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AGS THE AMERICAN GERIATRICS SOCIETY Geriatrics Health Professionals.

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Presentation on theme: "AGS THE AMERICAN GERIATRICS SOCIETY Geriatrics Health Professionals."— Presentation transcript:

1 FUNCTIONAL ASSESSMENT OF THE GERIATRIC SURGICAL PATIENT Rubina Malik, MD, MSc April 11, 2011
AGS THE AMERICAN GERIATRICS SOCIETY Geriatrics Health Professionals. Leading change. Improving care for older adults. Topic

2 OBJECTIVES Be able to identify:
Components of a geriatric assessment for surgical patients Common complications seen in elderly surgical patients Patients at high risk of geriatric syndromes There is growing evidence that perioperative care for the elderly is markedly different than that for nonelderly patients. One of my goals is that by the end of this presentation you will be able to identify the key components of a geriatric assessment, with a particular emphasis on the hospitalized surgical patient. Another goal is that with the geriatric assessment you will be able to identify patients at high risk of common geriatric syndromes and know how to approach them.

3 GROWING PROPORTION OF ELDERLY IN THE U.S. POPULATION
To begin, I want to highlight to you some changes that are anticipated in the US population over the next few decades. For those of you who are unaware, in 2010, the first set of baby boomers turned 65, and by 2030, it is anticipated that 1in 5 US residents will be geriatric. This means that from the current 38 million, the geriatric population is expected to rise exponentially to 88.5 million in 2050, more than doubling the number. In addition, one of the fastest growing segment of the geriatric population is the oldest old, or those >85 years of age. This is because of improved life expectancy; the numbers of individuals living into old age will be increasing. The number of people 85 years and older is expected to more than triple, from 5.4 million to 19 million between and 2050.

4 COMORBIDITIES IN THE ELDERLY
Besides this tremendous growth in the number of older individuals, we know that older individuals carry the burden of chronic disease. More than 80% of the elderly have 1 or more chronic disease. With increasing age, the burden of chronic disease increases even more.

5 Chronic Disease Burden
82% of elderly have at least 1 chronic disease 65% have 2 or more chronic diseases Chronic disease burden increases with increasing age Medicare expense increases exponentially with increasing disease burden Disease Hospitalizations Wolff Arch Intern Med 2002

6 IMPACT OF THE AGING POPULATION ON THE SURGERY WORKFORCE
Proportion of work within surgical specialty by age group <15 y 1544 yr 4564 yr 65+ yr Cardiothoracica 0% 0.3% 29.4% 70.3% General surgeryb 2.6% 12.3% 25.5% 59.6% Neurosurgery 2.8% 12.9% 39.1% 45.2% Ophthalmology 0.6% 0.7% 10.8% 88.0% Orthopedic surgery 16.1% 31.8% 51.4% Otolaryngology 39.6% 22.1% 29.9% 8.4% Urology 4.0% 6.3% 24.9% 64.8% The aging population will significantly increase the demand for surgical services. These data from 1996 highlight that for the most part, the geriatric population accounts for >50% of surgical specialties except ENT. It is anticipated that the surgical workforce will need to grow to meet the coming demands. In April 2008 the Institute of Medicine published a consensus report on the aging population. The media were quick to jump on the report, which highlighted that the nation is grossly unprepared for the aging population. Not only are there not enough geriatricians, but there are not enough workers specializing in the care of older adults, such as nurses, nurses aides, social workers, psychiatrists, pharmacists, and home aides. Unfortunately, too few surgeons and specialists have specific training in geriatric principles. The Institute of Medicine actually called for an expansion of geriatrics training. While we may not be able to produce enough geriatricians, we can certainly expand the knowledge and skills of primary care physicians and surgeons to meet the oncoming demands. Source: NHDS and NSAS 1996 aIn the 1996 NHDS sample, the incidence rate for specific cardiothoracic procedures in pediatric patients was too small to allow an accurate incidence rate bCategory includes vascular, breast, hernia, abdominal, gastrointestinal, and pediatric procedures Etzioni Ann Surg 2003

7 CASE STUDY An 83-year-old man presented to Montefiore’s ER in April 2009 with abdominal pain X-rays revealed dilated loops of small bowel The patient was evaluated by a surgical resident and admitted for possible small-bowel obstruction A medical consult was called for preoperative clearance for possible laparotomy

8 CASE STUDY (continued)
Medical issues: Precipitating factors for hospitalization Assess medical comorbidities Preoperative assessment At Montefiore our Geriatrics Division is primarily a hospitalist program. We provide a large number of consultations to the surgical services on elderly patients who present with acute surgical issues. In training house staff, we focus on the initial evaluation of a patient. It is important to understand that perioperative complications are extremely high in geriatric population, and a thorough assessment of both known and unknown comorbidities will help in the management of this group. 8

9 CASE STUDY (continued)
Past medical history Hypertension, 2 strokes, no surgical history Social Lives alone; has a private aide Medications Lisinopril 20 mg/day, multivitamin, metoprolol 25 mg BID, Aggrenox 1 capsule BID, Zocor 80 mg/day, Ativan 1 mg PRN

10 CASE STUDY (continued)
Physical exam BP 157/87, pulse 101, temperature 97.9 °F General – awake and alert, lungs clear, CV tachycardia, S1, S2 normal Abdomen distended, bowel sounds tinkling, hyperactive, mild tenderness with deep palpation. Extremities without edema Labs Creatinine 1.1, WBC 16, hmg 12.5, urinalysis rare WBCs EKG sinus tachycardia, normal axis, normal intervals, no Q-waves Based on the available data we now have to risk-stratify our patient.

11 ACC/AHA Preoperative Risk Assessment
Determine patient’s risk factors Assess functional level Surgical risk of procedure Several organizations have published clinical practice guidelines, most notably the American Heart Association/American College of Cardiology, or AHA/ACC, which published a guideline for perioperative cardiovascular evaluation for noncardiac surgery. This guideline was updated in 2007 and it focuses clinicians’ attention on 3 major areas: clinical risk predictors, surgery-specific risks, and functional capacity, to ensure a balanced evaluation. Fleisher Circulation 2007

12 Clinical Predictors of Perioperative Cardiac Risk
Major Acute MI <7 days Recent MI (>7 days but <1 month) Unstable or severe angina Large ischemic burden by symptoms or noninvasive testing Decompensated CHF Significant arrhythmias (high-grade AV block, SVT) Severe valvular disease Intermediate Mild angina Remote prior MI Compensated heart failure Creatinine > 2.0 mg/dL Diabetes mellitus Low Advanced age* Abnormal ECG Rhythm other than sinus Low functional capacity* History of stroke* Uncontrolled systemic hypertension Predictors of risk are stratified into major, intermediate and low risk factors. For our patient with an acute abdomen, I identified 3 risks in the low- risk category: age >70, history of stroke, and I anticipate he has low functional activity because he had am aide who was there to do things for him, although I really don’t know his functional capacity. In the intermediate-risk category, it is important not only to look at the absolute creatinine >2.0 as a risk factor, but also to calculate the estimated creatinine clearance for all geriatric patients. In our frail, older patients a normal creatinine may actually indicate reduced renal reserve. *Our patient

13 Functional status 14 METs — standard light home activities, walk around the house, walk 12 blocks on level ground 59 METs — climb a flight of stairs, walk uphill, walk on level ground briskly, run a short distance >10 METs — strenuous sports, heavy professional work Exercise tolerance is a major determinant of preoperative risk. It is usually evaluated by the estimated energy required for various tasks and graded in metabolic equivalents on a scaled defined by the Duke Activity Status index. Functional status is also categorized into low, intermediate, and high level of function. The lower the level of activity, the higher the perioperative complications. For our patient, I am not sure of his level of activity because it was not reported. Fleisher Circulation 2007 13

14 ACC/AHA Preoperative Risk Assessment
Age and hx of strokes are minor risk factors Chronic kidney disease is an intermediate risk factor, so calculate creatinine clearance Exercise tolerance is important in risk stratification Intra-abdominal surgery is an intermediate risk factor 1%5% risk of cardiovascular events In summarizing our patient’s risk assessment, age is a minor risk factor. He does not have chronic kidney disease, but his creatinine clearance should be calculated. Functional status, which is very important in the risk stratification, is unknown. The final area of assessment is the risk associated with the procedure itself. Vascular procedures carry a high risk of cardiovascular complications. Our patient with an acute abdomen falls into the intermediate-risk category for intraperitoneal and intrathoracic surgery, with a 1% to 5% risk of cardiovascular events. The patient is undergoing an intermediate-risk procedure. Fleisher Circulation 2007

15 CASE STUDY (continued) Medical Consult Note
No contraindication to exploratory laparotomy Optimize blood pressure Increase metoprolol to achieve target heart rate of 6070 beats/min Continue lisinopril Hold Aggrenox until cleared by general surgery to resume Optimize pain control Initiate DVT prophylaxis postoperatively In my experience, it is often very helpful to be explicit. Remember, the first person reading the consult is a first-year surgical intern who will probably start with whatever is familiar to him or her.

16 CASE STUDY (continued)
The patient undergoes exploratory laparotomy and is found to have stricture in the distal cecal area from an adenocarcinomatous mass He has a resection of the lesion and has a colostomy bag placed On post-op day 1, he is hypertensive, tachycardic, and more confused, according to the nursing staff Urgent medical follow-up is requested The patient undergoes a successful exploratory laparotomy and is found to have a cecal mass that is adenocarcinoma. He has the lesion resected and has a colostomy bag placed. On post-op day 1 he is hypertensive, tachycardic, and more confused according to the nursing staff, and an urgent medical follow-up is requested. What happened to him? Did we miss anything?

17 PERIOPERATIVE COMPLICATIONS
Older (>80 years) surgical patients 20% more likely to suffer at least one or more complications Pneumonia (5.6% vs 2.3%) UTI (5.6% vs 2.2%) Require intubation (2.8% vs 1.6%) Progressive renal failure (1.0% vs 0.4%) MI (1.0% vs 0.4%) Cardiac arrest (2.1% vs 0.9%) A very nice study by the Veterans Administration showed just how vulnerable our older individuals are in the perioperative period. This study analyzed 27,000 surgeries from 1991 to and found high rates of mortality and morbidity in patients > 80. Data from this study is a powerful piece of information to show us how vulnerable older adults are to morbidity and mortality in the perioperative period. Older surgical patients are twice as more likely to suffer pneumonia, uti, intubation, renal failure, MI and cardiac arrest in the perioperative period. Hamel JAGS 2005 Topic

18 Comprehensive Geriatric Assessment
Functional assessment Gait and mobility Sensory assessment Activities of daily living Instrumental activities of daily living Cognitive assessment Decision-making capacity Medication review Recognizing that older individuals are vulnerable during the perioperative period and that our current assessments often miss much vital information, an expert panel composed of surgeons, geriatricians, internists, and anesthesiologists selected several quality indicators to optimize the care of elderly surgical patients. This is called the comprehensive geriatric assessment. All elderly patients undergoing surgery should have a comprehensive geriatric assessment that includes a functional assessment, a cognitive assessment, and a medication review. Ideally this should be performed 8 weeks prior to surgery, but it can also be attempted on geriatric patients admitted for nonelective surgery. Domains to be addressed in the functional assessment include gait and mobility, vision and hearing, and activities of daily living. Once cognitive assessments are made, there has to be documentation of the patient’s decision-making capacity. McGory Annals of Surgery 2009 18

19 Functional assessment: GAIT AND MOBILITY
Ambulatory status Assistive device Any falls? Timed “Get up and go” test A functional assessment ideally should include an evaluation of gait and mobility, identifying whether the patient can walk or not, whether they need assistive devices, and whether they have a history of falls. It should also include the timed “Get Up and Go” test. Mathias Arch Phys Med Rehab 1986 McGory Annals of Surgery 2009

20 TIMED “GET UP AND GO” TEST
Have the patient sit in a straightback chair Get up (without the use of armrests) Stand still momentarily Walk forward 10 feet (3 meters) Turn around and walk back to chair Turn and be seated <20 seconds: patient is independently mobile >30 seconds: patient needs the assistance of others and is probably at high risk of falls Difficulty rising from a chair = leg weakness, a key indicator of falls risk. Factors to note include sitting balance, transfer from sitting to standing, pace and stability of walking, and ability to turn without staggering. If an assistive device is indicated, ask whether the patient has one and determine whether it is being used properly.

21 Functional assessment: SENSORY DEFICITS
The prevalence of sensory deficits increases with increasing age. These deficits probably affect more than a third of elderly patients. It is prudent to note whether patients have difficulty with hearing or vision and whether they use appropriate assistive devices such as eyeglasses and hearing aids. Mathias Arch Phys Med Rehab 1986 McGory Annals of Surgery 2009

22 FUNCTIONAL ASSESSMENT: ACTIVITIES OF DAILY LIVING
Bathing Dressing Toileting Transfer Continence Eating Asking about activities of daily living, or ADLs, is really helpful in assessing a patient’s functional status. The Activities of Daily Living instrument was created by Dr. Katz and colleagues in the 1960s while studying a group of patients with acute hip fractures. They noted that with the acute event, patients tended to lose their ability to perform these simple tasks. There is a hierarchy built into the ADLs instrument. If you were to ask one question, it would be, “Can you bathe independently?” If the patient says yes, you know that they are able to do all the skills below that activity, that is, dressing, toileting, transfer, continence and eating. The ADLs is an instrument that I use in my most impaired patients, such as hospitalized or nursing home patients. Katz JAMA 1963 Lawton Gerontologist 1969

23 PREVALENCE OF ADL LIMITATION BY AGE GROUP

24 FUNCTIONAL ASSESSMENT: INSTRUMENTAL ADLS
Using the telephone Traveling Shopping Preparing meals Housework Taking medication Handling money Questions about instrumental ALDs, or IADLs, are more likely to be used in the ambulatory setting. What I find very useful is that impairment in IADLs is a very good indicator of early cognitive or functional decline. A patient requires investigation if previously they were able to perform their IADLs but are now unable to do one or more activities. Is it because they are developing a physical impairment or is it an early cognitive impairment? Similar to the ADLs, there is a hierarchy in the IADLs. The first question to ask is whether the patient is able to manage their finances independently. A patient who is able to perform the IADLs probably has at least an intermediate level of functional activity. Katz JAMA 1963 Lawton Gerontologist 1969

25 PREVALENCE OF ADL AND IADL IMPAIRMENT BY YEAR

26 Cognitive assessment Screening tools for dementia
Mini-Cog Assessment (Mini-Cog) Short Portable Mental Status Questionnaire (SPMSQ) There are many cognitive assessment tools that can be used. The MMSE is one that we are all familiar with, so I would like to introduce you to the Mini-Cog and the Short Portable Mental Status Questionnaire. Borson Int J Geri Psych 2000 Folstein J Psych Res 1975 Pfeiffer JAGS 1975

27 Mini-Cog 3-Item recall Clock drawing Apple, penny, table
The Mini-Cog is very easy to do and quick. Its components are the 3- item recall and clock drawing. The only caveat is whether the patient will have the manual dexterity and visual input to carry out the clock drawing activity. Patients are asked to remember 3 items: apple, penny, and table. Then they are asked to draw a clock face, which is a visual spatial activity. After the completion of the clock drawing, patients are asked to recall the 3 items. Any difficulty with the item recall or the clock drawing is considered abnormal, and patients should be referred for further neuropsychological testing.

28 Short Portable Mental Status Questionnaire
SCORING:* 02 errors: Normal 34 errors: Mild impairment 57 errors: Moderate impairment 8 or more errors: Severe impairment *Allow 1 more error if the patient has had a grade school education or less Allow 1 less error if the patient has had education beyond high school 10 item verbal questionnaire -orientation -current events – presidents - serial 3 1. What is the date, month, and year? 2. What is the day of the week? 3. What is the name of this place? 4. What is your phone number? 5. How old are you? 6. When were you born? 7. Who is the current president? 8. Who was the president before him? 9. What was your mother's maiden name? 10. Can you count backward from 20 by 3's? Another instrument is the Short Portable Mental Status Questionnaire, or SPMSQ, which is a verbal questionnaire. There are 10 items on this questionnaire and it can be performed quickly in the office or hospital. The instrument was studied in hip fracture patients, and those who were unable to complete 3 questions had a worse prognosis. Unlike the Mini-Cog, the patient’s level of education can impact the scoring. Both the Mini-Cog and the SPMSQ are meant to be screening tools. They have been validated and have been noted to be very helpful in identifying cognitive impairments. However, patients with dementia will need to go through further neuropsychiatric testing to identify the type of dementia they have. Pfeiffer JAGS 1975

29 PREVALENCE OF COGNITIVE IMPAIRMENT
Besides knowing about a patient’s baseline functional status, there should be some understanding about a older patient’s cognitive abilities. Dementia is present in 5% to 15% of the population. The prevalence increases with increasing age, and it increases the risk of falls and perioperative delirium.

30 Decision-Making Capacity
If patient is able to give informed consent: Describe the surgery Identify potential complications Explain alternatives to surgery Elicit patient priorities and preferences Discuss advance directives Otherwise, identify surrogate or proxy who can: State patient’s priorities and preferences Identify the goals/preferred aggressiveness of care McGory Annals of Surgery 2009 Slide 30

31 IMPACT OF Cognitive and Functional Impairment
Increased mortality Increased length of stay Increased risk of medical complications Difficulty with rehab programs Increased risk of nursing home placement Givens JAGS 2008 Gruber-Baldini JAGS 2003

32 Medication Review Reconcile medications at home and in hospital
Confirm that there is an indication for every medication Adjust dose for renal function Calculate creatinine clearance Adjust for NPO status Identify potentially inappropriate medications Beers list Older patients take a disproportionate number of medications. In addition, they are predisposed to adverse drug reactions due to age- related changes in pharmacokinetics. It is important to match medications taken at home with the hospital regimen. All agents should have an indication for use, and all agents should be adjusted for renal function and for the NPO status. Potentially inappropriate medications should be identified. Several groups and classes have been identified as agents that should be avoided in the elderly. The Beers paper is probably the most widely known, and it includes a list of drugs that should not be prescribed above certain doses, as well as drug-disease and drug-drug combinations to avoid. Potter Clin Ortho Relat Res 2004 Rothberg 2008 J Hosp Med Steinman 2009 Arch Intern Med Beers Arch Intern Med 1997

33 CASE STUDY (continued)
Additional history from the patient’s daughter: Past medical history Patient has had several falls due to an unsteady gait. Wears glasses but still has poor vision. Needs a hearing aid but was unable to afford it. Social history Lives alone. Used a walker because of unsteady gait. Daughter came every week to pre-pour his medications and manage his finances. The private aide came daily to do the cooking, shopping, household cleaning, and watch over while he bathed. Impaired in 5/7 IADLs, 1/6 ADLs. Medications Took Ativan most nights because of difficulty sleeping and hallucinations at night.

34 CASE STUDY (continued)
Findings from post-op physical exam BP 190/100, pulse 110, temperature °F, pain 67 Lungs clear, CV tachycardia, S1, S2 normal Abdomen flat, no bowel sounds Colostomy bag had small amount of serosanguineous fluid surgical incision was intact Extremities were without edema The patient was awake, alert, and coherent but not oriented to place or time. He could relate what happened to him but was unable to recite current events in the world. Attention span was poor—he could not repeat 3 words and had waxing and waning mental status. Labs and EKG: no change from pre-op findings

35 In-HOSPITAL Delirium 40%-60% prevalence
Persisted in 32% at 1 month post-op Associated with worse outcomes Falls Incontinence Delayed recovery Prolonged length of stay Delirium is a major perioperative complication. It can occur at any time during the hospitalization for the patient with an acute hip fracture, and it can persist for a prolonged period. In one study, nearly half of patients with an acute hip fracture had delirium preceding their surgery, and the delirium often persisted postoperatively. Delirium was associated with greater odds of all 1-month and 6-month negative outcomes. Several studies have shown that patients with delirium have increased length of stay; suffer from post-op complications such as urinary incontinence, feeding problems, and pressure ulcers; have a higher likelihood of being institutionalized; and have less chance of recovering their preoperative functional status. Givens JAGS 2008 Mercantonio JAGS 2000 McGory Annals of Surgery 2009

36 DIAGNOSING DELIRIUM: CONFUSION ASSESSMENT METHOD (CAM)
Hallmark findings are: Acute onset and fluctuating course Inattention Disorganized thinking Altered level of consciousness The diagnosis of delirium by CAM requires the presence of features 1 and 2 and either 3 or 4 Sensitivity 94%100%, specificity 90%95% Conduct daily screening for the first 5 inpatient days after surgery It is well documented that delirium is under-recognized in hospitalized patients. Because patients with an acute hip fracture may have difficulty concentrating during the acute illness, it important to rule out acute delirium and obtain surrogate information regarding cognitive status. It is important to realize that delirium and dementia can coexist in more than half of all patients with hip fracture. The Confusion Assessment Method has been widely studied in the hospitalized patient and is determined to have good sensitivity and specificity. Inouye Ann Intern Med 1990 McGory Ann Surg 2009

37 Delirium: a Geriatric syndrome
INTERVENTIONS Electrolytes/fluid Oxygen Treat infections Treat urinary retention Treat constipation Manage pain Geriatric consultation RISK FACTORS >80 years of age Dementia Functional impairments Sensory deficits Multiple comorbidities Meperidine Delirium Delirium is another geriatric syndrome and has been studied in many hospitalized patients. Evidence-based risk factors for delirium in hospitalized patients have been identified as older age; dementia; having functional impairments, specifically sensory deficits; and the use of meperidine. In the hip fracture literature, interventions targeting infections, urinary retention, constipation, and pain were noted to reduce the rates of delirium in comparison with controls. In addition, having a geriatric consultation reduced the rates of delirium. I will briefly review each of these interventions as they pertain to the hip fracture patient. Inouye Ann Intern Med 1993 Siddiqi Cochrane Database Sys Rev 2007 McGory Annals of Surgery 2009

38 IMPACT OF GERIATRICS CONSULTATION ON DELIRIUM (1 of 3)
126 patients randomized after hip fracture Proactive geriatrics consultation was compared with usual care Geriatrics consultation occurred within 24 hours of admission and daily thereafter Structured protocol with 10 modules Primary outcome measure: incidence of delirium Marcantonio et. al. JAGS. 2001; 49:

39 IMPACT OF GERIATRICS CONSULTATION ON DELIRIUM (2 OF 3 )
Cumulative incidence of delirium reduced by 1/3 (50% to 32% intervention arm) NNT = 5.6 Incidence of severe delirium reduced by 50% (29% to 12% intervention arm) Geriatrics consultation was associated with a statistically significant one-third reduction in the incidence of delirium compared with usual care, and an even greater reduction in the incidence of severe delirium. Reduction in delirium was not associated with shortened length of stay. Marcantonio et. al. JAGS. 2001; 49: Topic

40 IMPACT OF GERIATRICS CONSULTATION ON DELIRIUM (3 of 3)
Geriatric components of the protocol Pain assessment Medication reconciliation Bowel and bladder function Nutrition Mobilization Environmental stimuli Agitation Marcantonio et. al. JAGS. 2001; 49:

41 PAIN MANAGEMENT Pain is undertreated in cognitively impaired elders
Poorly controlled perioperative pain can result in: Increased length of stay Delayed ambulation and function More complications Pain is a given with any surgery. Unfortunately, in patients with acute hip fractures, the high rates of dementia and delirium often preclude effective pain treatments. Higher pain levels after orthopedic surgery have been associated with longer lengths of stay, more complications, delays in ambulation, impaired functional recovery, and greater suffering. Morrison Pain 2003

42 PAIN PROTOCOL 249 hip fracture patients in a rehab setting
A novel interdisciplinary analgesic program was compared with usual care Fixed regimen of acetaminophen and opioids (oxycodone 3 mg q4h in pts > 70 years of age) Bowel regimen Pain reassessed frequently, rescue drug added PRN Primary outcome measures: pain scores, performance Novel protocol resulted in: Reduced pain at rest and with physical therapy Better performance on activities In selecting drug doses for older patients, the rule is to start low and go slow. Opioids can be used safely and effectively for postoperative pain and chronic pain as long as meperidine and propoxyphene are avoided, because both can cause delirium. Several studies suggest that when pain is well managed in hip-fracture patients, delirium is lessened. In a randomized study of patients undergoing surgery after hip fracture, researchers found that the implementation of 9 specific interventions, including pain management, significantly reduced delirium by one third. Pain management consisted of around-the-clock acetaminophen, 1 g 4 times daily; low- dose subcutaneous morphine early in the postoperative period; and oxycodone later in the postoperative period . Patients who received the novel intervention reported significantly less pain at rest and with physical therapy than patients who received usual care. Patients in the intervention arm had significantly faster 8-foot walk times at rehabilitation. Morrison Pain 2003

43 Urinary Problems AFTER HIP FRACTURE
Incontinence 21% of 6,500 women were incontinent at discharge Retention Of 244 women who had post-voiding residual volume measured: 37% had retention before surgery 56% had retention at 24 hours post-op 22% had retention at 5 to 7 days post-op Retention was a risk factor for mortality in first year Urinary incontinence is extremely common among men and women, especially with increasing age. Overactive bladder is reported to be the most common cause in both men and women; conservative estimates of its prevalence are 12%. Urinary incontinence is a geriatric syndrome and is associated with significant adverse outcomes, including falls. Treatment is with anticholinergic agents such as oxybutynin and tolterodine. Studies in hip fractures are limited but have shown an incidence of newly diagnosed incontinence in 25% of patients, as well as high rates of urinary retention. Urinary incontinence affects the majority of older patients with hip fracture because of mobility limitation. This can lead to cellulitis and pressure ulcers and is best treated with timed toileting, every 2 hours. More research is needed to identify appropriate interventions. Studies have recommended early removal of Foley catheters, reducing or eliminating anticholinergic agents, and treating constipation with early mobility. Palmer J Geront Bio Sci 2002 Halm Arch Intern Med 2003 Smith, Age Aging, 1996

44 Constipation Clinical trial after hip fracture
46 patients Most were on bowel regimens with opioids 70% developed newly diagnosed constipation postoperatively Advanced age and poor nutritional status were significant predictors Risk factors for constipation: older age, hospitalization, immobility, narcotics, anesthesia Elderly people frequently suffer from intestinal complaints, which can have a considerable impact on their quality of life. Constipation is common, with a prevalence ranging from 2% to 28% in the elderly population. The incidence rises to more than 80% among residents in homes for the old. Constipation is also one of the most frequent adverse drug reactions in hospital inpatients. Because of an increase in opioid receptors in the colon, older patients are more likely to experience constipation associated with postoperative pain medications. Therefore, stimulant (senna) or osmotic laxatives should be started at the same time as opioid analgesics. Increasing dietary fiber and encouraging oral fluids, as well as encouraging exercise, are established methods of both preventing and treating constipation. Spinzi Dig Dis 2007 Davies J Clin Pharm Ther 2008

45 Use of Antipsychotics Randomized, placebo-controlled study of haloperidol prophylaxis for elderly hip surgery patients at risk of delirium 430 patients randomized 0.5 mg haloperidol TID versus placebo Everyone received proactive geriatric consultation Primary outcome measure, incidence of delirium, did not differ between groups At present the broad use of antipsychotic agents in patients with delirium is not recommended, except in patients with an agitated delirium. As you know, antipsychotic use is associated with a black-box warning. Patients with dementia are at higher risk of cardiovascular events; these patients need to have an ECG prior to using an antipsychotic. Kalisvaart JAGS 2005

46 CASE STUDY (continued)
The patient had cognitive and functional impairments and was deemed to be at high risk of delirium as well as falls He had CAM performed daily The following recommendations were made: He was given his eyeglasses Because he had cognitive impairment with sundowning, his daughter came to the hospital daily to attend to her father’s needs and to orient him He had a urinary tract infection and was treated for it Pain management was optimized with a standing order for Tylenol, and oxycodone prior to rehab A bowel regimen was added once the patient was able to tolerate oral intake

47 SUMMARY “Age in and of itself is never a criterion for medical decision making: function is” Obtain baseline cognitive and functional status Identify common geriatric syndromes Recognize that multiple postoperative geriatric problems are the norm Use a proactive approach to identify causes of common geriatric syndromes

48 Acknowledgments David Hamerman, MD Laurie Jacobs, MD Amy Ehrlich, MD Geriatric Academic Career Award

49 www.americangeriatrics.org THANK YOU FOR YOUR TIME! Visit us at:
Facebook.com/AmericanGeriatricsSociety Twitter.com/AmerGeriatrics linkedin.com/company/american-geriatrics-society


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