Patient Safety Tip of the Week
September 25, 2012
Preoperative Assessment for Geriatric Patients
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 “Preoperative
Consultation – Time to Change” 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
“Preoperative
Consultation – Time to Change”
·
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
“Postoperative
Delirium”
·
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”
References:
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
http://www.journalacs.org/article/S1072-7515%2812%2900493-0/fulltext
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
http://www.journalacs.org/article/S1072-7515%2810%2900059-1/fulltext
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
http://www.journalacs.org/article/S1072-7515%2811%2900089-5/abstract
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
http://www.americanjournalofsurgery.com/article/S0002-9610%2812%2900299-1/abstract
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