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 AGSTHE AMERICAN GERIATRICS SOCIETYGeriatrics Health Professionals.Leading change. Improving care for older adults.Topic
2 OBJECTIVES Be able to identify: Components of a geriatric assessment for surgical patientsCommon complications seen in elderly surgical patientsPatients at high risk of geriatric syndromesThere 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 disease65% have 2 or more chronic diseasesChronic disease burden increases with increasing ageMedicare expense increases exponentially with increasing disease burdenDiseaseHospitalizationsWolff Arch Intern Med 2002
6 IMPACT OF THE AGING POPULATION ON THE SURGERY WORKFORCE Proportion of work within surgical specialty by age group<15 y1544 yr4564 yr65+ yrCardiothoracica0%0.3%29.4%70.3%General surgeryb2.6%12.3%25.5%59.6%Neurosurgery2.8%12.9%39.1%45.2%Ophthalmology0.6%0.7%10.8%88.0%Orthopedic surgery16.1%31.8%51.4%Otolaryngology39.6%22.1%29.9%8.4%Urology4.0%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 1996aIn the 1996 NHDS sample, the incidence rate for specific cardiothoracic procedures in pediatric patients was too small to allow an accurate incidence ratebCategory includes vascular, breast, hernia, abdominal, gastrointestinal, and pediatric proceduresEtzioni Ann Surg 2003
7 CASE STUDYAn 83-year-old man presented to Montefiore’s ER in April 2009 with abdominal painX-rays revealed dilated loops of small bowelThe patient was evaluated by a surgical resident and admitted for possible small-bowel obstructionA medical consult was called for preoperative clearance for possible laparotomy
8 CASE STUDY (continued) Medical issues:Precipitating factors for hospitalizationAssess medical comorbiditiesPreoperative assessmentAt 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 historyHypertension, 2 strokes, no surgical historySocialLives alone; has a private aideMedicationsLisinopril 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 examBP 157/87, pulse 101, temperature 97.9 °FGeneral – awake and alert, lungs clear, CV tachycardia, S1, S2 normalAbdomen distended, bowel sounds tinkling, hyperactive, mild tenderness with deep palpation.Extremities without edemaLabsCreatinine 1.1, WBC 16, hmg 12.5, urinalysis rare WBCsEKG sinus tachycardia, normal axis, normal intervals, no Q-wavesBased on the available data we now have to risk-stratify our patient.
11 ACC/AHA Preoperative Risk Assessment Determine patient’s risk factorsAssess functional levelSurgical risk of procedureSeveral 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 MajorAcute MI <7 daysRecent MI (>7 days but <1 month)Unstable or severe anginaLarge ischemic burden by symptoms or noninvasive testingDecompensated CHFSignificant arrhythmias (high-grade AV block, SVT)Severe valvular diseaseIntermediateMild anginaRemote prior MICompensated heart failureCreatinine > 2.0 mg/dLDiabetes mellitusLowAdvanced age*Abnormal ECGRhythm other than sinusLow functional capacity*History of stroke*Uncontrolled systemic hypertensionPredictors 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 status14 METs — standard light home activities, walk around the house, walk 12 blocks on level ground59 METs — climb a flight of stairs, walk uphill, walk on level ground briskly, run a short distance>10 METs — strenuous sports, heavy professional workExercise 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 200713
14 ACC/AHA Preoperative Risk Assessment Age and hx of strokes are minor risk factorsChronic kidney disease is an intermediate risk factor, so calculate creatinine clearanceExercise tolerance is important in risk stratificationIntra-abdominal surgery is an intermediate risk factor1%5% risk of cardiovascular eventsIn 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 laparotomyOptimize blood pressureIncrease metoprolol to achieve target heart rate of 6070 beats/minContinue lisinoprilHold Aggrenox until cleared by general surgery to resumeOptimize pain controlInitiate DVT prophylaxis postoperativelyIn 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 massHe has a resection of the lesion and has a colostomy bag placedOn post-op day 1, he is hypertensive, tachycardic, and more confused, according to the nursing staffUrgent medical follow-up is requestedThe 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 complicationsPneumonia (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 2005Topic
18 Comprehensive Geriatric Assessment Functional assessmentGait and mobilitySensory assessmentActivities of daily livingInstrumental activities of daily livingCognitive assessmentDecision-making capacityMedication reviewRecognizing 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 200918
19 Functional assessment: GAIT AND MOBILITY Ambulatory statusAssistive deviceAny falls?Timed “Get up and go” testA 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 1986McGory Annals of Surgery 2009
20 TIMED “GET UP AND GO” TEST Have the patient sit in a straightback chairGet up (without the use of armrests)Stand still momentarilyWalk forward 10 feet (3 meters)Turn around and walk back to chairTurn and be seated<20 seconds: patient is independently mobile>30 seconds: patient needs the assistance of others and is probably at high risk of fallsDifficulty 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 1986McGory Annals of Surgery 2009
22 FUNCTIONAL ASSESSMENT: ACTIVITIES OF DAILY LIVING BathingDressingToiletingTransferContinenceEatingAsking 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 1963Lawton Gerontologist 1969
24 FUNCTIONAL ASSESSMENT: INSTRUMENTAL ADLS Using the telephoneTravelingShoppingPreparing mealsHouseworkTaking medicationHandling moneyQuestions 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 1963Lawton Gerontologist 1969
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 2000Folstein J Psych Res 1975Pfeiffer 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:*02 errors: Normal34 errors: Mild impairment57 errors: Moderate impairment8 or more errors: Severe impairment*Allow 1 more error if the patient has had a grade school education or lessAllow 1 less error if the patient has had education beyond high school10 item verbal questionnaire-orientation-current events – presidents- serial 31. 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 surgeryIdentify potential complicationsExplain alternatives to surgeryElicit patient priorities and preferencesDiscuss advance directivesOtherwise, identify surrogate or proxy who can:State patient’s priorities and preferencesIdentify the goals/preferred aggressiveness of careMcGory Annals of Surgery 2009Slide 30
31 IMPACT OF Cognitive and Functional Impairment Increased mortalityIncreased length of stayIncreased risk of medical complicationsDifficulty with rehab programsIncreased risk of nursing home placementGivens JAGS 2008Gruber-Baldini JAGS 2003
32 Medication Review Reconcile medications at home and in hospital Confirm that there is an indication for every medicationAdjust dose for renal functionCalculate creatinine clearanceAdjust for NPO statusIdentify potentially inappropriate medicationsBeers listOlder 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 2004Rothberg 2008 J Hosp MedSteinman 2009 Arch Intern MedBeers Arch Intern Med 1997
33 CASE STUDY (continued) Additional history from the patient’s daughter:Past medical historyPatient 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 historyLives 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.MedicationsTook Ativan most nights because of difficulty sleeping and hallucinations at night.
34 CASE STUDY (continued) Findings from post-op physical examBP 190/100, pulse 110, temperature °F, pain 67Lungs clear, CV tachycardia, S1, S2 normalAbdomen flat, no bowel soundsColostomy bag had small amount of serosanguineous fluid surgical incision was intactExtremities were without edemaThe 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-opAssociated with worse outcomesFallsIncontinenceDelayed recoveryProlonged length of stayDelirium 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 2008Mercantonio JAGS 2000McGory Annals of Surgery 2009
36 DIAGNOSING DELIRIUM: CONFUSION ASSESSMENT METHOD (CAM) Hallmark findings are:Acute onset and fluctuating courseInattentionDisorganized thinkingAltered level of consciousnessThe diagnosis of delirium by CAM requires the presence of features 1 and 2 and either 3 or 4Sensitivity 94%100%, specificity 90%95%Conduct daily screening for the first 5 inpatient days after surgeryIt 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 1990McGory Ann Surg 2009
37 Delirium: a Geriatric syndrome INTERVENTIONSElectrolytes/fluidOxygenTreat infectionsTreat urinary retentionTreat constipationManage painGeriatric consultationRISK FACTORS>80 years of ageDementiaFunctional impairmentsSensory deficitsMultiple comorbiditiesMeperidineDeliriumDelirium 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 1993Siddiqi Cochrane Database Sys Rev 2007McGory Annals of Surgery 2009
38 IMPACT OF GERIATRICS CONSULTATION ON DELIRIUM (1 of 3) 126 patients randomized after hip fractureProactive geriatrics consultation was compared with usual careGeriatrics consultation occurred within 24 hours of admission and daily thereafterStructured protocol with 10 modulesPrimary outcome measure: incidence of deliriumMarcantonio 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 = 5.6Incidence 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 protocolPain assessmentMedication reconciliationBowel and bladder functionNutritionMobilizationEnvironmental stimuliAgitationMarcantonio 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 stayDelayed ambulation and functionMore complicationsPain 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 careFixed regimen of acetaminophen and opioids (oxycodone 3 mg q4h in pts > 70 years of age)Bowel regimenPain reassessed frequently, rescue drug added PRNPrimary outcome measures: pain scores, performanceNovel protocol resulted in:Reduced pain at rest and with physical therapyBetter performance on activitiesIn 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 Incontinence21% of 6,500 women were incontinent at dischargeRetentionOf 244 women who had post-voiding residual volume measured:37% had retention before surgery56% had retention at 24 hours post-op22% had retention at 5 to 7 days post-opRetention was a risk factor for mortality in first yearUrinary 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 2002Halm Arch Intern Med 2003Smith, Age Aging, 1996
44 Constipation Clinical trial after hip fracture 46 patientsMost were on bowel regimens with opioids70% developed newly diagnosed constipation postoperativelyAdvanced age and poor nutritional status were significant predictorsRisk factors for constipation: older age, hospitalization, immobility, narcotics, anesthesiaElderly 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 2007Davies J Clin Pharm Ther 2008
45 Use of AntipsychoticsRandomized, placebo-controlled study of haloperidol prophylaxis for elderly hip surgery patients at risk of delirium430 patients randomized0.5 mg haloperidol TID versus placeboEveryone received proactive geriatric consultationPrimary outcome measure, incidence of delirium, did not differ between groupsAt 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 fallsHe had CAM performed dailyThe following recommendations were made:He was given his eyeglassesBecause he had cognitive impairment with sundowning, his daughter came to the hospital daily to attend to her father’s needs and to orient himHe had a urinary tract infection and was treated for itPain management was optimized with a standing order for Tylenol, and oxycodone prior to rehabA 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 statusIdentify common geriatric syndromesRecognize that multiple postoperative geriatric problems are the normUse a proactive approach to identify causes of common geriatric syndromes
48 AcknowledgmentsDavid Hamerman, MDLaurie Jacobs, MDAmy Ehrlich, MDGeriatric Academic Career Award
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