Keywords

The Geriatrician’s Role

Geriatricians play a unique role in the care of older patients who are preparing for surgery. They may supply insight as a primary care provider and/or provide specialized recommendations in the pre- and postoperative care of a patient. Geriatricians have clinical skills in caring for a heterogeneous older adult population in different care settings. Geriatricians entering into practice, in and across all care settings (hospital, home office, and long-term care and subacute rehabilitation facilities), are able to provide patient-centered care that optimizes function and/or well-being; prioritize and manage the care of older patients by integrating the patients’ goals and values, comorbidities, and prognosis into the practice of evidence-based medicine; assist patients and families in clarifying goals of care and making care decisions; coordinate health care and health-care transitions for older adults with multiple chronic conditions and multiple providers; provide comprehensive medication review to maximize the number of medications and adverse events; provide geriatrics consultations and comanagement; and collaborate and work as a leader or member of an interprofessional health-care team. All these skills potentially add value to the anesthesiologist [1]. Many of the problems and issues that arise in caring for older adults are common and complex enough that expertise would be a benefit to the patient (Table 8.1).

Table 8.1 Geriatrician’s specialized clinical skills and knowledge
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There is great heterogeneity and variability in aging. Age is a demographic variable used as a surrogate to reflect medical complexity, disease burden, frailty, and physiologic decline in many organ functions. Some members of the oldest old (defined as people age 85 and above) maintain high physical function and should not necessarily be regulated to non-operative management. Caution should be given in ensuring chronological age itself is not used as a tool to determine treatment choices . Geriatricians balance a deep respect for the potential harms of interventions with the potential benefits given a patient’s individualized life trajectory. In this chapter, we identify aspects of the geriatrician’s role and assessments that may improve perioperative care.

Geriatric Medicine

What makes geriatric medicine different from, say, internal medicine and family medicine? There is not an absolute singular answer even among geriatricians themselves. However, most geriatricians will identify some commonalities: a focus on our patient’s functional capacity, identifying the presence of geriatric syndromes and its impact on function, and comfortably and effectively working in multidisciplinary teams to maximize our patient’s function [3]. All three of these aspects are important to the management of older adults in perioperative care.

Functional Assessment

Geriatricians are originally trained in family medicine or internal medicine and are able to evaluate chronic medical conditions that are prevalent in older adults such as heart failure, diabetes, or chronic kidney disease. Geriatricians will also routinely assess patients in terms of functional status and identify geriatric syndromes (see below) that may impede maximal functional abilities. Studies have shown an association between functional dependence and mortality after surgery [4,5,6]. Functional status is one of the most important predictors of outcomes after anesthesia. In general, low levels of function and functional dependence were associated with postoperative complications and operative mortality.

The geriatric assessment extends beyond the traditional medical evaluation and management of medial illnesses . It involves an evaluation of issues including physical, cognitive, affective, social, environmental, and spiritual aspects that may have a great impact on older adult’s life. The goal of such an assessment is to delay the onset of functional impairment while maintaining the highest level of independence, autonomy, and quality of life possible over a patient’s life course.

The comprehensive geriatric assessment (CGA ) is a tool that is familiar to all geriatricians. It is an evaluation and diagnostic framework that aims to maximize function by identifying common conditions such as geriatric syndromes and issues that reduce quality of life. Table 8.2 captures the core aspects of almost all CGAs. CGAs may vary by having additional components in the assessment.

Table 8.2 The comprehensive geriatric assessment (CGA)
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The use of CGAs in community-dwelling older adults guides management that in turn results in a decrease in mortality and a reduction in functional decline [7, 8]. However, there is significant variability in the implementation of CGAs in the outpatient environment. Positive results come from programs where a greater number of recommendations are implemented compared to those where there is limited or no implementation of recommendations [9]. In hospitalized older adults, care that is based on CGAs provided more consistent benefits in comparison to standard medical care. A Cochrane Review shows subjects who received CGA were more likely to be alive and in their own homes throughout the surveillance period (median 12 months). Hospitalized subjects who received CGAs were also less likely to be institutionalized, were less likely to suffer death or deterioration, and were more likely to experience improved cognition compared to the usual care group. These effects are consistently demonstrated from trials of geriatric wards (patients admitted directly to the specialist geriatric team) but not replicated in trials of geriatric consultation teams where the geriatric team passes on their recommendations to the primary team and may or may not be involved in delivering direct care [10]. Again, trials showing the most clinically and statistically significant improvement in mortality and functional decline are where recommendations are implemented.

Figure 8.1 illustrates the concept of maximizing function and using aspects of the CGA to achieve that goal. Over time older adults will experience a decline in function due to physiologic changes and conditions that are prevalent among older adults. Many of these changes and conditions are chronic, and cure is not possible. However, mitigating the impact of each condition may be enough to maintain one’s level of function above the threshold of losing independence .

Fig. 8.1
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Preservation of maximal function . Preserving high levels of function for as long as possible is one of the goals for geriatric medical care. The dotted line represents a low level of function where some form of institutionalization may be required. The comprehensive geriatric assessment is an evaluation and diagnostic framework that aims to maximize function by identifying common conditions such as geriatric syndromes and issues that reduce quality of life. Panel (a) shows how common issues can have an impact upon function over time. Panel (b) shows those same conditions being mitigated as represented by a change in the slope of the line. The impact of these conditions on function has been lessened, and loss of independence is delayed

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Geriatric Syndromes

Geriatric syndromes are multifactorial health conditions that occur when the accumulated effect of impairments in multiple different systems renders an older adult vulnerable to situational challenges [11]. These situational challenges can be a change in an environment such as a hospitalization or an acute exacerbation of a chronic medical condition.

A key aspect of geriatric syndromes is that underlying risk factors often overlap with other fields of medicine (e.g., physical therapy or occupational therapy ) because the syndrome is impacted by different physiologic systems. An example of a geriatric syndrome is falls. It is easy to imagine how the decline illustrated in Fig. 8.1 could contribute to falls. Assessment of physical deconditioning, cognition, the physical home environment, medications, and social support all involves different systems and assessment from different specialties. Intrinsic and extrinsic risk factors are identified with the goal of mitigating each risk factor’s impact on the geriatric syndrome. Risk factors are often not reduced to zero, but its impact on overall function can be lessened where the cumulative effects have a significant positive impact similar to what is illustrated in Fig. 8.1, Panel b.

Delirium can be used to exemplify this above concept. Delirium occurs not uncommonly in hospitalized older adults and often has multifactorial causality. The Hospital Elder Life Program (HELP ) is a multifaceted nonpharmacologic intervention that addresses some of the risk factors that contribute to developing delirium. Table 8.3 outlines HELP’s interventions. The HELP interventions have been shown to reduce delirium [12]. More importantly, HELP has been shown to be dose dependent [13]. The more the risk factors mitigated, the better the results.

Table 8.3 Hospital Elder Life Program (HELP )
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In 2012, the American College of Surgeons (ACS) NSQIP and the American Geriatrics Society (AGS) published “Optimal Preoperative Assessment of the Geriatric Surgical Patient: A Best Practice Guidelines.” The preoperative domains addressed were those most likely to affect the elderly, including cognition, frailty, polypharmacy, nutrition, and social support [14]. In the following sections, we will be addressing these areas from a geriatrician’s perspective.

Interprofessional Care

Many aspects of the geriatric functional assessment require multidisciplinary input. The CGA as outlined above is an inherently multidisciplinary diagnostic and treatment process. The geriatrician identifies the need for mitigating the risk factor’s impact on functional decline but then recruits the necessary discipline to evaluate and recommend a treatment course that is integrated into a patient-centered care plan.

Another central task of geriatricians is to coordinate care among several subspecialists and to define, sustain, and communicate clear goals of treatment to all providers involved. In addition to coordinating subspecialist providers, geriatricians must generally work in multidisciplinary teams. Their training and clinical practice often includes long-term care, rehabilitation, and hospice facilities where there is daily side-by-side collaborative care in furthering the patients’ goals. Geriatricians’ collaborative care coordination among family members, nurses, nurse practitioners, therapists, aides, social workers, and others is a particular skill that is not usually taught in physician training. When a patient depends on others, the patient’s physician should have a working knowledge of who is providing that help. In fact, most older adults depend on many individuals to maintain function and independence. The decisions as to whether an older adult should live at home alone, drive independently, or proceed with surgery with anticipated postoperative rehabilitation all can be improved by multidisciplinary input.

Goal Setting and Hospitalization-Associated Disability

Goal Setting

It is important to ensure that the patient’s goals for care and expectations are in line with anticipated outcomes prior to both elective and nonelective surgical procedures in older adults. The surgical intervention is only the beginning of a longer course to recovery for many older adults. Approximately 65% of Medicare patients who had a lower-extremity joint replacement surgery required stays in either a skilled nursing facility or inpatient rehab after surgery [15]. Incorporating discussions about the typical clinical course after surgery should be an important part of informed consent for surgery. A priority should be placed on understanding the patient’s goals and expectations for surgery.

The concept of lag time to benefit is helpful when thinking about goals of care for older adults [16]. Lag time to benefit refers to the time between the intervention (in this case surgery) and when positive health outcomes are received (e.g., improvement in mobility, cure from cancer, prevention of repeated bouts of cholecystitis). In other words, lag time to benefit addresses the question “when will it help my patient?” The model was originally intended for decisions of outpatient preventive interventions, such as cancer screening, but can be adopted for decisions regarding surgical interventions. One would expect that most surgical interventions have an immediate benefit. However, when extensive rehabilitation is required before the primary goal is achieved (e.g., improved function), surgery may not be the ideal solution.

Figure 8.2 illustrates a stepwise approach in helping to determine the benefits of offering interventions in older adults. This model incorporates life expectancy, the lag time to benefit, and patient preferences. It is important to elicit your patient’s preferences whenever you are delivering care and is most essential when the risks and benefits for a particular intervention are not straightforward.

Fig. 8.2
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A stepwise approach in helping to determine the benefits of interventions in older adults

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It can be difficult to estimate life expectancy . Although age is an important factor in life expectancy, it is not the only predictor. At any given age, an older adult’s life expectancy may be shortened by comorbidities or decreased functional status (i.e., dependence for activities of daily living) [17]. Life expectancy is also shortened by the presence of frailty. Although most clinicians will have a general clinical gestalt about any given individual’s life expectancy, incorporating different mortality models based on demographic variables can provide for a more standardized discussion based on evidence. Many models exist that attempt to prognosticate mortality and life expectancy. These models differ in the cohorts that generate the data for their modeling and range from community-dwelling to hospice cohorts and have variable time frames (months to a decade). ePrognosis (Fig. 8.3) is an application that incorporates many of these models into a simplified step-by-step process in estimating mortality [18, 19]. By inputting patient demographic variables, one can get an estimate of mortality risk for patients in the realm of days to years based on location of care and other patient-specific factors.

Fig. 8.3
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A bubble view of the different models incorporated into ePrognosis . ePrognosis is a repository of published geriatric prognostic indices [18]. Each bubble represents a different prognostic model. The size of each bubble represents the cohort size of the model. The x-axis represents the duration of years of the studied cohort, and the y-axis represents the quality of the data. For example, the Lee SJ et al. model is derived from a cohort of 11,701 community-dwelling older adults and validated in 8009 Health Retirement Survey interviewees and provides all cause 4- and 10-year mortality estimates [20]. The information on patients’ prognosis is intended as a rough guide to inform clinicians about possible mortality outcomes and is not intended to be the only basis for making care decisions, nor is it intended to be a definitive means of prognostication (Created using ePrognosis: http://eprognosis.ucsf.edu/index.php)

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Avoiding chronic debility, morbidity, and poor quality of life is often more important to older adults than staying alive. Understanding the patients’ hierarchy of what is important in their lives and their goals is a key component of shared decision-making in medicine and not solely regarding surgery. If a patient is not willing to live in a skilled nursing facility, even for a short period of time, it may not be helpful to have them undergo an elective procedure such as posterior spinal fusion that might require such a stay. Alternately, delineating that the patient highly values independence may lead one to recommend such a procedure that could improve their mobility and ability to participate in self-care for the long term. If a patients’ main goal is quality of life or comfort, then their acceptance of risk of discomfort or complications from a procedure with a lower potential to add quality years would be lower.

To find out a patient’s preferences , one can simply start by asking the patient the following question: Is one of the following goals more important to you than anything else: (1) Living as long as possible? (2) Keeping your ability to care for yourself and live independently? (3) Keeping comfortable, with minimal symptoms? If the discussion is not straightforward, consultation with a palliative medicine specialist, a geriatrician, or a provider who either has a strong rapport with the patient or with experience in goals of care discussions can be helpful [21].

Hospitalization-Associated Disability

An important part of the discussion of potential treatments is letting patients know what the potential next steps are and expected outcomes after a procedure, including recovery time in the hospital, estimated time in a rehabilitation facility, and frequency and timing of follow-up. Hospitalizations itself is commonly associated with functional loss in older adults . Hospitalization-associated disability is the loss of the ability to perform one of the basic activities of daily living (ADLs) and occurs between the onset of the acute hospitalization and discharge from the hospital [22]. Declines in ability to perform ADLs and mobility after hospitalization are common [23,24,25,26,27]. Age is the most important risk factor [28]. Thirty-five percent of patients declined in ADL function between baseline and hospital discharge in a prospective observational study of nearly 3000 patients aged 70 and older (mean age of 80) hospitalized to medical services. This rate of functional decline had a striking relationship with age, with rates exceeding 50% in patients aged 85 and older [28]. Similarly, in another prospective observational study in medical patients involving over 2000 patients, 40% of older adults continued to have a new or additional disability in ADL at 3 months post discharge compared to prior to admission. At 1 year, nearly a third of patients still had not recovered their prior function [23].

Striking reductions in mobility after hospitalizations for older adults are also seen. Nearly 500 hospitalized medical patients aged 70 and older followed prospectively showed that low mobility and bed rest were common [24]. Using average mobility level, scored from 0 to 12, the low mobility group was defined as having a score of 4 or less, high as higher than 8, and bed rest was assigned a score of 0. Complete bed rest episodes occurred 33% of patients. The development of new functional decline, becoming newly institutionalized, and having in-hospital death were all shown to have an inverse relationship with the initial level of mobility. In other words, the lower one’s mobility, the worse the outcomes.

Similar results were shown in a separate observational prospective study involving nearly 700 community-dwelling 65 years or older surgical and nonsurgical patients . On average, patients hospitalized for any reason experience decline in mobility [25]. Patients with a nonsurgical admission had little to no recovery of mobility to their baseline even after 2 years. Interestingly, surgical patients had better mobility before admission and recovered to at least their preadmission mobility within a year of hospitalization. The authors speculated that preoperative screening helped to determine the best candidates for surgical procedures.

Sager et al. developed a simple instrument to help identify patients at risk of functional decline following hospitalization. The Hospital Admission Risk Profile (HARP ) was developed and validated in two separate cohorts from four university and two private nonfederal acute care hospitals [29]. Using logistic regression analysis, the authors identified increasing age, lower admission Mini-Mental Status Exam scores, and lower preadmission IADL were independent predictors of functional decline. A scoring system was developed for each predictor variable, and patients were assigned to low-, intermediate-, and high-risk categories (Table 8.4). The HARP reinforces the value of identifying prior cognitive function and physical function as markers of posthospitalization outcomes. Other authors have also demonstrated that including information from short multidimensional prognostic assessments identifies older adults most likely to develop hospitalization-associated disability [30, 31].

Table 8.4 The Hospital Admission Risk Profile (HARP )
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There are multiple other tools available to assess for functional status. As recommended by the American College of Surgery/American Geriatric Society Guidelines, one can quickly screen for functional status at baseline [14]. One can ask patients these four screening questions:

  1. 1.

    Can you get out of bed or chair yourself?

  2. 2.

    Can you dress and bathe yourself?

  3. 3.

    Can you make your own meals?

  4. 4.

    Can you do your own shopping?

Deficits in any of these areas should prompt a more in-depth look at functional status and involvement of physical and occupation therapy as well as a geriatrician to further assess for reversible factors and help assess expected trajectory after surgery. A number of interventions have been implemented to reduce the incidence of hospitalization-associated disability. Many of these interventions are multidimensional addressing cognitive function, sensory impairment, mobility, nutrition and hydration, and limiting iatrogenesis [32].

Geriatric Syndromes

There is a growing recognition that geriatric syndromes such as cognitive impairment, sensory impairment, falls, malnutrition polypharmacy, and frailty have an impact on surgery and postoperative outcomes. Screening for many of these syndromes in the preoperative assessment is considered the best practice.

Cognitive Impairment

Cognitive impairment is common among older adults and includes both dementia and mild cognitive impairment . The prevalence of dementia increases with age. In persons 71–79 years old, the prevalence is 5% and increases to nearly 25% in those 80–89 years old and 37% in those 90 years old and older [33]. Mild cognitive impairment (MCI ) is a state of cognitive function where the impact is not severe enough to interfere with essential daily tasks referred to as instrumental activities of daily living (IADLs) (e.g., medication management and finances). Dementia, however, is severe enough cognitive impairment that it impairs one’s abilities to manage their own IADLs and eventual basic ADLS (e.g., dressing, bathing, etc.). MCI is classified into two subtypes, amnestic and non-amnestic. Amnestic MCI is clinically significant memory impairment that does not meet the criteria for dementia. Non-amnestic MCI is characterized by a decline in function in other non-memory cognitive domains such language or visuospatial skills. The rate of progression of MCI to dementia is uncertain [34]. MCI prevalence widely varies because of differences in the definition of MCI and methods used to determine cognitive impairment and ranges from 3% to 42% in adults 65 years and older [33].

Older adults with cognitive impairment have higher postoperative mortality and are at higher risk of postoperative delirium with potential for chronic impact on cognition and postoperative cognitive dysfunction (Chap. 30, Postoperative Delirium and Cognitive Dysfunction) and institutionalization. A systematic review found that cognitive impairment (defined as a chart diagnosis of dementia) was an independent predictor of postoperative mortality with risk of death ranging from 1.8 to 5.8 times higher compared to those without cognitive impairment [21]. Delirium risk in those who are cognitively impaired increases by two- to seventeen-fold, and the risk of nursing home placement on discharge doubles in comparison to those who are cognitively intact [21]. A discussion of the increased risk of delirium , discharge to a skilled nursing facility, and mortality should be included as part informed decision-making for patients with cognitive impairment and their families.

Screening for baseline cognitive impairment can help identify individuals whom collateral informants are needed to ensure accurate history of medical history and medication list. A validated quick screening tool for cognitive impairment is the Mini-Cog [35]. This tool involves a three item recall and a clock draw (Fig. 8.4). Another useful validated clinical tool is the Ascertain Dementia 8-item Informant Questionnaire (AD8 ). The AD8 can be used in a questionnaire form and is filled out by informants rather than the patient [36]. The AD8 can be particularly helpful in seeking corroborative history for dementia and can be used clinically over the phone when informants may not be present. Those who have a history of cognitive impairment or a suspicion after screening should have collateral informants involved and strong consideration for referral to a geriatrician or other providers who can further assess their cognitive impairment.

Fig. 8.4
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Mini-Cog™ (© S. Borson . All rights reserved. Reprinted with permission of the author solely for clinical and educational purposes. May not be modified or used for commercial, marketing, or research purposes without permission of the author (soob@uw.edu))

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Identification of preexisting cognitive impairment is not only important because it increases the awareness of postoperative delirium risk but also because the multicomponent nonpharmacologic interventions such as the Hospital Elder Life Program (HELP ) have the strongest evidence for preventing delirium. The strength of the evidence of multicomponent nonpharmacologic interventions for management of delirium is lower [37]. Nevertheless, multicomponent nonpharmacologic interventions are an integral part of caring for a patient at risk for delirium. HELP (Table 8.3) reduced the incidence of delirium in hospitalized medical older adult patients (mean age 80 year old) by 5% compared to those who received usual care. The number needed to treat is 20. The multicomponent nonpharmacologic interventions reduced the total number of days with delirium and the total number of episodes of delirium [12]. However, once an initial episode of delirium had occurred, the intervention had no significant effect on the severity of delirium or on the likelihood of recurrence placing emphasis on the importance of identifying those at risk for delirium then implementing preventative nonpharmacologic measures. Perhaps more importantly is that the HELP interventions have been shown to have a dose-response curve. Higher levels of adherence to the interventions resulted in reduced rates of delirium in a directly graded fashion [13].

Falls

Falls are common in older adults with one in three older adults falling each year [38]. In the inpatient setting, the rate of falls in older patients is between 3.4 and 5.2 per person year with over half of these falls resulting in serious injury including fracture and head injuries. Risk factors for falls in the inpatient setting include gait instability, agitated confusion (e.g., delirium), urinary incontinence, a history of prior falls, and use of psychotropic medications [39]. Screening for a history of falls and/or performing a mobility assessment such as the Timed Up and Go Test in the outpatient setting may identify older adults at risk for falls in the postoperative period and those who are more likely to be institutionalized after surgery. Screening for falls can be as simple as asking “have you fallen in the past year?” If a yes response is given, the individual is considered at increased risk of falling.

The Timed Up and Go Test (TUGT) is performed by having an older adult stand up from a chair, walk 10 feet, turn around, and return to the seat [40]. If it takes greater than 12 s, the patient is considered at increased risk of falls, and a more comprehensive geriatric assessment prior to elective surgery may be needed. Several small studies have found having an abnormal preoperative TUGT to be associated with an increase in postoperative institutionalization, length of stay, postsurgical complications, and one-year mortality [41, 42]. Inpatient care providers should be made aware in advance of those who are at increased risk of falls, so preventive strategies can be implemented. Successful strategies for preventing inpatient falls have included patient education and multifactorial interventions (with variation of interventions between studies) that target fall risk factors (e.g., therapy or exercise for decreased mobility, medication review). Further research is needed to elucidate which interventions are most effective.

Polypharmacy

The elderly are four times as likely as those under 65 years of age to be hospitalized due to a medication mishap [43]. This is in part due to the higher risk of polypharmacy in this population secondary to an increased number of medical conditions and greater number of physicians involved in their care [44]. Polypharmacy has been associated with adverse outcomes including risk of hospitalizations, falls and fall-related injury, weight loss, decline in functional and cognitive status, and mortality [45, 46]. The frequency of these geriatric syndromes as well as risk of adverse drug reaction (ADR) increases in proportion to the number of used medications [47]. In fact, polypharmacy has been recognized as the most important risk factor for an ADR . The risk increases from 13% for a person taking two medicines to 58% and 82% when taking five and seven or more medications, respectively [47,48,49].

While no consensus definition exists for the term “polypharmacy,” a threshold of five or greater concurrent medications is generally accepted [50,51,52]. Some studies and authors have tried to be more specific by using the term “inappropriate” polypharmacy when multiple medications are used to treat a single ailment or condition. The lack of consensus in defining polypharmacy has proven problematic when attempting to compare different strategies aimed at reducing medications and their associated clinical endpoints [52].

Believing that a patient is taking too many medicines does not help the clinician know which ones to stop [46]. Medical training often fails to supply providers with adequate knowledge and skills needed to prescribe appropriately to individuals who use multiple medications. As a result, physicians may inadvertently cause drug-drug-related problems. This is especially seen in older adults because of the multiple prescription medications and an inadequate understanding of pharmacology [53].

The term “deprescribing ” has been used to describe the complex process of planned and supervised tapering or ceasing of inappropriate medicines with the goal of managing polypharmacy and improving outcomes (Table 8.5) [54, 55]. This is especially important in the inpatient setting as polypharmacy is a preoperative risk factor for delirium and falls [56]. In addition, patients taking medications unrelated to their surgery are 2.5 more likely to develop postoperative complications [57, 58].

Table 8.5 A guided assessment of a “deprescribing process”
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Medication reconciliation is a framework used to help reduce medical errors by ensuring accuracy of a patient’s medication list. This process is the first step in deprescribing and is particularly important at times of transitions in care when prescribing errors are high [47]. A “brown bag” review in which patients bring in all of their medicines (including all prescriptions and over-the-counter medicines, vitamins, supplements, and herbal preparations) for documentation can be invaluable preoperatively. This type of review provides useful information about what a patient is actually taking versus what they have been prescribed. Utilizing a list from medical records or from the patient may not accurately reflect how and which medications are being taken in the home.

There are numerous decision aid tools to assist providers in reducing polypharmacy with little direct evidence to support one specific method of review over another. These tools have been developed in various settings and have varying levels of support for their use [44]. Although few have been used or validated in the perioperative setting, they all have face validity and could be of benefit. The selected tools below have been chosen for their usefulness and practicality of application when assessing polypharmacy in the elderly (Table 8.6). One shortcoming is while these tools do make recommendations regarding specific medications and medication classes, they do not offer guidance on dosing or alert providers to potentially harmful doses of appropriate medications for the geriatric patient.

Table 8.6 Clinical tools to reduce polypharmacy
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Although each type of surgical procedure requires different precautions, there are some general principles for management of medications in the perioperative period. An accurate and comprehensive medication list is essential to appropriately manage patients’ medications perioperatively. Review of this list and a straightforward, clear plan regarding discontinuation or continuation for each of the patient’s chronic medications should be made at a preoperative appointment. In the immediate preoperative period, providers should repeat their review of the patient’s medications and confirm that recommendations regarding management have been implemented. Ensuring nonessential medications have been stopped can reduce perioperative complications. In particular, herbal use can pose important cardiovascular, coagulation, and sedative risks in the perioperative period (see Chap. 13, Preoperative Risk Stratification and Methods to Reduce Risk, Table 13.8) [58]. A general practice of stopping self-prescribed OTC medications, herbals, or supplements 2 weeks before surgery is a strategy supported by the American Society of Anesthesiology and will ensure that longer-acting medications (e.g., St. John’s wort or garlic) will be fully eliminated [58]. Instructions should be kept simple for geriatric patients and caregivers such as stopping all nonessential medications at one time rather than a staged fashion will increase the likelihood that patients will be compliant with instructions. Clearly communicating continuing mediations with that are medically necessary or have the potential for withdrawal is equally important.

Most medications are tolerated well through surgery, and most drugs should be continued through the morning of surgery unless completely unnecessary (e.g., vitamins) or contraindicated. In particular, antihypertensives, anticonvulsants, and psychiatric medications should be given unless specifically contraindicated [64]. Notable exceptions to this continuation rule include:

  • Angiotensin converting enzyme inhibitors (ACEIs ) and angiotensin II receptor blockers (ARBs) may be held 24 h prior to anesthesia induction and surgery because of the potential for adverse circulatory effects such as hypotension [58].

  • Anticoagulants/antiplatelets including nonsteroidal anti-inflammatory agents (NSAIDs) could be held but are variable depending on the particular medication, indication for use, and type of surgery.

  • Selective estrogen receptor modulators (SERMs ) and estrogens should be held at least 1 week preoperatively (4 weeks for estrogen if possible) for surgeries associated with a moderate to high risk of deep vein thrombosis [64].

  • Diabetic oral agents should be held the morning of surgery. The exception is metformin which should be held for at least 1 day before surgery and restarted after 2–3 days when it is certain that no acute renal dysfunction has developed postoperatively [64].

  • Postprandial insulin should be held the day of surgery. Sliding-scale insulin can be used instead as needed to control serum glucose periprocedurally. Long-acting insulin can be administered but should be reduced by 50% of the usual dose day of surgery.

The long elimination half-life of some medications (e.g., the half-life of amiodarone is 58 days) may make it unreasonable to stop them to achieve low-serum drug concentrations before surgery.

Preoperative medication management in the elderly is commonly nuanced. Special attention to standardized surgery order sets with preset medications is imperative because medications in order sets are commonly inappropriate for older patients. Uniformity and ease of clinical care are some advantages of using a standardized order set. However, the preset doses may put older adults at high risk for hemodynamic, cognitive, or respiratory impairment. Discontinuation or dose adjustment of as needed (or routine) antihistamines, antiemetics, acetaminophen, narcotics, muscle relaxants, and anticonvulsants may be warranted. In some instances, the prescribing provider should be contacted for an in-person evaluation. For example, acute coronary syndromes (ACS ) may present as nausea rather than typical chest pain. Atypical presentations of ACS are more common in older patients. In comparison to typical chest pain, patients with atypical pain or dyspnea were older and had more cardiovascular risk factors yet were significantly less likely to receive evidence-based therapy and suffered worse in-hospital outcomes. The mortality rates were 3%, 2.5%, and 6% in patients presenting with typical chest pain, atypical chest pain, and dyspnea, respectively [65].

Given the high likelihood that medications with central nervous system effects will likely be added postoperatively, an effort to reduce a patient’s anticholinergic or sedative medication burden when possible is ideal. The authors of this chapter consider each clinical encounter as an opportunity to reconcile medications and identify the appropriateness of each medication. Discontinuation or dose reduction starting with the least destabilizing agents is ideal. For example, urinary anticholinergics like oxybutynin and non-benzodiazepine sleeping agents like zolpidem can potentially be stopped, and centrally active muscle relaxants like methocarbamol often can be titrated down (if on high/prolonged doses) or stopped as well. Thought should also be given to employing opioid-sparing techniques to reduce the potential untoward effects of opiate use. These may include scheduled preoperative acetaminophen or the addition of regional techniques such as neuraxial blockade or peripheral nerve blocks when appropriate (see Chap. 19) [56]. Initiating narcotics at half the dosage of typical younger patients and avoiding initiation of long-acting opiates (e.g., topical fentanyl, methadone) or opiates with active metabolites (morphine, meperidine) will also reduce central nervous system burden and potentially lessen delirium and fall risk [56].

Ensuring medications are scheduled in a way to avoid dosing in early morning or very late at night can reduce risk of sleep deprivation and fragmentation and consequently incidence delirium [12]. The National Institute for Health and Clinical Excellence (NICE) recommends efforts to improve sleep quality (i.e., avoiding unnecessary night time interruptions and to reducing environmental noise) to reduce delirium in hospitalized patients [66]. Clinical evidence linking sleep fragmentation with delirium comes from preventative nonpharmacologic strategies in the Hospital Elder Life Program. The nonpharmacologic sleep intervention not only reduced the use of sedative and hypnotics but also reduced delirium incidence [12, 67].

Sensory Impairment

Sensory impairment including vision and hearing loss is extremely common and places inpatient older adults at risk for delirium, falls, and miscommunication with providers. Nearly one in three adults over the age of 65 has hearing loss, and 12% of adults 65–74 years of age have visual impairment with prevalence of both conditions increasing with age [68, 69]. Inquiring about these deficits and use of assistive devices (i.e., hearing aids and glasses) can aid in planning for the patient’s hospital stay. Older adults with sensory impairment should be encouraged to bring these assistive devices with them to the hospital to aid in communication and reduce their risk of delirium. For those with visual or hearing impairment without access to assistive device, interactions can be enhanced by the use of devices such as hearing amplifiers, magnifying glasses or reading glasses, and using reading materials with larger font. Most hospitals will have access to resources such as large-print versions of reading materials for those with low vision. Speaking slowly, in a lower tone (i.e., deepening voice), at moderate volume at eye level can be very helpful in enhancing understanding for those who are hearing impaired. Counterintuitively, yelling does not usually help those with sensorineural hearing impairment. Yelling increases the pitch of the voice and making it harder for most with sensorineural hearing impairment to understand.

Malnutrition and Weight Loss

Malnutrition is common in community-dwelling older adults impacting over 20% of older adults. It is more even more prevalent in institutional settings. Malnutrition places older adults at increased risk for postoperative complications including infections, poor wound healing, delirium, and prolonged length of stay [14, 70]. There are multiple tools available to screen for malnutrition. One brief validated tool is the Mini Nutrition Assessment (Fig. 8.5) [71]. Another approach recommended by the American College of Surgery/American Geriatric Society preoperative guidelines for older adults is to screen for risk of malnutrition by identifying those with one of the following three factors: (1) BMI < 18.5 kg/m2, (2) serum albumin <3.0 g/dL, and (3) unintentional weight loss of 10%–15% within 6 months [14]. Patients with one of these three factors should be referred to a dietician to discuss perioperative nutrition.

Fig. 8.5
figure 5

Mini Nutrition Assessment (MNA©). (The MNA a simple validated tool that can be used for adults 65 years of age in identifying malnutrition. The MNA form is protected by copyright laws © Nestlé, 1994, Revision 2009. N67200 12/99 10 M and is also a registered trademark of ®Société des Produits Nestlé S.A., Vevey, Switzerland, Trademark Owners. www.mnaelderly.com)

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Social Support and Environmental Assessment

For older frail patients, the presence of a good social support is often the determining factor of whether a functionally dependent older adult remains at home or is institutionalized. The lack of available family and friends as caregivers may lead to poor posthospitalization outcomes [72]. Those who are cognitively impaired and without reliable family members or caregivers may have difficulty remembering preoperative instructions and following through on postoperative plans including wound care and medication changes. It is often prudent to question who would be available to help if the patient becomes ill even in robust and healthier older adults.

The older adult’s social support structure can be assessed by asking questions during the social history and also be triggered if dependency is noted during the functional assessment. For example, the clinician should inquire as to who provides help for the specific ADL and/or IADL functions and what time and days these individuals are available. Social work can assist in inquiring about social support prior to surgery allowing for more careful investigation and planning. For some, the lack of adequate social support may mean bringing in other paid or unpaid/family caregivers postoperatively, and for others, this may mean at least a temporary need for nursing homestay after surgery. Careful planning for those with inadequate social support can reduce unnecessary prolongation of hospitalization after surgery to make necessary arrangements and can help ensure that the patient has the needed support to follow through on postoperative recommendations.

Frailty

Frailty is a clinical syndrome that affects 10%–20% of community-dwelling older adults and is one of the leading causes of morbidity and mortality in older adults [73]. A recent consensus statement defined frailty as “a medical syndrome with multiple causes and contributors that is characterized by diminished strength, endurance, and reduced physiologic function that increases an individual’s vulnerability for developing increased dependency and/or death” [74]. Due to rapid population aging, the prevalence of frailty is expected to exponentially increase over the next few decades. The care of older adults with frailty will continue to pose significant and unique challenges to providers and the health-care system . Moreover, as the number of older adults undergoing major surgery increases, the impact of frailty on the perioperative management of older adults will require further research to optimize care and outcomes for these vulnerable patients.

Factors that influence frailty include age, body mass index (including obesity), comorbidity, cognitive impairment, dementia, and environmental or lifestyle factors. Frailty exists on a spectrum to a state of failure to thrive, inanition, and ultimately death. Frailty in older individuals is characterized by diminished physiologic reserve with a heightened vulnerability to decompensation and serious adverse health outcomes following acute stressors. Acute stressors can be minor in nature and result in significant morbidity in frail older patients.

Frailty is an adverse prognostic risk factor for many chronic diseases prevalent in older adults, such as cancer, dementia, coronary artery disease, congestive heart failure, and chronic kidney disease. Thus, there is a relationship between frailty and comorbidity. Frailty is associated with functional decline and disability but can occur independent of these outcomes. Interventions that impact upon frailty are a rapidly developing area of basic and clinical research, and more data are needed to provide optimal medical and surgical care for frail older individuals. Interventions that influence the progression of frailty are currently limited and thus a high research priority.

Pathophysiology

Frailty is a dynamic, accelerated aging process where gene-gene and gene-environment interactions play a significant role in its development and progression. On a systems level, age-related declines in multiple physiological systems, such as the neurologic, musculoskeletal, endocrine, and immune systems, contribute to frailty. Dysregulation of these physiologic systems along with chronic inflammation and changes in levels of steroid hormones and 25-hydroxyvitamin D influences the development of sarcopenia, which is a key feature in those with moderate to severe frailty. Elevations in pro-inflammatory cytokines such as interleukin-6 (IL-6), tumor necrosis factor alpha (TNF-α), and C-reactive protein (CRP) promote chronic low-grade inflammation and contribute to the high prevalence of subclinical and clinical cardiovascular disease among frail individuals.

On a cellular level, cell senescence is a driver of aging phenotypes. Senescence is a state of irreversible growth arrest that occurs in cells upon genotoxic damage, which is a protective mechanism against cancer development. Senescent cells accumulate with aging in tissues. However, this protective mechanism early in life paradoxically promotes aging phenotypes such as cancer in late life. This observation occurs due to elaboration of the senescence-associated secretory phenotype (SASP) by senescent cells, which is pro-inflammatory and pro-tumorigenic in nature [75]. Clearance of senescent cells with small molecule inhibitors has shown promise in reversing signs of age-related pathologies, such as sarcopenia in preclinical models [76]. Thus targeting of senescent cells holds promise to improve our ability to potentially treat and reverse frailty and other age-associated diseases, such as cancer and cardiovascular disease.

Diagnosis

There is currently no gold standard for the diagnosis of frailty. Many frailty tools exist in the literature; however, most are difficult to operationalize into routine clinical practice due to their length or need for technology to measure handgrip strength and gait speed. The gestalt approach to diagnose frailty is unreliable and bias prone. Frailty among obese individuals, termed “sarcopenic obesity,” can be overlooked due to excess adipose tissue masking low muscle mass.

Fried and colleagues characterized the frailty phenotype in a longitudinal study of community-dwelling older adults, which was predictive of adverse health outcomes [77]. The frailty phenotype was defined as a clinical syndrome with three or more of the following features : unintentional weight loss (10 lbs. in the past year), self-reported exhaustion and weakness (measured through grip strength), and slow gait speed and low physical activity. Individuals meeting two features were considered pre-frail and were at intermediate risk for adverse outcomes compared to non-frail individuals. The frailty phenotype was independently predictive of falls, disability in activities of daily living, hospitalization, and mortality. The study also showed that frailty was not synonymous with either comorbidity or disability. Rather, comorbiditie s were a risk factor for frailty, and disability was an outcome of frailty. Frailty was associated with lower socioeconomic status and education as well, demonstrating that extrinsic factors contribute to the syndrome of frailty.

Another conceptual model of frailty is based upon the accumulation of deficits with advancing age. The Frailty Index was devised by Rockwood and colleagues which evaluates impairments in medical, social, psychological, nutritional, and functional domains along with laboratory abnormalities. The more deficits that accumulate in an individual, the more likely for the development and progression of frailty [78]. In addition, there is a positive correlation in the severity of cognitive impairment with frailty.

Prior to the diagnosis of frailty, it is important to exclude potential conditions that can also present with signs and symptoms of weakness, weight loss, and functional decline. Depression, cognitive impairment, thyroid dysfunction, cardiovascular disease, and hematologic and malignant conditions should be considered in the differential diagnosis. A careful medication review should be performed and evaluation for potential drug-drug interactions and adverse drug effects. Other considerations in evaluation of frail patients are psychosocial factors such as food insecurity or dependency for feeding and activities of daily living. A general laboratory work-up for frail patients should include a complete blood count with differential, chemistry panel, liver function panel, prealbumin, vitamin B12, 25-hydroxyvitamin D, thyroid function tests, and hemoglobin A1c. Age-appropriate cancer screening should be considered.

Screening

The ability to detect frailty is important because it can help guide clinical decision-making and identify patients at high risk for adverse outcomes. A positive frailty screen should be followed by a comprehensive geriatric assessment (CGA). The 2013 Frailty Consensus recommended screening for frailty for all persons 70 years or older and those with significant (>5 lbs.) unintentional weight loss in the past year [74]. The current evidence to date supports screening for frailty as a variable in the perioperative risk assessment in older adults. Baseline preoperative frailty has been consistently correlated with poor surgical outcomes, serious adverse events, prolonged length of stay, discharge to an institutional care facility, hospital readmissions, and short- and long-term mortality.

However, no consensus exists on which frailty screening and measurement tool to use. The most well-developed and well-validated are the Fried criteria, Frailty Index, Edmonton Frail Scale, FRAIL Scale, and Clinical Frail Scale-9 (CFS-9). The CFS-9 developed by Rockwood and colleagues was found to be the best predictor of 1-year mortality in hospitalized geriatric patients, when compared to other frailty screening methods [79]. A study by Revenig and colleagues demonstrated that frailty assessment is feasible and provides critical information not captured by traditional surgical risk assessments. These authors used a modified version of the Fried frailty phenotype with shrinking and grip strength and inclusion of hemoglobin and American Society of Anesthesiology Class as additional variables [80].

Following the identification of frailty on a screening tool, comprehensive geriatric assessment can identify other geriatric syndromes that can be optimized in frail individuals and improve perioperative outcomes [81]. Among the criteria in the frailty phenotype, as a single measure for screening, gait speed (m/s) appears to be the best predictor of many adverse health and postoperative complications.

Consequences of Frailty

Frailty increases risk of mortality by twofold, independent of age and comorbidities. For frail older adults who are hospitalized or undergo surgery, these individuals are at increased risk of complications, delirium, cognitive decline, infection, sepsis, prolonged length of stay, institutionalization, disability, and death. In a recent analysis of the National Surgery Quality Improvement Program database, frailty was shown to have a significant impact on postoperative outcomes that varied with type of surgery but did not necessarily correlate with complexity of surgery. Colectomy, esophagectomy, lung resection, pancreatic resection, cardiac procedures, gastrectomy, nephrectomy, endovascular abdominal aortic aneurysm repair, and lower-extremity bypass surgery had the highest to lowest mortality rates in severely frail individuals [82]. Frailty has an important role in trauma care as well. Trauma centers are experiencing a disproportionate rise in the number of elderly trauma patients. Knowledge of the magnitude of frailty on trauma outcomes is needed. However, measures that are easy, reliable, and validated in the trauma population are limited [83]. Surgical intervention in patients who are frail requires knowledge of the patient’s priorities and goals of care in order to set realistic expectations on outcomes, impact on quality of life, and prognosis.

Frailty in Cardiovascular Disease

The majority of cardiovascular deaths occur in older adults. Frailty is common in older adults with cardiovascular disease (CVD ) and confers a twofold increase in mortality even after adjusting for age and comorbidities [84]. Congestive heart failure, chronic angina, and symptomatic atrial fibrillation may limit exertional capacity and contribute to frailty by reducing exercise tolerance and muscle function. Cardiac rehabilitation, which is underutilized, improves outcomes in patients with CVD and may be of particular benefit for frail patients.

The Cardiovascular Health Study screened for subclinical CVD in 4735 older adults. Frail individuals had increased prevalence of wall motion abnormalities and LVH on echocardiography, prehypertension, abnormal ankle brachial indexes, carotid artery stenosis, and brain infarcts on magnetic resonance imaging, which were clinically silent [85]. Current guidelines by the American College of Cardiology/American Heart Association (ACC/AHA) do not discuss frailty. A better understanding of the impact of frailty on CVD outcomes may improve the care of patients with CVD.

Interventions for Frailty

Frailty is potentially reversible if diagnosed early. Team-based and multimodal care which emphasizes physical exercise and treatment of protein-calorie malnutrition improves outcomes for frail older adults [86]. Physical exercise provides benefit to frail persons. However, the type of exercise, such as strength training, resistance, and/or aerobic exercises, and the optimal duration remains unclear [87]. Inclusion of palliative care services is also important for patients who are moderately to severely frail to establish patient-centered goals of care and provide support and symptom management.

Many questions regarding frailty remain to be answered by the field, from the best screening and measurement tools to the most effective interventions. Tools to screen and measure frailty need to be easy to administer, reliable, objective, and validated in the population specific to the patient. Identification of frailty or pre-frailty biomarkers is a rapidly developing area of investigation with the goal to standardize diagnoses, improve prognostication, and monitor the response to interventions. Pharmaceutical drugs are being developed and investigated in preclinical models that can potentially reverse frailty or halt its progression. Clinical trials are needed to evaluate the impact of “prehabilitation” on surgical outcomes in older adults with frailty. The optimal strategy for anesthesia on patients who are frail remains to be defined with the goal to reduce postoperative delirium and cognitive impairment.

Conclusion

A geriatrician’s assessment integrates goals setting, prior functional assessment, and identification of complicating geriatric syndromes into the usual perioperative assessment. Many geriatric conditions and syndromes have multiple causes and contributors that lead to weakness, unintentional weight loss, poor endurance with reduced physiologic reserve, and heightened vulnerability to disability and/or death. Improving the standard of care for these vulnerable patients requires multimodal and interdisciplinary care. Reducing disability and frailty will substantially impact patient quality of life, improve patient-centered outcomes, and reduce health-care utilization and costs.