Postoperative implications in the geriatric patient - American ...

Postoperative care
of the Geriatric Patient
Maria-Karnina Iskandar, MD
Amit Patel, MD
Konstantin Balonov
Anesthesiology Residents
Ruben J. Azocar, MD
Associate Professor of Anesthesiology
(Faculty Advisor)
Boston Medical Center is the primary teaching affiliate
of the Boston University School of Medicine.

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.
Harford foundation of New York City

Objectives
• Review the impact of postoperative complications in the
elderly
• Discuss the most common post-operative issues in the elderly
• Review the issues related to Postoperative Delirium and
Postoperative Cognitive dysfunction

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 often than

Age, comorbilities and Risk of Perioperative
Complications
Number of Complications per 1000
Surgeries
Number of Comorbilities
Can Anaesth Soc J 1986;33:336

6
Preoperative visit
• Review comorbilities and their current state
• Assess functional, cognitive and nutritional status
• Provide recommendations to prevent perioperative
complications

Implications of complications
• 30 day mortality for 60 vs. 80+ year olds
– 1.1 vs. 3.7% if no complications
– 15.1 vs. 26.1 if ≥1 complications
Hamel M et al JAGS 2005;53:424
• Three month mortality in 70+ year olds
(vs. non-surgical controls)
Kawalpreet M et al A&A 2003;96:583 and 590
– 2.9 hazard ratio if no complications
– 7.3 hazard ratio if ≥1 complications
• If survive three months, complications minimally increase
subsequent mortality
• Diminished functional status/↑dependency
compared to patients with no complications

Which Complications are severe?
• Heart failure: incidence of 5% in some studies, with
mortality as high as 65% Majeed A et al BMJ 2005;331:1374
• Pulmonary: 2.4 hazard ratio for death Kawalpreet M et al A&A
2003;96:583
• Renal: 6.1 hazard ratio for death Kawalpreet M et al A&A 2003;96:583
• Infection – UTI just as likely to lead to death as deep
surgical wound infection Hamel M JAGS 2005;53:424
• CNS
– Stroke
– Delirium
– POCD

Age and Perioperative Complications
Complication Rate
(%)
Mortality from the
Complication (%)
Complication Age

Cardiovascular complications
– Most frequently: hypertension or hypotension
– Second: dysrhythmias
– Third: ischemia

Cardiovascular complications
– Important to determine the cause.
• Hypotension:
– Chronic medications– i.e. Levodopa, bromocriptine,
tricyclic antidepressants
– Altered pharmacodynamics & kinetics causing
prolonged, residual effects
• Dysrhythmias:
– Hypoxia, hypercarbia
– Electrolyte imbalance, metabolic alkalosis/acidosis
– Pre-existing cardiac disease

Cardiovascular complications
• HR and rhythm can have greater impact on BP than in
younger pts
• Treatment:
– Be more cautious than in younger pts about
administering IVF as first-line treatment
– Consider increasing heart rate and peripheral
vasoconstriction (alpha-adrenergics or mixed alphabeta
agonists).
– Utilize Trendelenburg position as adjuvant

Pulmonary complications
• Why are geriatric patients more at risk for pneumonia,
hypoxemia, hypoventilation, & atelectasis post-op?
– Decline in pulmonary reserve, increased V/Q mismatch
– Diminished hypoxic & hypercapnic ventilatory drive
– Altered pharmacology of anesthetic drugs intraoperatively,
causing residual/prolonged effects
– Decrease on laryngeal reflexes makes them more prone to
aspiration

Pulmonary complications
• Who are at risk?
– Patients with:
• CHF
• Arrhythmias
• Dementia
• CVA
• Seizure disorder
• Emergency surgery

Pulmonary complications
• Inappropriate reversal of neuromuscular
blockade
– Subclinical paralysis might interfere with respiratory muscles and
lead to atlectasis

Renal complications
• Geriatrics patients at highest risk for more at risk for post-op
renal dysfunction
– Aging process changes renal circulation and tubular function
– Patient factors HTN, DM, CRI
– Consider placing Foley in at-risk patients, to monitor urine
output throughout perioperative period
– Intraoperative factors with prolonged hypotension, massive
transfusions

Silverstein, Jeffrey, et al
Central Nervous System Dysfunction after Noncardiac Surgery and Anesthesia in the Elderly
Anesthesiology. 106(3):622-628, March
.

Post-Operative 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.

Main clinical features
• 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

Factors continuing to POD
• Patient related
– Pain
– Hypoxemia
– Hypercarbia
– Hypotension
– Metabolic disorders
– Sepsis
– Substance abuse
– Preexisting disease
(depression/dementia)
– Visual/Hearing
impairments
• Patient un-related
– Restrains
– Cardiac surgery
– CNS drugs
– Sleep deprivation

Pathophysiology
Mantz, Jean Case Scenario: Postoperative Delirium in Elderly Surgical Patients
Anesthesiology. 112(1):189-195, January 2010

Pathophysiology
• Multifactorial
• Neurotransmitters
– 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.

Pathophysiology
• 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

Pathophysiology
• 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

Impact of Delirium
• Morbility
– Risk of injury
– CV/neurological events
– ? POCD after ICU delirium
• Mortality
• Loss of autonomy
• Duration of Hospital Stay
– 6.0 days vs. 4.6
• Nursing home Placement
• Health Care costs
– Average additional cost $2,947

Prevention and Management
• Identification patient at risk
– Baseline cognitive impairment
• Mini-mental Exam
• DEAR Score (Age, cognition, ADL’s, 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

BMC’S Delirium free Passport
• Multidisciplinary effort
• Checklist at all stage perioperative period
– Pilot in total knee replacement patients
• Education phase

Preoperative
clinic
Assess for
Delirium Risk
Dear Score:
Mini Cog Score:
Medical consult
Patient/Family
Education
-Verbal
-Brochure
Preoperative
Area
Review Delirium
Assessment
Counseling
Regional anesthesia
Avoid
Benzodiazepines
Assess hydration
status
Intraoperative PACU Postoperative
Use Depth of
Anesthesia
Monitor
Maintain
euvolemia
Monitor/treat
potential
causes of
Delirium
Avoidance of
Delirium
Causing
drugs
Order set
Assessment of patients
CAM Score
R/O Causes of
Delirium:
Metabolic
Hypoxia,
Hypercarbia,
Pain,
Drug withdrawal,,
Preexisting disease
Family at bedside
Return Dentures,
glasses, hearing
aids
Removal of Foley if
appropriate
Medical consult
Postoperative interventions
Removal of Foley/Return of
dentures, hearing aids,
glasses
Reorientation
Avoid Dehydration
Medication reconciliation
Pain Control
Avoidance of Delirium Causing
drugs
Facilitate normal sleep cycle
Mobility/Avoid restrains

Management
• Seek/treat cause
– Delirium is a medical emergency
– Medical issues a frequent cause of Delirium
• Hyperactive delirium
– Haloperidol
– Atypical antipsychotics
– Avoid Benzodiazepines

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 only warranted if:
– corroborated with neuropsychological testing
– evidence of greater memory loss than one would
expect due to normal aging

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: Long-term Consequences of Postoperative Cognitive Dysfunction. Anesthesiology.
2009:110;548-555

POCD Incidence
• Long term postoperative cognitive
dysfunction in the elderly:ISPOCD1 study
Moller JT et al THE LANCET 1998: 351; 857-861
• Collaborative research effort:
– Members from 8 European countries and USA
– 13 hospitals
• Research conducted from 1994 - 1996

ISPOCD1
• POCD occurred in 26% of patients at one week after
surgery and in 10% of patients at three months after
surgery
– Anesthesia and surgery cause long-term POCD
• Hypotension and/or hypoxemia not related to occurrence
of POCD

A Prospective Study Evaluating
The Relationship Between Age and POCD
• Single site - University of Florida: 1999 – 2002
Monk, T et al Anesthesiology. 108(1):18-30, January 2008
• 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)

Conclusions
• POCD
– Common in all age groups at hospital discharge (33-
44%)
– 3 months after surgery the POC incidence was:
• 4-5% in those younger than 65
• 13% in adults older than 60 years particularly on
those with lower educational achievement
• Associated with increased one-year mortality

POCD
• A follow-up study of the ISPOC group evaluated patients at 1
and 2 yr found that the rate of POCD decreased to
approximately 1%, which was not statistically significant.
Abildstrom H, Cognitive dysfunction 1-2 years after non-cardiac surgery in the elderly. ISPOCD
group. International Study of Post-Operative Cognitive Dysfunction. Acta Anaesthesiol Scand
2000; 1246-51

POCD
• A systematic review on the research POCD in
noncardiac surgery Newman, S: Postoperative Cognitive Dysfunction after
Noncardiac Surgery: A Systematic Review Anesthesiology: 2007:106;572-590
– In the early weeks after major non-cardiac surgery, a
significant proportion of people show POCD, with the
elderly being more at risk
– Minimal evidence was found that patients continue to
show POCD up to 6 months and beyond
– Studies on regional versus general anesthesia have
not found differences in POCD

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 yr?
• More research needed….

39
Conclusions
• Surgery and Anesthesia have a great impact in the decreased
physiological reserve of the elderly
• The number of comorbilities play an important role on the
incidence of complications
• CNS, Cardiac, Pulmonary and Renal complications have the
greatest impact in the older individual