Elderly Medicine Flashcards
What are the surgical outcomes in older patients?
- increased risk of complications 20% over 80
- increased morbidity and mortality, increased risk of falls
- increased risk in frailty scores
What is a comprehensive geriatric assessment?
tool taking into account perioperative care
- initial assessment usually multidisciplinary
best practice is preoperative assessment
80M Italian for TKR hx of HTN, BPH
on prazosin 1mg b.d.
what additional history might not have been obtained?
What complications might result?
MMSE 22/30, nocturia, falls in the past 3/12
- delirium
- poor oral intake
- fall
- fractures
- complications in rehabilitation
What are some preoperative interventions in the elderly?
minimal evidence
- CGA in small number - proactive care model in ortho surgery (POPS)
- ERAS (enhanced recovery after surgery) - in colorectal in elderly
reduced risk with CGA for:
- delirium, pneumonia, reduced length of stay
Consideration:
- optimise med conditions (accept higher HbA1c)
- improve cardioresp reserve (e.g. pul rehab)
- optimise functional mobility (OT therapy, identify inpatient rehab, identify risk of falls)
- improve cognition (no evidence, careful post op mgx, reduce risk of delirium/falls)
- improve continence (?trial of alpha blocker - monitor hypotension) - increased risk of falls
- nutrition - evidence immune enhancing nutritional supplements in ERAS
- patient education (LOS reduced in those where education, reduced anxiety, increased wellbeing)
- polypharmacy (reduce ones you don’t need e.g. NSAIDs, diuretics, antihypertensives, anticholinergics)
- advanced care planning
What are common postop complications in elderly?
common
- pneumonia
- cardiac
Elderly specific:
- pressure ulcers
- delirium
- bladder and bowel dysfunction
- falls
- functional decline
Pressure ulcer risk factors and what is the treatment?
RF:
- poor physical condition
- cog impairment
- impaired mental state
- immobility
- incontinence
- oedema
- comorbidities
Treatment?
- relieve the pressure
- regular repositioning ever 2 hrs
- elevate heels (pillow or wedge cushion)
- dynamic air mattress
- high vigilance
- control moisture/continence
- mobilise and return to usual function ASAP
- optimise nutrition
What are the rates of delirium? What way do you think of/how do you workup delirium?
Rates are high 15% in gen surg 60% post hip fracture
- increases mortality
Predisposing/Predisposing factors
- everyone has a threshold
Predisposing:
- preexisting cognitive impairment
- functional impairment
- coexisting medical illness
- sensory impairment
- psychotropic meds (>3)
Precipitating
- medications
- infection
- dehydration
- sleep disturbance
- number of procedures
- use of physical restraints
How can you prevent delirium post op?
- close to normal function
- avoid IV lines
- removal of catheters as able
- reversal of precipitant
How would you manage delirium?
- assess for post op things (pain, hypoxia, pneumonia etc.)
Supportive management
- 1:1 nursing, low bed, low light, maintain normal sleep/wake cycle
- avoid complications
- avoid meds unless danger to injury to patient/staff
- avoid benzos
low dose antipsychotics (0.5-1mg haloperidol)
Management of urinary function?
- PVR measuring often
- avoid routine catheters and remove as soon as possible
What are some causes of constipation? Management of constipation?
Causes
- medications (opiates, CCB, antipsychotics, parkinson’s medications, diuretics)
- dehydration
- reduced mobility
think of this in urinary retention, delirium, n/v, reduced PO intake, resp distress
Management
- bowel chart
- hydration
- early mobilisation
- regular apperients (movicol)
- low dose pain control
What are some interventions post fall?
- review of medications (low opiate, avoid benzos, caution with diuretics, use antipsychotics only if required)
- monitor postural BP
- treat and manage delirium
- keep corrective lenses within reach
- regular toileting
- use hi/low beds
DO NOT USE RESTRAINTS
What are some pain considerations in the elderly?
- avoid NSAIDs (ulcers and renal effects)
- paracetamol regularly
- caution tramadol (increased delirium in elderly)
- side effects of opiates (oversedate, constipation) - rotate opioid if needed
