Postoperative care of the Geriatric Patient

Transcription

1 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.

2 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

3 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

4 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 <65)

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

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

7 Implications of complications 30 day mortality for 60 vs. 80+ year olds 1.1 vs. 3.7% if no complications 15.1 vs 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 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

8 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

9 Age and Perioperative Complications Complication Rate (%) Mortality from the Complication (%) Complication Age <80 Age 80 Age <80 Age 80 Myocardial infarction Cardiac arrest Pneumonia >48 hours on ventilator Cerebrovascular accident Prolonged Ileus Hamel M et al J Am Geriatr Soc 2005;53:424

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

11 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

12 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

13 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

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

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

16 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

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

18 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.

19 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

20 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

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

22 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.

23 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

24 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

25 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

26 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

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

28 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

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

30 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

31 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;

32 POCD Incidence Long term postoperative cognitive dysfunction in the elderly:ispocd1 study Moller JT et al THE LANCET 1998: 351; Collaborative research effort: Members from 8 European countries and USA 13 hospitals Research conducted from

33 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

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

35 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

36 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;

37 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; 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

38 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 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