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Preoperative geriatric assessment reduced hospital stay and

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on 16 February 2018

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Transcript of Preoperative geriatric assessment reduced hospital stay and

Preoperative geriatric assessment reduced hospital stay and complications in patients >65 years old having vascular surgery
Anatomical Changes in Elderly
Study
Bryan A. Santiago
PGY-1 IM HESLP

Preoperative geriatric assessment Introduction
Epidemiology
In aging, multiple factors including biologic, genetic, environmental, and lifestyle choices effect longevity.

Elderly patients exhibit diminished physiologic reserves and often require exhaustion of these reserves to maintain homeostasis.

Decreased muscle mass in elderly patients associated with declined physical performance has been found to correlate with a markedly increased risk of mortality and morbidity.
Intro cont...
Muscle breakdown and anorexia occur due to an up-regulation of IL-1, IL-6, and TNF-alpha.

Sarcopenia is observed in more than half of patients over the age of 80 and leads not only to a loss of muscle mass but a decrease in strength and functionality.

There is a shift in body mass from muscle to adipose tissue. This is associated with a loss of lean body mass and total body water.
Sarcopenia represents approximate a fold increase risk of complications and mortality compared to the non-sarcopenic patient.
2 to 3
Cardiopulmonary
Changes
Decreased chest wall compliance

Decrese maximum inspiratory and expiratory force

Decrease vital capacity

Decrease mucociliary clearance

Decrease cough reflex

Decrease autonomic response to hypoxia and hypercapnia
Cardiac Changes
Septal thickening

Atrial and valvular dilation

Fibrosis of the conduction system
Overall, elderly experience decreased contractility, compliance, and arrhythmias
The most common cause of death in perioperative ederly is cardiac in nature
Perioperative myocardial infarction mortality:
>75 y/o: 17.8%

< 55 y/o: 2.0%

note:
renal changes
Decreased glomerular filtration
Volume overload
Acute-on chronic kidney injury
Electrolyte abnormalities
GI Changes
Remains relatively unchanged in physiology compared to those mentioned previously
Some studies have noted a shortening of the villi and thus decreased surface area of the intestine with age, which may compound the malnutrition observed in older patients.

The presence of malnourishment is observed in 70% of hospitalized elderly patients and is associated with increased morbidity and mortality
GI Changes
Rct of comprehensive geriatric assessment and optimization in vascular surgery
Study Background:

Increasing numbers of older patients are undergoing vascular surgery.

Inadequate pre-operative assessment and optimization may contribute to increased postoperative morbidity and mortality.
Rct of comprehensive geriatric assessment and optimization in vascular surgery
Methods:

Patients >65 years scheduled for elective aortic aneurysm repair or lower limb arterial surgery were enrolled by randomization.

Patient were design either to undergo:
- Standard preoperative assessment (control)
or
- Preoperative comprehensive geriatric
assessment and optimization (intervention).

A total of 176 patients were included in the analysis (control 91, intervention 85).
Outcomes:

Primary outcome was length of hospital stay.

Secondary outcome measures included new medical co-morbidities, postoperative medical or surgical complications, discharge to a higher level of dependency and 30-day readmission rate.
Rct of comprehensive geriatric assessment and optimization in vascular surgery
Elderly in vascular surgery
Take into consideration:
Anatomy and physiological changes (as mentioned previously )

Undiagnosed cognitive impairment, high delirium incidence and common impaired functional status.

Vascular risk factors such as smoking, hypertension and hypercholesterolaemia, which are common in patients undergoing vascular surgery.
Comprehensive preoperative assessment
- Comprehensive geriatric assessment is an established and evidence-based method of evaluating and optimizing physical, psychological, functional and social issues in older patients.

This conevelopment of an individualized care plan that includes investigation, treatment, rehabilitation sup- port and long-term follow-up.
Question #1
Two groups of investigators are interested in the problem of complications after vascular surgery in a population that has a high prevalence of smoking. One group conducted study A, which showed that smoking is associated with higher complications after vascular surgery, with an odds ratio (OR) of 1.51 and 95% confidence interval of 1.19 to 1.81. The other group conducted study B, which demonstrated an OR of 1.46 and 95% confidence interval of 0.95 to 1.97. Which of the following is the best statement concerning the results of these two studies?

A. The result of study A is not statistically significant

B. The sample in study B is poorly selected

C. The result in study A is not valid

D. The sample size in study B is small

E. P value in study B is less than 0.05
Answer: D

Although both studies have almost the same point estimate of association (OR of about 1 .5), study B has a wider confidence interval than study A. Furthermore, the confidence interval of study B includes 1.0; therefore, it is not statistically significant.
The lack of statistical significance of the results in study B is most probably due to a smaller sample size, which resulted in insufficient power to detect the difference between the exposed and unexposed subjects.
Increasing the sample size of study B will make the confidence interval tighter. Both studies reached the same conclusion, but because of a smaller sample size of study B, its estimated odds ratio does not reach statistical significance.

Question #2
550 patient who experience bleeding after lower extremity arterial Bypass surgery undergo a standard questioner to assess the use of NSAIDS within 7 weeks before surgery. A study was conducted to look for the relationship between the use of NSAIDs within 7 days before arterial Bypass surgery and bleeding (>500ml EBL) during or after surgery. The study showed that the use of the NSAIDs within 7 days days before the surgery increases bleeding during or after surgery, even after adjusting for race, other medication use, and commodities. The odds ratio (OR) is 1.5; p is <0.03. Which should be the major concern while interpreting the results of this study?

A. Selection bias

B. Interviewer bias

C. Recall bias

D. Observer bias

E. Confounding
Answer: C

Recall bias should always be considered as a potential problem in case-control studies because it can cause an overestimation of the effect of an exposure. This over-report can be due to psychological effect and the search for potential explanations of the problem.
Randomized control trial of comprehensive geriatric assessment and optimization in vascular surgery
Cont......
Preoperative Workup
Cardiac and Pulmonary Function Assessment
The Study
(EBPOM Guidelines)
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