II. Epidemiology
- Patients over age 65 years old undergo 5 million major surgeries each year in the U.S.
III. Evaluation: Is Surgery Indicated?
- Assess the Surgical Risks (patients underestimate risks)
- See Surgical Risk for Cardiac Event (procedure risk factors)
- See Revised Cardiac Risk Index (individual patient risk factors)
- Surgical Risk Calculator (ACS NSQIP)
- Assess the Surgical Benefits (patients overemphasize benefits)
- Is the priority extending Life Expectancy at any cost?
- Surgery may extend life, but result in Nursing Home Care
- Is the priority maintaining functional capacity and independence?
- Foregoing surgery may allow for continued status quo function
- Would the patient be better served with palliative measures?
- Is the priority extending Life Expectancy at any cost?
- Will the patient have adequate Life Expectancy to realize the surgical benefits?
- May life saving measures (Resuscitation, intubation, ventilation)
- If DNR status is suspeneded for surgery, when is it to be reinstated?
IV. Evaluation: General
- See Preoperative Exam
- Cardiac evaluation
- Respiratory evaluation
- Medications
-
Tobacco Abuse
- See Tobacco Cessation
- Tobacco use is associated with higher perioperative mortality, worse function, greater complications
-
Alcohol Abuse and Alcohol Withdrawal risk
- See Alcoholism Screening
- Abstinence is recommended 4-8 weeks before surgery
- Stay alert for perioperative Alcohol Withdrawal
V. Evaluation: Neurologic Status
-
Dementia
- See Mini-Cognitive Assessment Instrument (screening)
- See Saint Louis University Mental Status (SLUMS)
-
Delirium
- See Delirium for risk factors
- See Confusion Assessment Method Short Form
- Delirium results in greater complications including infections, patient falls and longer hospital stays
- Prevention includes keeping eyeglasses and Hearing Aids available to patient and frequent reorientation
- Other prevention includes early mobilization after surgery, adequate analgesia, nutrition and hydration
- Decision Making Capacity
- See Medical Decision-Making Capacity
- See CURVES Capacity Assessment Tool
- Consider surrogate decision maker
-
Major Depression
- Patient Health Questionaire 2 (PHQ-2, screening only)
- See Geriatric Depression Scale
- Major Depression is associated with worse functional recovery and Skilled Nursing Facility transfer
VI. Evaluation: Functional Status
- Assess Activities of Daily Living
- See Activities of Daily Living Scale (Katz ADL Scale)
- See Instrumental Activities of Daily Living (Lawton IADL Scale)
- Consider "Prehabilitation" with physical therapy and occupational therapy before surgery
- Assess Mobility and Fall Risk
- See Fall Prevention in the Elderly
- See Get Up and Go Test
- See Frailty
- Employ similar methods to the ADL assessment above
- Assess Nutritional Status
- See Geriatric Nutrition Checklist
- See Subjective Global Assessment of Nutritional Status
- Mini Nutritional Assessment
- Poor nutrition is associated with poor Wound Healing, post-op infection, mortality and longer hospital stays
- Consider dietitian Consultation and perioperative Nutritional Supplementation
VII. Evaluation: Disposition after surgery
- Evaluate Family Support
- Consider Skilled Nursing Facility arrangements
- Lack of family support
- Reduced patient functional capacity, comorbidities, neurologic status