UMMS CRIT Module I: Preoperative Assessment in the Older Adult Petra Flock, MD, MSc, CMD Division of...

UMMS CRIT Module I: Preoperative Assessment in the Older Adult

Petra Flock, MD, MSc, CMDDivision of GeriatricsUniversity of MassachusettsMedical School

UMMS CRIT 2010 Module I: Pre-Operative Assessment

Advancing Geriatrics Education (AGE) A UMMS initiative funded by the Donald W. Reynolds Foundation

• To describe the purpose of the preoperative assessment

• To provide strategies to minimize operative risks

Goals



- goal of surgery

- urgency of surgery (elective, urgent, emergent)

- patient’s/family’s goals and wishes

- baseline function, co-morbidities

- life expectancy

- anticipated outcomes/complications

The Big Question:Should this patient go for surgery?



• Not just for “clearance”

• To identify factors associated with increased risks of specific

complications related to a procedure

• To recommend a management plan to minimize these risks

Preoperative Assessment -Purposes

Cassel CK, Leipzig RM, Cohen HJ, et al. Geriatric Medicine: An Evidence Based Approach, 4th ed. New York: Springer; 2003.



• Delirium

• Infection

• Pressure sores

• Malnutrition

• Functional decline

increased mortality

poorer quality of life

need for increased care/change of place of living

What Do Geriatricians Worry About?



• Organ reserves are diminished

• Complications are more likely

• Less is often more

• Test only what you are able and prepared to correct and what will

improve outcome

• You minimize complications, if you prevent prolonged bed rest

(pre- and post-op)

Common Sense Geriatric “Rules”



• Functional Assessment

• Cognitive Assessment

• Nutritional Assessment

• Review of advance directives

Preoperative Assessment - Components



• American Society of Anesthesiologists (ASA) score

– Class I A normal healthy patient for elective operation

– Class II A patient with mild systemic disease

– Class III A patient with severe systemic disease that limits

activity but is not incapacitating

– Class IV A patient with incapacitating systemic disease that is a

constant threat to life

– Class V A moribund patient that is not expected to survive 24 hrs

with or without the operation

Functional Assessment



• Dementia and Hx of delirium are major predictor of post-op

delirium

• Patients with delirium have higher mortality

• Know your patient’s baseline cognitive function (Mini-Cog,

CAM, etc.)

Cognitive Assessment



• Poor nutrition is a risk factor for

– pneumonia

– poor wound-healing

– 30-day mortality

• Hypoalbuminemia (<3.3mg/dL)

– increased length of stay

– increased rates of readmission

– unfavorable disposition

– increased all-cause mortality

Nutritional Assessment

Corti M. Serum albumin level and physical disability as predictors of mortality in older persons. JAMA 1994;272:1036.



• Routine screening is low yield

– Pre-op testing should be based on the type and urgency of

surgery

• Manage hypertension

– lower blood pressure to under 180/110

• Avoid long periods without nutrition

• Treat easily reversible factors (anemia, infection, etc)

• Use ß-blockers peri-operatively for major surgery, if not contra-

indicated

Strategies to Minimize Risk - pre-operative



• Control diabetes without causing hypoglycemia

• Pay attention to constipation/urination

• Mobilize early/DVT prophylaxis

• Minimize use of psycho-active medication

• Control pain (your dementia patient won’t do PRN well)

• Avoid prolonged periods without nutrition

• Involve the families

Strategies to Minimize Risk - post operative



• Older adults have decreased reserves in multiple organ systems

• Disease burden and functional capacity outweigh age when

assessing preoperative risk

• Collaboration among providers helps to identify functional,

cognitive and nutritional deficits/risks and to create management

plans to minimize these deficits/risks when possible

Summary

UMMS CRIT Module I: Preoperative Assessment in the Older Adult Petra Flock, MD, MSc, CMD Division of...

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