Preop Geriatric Evaluation Guidelines Issued by ACS/AGS

Laurie Barclay, MD

October 02, 2012

October 2, 2012 — The American College of Surgeons (ACS) and the American Geriatrics Society (AGS) have issued a best practices guideline for preoperative evaluation of patients at least 65 years of age who are undergoing surgery. The new recommendations, which resulted from the first collaboration of ACS with AGS on this topic, appear in the October issue of the Journal of the American College of Surgeons.

"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," senior author Clifford Y. Ko, MD, director of the ACS National Surgical Quality Improvement Program (NSQIP) and the ACS Division of Research and Optimal Patient Care in Chicago, Illinois, said in a news release. "This population is growing in numbers and we want to emphasize the depth and breadth of care required for them. These evidence-based guidelines will enhance surgical practice by setting higher standards and performance measures for surgeons and the entire perioperative care team."

Another impetus behind these ACS/AGS recommendations, in addition to the rapid increase in the US geriatric population, is the number and severity of underlying medical conditions that often require multidisciplinary management.

"Patients who are 90 years old tend to have more comorbidities than those who are 65 years," Dr. Ko said. "There may be something wrong with the heart, the lungs, the kidneys, the liver. Surgeons have to plan and deal with these comorbidities simultaneously while the patient is undergoing a surgical procedure."

Between 2010 and 2050, the percentage of men and women aged 65 years and older will more than double, and this age group will increase by 20% of the total population by 2030, according to the US Census Bureau. In 2006, this age group accounted for 35.3% of all inpatient surgical procedures and 32.1% of all outpatient procedures.

After 2 years of research and analysis, a multidisciplinary expert panel of ACS and AGS members, as well as expert panelists from a variety of medical specialties, issued the new guidelines in response to the Elderly Surgery Measure. The ACS NSQIP developed this hospital-based performance measure with the Centers for Medicare and Medicaid Services to assess the quality of care among Medicare-eligible patients undergoing surgery. In October, a pilot program launched by both organizations will allow hospitals to publicly and voluntarily report outcomes using this measure.

13 Key Assessment Areas

The guidelines highlight 13 important areas requiring preoperative assessment in geriatric patients: cognitive impairment and dementia; decision-making ability; postoperative delirium; alcohol and substance abuse; cardiac assessment; pulmonary assessment; functional status, mobility, and fall risk; frailty; nutritional status; medication regimen; counseling; preoperative testing; and patient-family and social support system.

"There is no single magic bullet for rendering this level of surgical care," said Dr. Ko, who is also a professor of surgery at University of California, Los Angeles (UCLA), and director of UCLA's Center for Surgical Outcomes and Quality. "Each of the 13 issues covered by the guidelines is very important, comprehensive, and difficult to prioritize. For example, surgeons and perioperative team members may do perfectly well when analyzing a patient's cognitive functioning, but not so well on the polypharmacy issue, [which then] becomes the number-one issue for the surgical team to address during the preoperative care phase."

The guidelines recommend reducing risk for adverse drug reactions by identifying drugs that should be discontinued, avoided, or reduced in dosage before surgery.

"When surgeons evaluate elderly patients before they undergo operations, they want to know how many and what specific medications their patients are taking," Dr. Ko added. "This step will enable them to identify potential medication issues before operations and before the surgeons start adding pain medication to the patient's medication list."

To identify patients at higher risk for developing perioperative heart disease and myocardial infarction, all geriatric patients should be evaluated for perioperative cardiac risk, the guidelines state, in accordance with American College of Cardiology and American Heart Association algorithms for noncardiac surgery.

"Caring for the elderly generally requires a team approach," Dr. Ko said. "The surgeon knows how to perform surgery and the cardiologist knows how to take care of the heart. It's best for everyone to work together to take care of the patient. We want everyone on the same page of providing good quality care."

Checklist

The guidelines strongly recommend the following preoperative assessments for every geriatric patient:

  • Performing complete history and physical examination;

  • Conducting cognitive assessment, including the patient's ability to understand the purpose and likely outcomes of the planned surgical procedure;

  • Screening for depression;

  • Determining risk factors for postoperative delirium;

  • Screening for substance abuse/dependence, including alcohol;

  • Performing cardiac evaluation following the American College of Cardiology/American Heart Association algorithm for patients undergoing noncardiac surgery;

  • Assessing risk factors for postoperative pulmonary complications and implementing suitable preventive strategies;

  • Documenting functional status and fall history;

  • Calculating frailty score at baseline;

  • Assessing nutritional status and considering implementation of preoperative interventions for high-risk patients;

  • Taking a complete medication history, making needed perioperative adjustments, and monitoring for polypharmacy;

  • Identifying the patient's treatment goals and expectations in light of anticipated and unexpected treatment outcomes;

  • Assessing the family and social support system; and

  • Performing suitable diagnostic tests as needed for elderly patients.

The guideline authors have disclosed no relevant financial relationships.

J Am Coll Surg. 2012;215:453-466. Abstract

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