By Christina Frangou
Chicago—Comprehensive new guidelines for the preoperative care of the nation’s elderly have been issued by the American College of Surgeons (ACS) and The American Geriatrics Society (AGS). It is the first time the two societies have worked together to develop guidelines for older patients.
The guidelines, which were published in the October issue of the Journal of the American College of Surgeons, apply to the management of all patients who are aged 65 years and older (J Am Coll Surg 215:453-466). An expert panel comprising 14 medical centers, various surgical subspecialties and doctors from urology, anesthesiology and geriatric medicine, developed the document.
“The major objective of these guidelines is to help surgeons and the entire perioperative care team improve the quality of surgical care for elderly patients,” said Clifford Y. Ko, MD, director of the ACS National Surgical Quality Improvement Program and professor of surgery, University of California, Los Angeles.
“This population is growing in number and we want to emphasize the depth and breadth of care required for them.”
According to the U.S. Census Bureau, the number of Americans aged 65 years and older will more than double between 2010 and 2015. Surgeons say they can see the changing demographics in their practices.
“Certainly, in my practice, we’re seeing an increased number of geriatric patients and we are not really well equipped as surgeons to manage many problems specific to geriatric patients: problems with cognitive impairment and frailty,” said Zara Cooper, MD, assistant professor of surgery, Harvard Medical School, Boston. The guidelines are “useful, clinically relevant and important,” she said.
Dr. Cooper and her colleagues currently are trying to incorporate the guidelines into their preoperative checklist. “I’m a trauma surgeon, so very few of my patients are elective. It’s going to take some time to incorporate the guidelines into our practice.”
The guidelines address 13 key areas of preoperative care of the elderly: cognitive impairment and dementia; decision-making capacity; postoperative delirium; alcohol and substance abuse; cardiac evaluation; pulmonary evaluation; functional status, mobility and fall risk; frailty; nutritional status; medication management; patient counseling; preoperative testing; and patient-family and social support systems.
All the recommendations are summarized in a checklist that is to be completed during preoperative evaluations. The checklist is directed specifically at surgeons: Although parts of the checklist may be delegated to other physicians, the surgeon must be “able to interpret the results,” according to the report.
Among the recommendations, the panel calls for patients to be assessed for cognitive impairment using a tool such as the Mini-Cog test and also to be screened for depression. Both depression and cognitive impairment predict worse surgical outcomes.
Patients also should be screened for alcohol and substance abuse and dependence using the modified CAGE questionnaire. CAGE is a four-question survey used for identifying potential alcohol abuse. CAGE stands for the four areas identified: felt need to Cut back, Annoyance by critics, Guilt about drinking, and Eye-opening morning drinking. Patients with alcohol use disorder should receive perioperative daily multivitamins with folic acid and high-dose oral or parenteral thiamine.
The panel called on surgeons to identify the patient’s risk factors for developing postoperative delirium and to document these risk factors. For patients at risk, benzodiazepines and antihistamines should be avoided except in certain circumstances, they said.
The guidelines stress that evaluating patients for their perioperative cardiac risk and postoperative pulmonary complication risk are critical steps. Patients should be assessed according to the algorithm for patients undergoing noncardiac surgery set out by the American College of Cardiology and the American Heart Association.
Dr. Ko said the guidelines reflect the need for a multidisciplinary approach to managing cardiac risk. “The surgeon knows how to perform surgery and the cardiologist knows how to take care of the heart. It’s best for everyone to
Surgeons should document a patient’s functional status, such as any reported deficiencies in vision, hearing or swallowing and any history of falls. The panel recommends using the Timed Up and Go (TUG) test to establish a patient’s risk for falls, where any patient with difficulty rising from a chair or requiring more than 15 seconds to complete the test is considered at high risk. They also recommend that surgeons determine a patient’s baseline frailty score.
The guidelines do fall short when it comes to recommending what actions surgeons should take in “what-if” scenarios, said Dr. Cooper. “For instance, if a patient has frailty or cognitive impairment, I’d like more guidance on what
A significant portion of the guidelines is dedicated to medication management. The panel called on surgeons to review and document patients’ complete medication list and ask about use of nonprescription agents and herbal products. They suggest minimizing the patient’s risk for adverse drug reactions by identifying medications that should be avoided or discontinued before surgery. At the same time, surgeons should consider any medications that should be started or continued preoperatively to reduce perioperative risks for adverse events. They note that the doses of medication for renal function should be adjusted based on glomerular filtration rate and not on serum creatinine alone.
Patients should be evaluated for nutritional status and preoperative interventions, led by a dietician, should be considered if the patient is at severe nutritional risk, the panel said.
When it comes to preoperative testing, the panel did not recommend routine sets of preoperative screening tests, with the exception of hemoglobin, renal function tests and albumin. Diagnostic tests should be performed selectively and limited to high-risk patients.
Finally, the panel called for surgeons to determine the patient’s treatment goals and expectations of treatment outcomes and to identify the patient’s family and social support systems. Surgeons should ensure that the patient has an advance directive and a designated surrogate decision maker and this information should be placed in the chart.
Physicians who specialize in palliative medicine applaud the panel’s efforts to highlight the need for frank preoperative discussions. Geoffrey P. Dunn, MD, a surgeon at UPMC Hamot, Erie, Pa., and chairman of the Surgical Palliative Care Task Force of the ACS, said in an email: “The ACS/AGS guidelines are very consistent with the priorities of the palliative care community.”
The guidelines were developed in response to a performance measure, “The Elderly Surgery Measure,” developed by the ACS and the Centers for Medicare & Medicaid Services. They launched a pilot program in October that gives hospitals the opportunity to publicly and voluntarily report their outcome results for this performance measure.