Surgical Care of the Geriatric Patient – What Every Surgeon Should … · Proposed Competencies...

Tom Robinson MDGrand Rounds – Dec. 12th, 2011

Surgical Care of the Geriatric Patient –

What Every Surgeon Should Know

University of Colorado

Aging and SurgeryResearch Center

Katlic MR et al. Bull Am Coll Surg (2011) 96(6):24

Is geriatric surgery a specialty?

General Surgery

Cardiothoracic Surgery

Orthopedic Surgery

Transplant Surgery

Surgical Oncology Neurosurgery

Plastic Surgery Urology Vascular Surgery

Pre-Operative Operation Hospital Course After Discharge Care

Proposed Competencies in Geriatric Patient Care



Atypical presentationsAssess risk - frailtyMedication managementComplex/chronic illnessCognitive disordersInformed consent


Proposed Competencies in Geriatric Patient Care for Use in Assessment for Initial and Continued Board Certification of Surgical Specialists


Medication managementAdvance directivesComplex chronic illness





Medication managementDelirium managementTreat chronic illnessPatient safetyPalliative care / end-of-lifeTransitions of care

Bell RH et al. JACS 2011 213(5): 683.






Geriatric Surgery – Matrix Management Structure

Head of the Hospital

Chief of Surgery

Head of Surgical SpecialtiesGen Surg Urology Ortho Etc.

Diagram courtesy of Dr. Ben Eiseman MD.


Head Geriatric Surgery

Geriatrician

StaffFellow

Essentials in Geriatric

Surgery

Nursing-SNF

Pharmacy

Health Econ

Research


Chief of Surgery



Complementary Courses

Advanced Trauma Care for Nurses (ATCN) for Registered Nurses

Pre-Hospital Trauma Life Support (PHTLS) for Pre-hospital Care Providers

Trauma Evaluation and Management (TEAM) for Medical Students

A Model of Multi-Disciplinary Surgical Care

http://www.traumanurses.org/education/atcn�

http://www.traumanurses.org/education/atcn�

http://www.naemt.org/education/phtls_a.aspx�



http://www.facs.org/trauma/atls/team.html�

http://www.facs.org/trauma/atls/team.html�



Geriatrician

StaffFellow


Surgery

Nursing-SNF

Pharmacy

Health Econ

Research


Chief of Surgery



Co-Managed Geriatric Hip Fracture Center

• Clinical outcomes– Decreased length of stay– Decreased readmission rate– Decreased complications– Decreased mortality

Kates S et al. J Ortho Trauma (2011) 25:233

Co-Managed Geriatric Hip Fracture Center

• Clinical outcomes– Decreased length of stay– Decreased readmission rate– Decreased complications– Decreased mortality

• Cost of caring for hip fractures was 66.7% of expected cost.

Kates S et al. J Ortho Trauma (2011) 25:233

Age Demographic by Surgical Specialty

National Hospital Discharge Survey 2004

Surgical Specialty Age > 65 years

Cardiovascular 51%

Thoracic 48%

Urologic 45%

Gastrointestinal 43%

Orthopedic 39%

Ophthalmologic 34%

All 35%

U.S. Population Aged 65 and Over

0

20

40

60

80

1900 1930 1960 1980 2002 2030

Population(Millions)

0

5

10

15

20

25

Percent Total

Population

Calendar Year



Geriatrician

StaffFellow


Surgery

Nursing-SNF

Pharmacy

Health Econ

Research


Chief of Surgery



Bell RH et al. JACS 2011 213(5): 683.






Bell RH et al. JACS 2011 213(5): 683.






To operate or not to operate,

that is the question.

Circulation (2007) 116:1971.

Clin Geriatr Med (2003)19:35.

Hepatology (2001) 33:464.

Cleve Clin J Med (2006) 73:S4-7.

Traditional pre-operative risk assessment strategy does not distinguish risk in these two individuals.

Risk stratifying the geriatric patient requires assessment of vulnerability unique to older adults.

GeriatricAssessment

WalkingSpeed

FunctionalImpairment

GeriatricSyndromes

ImpairedCognition

Nutrition

ChronicDiseaseBurden

GeriatricAssessment

WalkingSpeed


GeriatricSyndromes

ImpairedCognition

Nutrition


Geriatric Assessment - Function

Activities of Daily Living (ADLs)• Bathing• Dressing• Transferring• Toileting• Grooming• Feeding

Geriatric Assessment - Function

Instrumental Activities of Daily Living (IADLs)• Using the telephone• Shopping• Food preparation• Housekeeping• Doing laundry• Utilization of transportation• Ability to medicate• Ability to handle finances

GeriatricAssessment

WalkingSpeed


GeriatricSyndromes

ImpairedCognition

Nutrition


Geriatric Assessment - Cognition

Mini-Cog• Three item recall - apple, table, penny

• Clock Draw - draw clock face, hands at 11:10

JAGS (2003) 51:1451.

GeriatricAssessment

WalkingSpeed


GeriatricSyndromes

ImpairedCognition

Nutrition


Geriatric Assessment – Chronic Disease Burden

• Charlson Index

• Cumulative Illness Rating Scale

• Polypharmacy

• ASA Score

• Anemia of chronic disease (< 35%)

J Chron Dis (1987) 40:373.JAGS (2008) 56:1926.

GeriatricAssessment

WalkingSpeed


GeriatricSyndromes

ImpairedCognition

Nutrition


Risk stratifying the geriatric patient requires assessment of vulnerability unique to older adults.

GeriatricAssessment

WalkingSpeed


GeriatricSyndromes

ImpairedCognition

Nutrition


Geriatric Assessment – Nutrition

• 10 lbs. weight loss in past year

• 10% weight loss in past year

• Albumin level

• Mini-Nutritional Assessment

GeriatricAssessment

WalkingSpeed


GeriatricSyndromes

ImpairedCognition

Nutrition


Geriatric Assessment – Walking Speed

Timed ambulation over 15 feet

Timed ambulation over 6 meters

Timed Up-and-Go

10 feet

GeriatricAssessment

WalkingSpeed


GeriatricSyndromes

ImpairedCognition

Nutrition


Geriatric Assessment – Geriatric Syndromes

A geriatric syndrome represents accumulated impairments in multiple organ systems that results in a clinical event.

• Falls

• Continence

Inouye SK et al. JAGS (2007) 55:780.

GeriatricAssessment

WalkingSpeed


GeriatricSyndromes

ImpairedCognition

Nutrition


WalkingSpeed


GeriatricSyndromes

ImpairedCognition

Nutrition


RiskScale

Accumulation of Geriatric “Deficits”

AVERAGE OUTCOMES

POOROUTCOMES

RiskScale


AVERAGE OUTCOMES

POOROUTCOMES


NormalGait Speed

RiskScale


AVERAGE OUTCOMES

POOROUTCOMES


NormalGait Speed

ImpairedCognition

No GeriatricSyndromes


AVERAGE OUTCOMES

POOROUTCOMES

RiskScale


RiskScale

AVERAGE OUTCOMES

POOROUTCOMES

WalkingSpeed


GeriatricSyndromes

ImpairedCognition

Nutrition


Frail

RISKSCALE

Better Outcome

PoorOutcome

RISKSCALE

Better Outcome

PoorOutcome

Non- Frail

Pre-OpEvaluation Operation Hospital

Course30-Day

Outcomes6-Month

Outcomes

Group Abnormal Domains

Non-Frail 0 or 1

Pre-Frail 2 or 3

Frail 4 or more

Post-Operative Complications


Course30-Day

Outcomes6-Month

Outcomes

0

10

20

30

40

50

60

70

1 2 30

10

20

30

40

50

60

70

One or MoreComplications

(%)

Non-Frail Pre-Frail Frail0

10

20

30

40

50

60

70

Robinson TN, et al. Ann Surg (2009) 250:449.Robinson TN, et al. J Am Coll Surg (2011) 213:37.Robinson TN, et al. Am J Surg (2011) epub Sept 2.

Hospital Length of Stay


Course30-Day

Outcomes6-Month

Outcomes

Hospital Length of Stay(days)


0

2

4

6

8

10

12

14

16

1 2 30

4

8

12

16

2

6

10

14

Non-Frail Pre-Frail Frail0

Thirty-Day Readmission Rate


Course30-Day

Outcomes6-Month

Outcomes

30-DayReadmission

(%)


0

5

10

15

20

25

30

1 2 3Non-Frail Pre-Frail Frail

5

20

30

10

15

25

0

Discharge to an Institutional Care Facility


Course30-Day

Outcomes6-Month

Outcomes

Dischargeto Institution

(%)


0

10

20

30

40

50

60

70


0

10

20

30

40

50

60

70

Cost of Hospitalization


Course30-Day

Outcomes6-Month

Outcomes

HospitalCost

($10K)


0

10

20

30

40

50

60

70

80


20

30

40

50

60

70

10

0

80

Post-Discharge to Six-Month Healthcare Costs


Course30-Day

Outcomes6-Month

Outcomes

Post-Hospital6-Month

Costs ($10K)


0

5

10

15

20

25

30

35

40


10

15

20

25

30

35

5

0

40

GeriatricAssessment

WalkingSpeed


GeriatricSyndromes

ImpairedCognition

Nutrition


GeriatricAssessment

WalkingSpeed


GeriatricSyndromes

ImpairedCognition

Nutrition


MoodExtrinsic MarkersExhaustionLow activity

Geriatric Assessment and Post-Op Outcomes

Function Cognition DiseaseBurden Nutrition Walking

SpeedGeriatricSyndrome

Dasgupta et al (2009)

Robinson et al (2009, ‘11)

Kristjannssonet al (2010)

Makary et al(2010)

Lee et al(2010)

Saxton et al(2011)







Makary et al(2010)

Lee et al(2010)

Saxton et al(2011)







Makary et al(2010)

Lee et al(2010)

Saxton et al(2011)







Makary et al(2010)

Lee et al(2010)

Saxton et al(2011)







Makary et al(2010)

Lee et al(2010)

Saxton et al(2011)







Makary et al(2010)

Lee et al(2010)

Saxton et al(2011)







Makary et al(2010)

Lee et al(2010)

Saxton et al(2011)

Preoperative Assessment:

What Really Matters

WalkingSpeed


GeriatricSyndromes

ImpairedCognition

Nutrition


RISKSCALE

Better Outcome

PoorOutcome

RISKSCALE

Better Outcome

PoorOutcome

Bell RH et al. JACS 2011 213(5): 683.






Why is delirium important?

DELIRIUM

Most common post-operative complication in the elderly.

Closely related to adverse outcomes.

Potentially preventable, and there is room to improve treatment.

What is Delirium?

Pandharipande et al. Curr Opin Crit Care (2005) 11:360.

Delirium is an acute, fluctuating change in mental status, with inattention and altered levels of consciousness.

Diagnostic Criteria for Delirium

1. Coexisting Physiologic Disturbance

2. Acute Onset

3. Disturbance of Consciousness

4. Change in Cognition

Diagnostic and Statistical Manual of MentalDisorders DSM IV - Fourth Edition (1994)

Cataract Surgery5 < 5%

Medical Ward1 15%

Vascular Operation4 36%

Hip Fracture3 40%

DVAMC SICU6 44%

DHMC Trauma ICU7 59%

Medical ICU2 72%

Incidence of Delirium

1NEJM (1999) 340(9):669.2JAGS (2006) 54:479.3JAGS (2002) 50:850

4Gen Hosp Psych (2002) 24:28.5Int Psych (2002) 14:301.6Ann Surg (2009) 249:173.

7Am J Surg (2008) 196:864.

Age and Post-Operative Delirium

0

20

40

60

80

100

50 - 59 60 - 69 70 - 79 80 - 89

Age by Decade(years)

Incidence of Delirium

(%)

Robinson TN et al. Ann Surg (2009) 249:173.

Pre-Operative Risk Factors

Impaired cognition

Functional impairment

High chronic disease burden

Older age

Low albumin

Robinson, TN et al. Ann Surg (2009) 249:173.

Multifactorial Model of Delirium

JAMA (1996) 275:852.

Predisposing Factors/Vulnerability

Precipitating Factors/Insults


JAMA (1996) 275:852.

High Risk

Low Risk

DELIRIUM




JAMA (1996) 275:852.

High Vulnerability

Low Vulnerability

Noxious Insult

Less Noxious Insult

High Risk

Low Risk

DELIRIUM




JAMA (1996) 275:852.

High Vulnerability

Low Vulnerability

Noxious Insult

Less Noxious Insult

High Risk

Low Risk

DELIRIUM



POST-OPDELIRIUMOPERATION

Risk Factors:Older ageDementiaFunctional Impairment

Co-MorbiditiesMalnutrition

Evaluation for an Identifiable Cause:




Sepsis

Hypoxemia

Hypoglycemia

Electrolyte Abnormality

Dehydration

Stroke

Medications

Treat Identifiable Cause

H&P Evaluation Mental Status Neuro Exam Substance Abuse Medications Vital Signs

Laboratory Tests CBC Glucose Electrolytes BUN / Cr UA O2 Saturation

Medical Evaluation of Delirium

Potter et al. Clin Med (2006) 6(3):303.

Evaluation for an Identifiable Cause:Electrolyte imbalanceHypoglycemiaHypoxemiaSepsisSubstance WithdrawalReview Medications




Identifiable Cause:Treat Appropriately






Multi-Component Treatment Plan







Supportive Measures:





Preventing Delirium in the Hospitalized Elderly

• HypothesisReducing the number of risk factors for delirium will prevent delirium in hospitalized elderly patients.

• Methods- 852 hospitalized medical patients

- Older than 70 years

- Compare effectiveness of reducing the riskfactors for delirium to standard of care

Inouye et al. NEJM (1999) 340(9):669.

Multi-Component Interventions To Prevent Delirium

Risk Factors Intervention

Cognitive Impairment Orientation protocol

Sleep Deprivation Sleep enhancement

Immobility Early mobilization

Visual Impairment Early vision correction

Hearing Impairment Hearing protocol

Dehydration Change BUN/Cr ratio

Inouye et al. NEJM (1999) 340(9):669.

Preventing Delirium in the Hospitalized Elderly

Inouye et al. NEJM (1999) 340(9):669.

STUDY GROUP

Intervention Usual Care p value

Incidence Delirium 9.9% 15.0% p=0.02

Total Days Delirium 105 161 p=0.02

Episodes of Delirium 62 90 p=0.03



Supportive Measures:Re-OrientationSleep EnhancementVision/Hearing ProtocolRemove Foley Medication Choices





Screen High Risk Patients in Pre-Operative Clinic










Pharmacologic Treatment:







Haldoperidol 2 mg q20 min(while agitation persists)

OR

Degree of Agitation

Initial Dose HaldoperidolPO, IM or IV

Mild 0.25-2mg

Moderate 2-4mg

Severe 4-8mg

Pharmacologic Treatment - ICU

Jacobi et al. Crit Care Med (2002) 30(1):119.


Maintenance Dose: 50% of total loading dose is the

maintenance dose divided every 6-8 hours daily

Continue maintenance dose for 24-48 hours before tapering

Taper: Taper maintenance dose by 20-30%

daily until off.


Haldoperidol Administration

Control Moderate Agitation2:00AM – 2mg IV2:30AM – 2mg IV3:00AM – 2mg IV3:30AM – Agitation controlled

Maintain Order 1mg TID IV or PO x 24 hrs.Keep daily dose for 24 – 48 hrs.

Taper 0.5mg PO BID for 24 hrs. then DC

General Recommendation:Haldoperidol 1-2 mg q2-4 hrs PRNMay be administered PO/IM/IV

For Elderly Patients:Haldoperidol 0.25-0.5mg q4hrs PRN

Pharmacologic Treatment - Ward

Practice Guideline for Treatment of Patients with Delirium (1999) American Psychiatric Association



Pharmacologic Treatment:1. ICUHaldoperidol 1-2mg IVRepeat every 20 min untilresolution of agitation

Taper over several days2. Surgical WardHaldoperidol 1mg PO/IM/IVMaintenance dose 0.25-0.5mgQ4hrsTaper over several days







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Surgical Care of the Geriatric Patient – What Every Surgeon Should … · Proposed Competencies...

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