GERIATRICS

ASSESSMENT

Data Gathering

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History

  • Ability to perform ADLs

  • Hearing aids

  • Visual aids

  • Cognitive impairment

  • Response to previous anesthesia

  • Falls

  • Mobility impairment/assistive devices

Symptoms

  • Memory loss

  • Hearing loss

  • Vision loss

  • Incontinence

  • Weakness

  • Fatigue

Risk Stratification

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Perioperative Neurocognitive Disoders (Postop Delirium & Postop Cognitive Dysfunction)

  • Risk Factors:

    • Age > 65 years

    • Chronic cognitive decline or dementia

    • Poor vision or hearing

    • Severe illness ​

    • Active Infection

  • Screen all patients age >65 years or with risk factors for PND with cognitive testing (e.g., Mini-Cog) (ASA Brain Health Initiative)

Frailty (SPAQI Guideline)

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  • Score 1-2 = prefrail

  • Score ≥3 = frail​

MANAGEMENT

Preoperative

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  • Confirm patient goals for surgery - life prolongation, maintenance of independence, or quality of life improvement (Dworsky et al)

  • Confirm and document advance directives, power of attorney for health care, and code status

  • Communicate potential risks and plan approach to management of complications that is consistent with patient's preferences (including "Required Reconsideration" - do not automatically suspend DNR in OR)

  • Consent should include discussion of risk of perioperative neurocognitive disorders by both the surgeon & anesthesiologist (ASA Brain Health Initiative)

  • Minimize clear liquid fast to only 2 hours before surgery (unless evidence of delayed gastric emptying)

  • Close scrutiny of chronic medications with elimination of non-essential meds

Intraoperative

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  • Consider regional anesthesia

    • Not definitively superior as primary anesthetic approach​

  • Opioid-sparing analgesia:

    • Non-opioid analgesics

    • Regional analgesia

      • Thoracotomy/abdominal surgery: consider epidural anesthesia/analgesia​

      • Hip fracture surgery: femoral nerve or iliac blockade (placed preoperatively)

  • Prevent hypothermia with forced air warmers &/or warmed IV fluids for surgery >30 min

Postoperative

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  • Delirium prevention

    • Daily monitoring with CAM-S (or CAM-ICU if patient in ICU)

    • Pain control

    • Sleep hygiene support (minimize nighttime disruptions, encourage family at bedside)

    • Vision and hearing aids accessible

    • Remove catheters

    • Minimize psychoactive medications

    • Avoid potentially inappropriate medications (see section below on perioperative neurocognitive dysfunction)

    • Prevent constipation

  • Delirium management

    • Consider common causes in older patients: urinary retention, hypoxia, uncontrolled pain, infection, fecal impaction

    • Frequent reorientation with voice, calendars and clocks

    • Calm environment

    • Eliminating restraint use except as needed to prevent harm

    • Familiar objects in the room

    • Ensuring use of assistive devices (glasses, hearing aids)

    • Antipsychotics only as second-line: 

      • Haloperidol 0.5-1 mg PO/IM/IV (IV route not recommended due to increased risk of prolonged QT interval)  Double dose if ineffective after 1 hour; monitor QT interval

      • Atypical anti-psychotics may also be used but have no proven advantages

  • Fall prevention

    • AHRQ universal fall precautions

    • Scheduled toileting

    • Early mobilization & physical/occupational therapy

    • Unclutter room, bathroom, and nearby hallways

    • Minimize tethers

  • Nutrition support

    • Monitor feeding ability

    • Aspiration precautions

    • Resume diet as early as feasible

    • Dentures made available

    • Oral supplementation for malnutrition, frailty, neurologic dysphagia, dementia, and orthopedic surgery

  • Pressure ulcers: close monitoring for development​

Perioperative Neurocognitive Dysfunction (PND) (ASA Brain Health Initiative)

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  • Discuss risks of PND during consent process

  • Screen all patients age >65 years & those with evidence of cognitive dysfunction with a cognitive screening test (e.g., Mini-Cog)

  • Intraoperative:

    • Monitor age-adjusted minimum alveolar concentration (MAC) fraction of volatile anesthetics

    • Conflicting evidence on the value of EEG monitoring of depth of anesthesia

    • Some evidence suggesting protective effect from dexmedetomidine

  • Avoid medications prone to causing PND​

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Frailty (SPAQI Guideline)

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  • Carefully assess goals of care - involve PCP as well geriatrics and palliative care as appropriate

  • Physical therapy (for prehabilitation)​

  • Nutritional optimization (increase protein intake, dietician consult)

  • Psychological counseling (for improvement of coping mechanisms)

  • Geriatrics referral for formal frailty assessment & postoperative co-management

  • If surgery non-urgent, consider delay for above

COUNSELING & COMMUNICATION

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  • Collaborate with patient's hematologists

  • For patients with bleeding disorders requiring blood products (vWD, hemophilia, and others) provide advance notice to blood bank of pending surgery and likely product needs since these may not be kept in stock in the amounts required