This workshop presented participants with three case scenarios of older adults needing surgical interventions, including inpatient management after traumatic rib fracture, vascular surgery for chronic lower extremity osteomyelitis with underlying malnutrition and failure to thrive, and femoral neck fracture with newly discovered heart murmur concerning for aortic stenosis. The workshop aimed to engage participants in discussion around the many challenges presented in the vignettes and to use available risk assessment tools to choose from different management options. The cases highlighted the importance of identifying the presence of frailty, functional dependence, malnutrition, and cognitive impairment in older adults by using validated risk assessment tools and applying age-friendly concepts in making management decisions.
Frailty is a multidimensional syndrome characterized by decreased physiological reserve, reduced recovery from stressors, including surgery. It is associated with increased postoperative morbidity and mortality. Additionally, the presence of low functional status before surgery is an indicator for postoperative complications such as increased length of stay and long-term mortality. Presurgical malnutrition is associated with poor wound healing, surgical site infection, and wound dehiscence, among other complications. Several validated frailty and nutritional assessment tools are available to identify patients at risk for poor postoperative outcomes. Preoperative optimization of functional and nutritional status may improve outcomes after surgery, but there is no clear consensus on the type, timing, or duration of interventions.
The vignettes describing traumatic rib fracture and vascular surgery highlight the significant role hospitalists play in recognizing frailty and applying the age-friendly “4Ms” framework, focusing on what Matters, Medication, Mentation, and Mobility to optimize the care of the complex geriatric surgical patient. By asking, “What matters to you?” hospitalists can elicit patient and family priorities and play an integral part in facilitating shared decision making, which has been shown to increase patient understanding, satisfaction, and accuracy of risk prediction and better align the patient’s healthcare goals with realistic outcomes. Additionally, caregiver and family insights into the patient’s baseline functioning and mentation should be considered when making treatment choices. Seeking accurate medication reconciliation from these caregivers or family members ensures appropriate medication management and decreases the risk for delirium and other iatrogenic complications. Finally, assessing mentation and managing delirium by addressing pain adequately, avoiding inappropriate medications, and encouraging early mobility further decreases the risk for complications.
The vignette on femoral neck fracture in an elderly patient with concern for aortic stenosis underlines the hospitalist’s role in facilitating interdisciplinary collaboration for appropriate risk assessment, shared decision-making, and preoperative optimization to improve patient outcomes and patient satisfaction.
In this case, the newly discovered heart murmur is concerning for aortic stenosis and should be evaluated before surgery to determine the severity of valvular dysfunction and assess for left ventricular systolic function. Asymptomatic patients with severe aortic stenosis and preservation of over 50% of left ventricular ejection fraction have similar postoperative outcomes to patients without aortic stenosis and can undergo surgery safely. However, symptomatic patients and those with left ventricular dysfunction or extremely severe aortic stenosis (i.e., peak velocity over 5 m/s or mean pressure gradient over 60 mmHg) are at higher risk for postoperative morbidity and mortality and require careful risk assessment including possible preoperative balloon valvuloplasty or minimalist transcatheter aortic valve replacement to decrease the risk or non-operative management.
Finally, although surgical intervention within 24 hours of a femoral neck fracture is ideal to decrease mortality, it carries a 10% rate of mortality at 30 days and up to 30% at one year. The benefits of surgery, such as increased mobility and pain control, should be carefully weighed against the risks of venous thromboembolism, pneumonia, stroke, myocardial infarction, immobility, delirium, and mortality. Underlying factors such as institutional residence and dependent functional status prior to surgery are poor predictors of postoperative outcomes and are associated with increased rates of mortality, postoperative delirium, and surgical intervention. These individuals may not benefit much from surgery to improve mobility, especially if they have manageable pain levels. Discussion with the surgeon on details of the hip fracture (i.e., displaced vs. nondisplaced fracture) can identify less invasive procedures or non-operative alternatives in patients at substantial risk for complications.
Key Takeaways
- The presence of preoperative frailty with functional decline and malnutrition is associated with elevated risk for poor postsurgical outcomes and mortality.
- Obtaining collateral information from the patient’s support system for careful medication reconciliation, avoiding potentially inappropriate medications, and considering non-pharmacologic interventions can decrease the risk of postoperative morbidity, including delirium in elderly patients with frailty.
- The shared decision-making framework facilitates identification of the patient’s health care priorities and effective communication of risk assessment to address the mismatch between the patient’s health care goals and realistic outcomes.
Dr. Khalighi is the director of the preoperative medicine clinic at Veterans Affairs Puget Sound Health Care System and a clinical associate professor of medicine in the division of General Internal Medicine at the University of Washington in Seattle, Wash.