New comprehensive guidelines for the pre-operative care of the nation’s elderly patients have been issued by the American College of Surgeons (ACS) and the American Geriatrics Society (AGS). The joint guidelines—published in the October issue of the Journal of the American College of Surgeons—apply to every patient who is 65 years and older as defined by Medicare regulations. The guidelines are the culmination of two years of research and analysis by a multidisciplinary expert panel representing the ACS and AGS, as well as by expert representatives from a range of medical specialties.
“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,” said Clifford Y. Ko, MD, FACS, director of the ACS National Surgical Quality Improvement Program (ACS NSQIP®) and the ACS Division of Research and Optimal Patient Care in Chicago, professor of surgery at University of California, Los Angeles (UCLA) and director of UCLA’s Center for Surgical Outcomes and Quality.
One of the driving forces behind the guidelines is America’s expanding geriatric population, Dr. Ko explained. The U.S. Census Bureau projects the percentage of men and women 65 years and older will more than double between 2010 and 2050 and will increase by 20 percent of the total population by 2030.* In 2006, elderly patients underwent 35 percent of inpatient surgical procedures and 32 percent of outpatient procedures according to study authors.
“For elderly patients undergoing surgical procedures, we want to ensure we are optimizing each patient’s medical condition,” Dr. Ko said. “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,” he said. This is the first time ACS has worked with AGS to develop guidelines for geriatric patients according to Dr. Ko.
The guidelines recommend and specify 13 key issues of preoperative care for the elderly: cognitive impairment and dementia; decision-making capacity; postoperative delirium; alcohol and substance abuse; cardiac evaluation; pulmonary evaluation; functional status, mobility, and fall risk; frailty; nutritional status; medication management; patient counseling; preoperative testing; and patient-family and social support system.
“There is no single magic bullet for rendering this level of surgical care,” Dr. Ko said. “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. So then suddenly, polypharmacy becomes the number-one issue for the surgical team to address during the preoperative care phase,” he explained.
Furthermore, the expert panel said there are complex problems specific to the elderly, including use of multiple medications, functional status, frailty, risk of malnutrition, cognitive impairment, and comorbidities. “When surgeons evaluate elderly patients before they undergo operations, they want to know how many and what specific medications their patients are taking. 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,” Dr. Ko explained.
As the guidelines state: “consider minimizing the patient’s risk for adverse drug reactions by identifying what should be discontinued before surgery or should be avoided and dose reducing or substituting potentially inappropriate medications.”
Additionally, the number and severity of underlying medical problems call for special strategies by the entire surgical team, according to Dr. Ko.
“Patients who are 90 years old tend to have more comorbidities than those who are 65 years,” he 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.”
The guidelines state that evaluating patients for developing heart disease and heart attack is critical to identify patients at higher risk. All patients should be evaluated for perioperative cardiac risk.
“Caring for the elderly generally requires a team approach,” said Dr. Ko. “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.”
These guidelines have been developed in response to a performance measure that the ACS has developed with the Centers for Medicare & Medicaid Services (CMS), according to Dr. Ko. The performance measure evaluates the quality of care in patients eligible for Medicare.
ACS NSQIP has worked with CMS to develop “The Elderly Surgery Measure.” This is a hospital-based measure that assesses the outcome of elderly patients undergoing surgical procedures. The ACS and CMS will launch a pilot program in October that gives hospitals the opportunity to publicly and voluntarily report the outcome results.