Background Elderly population in Singapore growing Specific - PowerPoint PPT Presentation

8/7/2014 Background • Elderly population in Singapore growing Specific Problems in Surgery in the • 6.3% aged above 65 currently Elderly • 25% by year 2030 TAN Kok-Yang (more than 1 million individuals) 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. Problem with Elderly Surgical Physiological Issues in Elderly Patients Surgical Patients • High incidence of co- morbidities • Limited functional reserves • Frequent acute surgical problems resulting in Old Brad Pitt emergency situations • Old Paris Hilton Department of General Surgery 1

8/7/2014 Ageing Heart • Reduced myocytes • Declining physiologic reserves • Increased collagen • May not be adequate in acute illness or • Decrease ventricular surgical stress compliance • Autonomic tissue changes • Reduced max capacity • ACS poorer outcomes Respiratory Renal • Reduced chest wall compliance • Capacity reduced • Loss of elasticity and collapse of small airways • Implications on pharmacology • Responses reduced • Reduced protective mechanism • Prone to infection 2

8/7/2014 Others Significant heterogeneity not only in physiologic alterations but also in associated co-morbidity and life • Nutrition expectancy • Dementia Problem of Risk Stratification Importance of Risk Stratification • Building blocks to: – Better decision making for surgical indication and planning – Anticipatory perioperative management – Robust informed consent Department of Surgery Department of Surgery, Khoo Teck Khoo Teck Puat Hospital Puat Hospital 3

8/7/2014 What do we know on Surgical Outcomes? Department of Surgery, Khoo Teck Puat Hospital 4

8/7/2014 Multivariate Analysis for Morbidity Risk Conclusion Factor Odds ratio 95% C.I. p • Octogenarians undergoing major colorectal Elective operation 0.99 resection have an acceptable perioperative Tumour presenting with 5.38 0.60 – 48.31 0.13 morbidity and mortality rate and survival rate complication Cormorbid diabetes mellitus 4.41 0.66 – 29.42 0.12 and should not be denied surgery based on Comorbid coronary artery disease 0.45 0.05 – 4.22 0.49 age alone. Comorbid heart failure 0.99 • Comorbidity index scores and ASA scores are Preoperative haemoglobin 0.89 0.52 – 1.54 0.69 useful tools to identify poor risk patients. 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 Quantification of comorbidities and physiological status helps risks stratification Quantification for surgery in a very heterogenous group of makes patients easier comparisons Department of Surgery, Khoo Teck Puat Hospital 5

8/7/2014 Tools for Pre-op Assessment ASA score ASA Status Criteria • ASA & Comorbidity index 1 A normal healthy patient » Tan et al WJS 2006 2 A patient with mild systemic disease » Tan et al Int J Colorectal Dis 2008 3 A patient with severe systemic disease • POSSUM, CR-POSSUM 4 A patient with severe systemic disease that is a • Barthels functional status constant threat to life 5 A moribund patient who is note expected to • Conventional biochemical markers survive without the operation • Alb 6 A declared brain-dead patient whose organs are being removed for donor purposes • Renal function • FBC Weighted Index of Comorbidity from Charlson Comorbidity Index Condition Assigned Weight Myocardial infarction 1 Congestive heart failure 1 Peripheral vascular disease 1 Physiological and Operative Severity Cerebrovascular disease 1 Dementia 1 Chronic pulmonary disease 1 Score for the enUmeration of Connective tissue disease 1 Ulcer disease 1 Mortality and morbidity (POSSUM) 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 6

8/7/2014 Physiological Possum Operative Possum 1 2 4 8 Severity Score Minor Moderate (colectomies) Major (APR) Major + Multiple 1 2 >2 Procedures 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)- 5.91 Predicted Morbidity Rate = 1/(1+ e ( -x ) ) y = (0.13* physiologic score)+(0.16*operative score)- 7.04 Predicted Mortality Rate = 1/(1+ e ( -y ) ) 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 >7 seconds Height < 159 >7 seconds cm cm 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 < 383 kcal / wk < 270 kcal / wk (MLTA) 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; Department of Surgery, Khoo Teck MLTA = Minnesota Leisure Time Activity Questionnaire; Puat Hospital CES-D = Center for Epidemiologic Studies Depression Scale. 7

8/7/2014 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 M.R.C.P. Mean Pred Mort 11.58 8.00 0.055 Department of General Surgery Physical phenotype of frailty may reflect Health status at the time of reduced functional reserves and thus assessment intolerance to the trauma of major surgery 8

8/7/2014 Delivering Surgical Care to the Complex ����������� ������������� Cancer Geriatric Patient ��������� ���� Comorbidity ��������� Treatment ADL ��������� Frail dependent Retonaz et al in Tan KY Ed. Colorectal Cancer in the Elderly, 2012 Department of Surgery, Khoo Teck Puat Hospital Transdisciplinary Geriatric Surgery Service Getting Round These Problems • Surgeons • Identification of high risk patients • Anaesthetists • Geriatric Medicine • Shift towards elective surgery Physicians • Cardiologist • Optimize comorbidities • Nurse Clinician through prehabilitation • Physiotherapist • Transdisciplinary approach • Dietitian • Medical Social Worker • Attention to details • Pharmacist • Befriender 9

8/7/2014 Multidisciplinary Approach DIETITIAN MSW PHYSIOTHERAPIST PATIENT ANAESTHETIST GERIATRICIAN CARDIOLOGIST SURGEON Adhoc, uncoordinated care rendered to patients not managed by Geriatric Surgery Service. Barbara Ms Adeline Wee Dr. Tan Kok Yang Physiotherapist Pharmacist Dr. Lawrence Tan Surgeon Geriatrician Dispenses of hierarchy Heightened communication Patient-centric Role extension (improve one’s own discipline) Dr. Ong Hean Yee Role enrichment (understand other disciplines) Cardiologist Dr. Naville Chia Anaesthetist Role expansion (interdisciplinary education) Role release (blurred boundaries) Role support (constant feedback and quality improvement) Coordinated and less Amy Vong Phyllis Tan fragmented care Dietitian Nurse Clinician Department of Surgery, Khoo Teck George Toh Tan Pei Pei Weiling Dr. Edwin Seet Puat Hospital Dietitian Medical Social Worker Befriender Anaesthetist 10

8/7/2014 Setting Goals Transdisciplinary Multi-level Risk Assessment • Goals for Team – Care plan – Attention to details • Goals for Patients – Return of function – Independence and QOL vs Survival Department of Surgery, Khoo Teck Puat Hospital OUTCOME STUDIES ON OLDER PATIENTS GSS Step-wise Consenting Process UNDERGOING SURGERY ARE MISSING • Consolidation of data of risk stratification and disease pathology 1 THE MARK • Patient education process on disease pathology 2 • Transdisciplinary patient and family conference 3 Joyce Chee, Tan Kok Yang • Exploration of treatment goals in accordance to patient 4 Journal of American Geriatric • Exploration of treatment options and setting treatment aims, risks and benefits Society 5 • Obtain consensus on treatment strategy between patient, surgical team and family JAGS Nov 2010; 58(11): 2238-40 6 • Clear documentation of discussions 7 Department of Surgery, Khoo Teck Puat Hospital 11