POSTOPERATIVE CARE OF THE GERIATRIC PATIENT

Maria-Karnina Iskandar, MDAmit Patel, MD

Konstantin BalonovAnesthesiology Residents

Ruben J. Azocar, MD Associate Professor of Anesthesiology

THE AMERICAN GERIATRICS SOCIETYGeriatrics Health Professionals.

Leading change. Improving care for older adults.

AGS

OBJECTIVES

• Review the impact of postoperative complications in the elderly

• Discuss the most common postoperative issues in the elderly

• Review the issues related to postoperative delirium and postoperative cognitive dysfunction

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DEVIATION FROM THE ROUTINE

• Geriatric patients compensate on a daily basis for physiological declines in every organ system

• Periods of extreme stress, such as surgery and anesthesia, can decompensate the older adult

• In 2005, patients over 65 years accounted for approximately 7 million surgeries/year(3.6 times more than patients <65)

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EFFECT OF AGE AND DISEASE ON RISKOF PERIOPERATIVE COMPLICATIONS

Number of Comorbidities

Num

ber o

f Com

plic

atio

nspe

r 100

0 S

urge

ries

Can Anaesth Soc J. 1986;33:336.Slide 4

PREOPERATIVE VISIT

• Review comorbidities and their current state

• Assess functional, cognitive and nutritional status

• Provide recommendations to prevent perioperative complications

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IMPLICATIONS OF COMPLICATIONS• 30-day mortality for 60-year-olds vs. patients 801

1.1% vs. 3.7% if no complications 15.1% vs. 26.1% if ≥1 complications

3-month mortality in patients 70 vs. nonsurgical controls2

2.9 hazard ratio if no complications 7.3 hazard ratio if ≥1 complications

• If survive 3 months, complications minimally increase subsequent mortality

• Diminished functional status/↑dependency compared to patients with no complications

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1. Hamel M et al. JAGS. 2005;53:424.2. Kawalpreet M et al. Anesth Analg. 2003;96:583.

WHICH COMPLICATIONS ARE SEVERE?

• Heart failure: incidence of 5% in some studies, with mortality as high as 65%1

• Pulmonary: 2.4 hazard ratio for death2

• Renal: 6.1 hazard ratio for death2

• Infection: UTI just as likely to lead to death as deep surgical wound infection is3

• CNS: stroke, delirium, post-op cognitive dysfunction

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1. Roche JJ et al. BMJ 2005;331:1374.2. Kawalpreet M et al. Anesth Analg. 2003;96:583.3. Hamel M et al. JAGS. 2005;53:424.

AGE ANDPERIOPERATIVE COMPLICATIONS

Complication Rate (%)Mortality from the Complication (%)

Complication Age <80 Age ≥80 Age <80 Age ≥80

Myocardial infarction 0.4 1.0 37.1 48.0

Cardiac arrest 0.9 2.1 80.0 88.2

Pneumonia 2.3 5.6 19.8 29.2

>48 hours on ventilator 2.1 3.5 30.1 38.5

Cerebrovascular accident 0.3 0.7 26.1 39.3

Prolonged Ileus 1.2 1.7 9.2 16

Hamel M et al. JAGS. 2005;53:424.Slide 8

CV COMPLICATIONS (1 of 3)

• Most frequent: hypertension or hypotension

• Second most frequent: dysrhythmias

• Third most frequent: ischemia

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CV COMPLICATIONS (2 of 3)

• Common causes of hypotension Chronic medications (eg, levodopa, bromocriptine,

tricyclic antidepressants) Altered pharmacodynamics and pharmacokinetics

causing prolonged/residual effects• Common causes of dysrhythmias

Hypoxia, hypercarbia Electrolyte imbalance, metabolic alkalosis/acidosis Preexisting cardiac disease

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CV COMPLICATIONS (3 of 3)

• HR and rhythm can have greater impact on BP than in younger patients

• Treatment: Be more cautious than in younger patients about

administering IVF as first-line treatment Consider increasing heart rate and peripheral

vasoconstriction (alpha-adrenergics or mixedalpha/beta-agonists)

Utilize Trendelenburg position as adjuvant

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PULMONARYCOMPLICATIONS (1 of 2)

Why are geriatric patients more at risk of post-op pneumonia, hypoxemia, hypoventilation, and atelectasis?

• Decline in pulmonary reserve, increased V/Q mismatch

• Diminished hypoxic & hypercapnic ventilatory drive

• Altered pharmacology of anesthetic drugs intraoperatively, causing residual/prolonged effects

• Decrease in laryngeal reflexes makes them more prone to aspiration

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PULMONARYCOMPLICATIONS (2 of 2)

• Patients at most risk are those with:CHFArrhythmiasDementiaCVASeizure disorderEmergency surgery

• Inappropriate reversal of neuromuscular blockade: subclinical paralysis might interfere with respiratory muscles and lead to atelectasis

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RENAL COMPLICATIONS

• Geriatric patients are more at risk of post-op renal dysfunction

Aging process changes renal circulation and tubular function

Patient-related factors: HTN, DM, CRI Intraoperative factors: prolonged hypotension,

massive transfusions

• Consider placing Foley in at-risk patients, to monitor urine output throughout perioperative period

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Silverstein et al. Anesthesiology. 2007;106:622-628.

TIME FRAME OF DELIRIUM AND POST-OP COGNITIVE DYSFUNCTION

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PACU = post-anesthesia care unit

POD = post-op delirium

POCD = post-op cognitive dysfunction

POSTOPERATIVE DELIRIUM (POD)

DSM-MS IV: A change in mental status, characterized by:• A prominent disturbance of attention and reduced

clarity of awareness of the environment• An acute onset, developing within hours to days,

and tends to fluctuate during the course of the day

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MAIN CLINICAL FEATURES OF POD• Acute onset• Fluctuating course• Inattention• Disorganized thinking• Alteration in consciousness• Cognitive deficit (memory, orientation, executive functions)• Hallucinations• Psychomotor disturbances• Lethargy (hypoactive delirium)• Agitation (hyperactive delirium)• Alterations of sleep-wake cycle• Emotional disturbances

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RISK FACTORS FOR POD

Patient-related• Pain• Hypoxemia• Hypercarbia• Hypotension• Metabolic disorders• Sepsis• Substance abuse• Preexisting disease

(depression/dementia) • Visual/hearing

impairments

Other• Restraints• Cardiac surgery• CNS drugs • Sleep deprivation

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PATHOPHYSIOLOGY OF POD (1 of 3)

Mantz J. Anesthesiology. 2010;112(1):189-195.Slide 19

PATHOPHYSIOLOGY OF POD (2 of 3)

• Multifactorial

• Deficit in cholinergic transmission (“cholinergic hypothesis”)Acetylcholine plays important roles in attention, consciousness, and

memory, and it is critically affected in dementia

Anticholinergic intoxication produces a delirium that can be reversed by cholinesterase inhibitors and by the propensity of antimuscarinic drugs to induce delirium

Serum anticholinergic activity is associated with delirium

Cholinesterase inhibitors do not typically treat or prevent postoperative delirium

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PATHOPHYSIOLOGY OF POD (3 of 3)

• γ-aminobutyric acid Many sedative/hypnotics, including inhaled anesthetics,

propofol, and benzodiazepines, potentiate γ-aminobutyric acid-mediated transmission through γ-aminobutyric acid type A receptors in the CNS

• The monoamine transmitters have prominent neuromodulatory roles in regulating cognitive function, arousal, sleep, and mood, and they are modulated by cholinergic pathways

Excess of dopaminergic transmission has been implicated in hyperactive delirium, which can respond to antipsychotic dopamine receptor antagonists such as haloperidol

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IMPACT OF POD

• Morbidity Risk of injury CV/neurological events ? Post-op cognitive dysfunction after ICU delirium

• Mortality

• Loss of autonomy

• Longer hospital stay: 6.0 days vs. 4.6 days

• Nursing home placement

• Health care costs: average additional cost $2,947

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PREVENTION ANDMANAGEMENT OF POD

• Identification of patients at risk Baseline cognitive impairment

• Mini-Mental State Exam• DEAR score (Age, cognition, ADLs, hearing/visual impairment,

chemical use) • Dementia/depression

Consider geriatric consultation

• Avoid/minimize/treat delirium-related factors

• Hospital Elder Life Program Cognitive impairment, sleep deprivation, immobility,

visual/hearing impairment, and dehydration

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BOSTON MEDICAL CENTER’S DELIRIUM-FREE PASSPORT

• Multidisciplinary effort

• Checklist at all stages of perioperative period Pilot in total knee replacement patients

• Education phase

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Preoperative Clinic

Preoperative Area

Intraoperative PACU Postoperative

• Assess for risk• DEAR score• Mini-Cog

score• Medical

consult• Patient/family

education (verbal, brochure

• Review delirium assessment

• Counseling• Regional

anesthesia• Avoid benzos• Assess

hydration status

• Monitor depth of anesthesia

• Maintain euvolemia

• Monitor/treat potential causes of delirium

• Avoid delirium-causing drugs

• Order set• Assessment of

patients• CAM score• R/O causes of

delirium• Family at bedside• Remove Foley• Return dentures,

hearing aids, glasses

• Medical consult

• Postoperative interventions

• Remove Foley• Return dentures, hearing

aids, glasses • Reorientation• Avoid dehydration• Medication reconciliation• Pain control• Avoid delirium-causing

drugs• Facilitate normal sleep

cycle• Mobility/avoid restraints

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PREVENTION AND MANAGEMENTOF POST-OP DELIRIUM

MORE ABOUTMANAGEMENT OF POD

• Seek/treat cause Delirium is a medical emergency Medical issues are a frequent cause of delirium

• Hyperactive delirium Haloperidol Atypical antipsychotics Avoid benzodiazepines

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POSTOPERATIVE COGNITIVE DYSFUNCTION (POCD)

• Deterioration of intellectual function presenting as impaired memory or concentration

• Not detected until days or weeks after anesthesia

• Duration of several weeks to permanent

• Diagnosis is warranted only if: Corroborated with neuropsychological testing There is evidence of greater memory loss than one

would expect due to normal aging

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IMPLICATIONS OF POCD

Abrupt decline in cognitive function heralds:

• Loss of independence

• Withdrawal from societyLeaving the labor market prematurelyDependency on social transfer payments

• Death

Steinmetz J. Anesthesiology. 2009:110;548-555.Slide 28

• ISPOCD collaborative research effort 19941996 Members from 8 European countries and USA 13 hospitals

• Anesthesia and surgery were associated with POCD

26% of patients at 1 week after surgery 10% of patients at 3 months after surgery

• Hypotension and/or hypoxemia not related to occurrence of POCD

INCIDENCE OF POCD

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Moller et al. Lancet. 1998:351;857-861.

LONG-TERM FOLLOW-UPOF ISPOCD COHORT

• Re-evaluated patients at 1 and 2 years

• The rate of POCD decreased to approximately 1%, which was not statistically significant

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Abildstrom et al. Acta Anaesthesiol Scand. 2000;44:1246-1251.

AGE AND POCD (1 of 2)

• Single site, University of Florida, 1999–2002

• 1200 patients undergoing elective surgery Young — 18 to 39 years of age Middle-aged — 40 to 59 years of age Elderly — 60 years and older

• Controls — primary family members

• Study design identical to ISPOCD study Same psychometric test battery Outcome endpoints: POCD (primary) and mortality (secondary)

Slide 31Monk et al. Anesthesiology. 2008;108:18-30.

AGE AND POCD (2 of 2)

• POCD was common in all age groups at hospital discharge (33%44%)

• 3 months after surgery the incidence of POCD was:4%5% in those younger than 6513% in adults older than 60 years, particularly those with

less than high school educationAssociated with increased 1-year mortality

Slide 32Monk et al. Anesthesiology. 2008;108:18-30.

POCD AND NONCARDIAC SURGERY

• Systematic review

• POCD affects a significant proportion of people in the early weeks after major noncardiac surgery, with the older adult being more at risk

• Minimal evidence that patients continue to show POCD up to 6 months and beyond

• Studies on regional versus general anesthesia have not found differences in POCD

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Newman S. Anesthesiology. 2007;106:572-590.

POCD

• Is POCD a measurable deterioration in older patients shortly after surgery and anesthesia with gradual resolution such that the incidence declines to levels nearly indistinguishable from control subjects by approximately 1 year?

• More research needed

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CONCLUSIONS

• Surgery and anesthesia have a great impact in the decreased physiological reserve of the elderly

• The number of comorbidities plays an important role in the incidence of complications

• CNS, cardiac, pulmonary and renal complications have the greatest impact in the older individual

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ACKNOWLEDGMENTS

Supported by a grant from the Geriatric Education for Specialty Residents Program (GSR), which is administered by the American Geriatrics Society and funded by the John A. Hartford Foundation of New York City

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