June 1, 2013
Volume 77, Number 6
Gero-centric Care: Can We Deliver?
Sheila Barnett, M.D. Committee on Geriatric Anesthesia
Jeffrey H. Silverstein, M.D., AGSF Committee on Geriatric Anesthesia
In his opening article, Ruben Azocar, M.D. refers to the “Gray Tsunami.” One could argue that our specialty has been preparing for this event for a long time; the first edition of Miller’s Anesthesia contained a chapter on the elderly written by Dr. Miller. Since then, essentially every anesthesia text and a number of specialty textbooks have addressed the perioperative care of the elderly. There is also a growing body of original research on the effects of anesthesia in the elderly – especially in the neurocognitive arena. Within the realm of education, elderly issues are increasingly the focus of many panels and events at our national meetings and are featured in our examinations.
Given the wealth of information available – appropriately represented within clinical, research and education forums – are we confident that the availability of information and guidelines appropriately translates into age-appropriate anesthesia care?
The accepted quality assessment performance measures for surgery (myocardial infarction, surgical site infection and deep venous thrombosis) are not specific to the elderly. Although older patients do have a higher incidence of cardiac complications, the same has not been shown for deep venous thrombosis and surgical site infection. The National Quality Foundation has adopted a risk-adjusted, case mix-adjusted elderly surgery outcome measure proposed by the American College of Surgeons (ACS) (Table 1). This list described “outcomes” – essentially as things to avoid. Importantly, all are morbidities which, while more common in the elderly, we would try to avoid in all our patients irrespective of age. These standard outcomes, and ones like them, will highlight the increased vulnerability of the elderly patient, but they do little to measure how good we are at providing “gero-centric” care.
In October 2012, a guideline for preoperative assessment of the geriatric patient was reported by an expert panel formulated by the ACS and the American Geriatrics Society (AGS). The overall checklist of recommendations is included in Table 2 (page 16). Although designed to be based primarily on evidence, many of the recommendations are, by necessity, those of the expert panel. This report makes clear the need for additional research into the preoperative assessment and the need for quality measures for geriatric patients. However, while we wait for primary evidence this document can be used as a guide for a “gero-centric” pre-anesthesia assessment.
Many of the recommendations in the preoperative guideline (described above) include process measures. Process measures look at multiple aspects of care such as interpersonal communication and diagnostic and treatment strategies. These global measures may provide a more relevant method of assessing the quality of care in complex elderly patients compared to the usual standard quality measures. Some examples include comorbidity assessment, medication usage, an assessment of decision-making capacity, patient provider discussion and discharge planning.
Functional status is becoming an increasingly important feature of the preoperative assessment. In reality, for the geriatric population, this may be one of the most important features of a preoperative assessment. Postoperative functional status will be a major determinant in deciding if an elderly patient can return home or will need to transfer to a skilled nursing facility or other assisted living-type arrangement. The “success” of the primary surgery may be far less relevant than function in the discharge planning process. Two of the most common measures of functional status are activities of daily living (ADL) and instrumental activities of daily living (IADL). Data in perioperative patients suggest that it takes three months for some patients to return to their preoperative level of ADLs and up to six months to return to IADLs. An assessment of preoperative ADL and IADL does not need to take much time and may yield valuable information for the patient, family and the physicians caring for the patient in the perioperative period. Perhaps a measure of ADL and IADL postoperatively would lead to a more focused recovery and may even help appropriately allocate resources in the perioperative period.
Confusion and cognitive decline following surgery and anesthesia are some of the most dreaded outcomes for the elderly patient. Postoperative delirium is associated with an increased hospital length of stay, costs and even mortality. Should we use the occurrence of delirium as an outcome measure? Although frequently unavoidable, the incidence of postoperative delirium in certain instances may be reduced or minimized through improved pain control, limiting intraoperative sedation or avoidance of selective medications such as anticholinergic medications. Postoperative cognitive dysfunction (POCD) is perhaps more controversial as an important outcome to be considered as a part of a more global outcome measure.
Given that we do not have well defined preoperative and postoperative measures, it is not surprising that there are little evidenced-based data on intraoperative and postoperative care. While we have many textbook chapters written, none of this material has been condensed into a useful approach for employment in either the operating room or the PACU. As the geriatric white paper described by Dr. Azocar suggests, there is an opportunity to focus on the care of the elderly with the objective of having anesthesiologists be the primary acute care physicians for these patients in the preoperative period. While we continue to disseminate information on the geriatric patient, it is time to partner with the Anesthesia Quality Institute, the ASA Committee of Performance and Outcome Measurement and the ASA Committee on Practice Parameters to focus on this goal. These groups address critical issues in anesthesia, and we need to ensure appropriate representation for the geriatric population!
The demand for good measures of quality is not unique to geriatrics, but given the impending “gray tsunami,” there is some urgency in the need for their development ... if we are going to stay ahead of the wave!
Table 2: Checklist for the Optimal Preoperative Assessment of the Geriatric Surgical Patient
In addition to conducting a complete history and physical examination of the patient, the following assessments are strongly recommended:
Assess the patient’s cognitive ability and capacity to understand the anticipated surgery.
Screen the patient for depression.
Identify the patient’s risk factors for developing postoperative delirium.
Screen for alcohol and other substance abuse/dependence.
Perform a preoperative cardiac evaluation according to the American College of Cardiology/American Heart Association algorithm for patients undergoing noncardiac surgery.
Identify the patient’s risk factors for postoperative pulmonary complications and implement appropriate strategies for prevention.
Document functional status and history of falls.
Determine baseline frailty score.
Assess patient’s nutritional status and consider preoperative interventions if the patient is at severe nutritional risk.
Take an accurate and detailed medication history and consider appropriate perioperative adjustments. Monitor for polypharmacy.
Determine the patient’s treatment goals and expectations in the context of the possible treatment outcomes.
Determine patient’s family and social support system.
Order appropriate preoperative diagnostic tests focused on elderly patients.
Sheila Barnett, M.D. is Director of
Remote Anesthesia, Medical Director
of Quality for Interventional
Procedures, and Associate Professor
of Anesthesiology, Harvard Medical
School and Beth Israel Deaconess Medical Center, Boston.
Jeffrey H. Silverstein, M.D., AGSF, is
Professor of Anesthesiology, Surgery
and Geriatrics & Palliative Care, Vice Chair for Research, Department of Anesthesiology, Associate Dean for Research, Icahn School of Medicine
at Mount Sinai, New York, New York.