We have long been advocates of major change in the way we prepare patients, particularly the elderly, for surgery (see our August 17, 2010 Patient Safety Tip of the Week “” and the multiple columns listed at the end of this column). We’ve also done multiple columns on the ability of measures of frailty to predict postoperative complications, morbidity and mortality, and discharge to institutional settings. And multiple columns on the risk factors for post-operative delirium. And numerous columns on the risk factors for postoperative opioid-related respiratory depression and identifying patients at risk for sleep apnea.
The American College of Surgeons and the American Geriatrics Society, in collaboration with numerous other constituents, have come together to publish a new guideline on the preoperative assessment for geriatric patients anticipating surgery (Chow 2012). This is a much needed guideline and addresses all the important issues we’ve raised above.
The guideline includes a Checklist for the Optimal Preoperative Assessment of the Geriatric Surgical Patient with the following recommendations:
· Complete history and physical examination.
· Assess the patient’s cognitive ability and capacity to understand the anticipated surgery.
· Screen the patient for depression.
· Identify the patient’s risk factors for developing postoperative delirium.
· Screen for alcohol and other substance abuse/dependence.
· Perform a preoperative cardiac evaluation according to the
· American College of Cardiology/American Heart Association algorithm for patients undergoing noncardiac surgery.
· Identify the patient’s risk factors for postoperative pulmonary complications and implement appropriate strategies for prevention.
· Document functional status and history of falls.
· Determine baseline frailty score.
· Assess patient’s nutritional status and consider preoperative interventions if the patient is at severe nutritional risk.
· Take an accurate and detailed medication history and consider appropriate perioperative adjustments. Monitor for polypharmacy.
· Determine the patient’s treatment goals and expectations in the context of the possible treatment outcomes.
· Determine patient’s family and social support system.
· Order appropriate preoperative diagnostic tests focused on elderly patients.
The guideline recommends cognitive assessment using the Mini-Cog (see our August 7, 2012 Patient Safety Tip of the Week “Cognition, Post-Op Delirium, and Post-Op Outcomes”) and has a good discussion about the legal requirements for assessing a patient’s capacity to consent. It recommends screening for depression with the PHQ-2 tool and if either question is answered “yes” it recommends referral to a primary care physician, geriatrician, or mental health specialist.
The guideline has a nice table of risk factors for postoperative delirium and for patients at risk for postoperative delirium the guideline recommends avoiding benzodiazepines and antihistamines.
The guideline suggests using a tool like the CAGE tool to screen for alcohol and substance abuse. It recommends following the ACC/AHA algorithm for evaluating cardiac risk. The guideline has a table of risk factors for postoperative pulmonary complications, separated into patient-related risk factors and surgery-related risk factors. It also has a table for pre-op strategies to reduce the risk for postoperative pulmonary complications.
The sections on assessing functional status, gait/mobility, and fall risk recommend assessing activities of daily living, doing the Timed Up and Go Test (TUGT), and assessing for fall risk factors. The discussion on frailty addresses most of the issues we discussed in our prior columns on frailty and surgical risk (see our November 2011 What’s New in the Patient Safety World column “Timed Up-and-Go Test and Surgical Outcomes” and our August 9, 2011 Patient Safety Tip of the Week “Frailty and the Surgical Patient” and our August 14, 2012 Patient Safety Tip of the Week“Gait Speed: A New Vital Sign?”). They highlight the contributions by Makary and colleagues (Makary et al 2010) and Robinson and colleagues in predicting postoperative complications based on frailty measures (Robinson 2009, Robinson 2011).
A nutritional status evaluation should include calculation of the BMI, a serum albumin level, and assessment for unintentional weight loss within the past 6 months. It has recommendations for both preoperative and perioperative nutritional support for those patients deemed at risk.
The section on medication management is excellent. In addition to addressing polypharmacy and drugs on Beers’ list, it discusses ACC/AHA guidelines for perioperative use of beta-blockers and statins, and adjusting medication doses as appropriate for the patient’s level of renal function.
The section on preoperative testing is also excellent. The overriding message is that “routine” testing is of little value and any preoperative tests should be individualized for the patient’s risks.
Lastly, the section on patient counseling is excellent. It emphasizes the need for advance directives and designation of a health care proxy and all such documents should be in the patient’s medical record. But it goes much further and discusses the need for the surgeon to take into account the patient’s preferences and expectations. The discussion must include potential complications and the possibility of functional or cognitive decline and potential need for rehabilitation or long term care. Assessing the patient’s family and social support systems should involve a social worker when indicated.
Overall, we really like this guideline. It is both comprehensive and practical and emphasizes the big picture, focusing on functional status and simple assessments rather than taking the “shotgun” approach to preoperative testing that we still see so commonly used. It is well thought out and has an excellent bibliography (117 references).
We’ve also seen several other good articles this year on preoperative assessment of patient’s about to undergo surgery. These have included the pre-op anesthesia evaluation (ASA 2012) and the pre-op medical consultation (Rivera 2012). Both concur that preoperative tests ordered on asymptomatic patients or patients lacking a specific indication do not contribute significantly to the management of the patient and should not be routinely ordered. The updated Practice Advisory for Preanesthesia Evaluation (ASA 2012) does discuss in what context various preoperative tests are indicated.
Rivera and colleagues (Rivera 2012) discuss some of the medication management issues pertinent to the preoperative medical consultation. In discussing the need to continue beta blocker therapy in patients previously on beta blockers, they suggest the consultation be done with sufficient time to allow for gradual titration of the beta blocker dose if indicated. They also have good recommendations regarding management of statins, antiplatelet agents, anticoagulants, antidepressants, antipsychotic agents, benzodiazepines, neurologic medications, and herbal medications.
Neither of the latter two articles focuses on functional status, cognitive issues or frailty. But they do complement the excellent job Chow and colleagues have done in the new ACS/AGS guideline on the preoperative assessment for geriatric patients anticipating surgery (Chow 2012). Use all three as valuable resources in preparing your elderly patients for surgery.
Some of our prior columns on preoperative assessment:
· August 17, 2010 “”
· November 2011 “Timed Up-and-Go Test and Surgical Outcomes”
· August 9, 2011 “Frailty and the Surgical Patient”
· March 31, 2009 “Screening Patients for Risk of Delirium”
· January 26, 2010 “Preventing Postoperative Delirium”
· June 2010 “The Frailty Index and Surgical Outcomes”
· August 31, 2010 “”
· September 2011 “Modified HELP Helps Outcomes in Elderly Undergoing Abdominal Surgery”)
· April 3, 2012 “New Risk for Postoperative Delirium: Obstructive Sleep Apnea”
· August 14, 2012 “Gait Speed: A New Vital Sign?”
· August 7, 2012 “Cognition, Post-Op Delirium, and Post-Op Outcomes”
Chow WB, Rosenthal RA, Merkow RP, et al. Optimal Preoperative Assessment of the Geriatric Surgical Patient: A Best Practices Guideline from the American College of Surgeons National Surgical Quality Improvement Program and the American Geriatrics Society. Journal of the American College of Surgeons 2012; 215(4): 453-466, October 2012
Makary MA, Segeve DL, Pronovost PJ, et al. Frailty as a Predictor of Surgical Outcomes in Older Patients. Journal of the American College of Surgeons 2010; 210(6): 901-908, June 2010
Robinson TN, Eiseman B, Wallace JI, et al. Redefining Geriatric Preoperative Assessment Using Frailty, Disability and Co-Morbidity. Annals of Surgery 2009; 250(3): 449-455, September 2009
Robinson TN, Wallace JI, Wu DS, et al. Accumulated Frailty Characteristics Predict Postoperative Discharge Institutionalization in the Geriatric Patient. J Am Coll Surg 2011; 213(1): 37-42, July 2011
ASA (American Society of Anesthesiologists) Committee on Standards and Practice ParametersASA. Practice Advisory for Preanesthesia Evaluation: An Updated Report by the American Society of Anesthesiologists Task Force on Preanesthesia Evaluation. Anesthesiology 2012; 116(3): 522-538, March 2012
Rivera RA, Nguyen MT, Martinez-Osorio JI, et al. Preoperative medical consultation: maximizing its benefits. Am J Surg 2012; ahead of print July 9, 2012