Optimisation of elderly

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Discusses challenges faced by Perioperative team regarding anesthetic management of elderly patients

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Optimising preoperative assessment of Elderly :

Optimising preoperative assessment of Elderly Sanjeev Nair Royal Hospital

Challenges for the peri‐operative care team:

Challenges for the peri‐operative care team The role of comprehensive geriatric assessment and innovative models of care The implications of frailty and its assessment The assessment and optimisation of nutritional status The assessment of neurocognitive dysfunction

Comprehensive Geriatric Assessment [CGA]:

Comprehensive Geriatric Assessment [CGA] " Geriatric syndrome " - multifactorial causes  cognitive impairment, delirium, incontinence, malnutrition, falls, gait disorders, pressure ulcers, sleep disorders, sensory deficits, fatigue, and dizziness.  Optimising physical, psychological, functional and social issues in elderly patients to improve long‐term outcome Collaboration from multidisciplinary teams in planning and implementing investigations and treatment, as well as arranging discharge and follow‐up plans

Within the surgical setting the evidence base for preoperative CGA is growing:

Within the surgical setting the evidence base for preoperative CGA is growing

Who Should Evaluate Elderly Patients? Care models:

Who Should Evaluate Elderly Patients? Care models Anaesthetist ‐led  The anaesthetist will stratify the risk in detail by assessing patients’ functional reserve, either by clinical assessment, or with objective physiological tests such as cardiopulmonary exercise testing. Geriatrician ‐led Liaises with the surgical teams about peri‐operative medical care, focusing on functional optimisation and discharge planning for both emergency and elective patients

Proactive care of older people undergoing surgery (POPS) :

Proactive care of older people undergoing surgery (POPS)   Innovative approach in improving quality care for older complex surgical patients. A consultant geriatrician + a full-time nurse specialist for older people, occupational therapist, physiotherapist, and social worker. CGA and patient education Post-operative visits Follow-up therapy home visit

Challenges for the peri‐operative care team:

Challenges for the peri‐operative care team The role of comprehensive geriatric assessment and innovative models of care The implications of frailty and its assessment The assessment and optimisation of nutritional status The assessment of neurocognitive dysfunction

Frailty and its peri‐operative implications:

Frailty and its peri‐operative implications  An emerging concept in medicine yet to be explored as a risk factor.. drawn from gerontology It is an age‐related, progressive decline in multiple physiological reserves that results in diminished resilience, loss of adaptive capacity, and increased vulnerability to stressors .. It is seen in 40% of patients aged 80 years or older The AGS published a major consensus statement in 2015 on ‘ Frailty for specialists ’, which highlighted the importance of incorporating frailty assessment into the pre‐operative journey

Frailty and anaesthesia: what we need to know :

Frailty and anaesthesia : what we need to know

Slide16:

Characteristic of frailty Measurement Weakness Grip strength: lowest 20% (by sex, BMI) Slowness Time taken to walk 15 feet: slowest 20% (by sex, height) Low level of physical activity kcal.week −1 : lowest 20% Men: < 383 kcal.week −1 Women: < 270 kcal.week −1 Exhaustion ‘Exhaustion’ , poor endurance Weight loss Unintentional weight loss > 10  lb in prior year

Slide18:

Fast≤10 sec, Intermediate=11-14 sec Slow≥15 sec.

Fraility and outcome:

Fraility and outcome Frailty is associated with adverse surgical outcomes , but the recognition of frailty is only useful if it can modify peri‐operative care and improve outcomes. At the anaesthetic clinic, we can discuss anticipated outcomes with patients and their families based on the magnitude of the frailty score and co‐existing morbidities. In terms of surgical planning, we can advise surgeons to adopt the least invasive approach, or even consider a staged or ‘damage control’ approach, so as to minimise the stress induced by major surgery. In all circumstances, anaesthetists play an important role in initiating an appropriate level of monitoring, choosing and titrating anaesthetics intra‐operatively , as well as maintaining normothermia, which can help to minimise complications.

Can frailty be modifed? :

Can frailty be modifed ? Prehabilitation – for elective cases review of current medication, cognitive screening, treatment of depression or mood disorders, improving nutrition, physiotherapy, arranging social support

Challenges for the peri‐operative care team:

Challenges for the peri‐operative care team The role of comprehensive geriatric assessment and innovative models of care The implications of frailty and its assessment The assessment and optimisation of nutritional status The assessment of neurocognitive dysfunction

Assessment and optimisation of nutritional status:

Assessment and optimisation of nutritional status Malnutrition [ upto 38%] is a strong independent predictor of higher peri‐operative mortality, morbidities, length of hospital stay and re‐admission rates. Current guidelines  define malnutrition as a BMI < 18.5 kg.m −2 . Checking serum albumin levels is inexpensive and routinely available, and represents a strong predictor of surgical risk and mortality (cut‐off at 30 g/l)

Nutritional support:

Nutritional support Patients at high risk of malnutrition should be referred to a dietician for a comprehensive nutritional assessment. It should also be initiated if the patient will not be able to have adequate oral intake for more than 5 days peri‐operatively . In principle, oral nutritional supplements should be considered before tube feeding, unless contraindicated. If oral and enteral routes are impossible, intolerable or inadequate , then parenteral nutrition is recommended. Oral nutritional supplementation, particularly with high protein content, can reduce the risk of developing pressure ulcers in the elderly.

Slide26:

Unnecessary prolonged pre‐operative fasting should be avoided. Clear fluids should be allowed up to 2 h A pre‐operative drink containing at least 45 g of carbohydrate is recommended in patients undergoing major surgery Postoperatively, a high‐protein diet should be commenced as tolerated, except in patients with significant bowel pathology Fasting

Challenges for the peri‐operative care team:

Challenges for the peri‐operative care team The role of comprehensive geriatric assessment and innovative models of care The implications of frailty and its assessment The assessment and optimisation of nutritional status The assessment of neurocognitive dysfunction

Assessment of cognition:

Assessment of cognition

Postoperative cognitive disorders:

Postoperative cognitive disorders A spectrum of diseases ranging from immediate postoperative delirium [ POD ] to postoperative cognitive dysfunction [ POCD ] Mental state of reduced awareness and disturbance of attention - acute and fluctuating The incidence of POD in elderly patients ranges from 37% to 53% It is also associated with prolonged hospitalisation , institutionalisation and higher long‐term mortality

PREVENTION OF DELIRIUM:

PREVENTION OF DELIRIUM Implementation of fast‐track surgery Premedication with benzodiazepines to be avoided. Depth of anaesthesia monitoring with a Continuous intra‐operative analgesic regimen Non‐pharmacological measures Medical evaluation Pharmacological treatments

Postoperative cognitive dysfunction [POCD]:

Postoperative cognitive dysfunction [POCD] Impairment of cognitive function, including memory, concentration, executive function and speed of mental processing Seen in 25.8% of elderly patients aged 60 years or above one week after major non‐cardiac surgery, and in 9.9% of elderly patients 3 months after surgery. In cardiac surgery, the use of cardiopulmonary bypass has been implicated as a precipitating factor. Paradoxically, hypotension or hypoxia are not associated with the development of postoperative cognitive dysfunction

Slide33:

Between August 2007 and May 2009, 2128 consecutive patients over the age of 65 years. In all patients median LOS was reduced when compared with both our own data before the introduction of the pathway (6 to 4 days) Difference in LOS was most pronounced in patients aged 85 years and over (9 to 5 days for THR and 8 to 5 days for TKR). Age and Ageing 2014

Quality improvement approaches:

Quality improvement approaches Establishment of a POPS service Preoperative elective care Assess perioperative risk Medically optimise patients to modify risk Provide functional and psychosocial assessment Promote shared decision making Provide an individually tailored perioperative management plan Postoperative care (elective and emergency) Education and training – local and national

Conclusion :

Conclusion As the world population ages, the demand for surgical care for elderly patients is increasing Comprehensive geriatric assessment is an established clinical approach New strategies to deliver effective care include a preoperative risk stratification using a frailty index Anaesthetists should be proactive in both assessing and optimising medical conditions and the nutritional status of elderly patients pre‐operatively We should also explore social issues, and actively involve patients and their families in major decision‐making

References :

References Enhanced recovery programmes for the elderly (EJA):  June 2016 Peri‐operative optimisation of elderly and frail patients: a narrative review: Jan 2019, Anaesthesia Total intravenous anesthesia with propofol is associated with a lower rate of postoperative delirium in comparison with sevoflurane anesthesia in elderly patients ; Journal of Clinical Anesthesia (2016) 33, 428–431 Guidelines for the peri‐operative care of people with dementia.  Anaesthesia  2019 Peri‐operative care of the elderly 2014 ; https:// doi.org /10.1111/anae.12524 Slower Walking Speed Forecasts Increased Postoperative Morbidity and One-Year Mortality Across Surgical Specialties ; Ann Surg. 2013 October Proactive care of older people undergoing surgery ; Aging Clin Exp Res. 2018

Slide38:

I think you will be interested in the next patient. He is 92 years and accompanied by his parents.

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