© 2018 Kurt Pfeifer.

GERIATRICS

ASSESSMENT

Data Gathering

History

Symptoms

  • Ability to perform ADLs

  • Hearing aids

  • Visual aids

  • Cognitive impairment

  • Response to previous anesthesia

  • Falls

  • Mobility impairment/assistive devices

  • Memory loss

  • Hearing loss

  • Vision loss

  • Incontinence

  • Weakness

  • Fatigue

Risk Stratification

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)

FRAIL.jpg
  • Score 1-2 = prefrail

  • Score ≥3 = frail​

MANAGEMENT

Preoperative

  • 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

  • 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

  • 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)

  • 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​

Beers meds.jpg

Frailty (SPAQI Guideline)

  • 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