Perioperative Management of the Geriatric Patient Publications (273)


Perioperative Management of the Geriatric Patient Publications

Undernutrition prior to major abdominal surgery is frequent and increases morbidity and mortality, especially in older patients. The management of undernutrition reduces postoperative complications. Nutritional management should be a priority in patient care during the preoperative period. Read More

However undernutrition is rarely detected and the guidelines are infrequently followed. Preoperative undernutrition screening should allow a better implementation of the guidelines.
The ANC ("Age Nutrition Chirurgie") study is an interventional, comparative, prospective, multicenter, randomized protocol based on the stepped wedge trial design. For the intervention, the surgeon will inform the patient of the establishment of a systematic preoperative geriatric assessment that will allow the preoperative diagnosis of the nutritional status and the implementation of an adjusted nutritional support in accordance with the nutritional guidelines. The primary outcome measure is to determine the impact of the geriatric intervention on the level of perioperative nutritional management, in accordance with the current European guidelines. The implementation of the intervention in the five participating centers will be rolled-out sequentially over six time periods (every six months). Investigators must recommend that all patients aged 70 years or over and who are consulting for a surgery for a colorectal cancer should consider participating in this study.
The ANC study is based on an original methodology, the stepped wedge trial design, which is appropriate for evaluating the implementation of a geriatric and nutritional assessment during the perioperative period. We describe the purpose of this geriatric intervention, which is expected to apply the ESPEN and SFNEP recommendations through the establishment of an undernutrition screening and a management program for patients with cancer. This intervention should allow a decrease in patient morbidity and mortality due to undernutrition.
This study is registered in NCT02084524 on March 11, 2014 (retrospectively registered).

Orthopade 2017 Jan;46(1):54-62
Klinik für Anästhesiologie und Intensivmedizin, Universitätsklinikum Essen, Hufelandstraße 55, 45122, Essen, Deutschland.

The management of major orthopedic surgery in the elderly prototypically reflects the perioperative risks of geriatric, often very frail patients reflecting an aging population. To improve outcome, the risks of anesthesia and surgery as well as of patient comorbidities must be thoroughly assessed and balanced using a multidisciplinary approach. Particular risks include cardiopulmonary morbidity, anemia, risk of hemorrhage and the management by anticoagulation, cerebral impairments as well as frailty and limited physiological reserves in general. Read More

Accordingly, an optimized therapy prior to, during, and after surgery will likely influence not only the immediate postoperative course but also hospital mortality and long-term outcome. Publications on the topic of perioperative management of geriatric patients are fortunately gaining in quality and quantity, not least against the background of the demographic developments. Accordingly, specific influencing factors relevant for perioperative management can be increasingly more identified. This short review summarizes the current state of knowledge to provide an overview and rationale for clinical decision making.

J Orthop Trauma
J Orthop Trauma 2017 Jan;31(1):e1-e8
*University of Miami, Coral Gables, FL; and †Department of Orthopaedic Surgery, Regions Hospital, University of Minnesota, Saint Paul, MN.

To analyze functional outcomes, motion, and strength in patients 65 years of age and older who underwent operative management of a scapula fracture.
Retrospective review of prospective database.
A single level-1 teaching trauma center. Read More

Two hundred fifty patients with scapula fractures were operated between January 2002 and March 2014. A review identified 16 geriatric patients 65 years of age and older.
All patients underwent operative treatment of a scapular fracture.
Disabilities of the Arm, Shoulder, and Hand (DASH), Short-Form Health Survey versions 1 and 2 (SF-36), Range of Motion (ROM), and Strength assessment at final follow-up 1 year or greater.
Outcomes were attained on 15/16 patients at a mean follow-up of 40 months (range = 12-114). All fractures were united. Three patients experienced minor perioperative complications (temporary delirium in 2 patients, urinary tract infection in 1). One patient required subsequent removal of an intraarticular screw, and 1 patient required resection of heterotopic ossification and requested implant removal. The mean ROM expressed as a percent of contralateral ROM ranged from 78% to 96%. The mean strength expressed as a percent of contralateral strength ranged from 76% to 92%. The mean DASH score was 8.4. SF-36 scores were comparable with the normal population. All patients returned to activities.
Operative treatment for displaced fractures in patients 65 years of age and older is safe and can yield good functional results and return to function.
Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

J. Urol.
J Urol 2016 Dec 13. Epub 2016 Dec 13.
Department of Urology, Weill Cornell School of Medicine, New York, NY.

Frailty and functional status have emerged as significant predictors of morbidity and mortality for patients undergoing cancer surgery. To articulate their impact on value (i.e. Read More

, quality per cost), we compared perioperative outcomes and expenditures according to patient function for older adults undergoing kidney cancer surgery.
Using linked SEER-Medicare data, we identified 19,129 elderly patients with kidney cancer treated with non-ablative surgery from 2000-2009. We quantified patient function using function-related indicators-claims indicative of dysfunction and disability-and measured 30-day morbidity, mortality, resource use, and cost. Using multivariable, mixed-effects models to adjust for patient and hospital characteristics, we estimated the relationship between patient functionality and both treatment outcomes and expenditures.
Of 19,129 patients, we identified 5,509 (28.8%) and 3,127 (16.4%) with a function-related indicator count of 1 and ≥2, respectively. While surgical complications did not vary (OR 0.95, 95% CI 0.86-1.05), patients with ≥2 indicators more often experienced a medical (OR 1.22, 95% CI 1.10-1.36) or geriatric (OR 1.55, 95% CI 1.33-1.81) event or died within 30 days of surgery (OR 1.43, 95% CI 1.10-1.86) compared with patients with no baseline dysfunction. These patients utilized significantly more medical resources and amassed higher acute care expenditures (p<0.001).
During kidney cancer surgery, patients in poor functional health can face a more eventful medical recovery at elevated cost, indicating lower value care. Greater consideration of frailty and functional status during treatment planning and transitions may represent areas for value enhancement in kidney cancer and urology care.

Clin Spine Surg
Clin Spine Surg 2016 Dec 13. Epub 2016 Dec 13.
Department of Orthopaedic Surgery, University of California-San Francisco, San Francisco, CA.

Retrospective cohort analysis.
To compare 30-day perioperative clinical outcomes of surgical odontoid stabilization by an anterior or posterior operative approach in elderly patients.
Surgical stabilization of odontoid fractures is superior to nonoperative management in geriatric patients. Read More

How elderly patients with odontoid fractures fare after anterior and posterior approaches, however, is not well defined.
Retrospective review of the prospectively collected American College of Surgeons National Surgical Quality Improvement Program database (2005-2013). Elderly patients (≥65 y) with odontoid fractures who underwent odontoid stabilization through anterior or posterior approaches were identified by International Classification of Diseases 9th Revision/Common Procedure Terminology codes. Exclusion criteria included concomitant subaxial spine surgery, instrumentation noncontiguous with the atlantoaxial interval, and combined approaches. Baseline demographics and perioperative details were compared. Adverse events, mortality, reoperation, discharge, and readmission rates within 30 days of operation were compared using bivariate and multivariate generalized linear regressions.
One hundred forty-one patients (male-81; female-60; average age: 77.8±6.5 y; anterior approach-48; posterior approach-93) were analyzed. Patients scheduled to have a posterior approach had significantly more nonunions preoperatively and higher body mass indices. Operative times for posterior surgeries were significantly longer. Age, comorbidities, functional dependence, time to surgery, and length of hospital stay were similar between groups. There were no significant differences in the relative risk (RR) of the composite outcome of "any adverse event" after adjusting for differences in baseline characteristics. Patients who underwent an anterior approach were more likely to have an unplanned hospital readmission (RR=8.95; 95% confidence interval, 2.21-36.29; P=0.002) and have significantly more revision operations (RR=19.51; 95% confidence interval, 2.49-152.62; P=0.005) than patients who had a posterior operation.
An anterior approach for odontoid fracture stabilization in patients ≥65 years old were associated with shorter operative times and greater RRs of unplanned readmissions and revision operations within 30 days of surgery relative to a posterior approach.

Transl Androl Urol
Transl Androl Urol 2016 Oct;5(5):683-691
Department of Urology, Medical University of Vienna, Vienna, Austria; ; Department of Urology, University of Texas Southwestern Medical Center, Dallas, USA; ; Department of Urology, Weill Cornell Medical College, New York, USA.

Bladder cancer (BCa) is a disease of the elderly and as the population is aging, BCa will become an even bigger public health challenge in the future. Nowadays the correct management of BCa in the elderly remains controversial. The purpose of this article was to review the previous literature to summarize the current knowledge. Read More

Using Medline, a non-systematic review was performed including articles between January 2000 and February 2016 in order to describe the management of BCa in the elderly in all its aspects. English language original articles, reviews and editorials were selected based on their clinical relevance. In the literature, the definition of elderly is variable and based on chronological, not biological, age. BCa seems to be more aggressive in the elderly. The management of non-muscle invasive bladder cancer (NMIBC) does not strongly differ from younger patients, except for the role of adjuvant immunotherapy. In patients with muscle invasive bladder cancer (MIBC) the role of a multidisciplinary geriatric evaluation is potentially beneficial. The curative treatment in MIBC remains radical cystectomy (RC) and elderly patients should not be withheld a potentially life-saving intervention only based on chronological age. Patients unsuitable to a major surgical approach may be eligible for bladder-sparing techniques. Geriatric assessment could help identify the frail elderly and customize their perioperative care (i.e., pre and re habilitation). In conclusion the treatment of BCa in the elderly has to be patient-centered and focused on biological age and functional reserves.

Clin Interv Aging
Clin Interv Aging 2016;11:1239-1246. Epub 2016 Sep 12.
Center for Orthopedics and Trauma Surgery.

Most studies focusing on improving the nutritional status of geriatric trauma patients exclude patients with cognitive impairment. These patients are especially at risk of malnutrition at admission and of worsening during the perioperative fasting period. This study was planned as a feasibility study to identify the difficulties involved in including this high-risk collective of cognitively impaired geriatric trauma patients. Read More

This prospective intervention study included cognitively impaired geriatric patients (Mini-Mental State Examination <25, age >65 years) with hip-related fractures. We assessed Mini Nutritional Assessment (MNA), Nutritional Risk Screening (NRS 2002), body mass index, calf circumference, American Society of Anesthesiologists' classification, and Braden Scale. All patients received parenteral nutritional supplementation of 800 kcal/d for the 96-hour perioperative period. Serum albumin and pseudocholinesterase were monitored. Information related to the study design and any complications in the clinical course were documented.
A total of 96 patients were screened, among whom eleven women (median age: 87 years; age range: 74-91 years) and nine men (median age: 82 years; age range: 73-89 years) were included. The Mini-Mental State Examination score was 9.5 (0-24). All patients were manifestly undernourished or at risk according to MNA and NRS 2002. The body mass index was 23 kg/m(2) (13-30 kg/m(2)), the calf circumference was 29.5 cm (18-34 cm), and the mean American Society of Anesthesiologists' classification status was 3 (2-4). Braden Scale showed 18 patients at high risk of developing pressure ulcers. In all, 12 patients had nonsurgical complications with 10% mortality. Albumin as well as pseudocholinesterase dropped significantly from admission to discharge. The study design proved to be feasible.
The testing of MNA and NRS 2002 was feasible. Cognitively impaired trauma patients proved to be especially at risk of malnutrition. Since 96 hours of parenteral nutrition as a crisis intervention was insufficient, additional supplementation could be considered. Laboratory and functional outcome parameters for measuring successive supplementation certainly need further evaluations involving randomized controlled trials.

Foot Ankle Int
Foot Ankle Int 2017 Jan 1;38(1):41-48. Epub 2016 Oct 1.
1 Center for Orthopaedics and Trauma Surgery, University Hospital of Giessen and Marburg, Marburg, Germany.

The incidence of geriatric ankle fractures has increased during the last few decades. In contrast to younger patients, increased complication rates have been observed. Thus, the goal of the present study was to identify risk factors for perioperative complications following open reduction and internal fixation of geriatric ankle fractures. Read More

Two hundred thirty-seven patients over the age of 65 years (mean, 72.5 ± 6.1 years) treated for ankle fractures in our institution between 2004 and 2014 were included. Complications associated with operative treatment as well as complications requiring revision surgery were analyzed. In a multivariate analysis, risk factors were determined.
In 68 patients (28.7%), 74 complications were documented. The most common complications were impaired wound healing and operative site infections. The multivariate analysis revealed that the operative time was the only independent risk factor for the development of a complication. The operative time as well as the presence of an open fracture represented risk factors for needing revision surgery. Comorbidities did not influence the development of complications.
The operative management of geriatric ankle fractures was associated with a high complication rate. In the present study, the operative time was the only modifiable factor for the development of a complication that required revision surgery. During preoperative preparation, we believe that perfusion of the affected limb should be optimized to reduce the incidence of wound complications.
Level III, retrospective cohort study.

J Am Acad Orthop Surg
J Am Acad Orthop Surg 2016 Oct;24(10):683-90
From the Warren Alpert Medical School of Brown University, Providence, RI.
Z Gerontol Geriatr
Z Gerontol Geriatr 2016 Oct 12;49(7):639-656. Epub 2016 Aug 12.
Medizinische Klinik 8, Schwerpunkt Kardiologie, Klinikum Nürnberg, Paracelsus Medizinische Privatuniversität, Nürnberg, Deutschland.

The treatment of severe symptomatic aortic valve stenosis by conventional aortic valve replacement (AVR) or by transcatheter aortic valve implantation (TAVI) has a good perinterventional prognosis even for patients of advanced age. Having a heart team select the best management strategies based on current guidelines for each individual patient is essential for success. Especially in elderly and increasingly multimorbid patients with sometimes severe preconditions, the detection of functional deficits is relevant not only for the mortality but also for perioperative and postoperative complications as well as the functional outcome. Read More

Various methods of geriatric assessment are important supplements to standard risk scores. The aim is to implement targeted interventions to minimize the risk factors and to improve the prognosis for elderly patients. The aim of this article is to provide an overview of the current therapy options for aortic valve replacement and to summarize current aspects of treatment options for elderly patients.