Preoperative Guidelines for Surgery on Elderly
Last week the American College of Surgeons (ACS) and the American Geriatrics Society (AGS) issued new guidelines for the preoperative care of patients aged 65+ years.
These new guidelines offer a systematic way to check and cross check the fitness of elderly patients for elective surgery and they also make recommendations for pre-surgical investigations.
There are 12 areas that require attention:
Assess cognitive function/dementia; capacity to understand anticipated surgery
- The Mini Cog™ is a three item recall and clock draw exercise.
- One in five people over the age of 71 years have cognitive impairment.
- Preoperative assessment aims to establish a baseline cognitive status.
- Patient is able to describe in his/her own words features of the medical condition, indication, benefits, risk and alternatives to surgery.
Screen for depression
- The prevalence of depression amongst the US population aged 71+ years is 11%.
- Risk factors include being female, disability, bereavement, sleep disturbance, and earlier depression.
- Depression has been associated with higher pain perception and increased postoperative analgesic use.
- The prevalence of postoperative delirium in elderly patients is 9%
- Risk factors: cognitive impairment, pain, depression, alcolhol use, sleep deprivation; anaemia (including hypoxia, renal impairment); poor nutrition, dehydration, electrolyte abnormalities; poor functional status, immobilisation, hearing or vision impairment; medication (benzodiazepines, antihistamines, anticholinergics); indwelling catheters, urinary retention, constipation.
- Delirium causes higher surgical complications, long hospital stay, delayed recovery
- Avoid benzodiazepines, antihistamines when possible
Screen for alcohol and substance abuse
- Alcohol abuse is associated with increased risk of surgical complications including pneumonia, sepsis, and wound infection, prolonged hospital stay.
- Patients at risk should receive daily multivitamins (with folic acid) and high-dose oral or parenteral thiamine (100 mg).
- Overall the risk of major cardiac complications is 2%
- Postoperative myocardial infarct mortality is high (15% to 25%)
- Patients with a non-fatal cardiac event are at high risk of developing a fatal cardiac event up to 6 months post surgery
- It is recommended that all elderly patients have a cardiac echo. However, no randomised trial has ever shown improved postoperative outcomes with echo.
- In elderly patients who had elective abdominal surgery the risk of pulmonary complications was significant.
- Pulmonary complications contribute to higher overall surgical complication rates
- Optimise COPD or asthma
- Cease smoking (8 weeks before surgery)
- Preoperative inspiratory muscle training
- Pulmonary function tests if indicated
Functional status, mobility, and fall risk
- Timed Up and Go Test: Rise from the chair (if possible without using armrest), walk 5 metres, turn, return to the chair and sit down again. Standard walking aids are allowed. Any person requiring more than 15 seconds is at high risk for falls. (try it ;-)
- Patients with impaired functional status are at higher risk to develop delirium, acquire infections and require rehab post discharge.
- Frailty is an expression of decreased physiologic reserve and resistance to stressors.
- There are 5 dimensions of frailty:
- Weight loss
- Weakness (decreased grip strength)
- Exhaustion: Poor energy and endurance
- Low physical activity
- Slowness: slow walking
Assess nutritional status
- Document height and weight (BMI): BMI less than 18.5 kg/m2 constitutes high risk.
- Note: Obesity is also a risk factor for surgical complications in both, laparoscopic and open surgery
- Serum albumin (and prealbumin) of less than 3.0 g/dL constitutes high risk.
- Document unintended weight loss of 10% body weight is high risk.
- For patients with advanced ovarian cancer and ascites, weight loss is an inappropriate measure. Currently we use a multifaceted questionnaire (PG-SGA) instead to determine nutritional status.
Take medication history and adjust peri-operatively
- Review the patients complete medication list (including over the counter drugs, herbs and supplements)
- Discontinue medication that can be harmful (blood thinners) or non-essential
- Starting or continue beta-blockers and statins for patients who have known vascular disease, elevated LDL cholesterol, or cardiac risk factors.
Clarify expectations from treatment
- The surgeon should discuss treatment goals.
- The surgeon should understand the patients preferences and expectations
- The surgeon should describe possible complications and possible functional decline
- Explore family and social support systems (discharge planning)
- All patients should have a designated health care proxy (surrogate decision maker)
- Screening tests (in all patients): blood count, renal function, albumin
- Diagnostic tests (in patients with symptoms or a suspicion based on earlier tests):
- Coagulation tests: cancer surgery, malnutrition, liver impairment
- Electrolytes: renal failure, taking heart medication
- Serum glucose: diabetes, obesity
- Urinalysis: known diabetes
- Preoperative imaging:
- Chest X-ray: cardiopulmonary risk factors, any surgery other than minor surgery
- ECG: any medical co-morbidities, any surgery other than minor surgery
- Normal tests results up to 4 months before surgery are acceptable (pending interval changes).