Preop guidelines published for geriatric surgery patients

Guidelines from ACS and American Geriatrics Society

New comprehensive guidelines for the preoperative care of elderly patients have been issued by the American College of Surgeons (ACS) and the American Geriatrics Society (AGS).

The joint guidelines, published in the October issue of the Journal of the American College of Surgeons, apply to every patient who is 65 years and older.

"The major objective of these guidelines is to help surgeons and the entire perioperative care team improve the quality of surgical care for elderly patients," said Clifford Y. Ko, MD, FACS, director of the ACS National Surgical Quality Improvement Program (ACS NSQIP) and the ACS Division of Research and Optimal Patient Care in Chicago, professor of surgery at University of California, Los Angeles (UCLA) and director of UCLA' s Center for Surgical Outcomes and Quality.

The U.S. Census Bureau projects the percentage of men and women 65 years and older will more than double between 2010 and 2050 and will increase by 20% of the total population by 2030. In 2006, elderly patients underwent 32% of outpatient procedures and 35% of inpatient surgical procedures, according to the study authors.

Gisele Wolf-Klein, MD, FACP, FAGS, director of geriatric education at North Shore-LIJ Health System in Great Neck, NY, and professor of clinical medicine, Hofftra North Shore-LIJ School of Medicine in Hempstead, NY, is "delighted" at the recent release of the geriatric guidelines. "I believe more and more elderly are going to have to face surgery," Wolf-Klein says. "It is imperative that we develop higher quality care criteria for ambulatory surgery patients."

13 key areas to address

The guidelines recommend and specify 13 key issues of preoperative care for the elderly: cognitive impairment and dementia; decision-making capacity; postoperative delirium; alcohol and substance abuse; cardiac evaluation; pulmonary evaluation; functional status, mobility, and fall risk; frailty; nutritional status; medication management; patient counseling; preoperative testing; and patient-family and social support system.

Assessing patient cognitive ability and capacity to understand the anticipated surgery "is particularly important since we have data indicating that between one-third and one-half of patients over the age of 85 have a degree of cognitive impairment, which is often not appreciated and recognized by healthcare practitioners," Wolf-Klein says.

First, you need to make sure the patient understands the procedure and the informed consent process. "You need to make sure the patient has the cognitive ability to undertake the procedure, and to accept and fulfill the postop recommendations," she says. "In other words, if the surgeon recommends drops, ointment, dressing — whatever it is — a person with cognitive impairment might not be able to follow up."

She shares that one of her patients had inguinal hernia repair surgery while he was in Florida. Apparently the patient was told to return to have the sutures removed, but he didn' t obtain follow-up care until he returned to New York and saw Wolf-Klein for a routine visit. The sutures had not been removed, and infection had developed.

To evaluate cognitive impairment, the guidelines suggests a "mini-COG" test based on a clock draw test that Wolf-Klein published about in the mid-1970s. The mini-COG suggests having a patient remember three words, then draw a clock, then repeat the three words. This test is essential but often overlooked, Wolf-Klein says.

A depression screen also is important, she says. Depression is frequently seen in older patients, and those patients typically do worse after surgery because they don' t have the will to carry on and they don' t comply with their surgeon' s recommendations, Wolf-Klein says.

Equally important is the suggestion to identify patients at risk for developing postop delirium, which is often under-recognized and under-treated, she says. While most staff can recognize the signs of hyperactive delirium, they don' t always recognize the signs of hypoactive delirum, when the patient is staring and vague. Patients in that condition often don' t have the capacity to carry out the surgeon' s recommendations, Wolf-Klein says.

The expert panel recognized there are complex problems specific to the elderly, including use of multiple medications, functional status, frailty, risk of malnutrition, cognitive impairment, and comorbidities. "When surgeons evaluate elderly patients before they undergo operations, they want to know how many and what specific medications their patients are taking. This step will enable them to identify potential medication issues before operations and before the surgeons start adding pain medication to the patient' s medication list," Ko explained.

The guidelines state that you should "consider minimizing the patient' s risk for adverse drug reactions by identifying what should be discontinued before surgery or should be avoided and dose reducing or substituting potentially inappropriate medications."

Check for underlying medical problems

The number and severity of underlying medical problems call for special strategies by the entire surgical team, according to Ko.

"Patients who are 90 years old tend to have more comorbidities than those who are 65 years," he said. "There may be something wrong with the heart, the lungs, the kidneys, the liver. Surgeons have to plan and deal with these comorbidities simultaneously while the patient is undergoing a surgical procedure."

The guidelines state that evaluating patients for developing heart disease and heart attack is critical to identify patients at higher risk. All patients should be evaluated for perioperative cardiac risk.

"Caring for the elderly generally requires a team approach," said Ko. "The surgeon knows how to perform surgery, and the cardiologist knows how to take care of the heart. It' s best for everyone to work together to take care of the patient. We want everyone on the same page of providing good quality care."

ACS NSQIP has worked with the Centers for Medicare and Medicaid Services (CMS) to develop "The Elderly Surgery Measure." This hospital-based measure assesses the outcome of elderly patients undergoing surgery. At press time, the ACS and CMS were scheduled to launch a pilot program in October that would give hospitals the opportunity to publicly and voluntarily report the outcome results.