Comprehensive Geriatric Assessment in Perioperative Medicine
13.3 Comprehensive Geriatric Assessment in the Preoperative Setting
Conducting effective comprehensive geriatric assessment in the preoperative setting requires a thorough knowledge of frequently encountered postoperative complications and the risk factors for developing these adverse events. These complications include surgical and medical complications, functional deterioration with delays to transfer of care or discharge home and changes in the underlying trajectory of disease (e.g. delir- ium changing the trajectory of underlying cognitive impairment). This should prompt the multidisciplinary team to use comprehensive geriatric assessment to:
a. Describe and optimise recognised disease.
For example, the patient might be a smoker with a diagnosis of chronic obstruc- tive pulmonary disease (COPD) presenting for elective abdominal aortic aneurysm repair with a self-reported exercise tolerance of 50 m. Tailoring comprehensive geri- atric assessment in this perioperative scenario involves:
– Objective evaluation of known COPD using history (length of diagnosis, symp- toms, frequency of exacerbation, prior need for invasive medical support, etc.), examination (including appraisal of respiratory reserve using tool such as 6 min walk test or shuttle walk) and investigation (pulmonary function tests)
– Multidisciplinary optimisation including referral for smoking cessation, pulmo- nary rehabilitation (which may be undertaken preoperatively or scheduled
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postoperatively depending on surgical urgency), appropriate prescribing accord- ing to current guidelines and evaluation of inhaler technique
– Shared decision-making regarding risk/benefit of undertaking life-protracting surgery in a patient with coexistent life-limiting condition causing functional impairment – Individualised perioperative care plan, for example, recommending appropriate
use of postoperative level 2/3 care
– Proactive multidisciplinary postoperative management planning including set- ting target oxygen saturations, early postoperative mobilisation, etc.
b. Identify and optimally manage previously unrecognised disease.
For example, a patient with a new finding of atrial fibrillation (AF) presenting in preparation for transurethral resection of prostate gland is at increased risk of late cancellation of surgery due to inadequate rate control, intraoperative and postopera- tive fast AF and longer-term risk of thromboembolic stroke. Tailoring comprehen- sive geriatric assessment to this perioperative scenario involves:
– Screening for AF (a common cardiac arrhythmia prevalent in older patients) using preoperative ECG.
– Investigation for possible underlying causes, e.g. hyperthyroidism, alcohol excess, hypertension and managing these accordingly.
– Preoperative treatment informed by the decision to rate or rhythm control. This should take the timing and indication for surgery into account. For example, in cancer surgery, postponing the procedure in order to electrically cardiovert with the necessary prior of anticoagulation may not be appropriate. Instead the emphasis should be on rate control using evidence-based guidelines extrapolated to the peri- operative setting, e.g. using beta blockers as opposed to digoxin for rate control.
– Standardisation of perioperative management, for example, ensuring magnesium is replaced, and continuation of rate/rhythm controlling medications throughout the perioperative period.
– Longer-term management with reconsideration of the rate or rhythm strategy and evaluation of stroke risk and need for anticoagulation.
c. Tailor the assessment and management to the available timeline.
For example, a patient is presenting with acute bowel obstruction secondary to incarcerated inguinal hernia with resultant acute delirium. Tailoring comprehensive geriatric assessment to this perioperative scenario involves:
– Rapidly obtaining collateral history regarding premorbid cognitive issues, medi- cal multimorbidity and functional status
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– Assessment of capacity regarding treatment options (conservative/palliative/
operative management) and identification of any legal arrangements for proxy decision-making (such as lasting power of attorney in England)
– Preoperative medical optimisation including analgesia, volume resuscitation, antibiotics and optimisation of other comorbidities (e.g. iron deficiency anaemia management)
– Perioperative planning including relevant use of level 2/3 care and ensuring appropriate ceilings of care
– Standardisation of postoperative care particularly using an evidence-based approach to the management of postoperative delirium (e.g. HELP) and associ- ated risks, e.g. falls
– A proactive rehabilitation strategy with clear goal setting and multidisciplinary decision-making regarding place of discharge (rehabilitation in bed-based unit, rehabilitation and care provision at home, need for institutional care, etc.) – Longer-term management with memory service evaluation
d. Pre-emptively consider the discharge plan from hospital even prior to admission.
For example, a patient is listed for elective hip arthroplasty who is sleeping downstairs on the sofa and currently unable to manage personal activities of daily living because of pain and functional limitation due to rheumatoid and osteoarthri- tis. Tailoring comprehensive geriatric assessment to this perioperative scenario involves:
– Screening for issues related to the pre-existing musculoskeletal conditions known to be relevant in the perioperative period and providing individualised plans for managing these (stopping non-steroid anti-inflammatory medications due to renal risk, providing a perioperative plan for increased steroid cover in those on long-term exogenous steroids, evaluating cervical spine stability and movement in preparation for intubation, etc.)
– Proactive multidisciplinary optimisation of functional limitation and domestic environment thus preventing an elective admission without a clear discharge strategy (this may involve establishing a micro-environment downstairs in order that the patient does not need to use the stairs, providing carers to facilitate activ- ities of daily living, use of equipment to promote independence, referral for exer- cise programmes aimed at improving function and reducing falls, providing clear expectations regarding length of hospital stay to the patient and their family, etc.) – Standardised postoperative management including analgesic strategy, therapy
goals, discussion at ward level multidisciplinary team meeting, estimated dis- charge date setting, etc.
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13.4 Comprehensive Geriatric Assessment to Facilitate