
• Early mobilization/Avoid prolonged bed rest
• DVT prophylaxis
• Avoid/Remove catheters if possible
• Regularly review medications
• Address nutritional needs
• Communicate with proxy/family
UMMS CRIT 2012 Module I: Preoperative Assessment in the Older Adult
Advancing Geriatrics Education (AGE) A UMMS initiative funded by the Donald W. Reynolds Foundation
Summary
• Elderly patients have decreased reserves in multiple organ systems which
increases their risk for several perioperative complications
• Preoperative assessment should be individualized, comprehensive, and
multidisciplinary
• Comprehensive perioperative management minimizes complications in
older patients, especially those with chronic medical problems and
functional impairments
UMMS CRIT 2012 Module I: Preoperative Assessment in the Older Adult
Advancing Geriatrics Education (AGE) A UMMS initiative funded by the Donald W. Reynolds Foundation