Perioperative Careof Older People
Philip Braude, Consultant Geriatrician
POPS – Proactive care of Older People undergoing Surgery
Guy’s and St Thomas’ Hospital
@DrPhilipBraude #AGM17conf
Prevalence surgical pathology increases with age
Neoplastic
Degenerative
Vascular
Elective surgery
Emergency surgery
0
1,0
00
2,0
00
3,0
00
4,0
00
5,0
00
Patie
nts
<31 31-40 41-50 51-60 61-70 71-80 81-90 >90
Surgery rates not reflect incidence
National Cancer Intelligence Network, UK 2010Access All Ages, RCS 2012
Why might this be?
• Multimorbidity
• Cognitive impairment
• Polypharmacy
• Frailty
• Dependence
• Ageism?
Older people get more complications
• Systematic review
• 28 papers = 34,194 patients
Outcomes in Older People Undergoing Operative Intervention for Colorectal Cancer. Patel, JAGS, 2001
Older people get more complications
• Systematic review
• 28 papers = 34,194 patients
Outcomes in Older People Undergoing Operative Intervention for Colorectal Cancer. Patel, JAGS, 2001
Older people get more complications
• Systematic review
• 28 papers = 34,194 patients
Outcomes in Older People Undergoing Operative Intervention for Colorectal Cancer. Patel, JAGS, 2001
Older people get more likely to die
Temporal Patterns of Postoperative Complications. Thompson, Arch Surg, 2003
Death rate +/- complications
with without
30day mortality 13% 1%
1 year mortality 28% 7%
5year mortality 58% 40%
…and have functional deterioration…
Functional independence after major abdominal surgery in the elderly.Lawrence. J Am Coll Surg, 2004
“Never mind dying, how long before I get back to normal?”
(...plus cost more)
• Late cancellations
• Length of stay
• Readmissions
• Social care costs
• Informal care costs
J Vasc Surg 1997;25:298-311
Who is at high risk of adverse outcomes?
• Poor functional recovery – Older people• Deterioration in function persisting up to 6months
• Poor cognitive recovery – Older people• Delirium, postop cognitive dysfunction, dementia
• Common, serious, distressing
• Poor experience – Older people• NCEPOD An age old problem, Francis report
So, why do older patients do worse?
Age not an independent factor
Age not an independent factor
"You don't make a pig fatter by weighing the pig”
– Don Berwick
But you knew all that already…
Traditional hospital model
Assess risk factors
Not ‘fit’ for surgery
vs
Fit for surgery
Discharge to community
Admit to SAL/Sx ward
React to complications
Traditional hospital model
Pain Opiates
Post-op ileus On/off ‘sliding scale’
Hypovolaemic (AKI) Fluids
Anaemia Blood
Peripheral oedema Diuretics
Depressed (delirium) Anti-depressants
Functional decline Carers & Rehab
Endocrinology
Haematology
Cardiology
Psychiatry
Geriatrics
Nephrology
On
Call
Medical
Registrar
74yo Joyce
What we should be doing
Assessment of risk
Modification of risk
Care in the right place
Manage complications
Shared decision making
PREMPROM
Long term health
A variety of novel approaches are being taken
Who?
• Anaesthetist led and delivered
• Geriatrician led and delivered
• Hospitalist led and delivered
When?
• Preoperative only
• Postoperative only
• Whole pathway
Braude FHC Journal 2016
Emerging specialty of ‘perioperative medicine’
10 million having surgery/pa in UK
1.6 million as in-patients
250,000 defined as high risk
“Promote multidisciplinary, patient centred medical care from contemplation of surgery until full recovery”
Emerging specialty of ‘perioperative medicine’
“Promote multidisciplinary, patient centred medical care from contemplation of surgery until full recovery”
Emerging specialty of ‘perioperative medicine’
“Promote multidisciplinary, patient centred medical carefrom contemplation of surgery until full recovery”
National guidelines
…and the relevant preoperative guidelines…
Preoperative
Assessment IHD/failure ACC/ESC
Optimization Anaemia PBM
Planning Diabetes NHS DiabeteS
Prevention of AKI NICE
Prevention of POD NICE
…the intraoperative guidelines…
Intra-operative
MAP/BIS/temp
Fluid balance
Analgesia
…and the relevant postoperative guidelines
Post-operative
AKI
Sepsis
AF
ACS
POD
Clinical pathway
Cognition
Cardioresp fitness
Frailty
Anaemia
Manage comorbidity
Nutrition
This is complicated…
This is complicated…
Clinical pathway
Cognition
Cardioresp fitness
Frailty
Anaemia
Manage comorbidity
Nutrition
Interdisciplinary
Length of stay
Waiting list targets
Cancer treatment targetsInvestigations
Resource limitations
Consent and capacity
This is complicated…
Clinical pathway
Cognition
Cardioresp fitness
Frailty
Anaemia
Manage comorbidity
Nutrition
Interdisciplinary
Length of stay
Waiting list targets
Cancer treatment targetsInvestigations
Resource limitations
Consent and capacity
This is complicated…
Geriatrics
Cognition
Cardioresp fitness
Frailty
Anaemia
Manage comorbidity
Nutrition
Interdisciplinary
Length of stay
Waiting list targets
Cancer treatment targetsInvestigations
Resource limitations
Consent and capacity
…and to geriatricians sounds like Comprehensive Geriatric Assessment
30% higher chance of being alive and in own homeNNT 13
Holistic, multidimensional, interdisciplinary
Formulation of:• a list of needs, wants and priorities• issues to tackle• tailored individualised care plan
Comprehensive Geriatric Assessment
…works as it allows…
Risk assessment
• Recognise comorbidity
• Identify disability & frailty
• Assess functional reserve
Optimisation
• Medical, functional, psychological & social
• Organ specific guidelines
• MDT interventions
…and facilitates…
Collaborative decision making • Harm vs benefit• Consent, capacity, advance directives • Communication
Traditional hospital model
Pain Opiates
Post-op ileus On/off ‘sliding scale’
Hypovolaemic (AKI) Fluids
Anaemia Blood
Peripheral oedema Diuretics
Depressed (delirium) Anti-depressants
Functional decline Carers & Rehab
Endocrinology
Haematology
Cardiology
Psychiatry
Geriatrics
Nephrology
On
Call
Medical
Registrar
74yo Joyce
Traditional hospital model
Pain Opiates
Post-op ileus On/off ‘sliding scale’
Hypovolaemic (AKI) Fluids
Anaemia Blood
Peripheral oedema Diuretics
Depressed (delirium) Anti-depressants
Functional decline Carers & Rehab
Endocrinology
Haematology
Cardiology
Psychiatry
Geriatrics
Nephrology
On
Call
Medical
Registrar
Unrecognised disease/syndromes
Suboptimal control of comorbidity
Unrecognised complications
Poor coordination of care
74yo Joyce
A typical ‘not too complicated’ story
74yo Joyce
Living aloneNo support
Difficulthistorian
OA
Diabetes
HTN
SOB ?cause
‘Difficult’historian
A typical ‘not too complicated’ story
74yo Joyce
Living aloneNo support
Difficulthistorian
OA
Diabetes
HTN
SOB ?cause
‘Difficult’historian
Pain
HbA1c 8.2%
BP 170/88
Ischaemic ECG
Anaemia
Deconditioning
MoCA 21/30
Social issues
The same patient with POPS input...
Analgesia/physio
Treat/plan
ABPM/treat
Undiagnose
IV iron and blood
Exercise programme
Delirium risk/mx
Equipment/POCPsychological supportDischarge planning
OA
Diabetes
HTN
SOB ?cause
‘Difficult’historian
Pain
HbA1c 8.2%
BP 170/88
Ischaemic ECG
Anaemia
Deconditioning
MoCA 21/30
Social issues
74yo Joyce
Living aloneNo support
Difficulthistorian
…with clear communication…
Based on the history and cognitive testing Ms X has likely dementia. This raises the following issues;
a) CapacityDisplays capacity to consent to proposed procedure – but requires adequate time and clear
explanation
b) Delirium riskCognitive impairment and poor vision put Mrs X at risk of developing POD.
Patient has been counselled about this. When admitted please ensure that;
i) Trust delirium guideline is printed, filed in notes and followed
ii) Deliriogenic drugs are avoided where possible
iii) Adequate hydration is maintained
iv) Falls risk is assessed (using STRATIFY)
v) Day night routine is maintained
vi) Sensory impairments are optimised (I have told Ms X to bring in her glasses
c) Long term managementPlease could GP monitor and consider referral to memory assessment services.
Evidence? CGA in perioperative medicine
Partridge, Anaesthesia 2014
5 studies; 3 before and after, 2 RCT (not all ‘really’ CGA)Conclusions; preop CGA may reduce postop comps
Harari, Age Ageing 2007; 36: 190
Evidence? Observational cohort
Pre-POPS n=54 POPS n=54
Age 75 74
Cardiac 33% 55%
Diabetes 13% 20.4%
Renal 3.7% 22.2%
Hypertension 51.9% 80%
Delirium 18.5% 5.6%
Pneumonia 20% 4%
ACS 7.4% 3.7%
Arrhythmia 13% 7.4%
Heart failure 3.7% 0%
Thrombosis 11% 2% (1)
Wound sepsis 22.2% 3.7% (2)*
Harari, Age Ageing 2007
Evidence? Observational cohort
Pre-POPS Post-POPS
Uncontrolled pain 29.6% 1.9%
NBM >4days 9.3% 0%
Catheter>4/7 20.4 % 7.4 %
Dependent transfers 14.8% 0%
Bedridden >3days 27.8 % 9.3%
Pressure sores 18.5% 3.7%
Length of stay 15.8 ± 13.2 11.5 ± 5.2
Delayed discharge 70.4% 24.1%
- medical problems 37% 13%
- slow rehab’n 13% 7.4%
- wait for OT/equipment 20.4% 3.7%
Evidence? Observational cohort
Evidence? RCT
Evidence? RCT
Partridge, British Journal of Surgery Jan 2017
New diagnosisOT/Social worker referralMedication changesPlanning with primary carePlanning with ward team
Patients aged over 65 years undergoing elective AAA or LEAR surgery, randomised to routine care versus CGA
Reduction in Median LOS5.5 days to 3.3 days (p<0.001)0
20
40
60
80
Pe
rcen
tage
Medical complications (p=0.002) Surgical complications (p=0.04) Delayed discharge (p=0.05)
Control Intervention Control Intervention Control Intervention
Percentage of patients with complications and delayed discharge by trial arm
Evidence? QIP - elective
Before February 1st
11 MedianAfter February1st
7 Median
• Length of stay ↓ 4 days
• 30 day readmission rate ↓ 13.2%
• Times seen by non surgeon ↓ 18%
• Medication reviews ↑ 51%
• Coding complications ↑↑
• Coding comorbidities ↑↑
Courtesy of
Dr Vilches-Moraga, Salford
Evidence? QIP - emergency
Is there an appetite for CGA?
• 70% describe inadequate training in complex older patients
• 68% difficulty in accessing medical support
• 8% no need for closer working
Ideal components of a collaborative geriatric medicine-surgical service
Medical Optimisation 79%
Mental Capacity Assessment 71%
Quantifying Medical Risks of Surgery
64%
Managing Medical Complications 87%
Communication with patients and families
38%
Post-op rehab/ discharge planning 92%
Do Surgical Trainees Believe They Are Adequately Trained to Manage the Ageing Population? A UK Survey of Knowledge and
Beliefs in Surgical Trainees. Shipway. JSE, 2015.
But is yet to be translated into routine care…
Partridge, Age and Ageing 2014
…and emergency care
…however, this picture is already changing…
Chelmsford
Imperial
BelfastEdinburgh
Nottingham
Guildford
Southmead
North TeesSalford
GSTT, London
Cambridge
Kings, London
Oxford Portsmouth
The workforce challenge - not enough geriatricians!
2011 2035
Population 63 million 73.2 million
Population 65+ 10.4 million 16.8 million
Number of geriatricians 1222* 1464**
High number of unfilled posts
* current number of consultant geriatricians** required number of consultant geriatricians
Geriatric medicine workforce planning: a giant geriatric problem or has the tide turned? Fisher. Clinical Medicine, 2014.
Need to consider alternative workforce…
Specialty
• Primary care
• Anaesthetists
• Geriatricians
• General physicians (hospitalists)
Discipline
• Nurses
• Occupational therapists
• Physiotherapists
• Pharmacists
• Physician associates
Many training resources available
…and training opportunities…
www.popsteam.co.uk
•British Geriatrics Society POPS Special Interest Group
•POPS – AAA conference: March 2018 (www.bgs.org.uk)
•POPS OOPE posts
•RCoA Perioperative medicine programme
•UCL Perioperative Medicine MSc
•EBPOM, NELA
•Age Anaesthesia Association