Assessment of the Elderly Patient

Dr Irwin Foo
Lecture Abstract : 2013 Conference

With the ever growing elderly population, it is inevitable that we will be involved in the assessment of increasingly older patients for a myriad of surgical procedures in our clinics. As healthcare professionals, we have to realise that the practice of ‘one size fits all medicine’ is inappropriate for this group of surgical patients. We are all well aware that elderly patients have multiple comorbidities and variable ageing processes which determine their ability to withstand surgical insults. What we are less appreciative of are the elderly specific issues and process measures that are more applicable for this group e.g. risk of delirium , polypharmacy issues1. Understanding these elderly specific issues will help us plan and improve/facilitate good practice in this age group. This talk will explore some of these issues:

Accurate assessment of functional reserve has allowed for better preoperative optimisation of this patient group. However, elderly surgical patients can be poor historians and this has implications in terms of preoperative risk assessments. The use of dynamic tests such as cardiopulmonary exercise testing (CPET) or even testing the ability to climb stairs may be more appropriate. Furthermore, using clinical history alone has been shown to be inadequate in selecting patients for CPET2. Frailty is the state of being easily broken and although primarily a geriatric syndrome, it is increasingly recognised as a powerful indicator of outcomes in the elderly3. Assessment of frailty using a scoring system which includes dynamic tests should be incorporated in the preoperative clinic setting as this may facilitate risk assessment and act as a trigger for medicine of the elderly involvement. The current gold standard is the use of the comprehensive geriatric assessment tool as championed by the POPS team (Proactive Care of Older People undergoing Surgery) in St Thomas’s Hospital, London4. An alternative model is the enhanced recovery plus clinic which is being piloted at present at the Western General Hospital, Edinburgh.

Identification of patients at high risk of delirium – this condition is not just a nuisance but it prolongs hospital stay, increases hospital acquired complications and mortality5. Unfortunately, delirium may be missed in up to two-thirds of cases especially the hypoactive subtype. Preoperative identification of patients at high risk of developing postoperative delirium coupled with recovery room delirium detection appears promising. It allows strategies to be put into place to reduce the severity and duration of delirium. e.g. proactive geriatric consultation6 or the use of pharmacological agents.7

Prehabilitation describes the relatively new concept of exercise training before undergoing surgery. Exercise is safe even for frail elderly patients and has beneficial effects e.g. increasing muscle strength, improving balance and postponing cognitive decline. Small scale studies have demonstrated a reduction in postoperative respiratory complications with this simple strategy.8

Information giving/Education of the older patient is important to manage expectations especially in terms of functional outcomes (e.g. activities of daily living take an average of 3 months to recover after abdominal surgery9) and postoperative cognitive dysfunction (POCD) - the deterioration of cognitive function (e.g. concentration or memory weeks and months after an operation) which tends to recover in the majority with time10.


References

1.  McGory ML et al. Developing quality indicators for elderly surgical patients. Ann Surg 2009;250:338-347

2.  Wilson RJT et al. Impaired functional capacity is associated with all-cause mortality after major elective intra-abdominal surgery. BJA 2010; 105: 297-303

3. Mackary MA et al. Frailty as a predictor of surgical outcomes in older patients. J Am Coll Surg 2010; 210: 901-908.

4.  Harari et al. Proactive care of older people undergoing surgery (‘POPS’): designing, embedding, evaluating and funding a comprehensive geriatric service for older elective surgical patients. Age and Ageing 2007;36:190-196.

5.  O’Regan NA et al. Delirium: A key challenge for perioperative care. Int J of Surg 2013;11:136-144

6.  Marcantonio ER et al. Reducing delirium after hip fracture: a randomised trial. J Am Geriatr Soc 2001;49:516-22.

7. Wang W et al. Haloperidol prophylaxis decreases delirium incidence in elderly patients after non-cardiac surgery: A randonised controlled trial. Crit Care Med 2012;40:731-739.

8.  Valkenet K et al. The effects of preoperative exercise therapy on postoperative outcome: a systematic review. Clinical Rehab 2011;25: 99-111.

9.  Lawrence VA et al. Functional independence after major abdominal surgery in the elderly. J Am Coll Surg 2004;199: 762-772.

10.  Abildstrom H et al. ISPOCD group. Cognitive dysfunction 1-2 years after non-cardiac surgery in the elderly. International Study of Post-Operative       Cognitive Dysfunction. Acta Anaesthesiol Scand 2000;44:1246-1251.