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Preoperative Examination in Older Adults
Aka: Preoperative Examination in Older Adults, Perioperative Evaluation in the Elderly, Geriatric Preoperative Assessment
- See Also
- Preoperative Exam
- Epidemiology
- Patients over age 65 years old undergo 5 million major surgeries each year in the U.S.
- 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)
- https://riskcalculator.facs.org/RiskCalculator/
- 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?
- Will the patient have adequate Life Expectancy to realize the surgical benefits?
- See Comorbidity-Adjusted Life Expectancy
- See Four Year Prognostic Index
- May life saving measures (Resuscitation, intubation, ventilation)
- If DNR status is suspeneded for surgery, when is it to be reinstated?
- Evaluation: General
- See Preoperative Exam
- Cardiac evaluation
- See Preoperative Cardiovascular Evaluation
- Respiratory evaluation
- See Preoperative Respiratory Risk Modification
- Medications
- See Preoperative Guidelines for Medications Prior to Surgery
- See Medication Use in the Elderly
- 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
- See Clinical Institute Withdrawal Assessment for Alcohol (CIWA-Ar)
- 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
- 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
- https://www.nestle.com/asset-library/documents/library/events/2010-malnutrition-in-older-people/mna_mini_english.pdf
- Poor nutrition is associated with poor Wound Healing, post-op infection, mortality and longer hospital stays
- Consider dietitian Consultation and perioperative Nutritional Supplementation
- Evaluation: Disposition after surgery
- Evaluate Family Support
- Consider skilled nursing facility arrangements
- Lack of family support
- Reduced patient functional capacity, comorbidities, neurologic status
- References
- Kumar (2018) Am Fam Physician 98(4): 214-20 [PubMed]