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March/April 2013
Comprehensive Preoperative AssessmentBy Stanley J. Dudrick, MD, FACS Comprehensive preoperative assessment and correction of inadequacies or deficiencies to the greatest extent possible is necessary to achieve optimal surgical outcomes in elderly patients. Americans’ increasing life expectancy is resulting in a double-edged sword: As longevity increases, so does the likelihood of pathophysiologic disorders, diseases, or trauma that likely will require hospitalization and significant medical and/or surgical interventions. The elderly undergo significantly more surgical procedures compared with younger age groups. In 2006, they underwent 35.3% of inpatient surgical procedures and 32.1% of outpatient surgical procedures, and as the population continues to age, there will be even greater demands on surgical services.1-3 Therefore, comprehensive screening, especially the assessment of nutritional status and intervention in selected settings, has been proposed as an appropriate cost-effective preventive health and safety measure. For example, in a recent review of malnutrition in nursing homes, researchers documented an alarmingly high rate of 30% to 50% protein/calorie malnutrition which, in turn, was associated with increased mortality rates.4 Moreover, much of this malnutrition was preventable or reversible, although some wasting and nutrient deficiencies commonly result from chronic diseases and disorders and cannot be easily prevented or reversed. On the other hand, many studies have demonstrated that malnutrition is neither integral to aging nor is it inevitable with all illnesses. It is clear that appropriate corrective nutritional interventions have resulted in improvements in quality of life and the nutritional status of community-dwelling elderly, the chronically institutionalized elderly, and the acutely ill elderly.4 Achieving Optimal OutcomesIn acknowledging the necessity for improving the quality of geriatric surgical care, the American College of Surgeons National Surgical Quality Improvement Program and the American Geriatrics Society recently undertook a massive collaborative effort to create best practice guidelines relevant to optimal comprehensive surgical care of geriatric surgical patients, including focusing on optimal preoperative assessment.5 After extensive deliberation and subsequent consensus, this expert panel made evidence-based recommendations for improving the preoperative assessment of geriatric patients. In addition to a complete history and physical examination of the patient, the following assessments are strongly recommended5:
Recommended Corrective MeasuresIf a patient displays evidence of cognitive impairment, consider referral to a mental health specialist for further evaluation. Cognitive impairment and dementia were estimated to occur in 22.2% and 13.9%, respectively, of individuals aged 71 and older in the United States.6,7 The prevalence of dementia increases exponentially after the age of 65, and the number of elderly Americans aged 85 and older with dementia is projected to rise dramatically.8,9 Cognitive impairment is critically important because it strongly predicts postoperative delirium, which is associated with worse surgical outcomes, including longer hospital stays, increased mortality rates, and postoperative functional decline.10 In screening patients for depression, use simple tools such as the Patient Health Questionnaire-2. At minimum, ask the patient the following questions: In the past 12 months, have you ever felt sad or depressed for at least two weeks? In the past 12 months, have you ever experienced a span of two weeks or longer when you didn’t care about the things you usually cared about or when you didn’t enjoy the things that you usually enjoyed?11 If a patient answers yes to either question, then further evaluation is recommended.5 In a recent study, the prevalence of depression among those aged 71 and older was estimated to be 11%.12 The risk factors for depression identified among geriatric patients include female gender, disability, bereavement, sleep disturbance, poor health status, cognitive impairment, living alone, and the recent development of a new medical illness.5 Preoperative depression has been associated with increased sensitivity to pain, increased postoperative analgesic use, and increased mortality, especially after coronary artery bypass graft operations.5 In elderly patients, postoperative delirium is a common complication, and in one study of patients undergoing major elective noncardiac operations, 9% of patients developed postoperative delirium.13 In another study of surgical patients requiring postoperative ICU treatment, 44% of patients demonstrated postoperative delirium.15 Multiple other studies have reported the incidence of delirium in the elderly ranging from 5.1% to 52.2%, with the higher rates following major hip fracture and aortic surgery.14 In addition to any or all of the positive findings in the preoperative assessment, risk factors for developing postoperative delirium include severe illness or comorbidity, renal insufficiency, anemia, hypoxia, dehydration, electrolyte abnormalities, immobilization, hearing or vision impairment, urinary retention or placement of a urinary catheter, constipation, and use of psychotropic drugs or polypharmacy.5,14 Postoperative delirium is associated with higher rates of mortality and complications, increased use of hospital resources and costs of hospitalization, longer duration of stay, compromised functional recovery, and increased rates of subsequent institutionalization.5,10,13-15 Preoperative alcohol and/or substance abuse or dependence are associated with increased rates of postoperative complications and mortality, including pneumonia, infection, sepsis, wound disruption, and prolonged hospital stay. A recent national survey estimated that 60% of individuals aged 50 and older used alcohol, but that fewer used drugs—2.6% marijuana and 0.41% cocaine, respectively.16 In elderly men aged 65 and older, the prevalence of at-risk drinking (two or more drinks per day) and binge-drinking (five or more drinks per day) were 13% and 14.5%, respectively.17 For elderly women in this age group, the prevalence was 8.1% and 3.3%, respectively.17 Patients with alcohol-use disorders should receive daily multiple vitamins containing folic acid along with 100 mg oral or parenteral thiamine, both preoperatively and postoperatively.4,5 Appropriate ScreeningsConsideration should be given to screening patients for alcohol and substance abuse and dependence using the modified CAGE questionnaire (cut down, annoyed, guilty, eye-opener).18 CAGE is derived from the following questions:
Preoperative and postoperative prophylaxis for withdrawal symptoms should be considered for patients who answer yes to any of these questions. If the operation can be delayed safely, motivated patients should be considered for referral to a substance abuse specialist for preoperative controlled abstinence or detoxification.5 Postoperative myocardial infarction is associated with hospital mortality rates of 15% to 25%, and those patients who survive nonfatal myocardial infarction are at greater risk of cardiovascular death for six months after surgery.5 Since older surgical patients are more vulnerable to adverse cardiac events, it is critical to evaluate cardiac risk in the elderly preoperatively according to the ACC/AHA algorithm to effectively communicate operative risk to the patient and determine appropriate preoperative and postoperative management.5 In patients undergoing elective abdominal procedures, pulmonary complications occur more often than cardiac adverse events and are associated with longer hospital stays. They also predicted long-term mortality in elderly patients aged 70 and older undergoing noncardiac surgery. The rate of pulmonary complications in the overall population undergoing noncardiac surgery is 6.8% compared with 14% and 15% in patients aged 65 and older and those aged 70 and older, respectively.5,19 Preoperative measures for preventing or minimizing postoperative pulmonary complications in the elderly include the following5:
Elderly patients should undergo an assessment of their ability to perform daily activities as an evaluation of their functional status. A study of elderly patients undergoing major operations and requiring an ICU stay found that functional dependence was the strongest predictor of mortality for as long as six months postoperatively.20 A VA study of patients aged 80 and older showed that 30-day mortality was more strongly predicted by functional status than by age.21 Additionally, impaired functional status and mobility in elderly patients has been associated with an increased risk of postoperative delirium and surgical site infections. Moreover, an independent preoperative status strongly predicted better postoperative function and shorter recovery periods after major abdominal surgery.22 An abbreviated simplified screening test for assessing baseline current functional status in ambulatory patients includes asking patients the following questions5,23:
If the answer to any of these questions is no, an in-depth evaluation should be carried out, including full assessment of activities of daily living and instrumental activities of daily living.5 All functional deficits should be documented and may benefit from referral to occupational therapy, physical therapy, and proactive discharge planning.5 Frailty is a clinically distinct syndrome from comorbidities and disabilities, and is characterized by decreased physiologic reserve and resistance to stressors, which renders the patient more vulnerable to poor health, falls, worsening mobility and ADL ability, hospitalizations, poor outcomes, and death.24 Frailty independently predicts higher rates of postoperative complications, increased hospital stay, and greater likelihood of discharge to a skilled or assisted-living facility.25 In the elderly, malnutrition has been reported in 5.8% of individuals in the community, 13.8% of individuals in nursing homes, 38.7% of hospitalized patients, and 50.5% of patients going through rehabilitation.26 In patients undergoing elective gastrointestinal surgery, an increased risk of postoperative adverse events has been associated with poor nutritional status, consisting mostly of infectious complications such as surgical site infections, pneumonia, and urinary tract infections; wound complications, including dehiscence and anastomotic leaks; and increased length of hospital stay.27 A minimally acceptable assessment of nutritional status should include documentation of height and weight, and calculation of BMI; measurement of baseline serum albumin and prealbumin concentrations; and notation of any unintentional or unexplained weight loss during the past year.5 Severe nutritional risk is characterized by any of the following within the past six months: BMI < 18.5, serum albumin level < 3, or weight loss > 10% to 15%.5 Patients at severe nutritional risk should undergo a comprehensive nutritional assessment by a dietitian or other qualified member of a nutritional support team to design an effective nutritional plan to address the deficits.4,5 Elderly patients’ risk of adverse drug-related complications should be minimized by identifying all medications that should be discontinued or avoided before surgery and by reducing the dose of or substituting for required medications to the maximum extent possible.5 In patients at risk of developing postoperative delirium, benzodiazepines should be avoided or reduced whenever possible; meperidine should be avoided for treatment of pain (However, pain must be adequately controlled by other means to reduce delirium.); antihistamines and other medications with strong anticholinergic effects should be avoided but if necessary, used with caution; and ACC/AHA guidelines should be followed for starting or continuing beta blockers and statins after surgery. Finally, elderly patients are at greater risk of adverse drug reactions and are more likely to have impaired renal function and chronic kidney disease, requiring that medication dosages be adjusted to compensate for impaired renal clearance.5 Routine preoperative screening tests are not recommended; however, the three exceptions are hemoglobin, renal function evaluation, and serum albumin determinations, which are indicated for all geriatric surgical patients.4,5 Preoperative diagnostic tests should be limited to higher-risk patients based on the history and physical examination, known comorbidities, and surgical procedure to be performed. They should be used selectively as follows5:
In conclusion, comprehensive preoperative assessment and correction of inadequacies or deficiencies to the maximum extent possible is mandatory if optimal surgical results, safety, and outcomes are to be obtained in the geriatric population. — Stanley J. Dudrick, MD, FACS, is the Robert S. Anderson, MD, Endowed Chair and Professor and medical director of physician assistant studies in the College of Arts and Sciences at Misericordia University in Dallas, Pennsylvania. He also is professor emeritus of surgery from the Yale University School of Medicine and chairman emeritus and program director emeritus of the department of surgery from Yale-affiliated Saint Mary’s Hospital in Waterbury, Connecticut.
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