Geriatric Patients

14.1 Approach to Geriatric Surgical Patients

Sunghye Kim

Age is a strong predictor of postoperative morbidity and mortality. For noncardiac surgery, 30-day mortality increases by a factor of 1.35 per decade of age (1). The elderly have a greater risk of postoperative complications, longer hospital stays, and greater need for long-term care, all of which incur greater costs. Traditionally, preoperative risk assessments consider comorbidities and focus on organ-based outcomes. These risk assessments may overlook geriatric-specific syndromes and functional impairment that can predict surgical outcomes. Newer assessment tools (2) incorporate preoperative functional status as an important predictor for postoperative complications, length of stay, and institutionalization. However, none of the risk assessment tools to date can predict functional recovery of elderly patients who are undergoing surgery. In a survey study of 357 elderly from senior centers and independent/assisted living facilities, maintaining independence was ranked as the most important health outcome by 76% of the participants (3). Tools that predict functional recovery after surgery can help guide decision-making processes for older surgical patients. With the unique challenges of older surgery patients, the American College of Surgeons (ACS) National Quality Improvement Program and the American Geriatric Society (AGS) published a guideline on optimal preoperative assessment of geriatric surgical patients (ACS NSQIP/AGS Best Practice Guidelines) (4). Table 14.1 is the checklist from the guideline.

COGNITIVE IMPAIRMENT AND DEMENTIA

The prevalence of cognitive impairment increases with aging. The prevalence of cognitive impairment and dementia are 22% and 14% in older adults (>70 years) (4). Preoperative cognitive impairment is a well-established risk factor for postoperative delirium. In addition, cognitive impairment is associated with postoperative pulmonary complications, adverse postoperative outcomes, postoperative functional decline, and postoperative mortality. The ACS/AGS guideline recommends obtaining a detailed history and performing a cognitive assessment, using tools such as the mini-Cog shown in Table 14.5 (5).

DECISION-MAKING CAPACITY

The legally relevant criteria for decision-making capacities are: (1) The patient can clearly indicate his or her treatment choice; (2) The patient understands the relevant information
communicated by the physician; (3) The patient acknowledges his or her medical condition, treatment options, and the likely outcomes; (4) The patient can engage in a rational discussion about the treatment options (4). Decision-making capacity should be assessed to determine the patient’s ability to provide informed consent.

TABLE 14.1 Checklist for the Optimal Preoperative Assessment of the Geriatric Surgical Patient

In addition to conducting a complete history and physical examination of the patient, the following assessments are strongly recommended:

□ Assess the patient’s cognitive ability and capacity to understand the anticipated surgery

□ Screen the patient for depression

□ Identify the patient’s risk factors for developing postoperative delirium

□ Screen for alcohol and other substance abuse/dependence

□ Perform a preoperative cardiac evaluation according to the American College of Cardiology/American Heart Association algorithm for patients undergoing noncardiac surgery

□ Identify the patient’s risk factors for postoperative pulmonary complications and implement appropriate strategies for prevention

□ Document functional status and history of falls

□ Determine baseline frailty score (Table 14.2)

□ Assess the patient’s nutritional status and consider preoperative interventions if the patient is at severe nutritional risk (Table 14.3)

□ Take an accurate and detailed medication history and consider appropriate perioperative adjustments. Monitor for polypharmacy

□ Determine the patient’s treatment goals and expectations in the context of the possible treatment outcomes

□ Determine the patient’s family and social support system

□ Order appropriate preoperative diagnostic tests focused on elderly patients (Table 14.4)

Chow WB, Rosenthal RA, Merkow RP, et al. Optimal preoperative assessment of the geriatric surgical patient: a best practices guideline from the American College of Surgeons National Surgical Quality Improvement Program and the American Geriatrics Society. J Am Coll Surg. 2012;215(4):453-466.

Preoperative depression is common and is associated with longer length of stay and higher likelihood of requiring skilled nursing assistance and higher postoperative mortality (4). The ACS NSQIP/AGS Guidelines recommend screening patients for depression using tools such as the Patient Health Questionnaire-2 (see Table 14.6).

DELIRIUM

The incidence of postoperative delirium is reported to be 5% to 15% with up to 62% among elderly patients who undergo surgery for hip fracture (6). Postoperative delirium is associated with longer length of stay, higher rates of institutionalization, postoperative functional decline, and mortality (7). The ACS NSQIP/AGS guidelines recommend

documenting risk factors (Table 14.7) for delirium and avoiding benzodiazepines and antihistamines in patients who are identified at risk for postoperative delirium.

TABLE 14.2 Frailty Score

Frailty Criteria	Definition
Weight loss	Unintentional weight loss ≥10 pounds in the past year
Decreased grip strength (weakness)	Grip strength in the lowest 20th percentile by gender and BMI. Three trials are performed with a hand-held dynamometer and the average value is used
	Women
	BMI	Kg Force
	≤23	≤17
	23.1-26	≤17.3
	26.1-29	≤18
	>29	≤21
	Men
	BMI	Kg Force
	≤24	≤29
	24.1-26	≤30
	26.1-28	≤30
	>28	≤32
Exhaustion	For the following two statements: “I felt that everything I did was an effort.” “I could not get going” The patient is asked: “How often in the last week did you feel this way?” 0 = rarely or none of the time (<1 day) 1 = some or a little of the time (1-2 days) 2 = a moderate amount of the time (3-4 days) 3 = most of the time The criterion is met if patient answers 2 or 3 to either statement
Low physical activity	Weekly energy expenditure, determined with the short version of the Minnesota Leisure Time Activities Questionnaire in the lowest 30th percentile by gender: Men: <383 kcal/wk. Women: <270 kcal/wk.
Slow walking speed	Walking speed in the lowest 20th percentile by gender and height. Time is measured for a distance of 15 feet at normal pace. The average of three trials is used
	Men
	Height	Time
	≤173 cm	≥7 seconds
	>173 cm	≥6 seconds
	Women
	Height	Time
	≤159 cm	≥7 seconds
	>159 cm	≥6 seconds
Chow WB, Rosenthal RA, Merkow RP, et al. Optimal preoperative assessment of the geriatric surgical patient: a best practices guideline from the American College of Surgeons National Surgical Quality Improvement Program and the American Geriatrics Society. J Am Coll Surg. 2012;215(4):453-466.

TABLE 14.3 Screening for Severe Nutritional Risk

Risk factors for severe nutritional risk

BMI <18.5 kg/m²
Serum albumin <3.0 g/dL (with no evidence of hepatic or renal dysfunction)
Unintentional weight loss >10-15% within 6 months

Interpretation of Nutritional Screening

If YES to any of the above criterion, then the patient is at severe nutritional risk and should, if feasible, undergo a full nutritional assessment by a dietician to design a perioperative nutritional plan to address deficits.

ALCOHOL AND SUBSTANCE ABUSE

Approximately 10% of older adults admit to at-risk alcohol use. Preoperative alcohol use is associated with postoperative morbidity and mortality (4). The ACS NSQIP/AGS guidelines recommend screening patients for alcohol and substance abuse and dependence using the modified CAGE (Cut down, Annoyed, Guilty, Eye-opener) questionnaire. Perioperative prophylaxis for withdrawal symptoms is important and if the operation can be delayed, referral to substance abuse specialists is important.

TABLE 14.4 Preoperative Tests for Geriatric Surgical Patients

Preoperative Tests	Indications
Pulmonary function tests (PFTs)	NOT RECOMMENDED for routine preoperative screening Recommended for patients undergoing lung resection For patients not undergoing thoracic surgery, PFTs are recommended for patients who: Have poorly characterized dyspnea or exercise intolerance and diagnostic uncertainty exists among a cardiac or pulmonary limitation and simple deconditioning Have obstructive lung disease if it is not clear from the clinical evaluation if patients are optimized
Noninvasive stress testing	Same indications as for nongeriatric patients. See Chapter 3.1 for recommendations
Chow WB, Rosenthal RA, Merkow RP, et al. Optimal preoperative assessment of the geriatric surgical patient: a best practices guideline from the American College of Surgeons National Surgical Quality Improvement Program and the American Geriatrics Society. J Am Coll Surg. 2012;215(4):453-466.

TABLE 14.5 Cognitive Assessment With the Mini-Cog

Get the patient’s attention, then say: “I am going to say three words that I want you to remember now and later. The words are: banana, sunrise, chair. Please say them for me now.” Give the patient three tries to repeat the words. If unable after three tries, go to next item Say all the following phrases in the order indicated “Please draw a clock in the space below.” “Start by drawing a large circle. Put all the numbers in the circle and set the handle to show 11:10 (10 past 11).” If subject has not finished clock drawing in 3 minutes, discontinue and ask for recall items Say “What were the three words I asked you to remember?” Scoring
	Three items recall (0-3 points):	1 point for each correct word
	Clock draw (0-2 points):	0 point for incorrect clock 2 points for correct clock
A normal clock has all of the following elements: all numbers 1 to 12, each only once, are present in the correct order and direction inside the circle; two hands are present, one pointing to 11 and one pointing to 2; any clock missing any of these elements is scored abnormal (0 points). Refusal to draw a clock is scored abnormal.
Total score of 0-2 suggests possible impairment
Total score of 3-5 suggests no impairment
With permission of Chow WB, Rosenthal RA, Merkow RP, et al. Optimal preoperative assessment of the geriatric surgical patient: a best practices guideline from the American College of Surgeons National Surgical Quality Improvement Program and the American Geriatrics Society. J Am Coll Surg. 2012;215(4):453-466.

TABLE 14.6 Screening for Depression With the Patient Health Questionnaire-2 (PHQ-2)

Ask the patient the following questions:

“In the past 12 months, have you ever had a time when you felt sad, blue, depressed, or down for most of the time for at least 2 weeks?”
“In the past 12 months, have you ever had a time, lasting at least 2 weeks, when you didn’t care about the things that you usually cared about or when you didn’t enjoy the things that you usually enjoyed?”

If the patient answers YES to either question, then further evaluation by a primary care physician, geriatrician, or mental health specialist is recommended.

TABLE 14.7 Risk Factors for Postoperative Delirium

Cognitive or Behavioral Disorders

Cognitive impairment or dementia

Untreated or inadequately controlled pain

Depression

Alcohol use

Sleep deprivation

Metabolic

Poor nutrition

Dehydration

Electrolyte abnormalities

Disease or Illness Related

Severe illness or comorbidities

Renal insufficiency

Anemia

Hypoxia

Functional Impairments

Poor functional status

Immobilization

Hearing or vision impairment

Other

Age ≥70 years

Polypharmacy and use of psychotropic medications

(benzodiazepines, anticholinergics, antihistamines)

Urinary retention, constipation, presence of urinary catheter

FUNCTIONAL STATUS, MOBILITY, AND FALL RISK

Preoperative functional status and mobility predicts postoperative complications, length of stay, postoperative institutionalization, and recovery (8). The ACS NSQIP/AGS guidelines recommend screening elderly patients for functional assessment as shown in Table 14.8.

Any problems with vision, hearing, swallowing, and history of falls should be sought. The Timed Up and Go Test, which measures the time to rise from a chair, walk 10 feet, turn, return to the chair, and sit down is recommended for mobility assessment. A patient who demonstrates difficulty rising from the chair or requiring ≥12 seconds to complete the test is at risk for falls and referral to physical therapy should be considered.

MEDICATION MANAGEMENT

The vast majority of adults over 65 years are taking one or more prescription medications and many take at least five drugs which is defined as polypharmacy. Elderly
patients are at particularly high risk for drug side effects and drug-drug interactions. Older patients have low muscle mass and high body fat that results in changes in the volume of distribution and the duration of drug effects. Hypoalbuminemia can increase the free fraction of medications. Decreased renal function affects the pharmacokinetics of some medications (9). Reviewing the patients’ complete medication list and minimizing the risk for adverse drug reactions are important. Avoiding benzodiazepines and meperidine and ensuring adequate pain control can mitigate postoperative delirium. Caution should be used when prescribing antihistamine H1 antagonists and other medications with strong anticholinergic effects. Medication adjustments are based on glomerular filtration rate, not serum creatinine alone. Nonessential drugs need to be discontinued and the addition of new medications kept to a minimum.

TABLE 14.8 Short Simple Screening Test for Functional Assessment

Ask the patient the following questions: