problem with elderly surgical patients physiological ... · leukemia 2 malignant lymphoma 2 liver...

1

8/7/2014

Specific Problems in Surgery in the

Elderly

TAN Kok-Yang

MMed(Surg), FRCSE, FAMS

Head & Senior Consultant, Department of Surgery

Clinical Director, Geriatric Surgery Service

Khoo Teck Puat Hospital

KTPH Surgery. To deliver progressive and

collaborative surgical care with a passion for

safety and culture of compassion.

• Elderly population in Singapore growing

• 6.3% aged above 65 currently

• 25% by year 2030

(more than 1 million individuals)

Background

Problem with Elderly Surgical

Patients • High incidence of co-

morbidities

• Limited functional reserves

• Frequent acute surgical

problems resulting in

emergency situations

• Old Paris Hilton

Department of General Surgery

Physiological Issues in Elderly

Surgical Patients

Old Brad Pitt

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Ageing

• Declining physiologic reserves

• May not be adequate in acute illness or

surgical stress

Heart

• Reduced myocytes

• Increased collagen

• Decrease ventricular

compliance

• Autonomic tissue

changes

• Reduced max capacity

• ACS poorer outcomes

Respiratory

• Reduced chest wall

compliance

• Loss of elasticity and

collapse of small

airways

• Responses reduced

• Reduced protective

mechanism

• Prone to infection

Renal

• Capacity reduced

• Implications on

pharmacology

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Others

• Nutrition

• Dementia

Significant heterogeneity not only in

physiologic alterations but also in

associated co-morbidity and life

expectancy

Problem of Risk Stratification

Department of Surgery

Khoo Teck Puat Hospital

Importance of Risk Stratification

• Building blocks to:

– Better decision making for

surgical indication and

planning

– Anticipatory perioperative

management

– Robust informed consent

Department of Surgery, Khoo Teck

Puat Hospital

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Puat Hospital

What do we know on

Surgical Outcomes?

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8/7/2014

Factor Odds ratio 95% C.I. p

Elective operation 0.99

Tumour presenting with

complication

5.38 0.60 – 48.31 0.13

Cormorbid diabetes mellitus 4.41 0.66 – 29.42 0.12

Comorbid coronary artery disease 0.45 0.05 – 4.22 0.49

Comorbid heart failure 0.99

Preoperative haemoglobin 0.89 0.52 – 1.54 0.69

Preoperative serum albumin 1.26 0.38 – 4.26 0.70

Preoperative BUN 0.97 0.86 – 1.09 0.63

ASA score > 3 64.85 3.26 – 1290.92 0.01

Comorbidity index > 5 8.41 1.22 – 57.97 0.03

Surgical blood loss > 1000mls 13.58 1.01 – 181.76 0.05

Multivariate Analysis for Morbidity RiskConclusion

• Octogenarians undergoing major colorectal

resection have an acceptable perioperative

morbidity and mortality rate and survival rate

and should not be denied surgery based on

age alone.

• Comorbidity index scores and ASA scores are

useful tools to identify poor risk patients.

Quantification of comorbidities and

physiological status helps risks stratification

for surgery in a very heterogenous group of

patients


Puat Hospital

Quantification makeseasier comparisons

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Tools for Pre-op Assessment

• ASA & Comorbidity index» Tan et al WJS 2006

» Tan et al Int J Colorectal Dis 2008

• POSSUM, CR-POSSUM

• Barthels functional status

• Conventional biochemical markers

• Alb

• Renal function

• FBC

ASA scoreASA Status Criteria

1 A normal healthy patient

2 A patient with mild systemic disease

3 A patient with severe systemic disease

4 A patient with severe systemic disease that is a

constant threat to life

5 A moribund patient who is note expected to

survive without the operation

6 A declared brain-dead patient whose organs are

being removed for donor purposes

Weighted Index of Comorbidity from Charlson Comorbidity Index

Condition Assigned Weight

Myocardial infarction 1

Congestive heart failure 1

Peripheral vascular disease 1

Cerebrovascular disease 1

Dementia 1

Chronic pulmonary disease 1

Connective tissue disease 1

Ulcer disease 1

Liver disease mild 1

Diabetes 1

Hemiplegia 2

Renal disease moderate or severe 2

Diabetes with end organ damage 2

Any malignancy 2

Leukemia 2

Malignant lymphoma 2

Liver disease. moderate or severe 3

Metastatic solid malignancy 6

AIDS 6

Physiological and Operative Severity

Score for the enUmeration of

Mortality and morbidity (POSSUM)

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Physiological Possum

1 2 4 8

Severity Score Minor Moderate (colectomies) Major (APR) Major +

Multiple

Procedures

1 2 >2

Blood Loss (mls) <100 101-500 501-999 >999

Contamination None Minor (serous) Local pus Free bowel content, pus or blood

Presence of Ca None Primary Nodal mets Distant mets

Mode of Surgery Elective Urgent Emergency (immediate <2hrs)

x = (0.16* physiologic score)+(0.19*operative score)-5.91Predicted Morbidity Rate = 1/(1+ e(-x))y = (0.13* physiologic score)+(0.16*operative score)-

7.04

Predicted Mortality Rate = 1/(1+ e(-y))

Operative Possum


Puat Hospital

One must have 3 or more of the following criteria to be frail

Male Female

Weight Loss Greater than 10lbs or 5% weight loss in the last year

15 foot Walk Time Height < 173

cm

>7 seconds Height < 159

cm

>7 seconds

Height >173 cm > 6 seconds Height >159 cm > 6 seconds

Grip Strength BMI < 24 < 29 BMI < 23 < 17

BMI 24.1 - 26 < 30 BMI 23.1 - 26 < 17.3

BMI 26.1 - 28 < 30 BMI 26.1 - 29 < 18

BMI > 28 < 32 BMI > 29 < 21

Physical Activity

(MLTA)

< 383 kcal / wk < 270 kcal / wk

Exhausation A score of 2 or 3 on either question on the CES-D*

*How often in the last week did you feel this way?

a) I felt that everything I did was an effort.

b) I could not get going.

0 = 1 day; 1 = 1–2 days; 2 = 3–4 days; 3 = more than 4 days

BMI = Body Mass Index;

MLTA = Minnesota Leisure Time Activity Questionnaire;

CES-D = Center for Epidemiologic Studies Depression Scale.

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M.R.C.P.Correlation with Major Complication

Risk 95% CI p

ASA > 3 1.048 0.323-3.400 0.938

WCIS > 5 1.424 0.426-4.759 0.564

Frail 3.467 1.113 – 10.795 <0.001

Major complication Yes No p

Mean Pred Mort 11.58 8.00 0.055

Department of General Surgery

Physical phenotype of frailty may reflect

reduced functional reserves and thus

intolerance to the trauma of major surgery

Health status at the time of

assessment

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Puat Hospital

Assessment

Patient 2

Patient 1

Cancer

Patient 3

time

Health status

Treatment

Tan KY Ed. Colorectal Cancer in the Elderly, 2012

Retonaz et al in

Delivering Surgical Care to the Complex

Geriatric Patient

Comorbidity

FrailADL

dependent

• Identification of high risk patients

• Shift towards elective surgery

• Optimize comorbidities

through prehabilitation

• Transdisciplinary approach

• Attention to details

Getting Round These ProblemsTransdisciplinary Geriatric Surgery Service

• Surgeons

• Anaesthetists

• Geriatric Medicine Physicians

• Cardiologist

• Nurse Clinician

• Physiotherapist

• Dietitian

• Medical Social Worker

• Pharmacist

• Befriender

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DIETITIAN

SURGEON

PATIENT

Multidisciplinary Approach

Adhoc, uncoordinated care rendered to patients

not managed by Geriatric Surgery Service.

MSW PHYSIOTHERAPIST

ANAESTHETISTCARDIOLOGISTGERIATRICIAN


Puat Hospital

Dr. Tan Kok YangSurgeon Dr. Lawrence Tan

Geriatrician

Ms Adeline WeePharmacist

Dr. Naville ChiaAnaesthetist

WeilingBefriender

Tan Pei PeiMedical Social Worker

Dr. Edwin SeetAnaesthetist

Dr. Ong Hean YeeCardiologist

Amy VongDietitian

Dispenses of hierarchyHeightened communicationPatient-centricRole extension (improve one’s own discipline)

Role enrichment (understand other disciplines)Role expansion (interdisciplinary education)Role release (blurred boundaries)Role support (constant feedback and quality improvement)

Coordinated and less fragmented care

George TohDietitian

BarbaraPhysiotherapist

Phyllis TanNurse Clinician

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Transdisciplinary Multi-level Risk Assessment Setting Goals

• Goals for Team

– Care plan

– Attention to details

• Goals for Patients

– Return of function

– Independence and QOL

vs Survival


Puat Hospital

OUTCOME STUDIES ON OLDER PATIENTS

UNDERGOING SURGERY ARE MISSING

THE MARK

Joyce Chee, Tan Kok Yang

Journal of American Geriatric

Society

JAGS Nov 2010; 58(11): 2238-40

GSS Step-wise Consenting Process

1• Consolidation of data of risk stratification and disease pathology

2• Patient education process on disease pathology

3• Transdisciplinary patient and family conference

4• Exploration of treatment goals in accordance to patient

5• Exploration of treatment options and setting treatment aims, risks and benefits

6• Obtain consensus on treatment strategy between patient, surgical team and family

7• Clear documentation of discussions


Puat Hospital

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Components of Prehabilitation

• Education

• Optimisation of lung

function

• Mobilisation

• Muscle strengthening

• Nutrition

Prehabilitation

Selection Criteria

Prehabilitation Post Rehabilitation

Criteria Day

Rehabilitation

Centre

Home

Prehabilitation

Criteria Home

Rehabilitation

Inpatient

Rehabilitation

(AMKCH)

Charlson

Comorbidity

Index

>3 >3 Charlson

Comorbidity

Index

>3 >3

Frailty

Syndrome

Positive Positive Frailty

Syndrome

Positive Positive

Mobility Moderate Poor to

moderate

Peri-operative

complication(s)

requiring more

specific care

Negative Positive

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Patient Education Materials

Prehab Education

Twice per week home visit

Barthels Index after 2 weeks

of prehabilitation :

71/100 from 65/100

Satisfied patient and family

reported overall improvement in functional

status.

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Component Initial

Assessment

One Week after prehabilitation Two Weeks after

prehabilitation

Target

Education and

Compliance

Understand

disease and

indication for

surgery

Patient

understands

disease and

indication for

surgery

Yes � No � Patient

understands

disease and

indication for

surgery

Yes

�

No

�

Patient understands

disease and indication

for surgery

Knows what to

expect

Patient knows

what to expect

Yes � No � Patient knows

what to expect

Yes

�

No

�

Patient knows what to

expect

Preparation of

Operation

Patient knows

what to do

Yes � No � Patient knows

what to do

Yes

�

No

�

Patient knows what to

do

Weight Change

Current Weight: No Weight Loss � No Weight Loss � No Weight Loss Over

past 2 weeks

Weight Loss <5% � Weight Loss <5% �

Weight Loss >5�

Weight Loss >5�

Dietary Intake

Usual Intake: Achieved 100%

of dietary

requirement 5 in

7days

Yes � No � Achieved 100%

of dietary

requirement 5 in

7days

Yes

�

No

�

Achieved 100% of

dietary requirement 5

in 7days

050

100150200250300350400450500

Pre op 1st postop 2nd post op 3rd post op 4th post op 5th post op discharge

Dis

tan

ce (

m)

2/ 6MWT 2mwt 6mwt

05

101520253035404550

Fo

rce (

kg

)

Ankle Dorsiflexion ankle dorsiflexion Left

ankle dorsiflexion Right

02468

101214161820

no

. o

f re

ps

Chair riseChair rise

0

10

20

30

40


Dis

tan

ce (

cm

)

Forward reachForward reach

0

5

10

15

20


no

. o

f re

ps

Step Test Left step up Right step up

0

5

10

15

20

25

30


Tim

e (

s)

TUG TUG


Puat Hospital

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8/7/2014

Intraoperative Care Planning

Anaesthesia

Hypothermia

Fluids

Tubes


Puat Hospital

01565605

Endoscopic Submucosal Dissection for Early Cancers

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8/7/2014

Postoperative


Puat Hospital

Post-operative

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8/7/2014

Early Mobilisation POD1 Anterior Resection and Partial

Cystectomy

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8/7/2014

Geriatric Surgery Service continue to provide home based rehabilitation after discharge to ensure preservation of functional state and quality of life as per premorbid.

Ability to perform self care with

minimal/no assistance.

Post Discharge Rehabilitation

Medication reconciliation at home after surgery

Activities of Daily Living

After surgery at 84 years old.

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Friends of Geriatric Surgery Service at work

83 years old.Back to teaching Qi Gong

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-18

-16

-14

-12

-10

-8

-6

-4

-2

0

2

4

1 3 5 7 9 11 13 15 17 19 21 23 25 27 29 31 33 35 37 39 41 43 45 47 49 51 53 55 57 59 61 63 65

Patient no.

Collaborative Transdisciplinary

ApproachStandard Treatment

Patient no.

-4

-3

-2

-1

0

1

2

1 3 5 7 9 11 13 15 17 19 21 23 25 27 29 31 33 35 37 39 41 43 45 47 49 51 53 55 57 59 61 63

Functional Outcomes of Elderly Adults who have

Undergone Major Colorectal Resections

• Wang Zhongkai, Tan Kok Yang

• Journal of American Geriatric

Society

• JAGS Dec 2013; 61(12): 2249-50

Mean follow-up of 91.2 months93.6% had Barthels Index not inferior to preoperative

score

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8/7/2014


Puat Hospital

problem with elderly surgical patients physiological ... · leukemia 2 malignant lymphoma 2 liver...

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