Postoperative Care in the Geriatric Patient

Report
POSTOPERATIVE CARE
OF THE GERIATRIC
PATIENT
AGS
Maria-Karnina Iskandar, MD
Amit Patel, MD
Konstantin Balonov
Anesthesiology Residents
Ruben J. Azocar, MD
Associate Professor of
Anesthesiology
THE AMERICAN GERIATRICS SOCIETY
Geriatrics Health Professionals.
Leading change. Improving care for older adults.
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
Slide 2
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)
Slide 3
Number of Complications
per 1000 Surgeries
EFFECT OF AGE AND DISEASE ON RISK
OF PERIOPERATIVE COMPLICATIONS
Number of Comorbidities
Can Anaesth Soc J. 1986;33:336.
Slide 4
5
PREOPERATIVE VISIT
• Review comorbidities and their current state
• Assess functional, cognitive and nutritional status
• Provide recommendations to prevent
perioperative complications
Slide 5
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
1. Hamel M et al. JAGS. 2005;53:424.
2. Kawalpreet M et al. Anesth Analg. 2003;96:583.
Slide 6
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
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.
Slide 7
AGE AND
PERIOPERATIVE COMPLICATIONS
Complication Rate (%)
Mortality from the
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
Complication
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
Slide 9
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
Slide 10
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 mixed
alpha/beta-agonists)
 Utilize Trendelenburg position as adjuvant
Slide 11
PULMONARY
COMPLICATIONS (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
Slide 12
PULMONARY
COMPLICATIONS (2 of 2)
• Patients at most risk are those with:






CHF
Arrhythmias
Dementia
CVA
Seizure disorder
Emergency surgery
• Inappropriate reversal of neuromuscular blockade:
subclinical paralysis might interfere with respiratory
muscles and lead to atelectasis
Slide 13
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
Slide 14
TIME FRAME OF DELIRIUM AND
POST-OP COGNITIVE DYSFUNCTION
PACU
24- 72 hrs.
• Emergence
Delirium
• POD
Weeks/
Months
• POCD
Persistent
• Dementia
PACU = post-anesthesia care unit
POD = post-op delirium
POCD = post-op cognitive dysfunction
Silverstein et al. Anesthesiology. 2007;106:622-628.
Slide 15
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
Slide 16
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
Slide 17
RISK FACTORS FOR POD
Patient-related
Other
•
•
•
•
•
•
•
•
•
•
•
•
Pain
Hypoxemia
Hypercarbia
Hypotension
Metabolic disorders
Sepsis
Substance abuse
Preexisting disease
(depression/dementia)
• Visual/hearing
impairments
Restraints
Cardiac surgery
CNS drugs
Sleep deprivation
Slide 18
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
Slide 20
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
Slide 21
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
Slide 22
PREVENTION AND
MANAGEMENT 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
Slide 23
BOSTON MEDICAL CENTER’S
DELIRIUM-FREE PASSPORT
• Multidisciplinary effort
• Checklist at all stages of perioperative period
 Pilot in total knee replacement patients
• Education phase
Slide 24
PREVENTION AND MANAGEMENT
OF POST-OP DELIRIUM
Preoperative
Clinic
• Assess for risk
• DEAR score
• Mini-Cog score
• Medical
consult
• Patient/family
education
(verbal,
brochure
Preoperative
Area
Intraoperative
PACU
• Review
delirium
assessment
• Monitor
depth of
anesthesia
• Order set
• Counseling
• Maintain
euvolemia
• CAM score
• Regional
anesthesia
• Avoid benzos
• Assess
hydration
status
• Monitor/treat
potential
causes of
delirium
• Avoid
deliriumcausing
drugs
• Assessment of
patients
• R/O causes of
delirium
Postoperative
• Postoperative
interventions
• Remove Foley
• Return dentures, hearing
aids, glasses
• Reorientation
• Family at bedside
• Avoid dehydration
• Remove Foley
• Medication reconciliation
• Return dentures,
hearing aids,
glasses
• Pain control
• Medical consult
• Facilitate normal sleep
cycle
• Avoid delirium-causing
drugs
• Mobility/avoid restraints
Slide 25
MORE ABOUT
MANAGEMENT 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
Slide 26
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
Slide 27
IMPLICATIONS OF POCD
Abrupt decline in cognitive function heralds:
• Loss of independence
• Withdrawal from society
 Leaving the labor market prematurely
 Dependency on social transfer payments
• Death
Steinmetz J. Anesthesiology. 2009:110;548-555.
Slide 28
INCIDENCE OF POCD
•
ISPOCD collaborative research effort 19941996
 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
Moller et al. Lancet. 1998:351;857-861.
Slide 29
LONG-TERM FOLLOW-UP
OF ISPOCD COHORT
• Re-evaluated patients at 1 and 2 years
• The rate of POCD decreased to approximately
1%, which was not statistically significant
Abildstrom et al. Acta Anaesthesiol Scand. 2000;44:1246-1251.
Slide 30
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)
Monk et al. Anesthesiology. 2008;108:18-30.
Slide 31
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 65
 13% in adults older than 60 years, particularly those
with less than high school education
 Associated with increased 1-year mortality
Monk et al. Anesthesiology. 2008;108:18-30.
Slide 32
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
Newman S. Anesthesiology. 2007;106:572-590.
Slide 33
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
Slide 34
35
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
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
Slide 36
THANK YOU FOR YOUR TIME!
Visit us at:
www.americangeriatrics.org
Facebook.com/AmericanGeriatricsSociety
Twitter.com/AmerGeriatrics
linkedin.com/company/american-geriatricssociety
Slide 37

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