perioperative care of older people - rcp london

Perioperative Careof Older People

Philip Braude, Consultant Geriatrician

POPS – Proactive care of Older People undergoing Surgery

Guy’s and St Thomas’ Hospital

@DrPhilipBraude #AGM17conf

Prevalence surgical pathology increases with age

Neoplastic

Degenerative

Vascular

Elective surgery

Emergency surgery

0

1,0

00

2,0

00

3,0

00

4,0

00

5,0

00

Patie

nts

<31 31-40 41-50 51-60 61-70 71-80 81-90 >90

Surgery rates not reflect incidence

National Cancer Intelligence Network, UK 2010Access All Ages, RCS 2012

Why might this be?

• Multimorbidity

• Cognitive impairment

• Polypharmacy

• Frailty

• Dependence

• Ageism?

Older people get more complications

• Systematic review

• 28 papers = 34,194 patients

Outcomes in Older People Undergoing Operative Intervention for Colorectal Cancer. Patel, JAGS, 2001

Older people get more likely to die

Temporal Patterns of Postoperative Complications. Thompson, Arch Surg, 2003

Death rate +/- complications

with without

30day mortality 13% 1%

1 year mortality 28% 7%

5year mortality 58% 40%

…and have functional deterioration…

Functional independence after major abdominal surgery in the elderly.Lawrence. J Am Coll Surg, 2004

“Never mind dying, how long before I get back to normal?”

(...plus cost more)

• Late cancellations

• Length of stay

• Readmissions

• Social care costs

• Informal care costs

J Vasc Surg 1997;25:298-311

Who is at high risk of adverse outcomes?

• Poor functional recovery – Older people• Deterioration in function persisting up to 6months

• Poor cognitive recovery – Older people• Delirium, postop cognitive dysfunction, dementia

• Common, serious, distressing

• Poor experience – Older people• NCEPOD An age old problem, Francis report

So, why do older patients do worse?

Age not an independent factor

"You don't make a pig fatter by weighing the pig”

– Don Berwick

But you knew all that already…

Traditional hospital model

Assess risk factors

Not ‘fit’ for surgery

vs

Fit for surgery

Discharge to community

Admit to SAL/Sx ward

React to complications


Pain Opiates

Post-op ileus On/off ‘sliding scale’

Hypovolaemic (AKI) Fluids

Anaemia Blood

Peripheral oedema Diuretics

Depressed (delirium) Anti-depressants

Functional decline Carers & Rehab

Endocrinology

Haematology

Cardiology

Psychiatry

Geriatrics

Nephrology

On

Call

Medical

Registrar

74yo Joyce

What we should be doing

Assessment of risk

Modification of risk

Care in the right place

Manage complications

Shared decision making

PREMPROM

Long term health

A variety of novel approaches are being taken

Who?

• Anaesthetist led and delivered

• Geriatrician led and delivered

• Hospitalist led and delivered

When?

• Preoperative only

• Postoperative only

• Whole pathway

Braude FHC Journal 2016

Emerging specialty of ‘perioperative medicine’

10 million having surgery/pa in UK

1.6 million as in-patients

250,000 defined as high risk

“Promote multidisciplinary, patient centred medical care from contemplation of surgery until full recovery”


“Promote multidisciplinary, patient centred medical care from contemplation of surgery until full recovery”


“Promote multidisciplinary, patient centred medical carefrom contemplation of surgery until full recovery”

National guidelines

…and the relevant preoperative guidelines…

Preoperative

Assessment IHD/failure ACC/ESC

Optimization Anaemia PBM

Planning Diabetes NHS DiabeteS

Prevention of AKI NICE

Prevention of POD NICE

…the intraoperative guidelines…

Intra-operative

MAP/BIS/temp

Fluid balance

Analgesia

…and the relevant postoperative guidelines

Post-operative

AKI

Sepsis

AF

ACS

POD

Clinical pathway

Cognition

Cardioresp fitness

Frailty

Anaemia

Manage comorbidity

Nutrition

This is complicated…


Clinical pathway

Cognition

Cardioresp fitness

Frailty

Anaemia

Manage comorbidity

Nutrition

Interdisciplinary

Length of stay

Waiting list targets

Cancer treatment targetsInvestigations

Resource limitations

Consent and capacity


Geriatrics

Cognition

Cardioresp fitness

Frailty

Anaemia

Manage comorbidity

Nutrition

Interdisciplinary

Length of stay

Waiting list targets

Cancer treatment targetsInvestigations

Resource limitations

Consent and capacity

…and to geriatricians sounds like Comprehensive Geriatric Assessment

30% higher chance of being alive and in own homeNNT 13

Holistic, multidimensional, interdisciplinary

Formulation of:• a list of needs, wants and priorities• issues to tackle• tailored individualised care plan

Comprehensive Geriatric Assessment

…works as it allows…

Risk assessment

• Recognise comorbidity

• Identify disability & frailty

• Assess functional reserve

Optimisation

• Medical, functional, psychological & social

• Organ specific guidelines

• MDT interventions

…and facilitates…

Collaborative decision making • Harm vs benefit• Consent, capacity, advance directives • Communication


Pain Opiates



Anaemia Blood




Endocrinology

Haematology

Cardiology

Psychiatry

Geriatrics

Nephrology

On

Call

Medical

Registrar

74yo Joyce


Pain Opiates



Anaemia Blood




Endocrinology

Haematology

Cardiology

Psychiatry

Geriatrics

Nephrology

On

Call

Medical

Registrar

Unrecognised disease/syndromes

Suboptimal control of comorbidity

Unrecognised complications

Poor coordination of care

74yo Joyce

A typical ‘not too complicated’ story

74yo Joyce

Living aloneNo support

Difficulthistorian

OA

Diabetes

HTN

SOB ?cause

‘Difficult’historian

A typical ‘not too complicated’ story

74yo Joyce


Difficulthistorian

OA

Diabetes

HTN

SOB ?cause


Pain

HbA1c 8.2%

BP 170/88

Ischaemic ECG

Anaemia

Deconditioning

MoCA 21/30

Social issues

The same patient with POPS input...

Analgesia/physio

Treat/plan

ABPM/treat

Undiagnose

IV iron and blood

Exercise programme

Delirium risk/mx

Equipment/POCPsychological supportDischarge planning

OA

Diabetes

HTN

SOB ?cause


Pain

HbA1c 8.2%

BP 170/88

Ischaemic ECG

Anaemia

Deconditioning

MoCA 21/30

Social issues

74yo Joyce


Difficulthistorian

…with clear communication…

Based on the history and cognitive testing Ms X has likely dementia. This raises the following issues;

a) CapacityDisplays capacity to consent to proposed procedure – but requires adequate time and clear

explanation

b) Delirium riskCognitive impairment and poor vision put Mrs X at risk of developing POD.

Patient has been counselled about this. When admitted please ensure that;

i) Trust delirium guideline is printed, filed in notes and followed

ii) Deliriogenic drugs are avoided where possible

iii) Adequate hydration is maintained

iv) Falls risk is assessed (using STRATIFY)

v) Day night routine is maintained

vi) Sensory impairments are optimised (I have told Ms X to bring in her glasses

c) Long term managementPlease could GP monitor and consider referral to memory assessment services.

Evidence? CGA in perioperative medicine

Partridge, Anaesthesia 2014

5 studies; 3 before and after, 2 RCT (not all ‘really’ CGA)Conclusions; preop CGA may reduce postop comps

Harari, Age Ageing 2007; 36: 190

Evidence? Observational cohort

Pre-POPS n=54 POPS n=54

Age 75 74

Cardiac 33% 55%

Diabetes 13% 20.4%

Renal 3.7% 22.2%

Hypertension 51.9% 80%

Delirium 18.5% 5.6%

Pneumonia 20% 4%

ACS 7.4% 3.7%

Arrhythmia 13% 7.4%

Heart failure 3.7% 0%

Thrombosis 11% 2% (1)

Wound sepsis 22.2% 3.7% (2)*

Harari, Age Ageing 2007


Pre-POPS Post-POPS

Uncontrolled pain 29.6% 1.9%

NBM >4days 9.3% 0%

Catheter>4/7 20.4 % 7.4 %

Dependent transfers 14.8% 0%

Bedridden >3days 27.8 % 9.3%

Pressure sores 18.5% 3.7%

Length of stay 15.8 ± 13.2 11.5 ± 5.2

Delayed discharge 70.4% 24.1%

- medical problems 37% 13%

- slow rehab’n 13% 7.4%

- wait for OT/equipment 20.4% 3.7%


Evidence? RCT

Evidence? RCT

Partridge, British Journal of Surgery Jan 2017

New diagnosisOT/Social worker referralMedication changesPlanning with primary carePlanning with ward team

Patients aged over 65 years undergoing elective AAA or LEAR surgery, randomised to routine care versus CGA

Reduction in Median LOS5.5 days to 3.3 days (p<0.001)0

20

40

60

80

Pe

rcen

tage

Medical complications (p=0.002) Surgical complications (p=0.04) Delayed discharge (p=0.05)

Control Intervention Control Intervention Control Intervention

Percentage of patients with complications and delayed discharge by trial arm

Evidence? QIP - elective

Before February 1st

11 MedianAfter February1st

7 Median

• Length of stay ↓ 4 days

• 30 day readmission rate ↓ 13.2%

• Times seen by non surgeon ↓ 18%

• Medication reviews ↑ 51%

• Coding complications ↑↑

• Coding comorbidities ↑↑

Courtesy of

Dr Vilches-Moraga, Salford

Evidence? QIP - emergency

Is there an appetite for CGA?

• 70% describe inadequate training in complex older patients

• 68% difficulty in accessing medical support

• 8% no need for closer working

Ideal components of a collaborative geriatric medicine-surgical service

Medical Optimisation 79%

Mental Capacity Assessment 71%

Quantifying Medical Risks of Surgery

64%

Managing Medical Complications 87%

Communication with patients and families

38%

Post-op rehab/ discharge planning 92%

Do Surgical Trainees Believe They Are Adequately Trained to Manage the Ageing Population? A UK Survey of Knowledge and

Beliefs in Surgical Trainees. Shipway. JSE, 2015.

But is yet to be translated into routine care…

Partridge, Age and Ageing 2014

…and emergency care

…however, this picture is already changing…

Chelmsford

Imperial

BelfastEdinburgh

Nottingham

Guildford

Southmead

North TeesSalford

GSTT, London

Cambridge

Kings, London

Oxford Portsmouth

The workforce challenge - not enough geriatricians!

2011 2035

Population 63 million 73.2 million

Population 65+ 10.4 million 16.8 million

Number of geriatricians 1222* 1464**

High number of unfilled posts

* current number of consultant geriatricians** required number of consultant geriatricians

Geriatric medicine workforce planning: a giant geriatric problem or has the tide turned? Fisher. Clinical Medicine, 2014.

Need to consider alternative workforce…

Specialty

• Primary care

• Anaesthetists

• Geriatricians

• General physicians (hospitalists)

Discipline

• Nurses

• Occupational therapists

• Physiotherapists

• Pharmacists

• Physician associates

Many training resources available

…and training opportunities…

www.popsteam.co.uk

•British Geriatrics Society POPS Special Interest Group

•POPS – AAA conference: March 2018 (www.bgs.org.uk)

•POPS OOPE posts

•RCoA Perioperative medicine programme

•UCL Perioperative Medicine MSc

•EBPOM, NELA

•Age Anaesthesia Association

http://www.popsteam.co.uk/

[email protected]

@DrPhilipBraude

perioperative care of older people - rcp london

Documents