Mai NguyenMercer University COPHS

Doctor of Pharmacy Candidate 2012November 8, 2011

Preceptor: Dr. Ali Rahimi

Thomas R. Hornick, MD.

Clinics in Geriatric Medicine. 2006;22: 499-513.

In the past, major surgery was rare in the elderly population.

But now, indications for surgery are being extended to include older patients for many major operations that were limited to younger patients not long ago.

In 1996, people >65 yo accounted for 35% of all operations in the US

In 2002-2003, there were 4.2 million hospital stays with at least one procedure done in those older than 75 years.

Multiple chronic diseases

Susceptible to common in-hospital complications: Adverse drug events Delirium Functional decline Falls Incontinence Pressure ulcers

Patients’ resultant comfort or sense of well being

Extent to which they were able to maintain reasonable physical, emotional, and intellectual function

Degree to which they retain their ability to participate in valued activities with the family, in the workplace and in the community

Measured by questionnaires Short-form-36 (SF-36) or its shortened version,

short-form-12 (SF-12)

These scales measure areas of mental and physical health. Physical health: physical functioning, problems with

work or other daily activities as a result of physical problems, bodily pain, and general health perception.

Mental health: perceived mental health, problems with work or other daily activities as a result of emotional problems, social function, and vitality.

HRQOL and joint replacements have been well studied.

Older individuals who have severe OA have poor SF-36 scores for pain, physical function, and problems with work or other daily activities as a result of physical health.

These scores improve remarkably after joint replacement, often reaching or exceeding scores of normal population after 6 months.

Valve replacement surgery has greater risks and benefits in the elderly.

Rates for short-term mortality range from 8% to 20%, depending on valve and comorbidities.

QOL in those surviving valve replacement is greatly improved, with improvement in SF-36. SF-36 improvement at 18 months was significant in

almost all QOL areas and the mean scores were comparable to the scores of healthy elderly patients.

Removal of cataracts improves vision and vision-related QOL with low risk. 72% to 92% of patients reporting

improvement in visual function after surgery

89% of patients showing improvement on vision-specific HRQOL scales

Morbidity and mortality are low despite its use in the very elderly.

As surgery has been extended into the elderly population, HRQOL has been added as a parameter to evaluate surgical success.

Surgery remains of significant risk in older patients Estimate of the type of outcome, including

morbidity, mortality, and HRQOL can aid in that decision.

Selvon F. St. Clair, et al.

Clinics in Geriatric Medicine. 2006;22: 515-533.

OA is a chronic widespread form of arthritis that affects all joint structures and commonly manifested in hip and knee.

Risk factors for OA: genetic origins, microtrauma, increased cytokine activity, lack of nutrients (antioxidants), and obesity.

Approximately 68% of total hip arthroplasties and 74% of total knee arthroplasties are performed on people over age 65.

THA was developed in the 1960s and is considered the standard of care for severe end-stage OA of the hip in elderly patients

Typically takes approximately 1.5 hours to complete

Involves the surgical excision of the head and proximal neck of the femur and removal of the acetabular cartilage and subchondral bone Replacement of hip joint with prosthetic implant.

TKA is the treatment of choice in patients over 55 years who have progressive and painful OA and who have failed nonsurgical and less invasive treatments.

Replacement of diseased or damaged joint surfaces of the knee with different type of metals, polyethylene, or ceramics prosthesis.

Intraoperative Complications (rare)

Postoperative Complications

Fat embolism

Nerve injury (sciatic nerve) with resultant foot drop

Vascular injury

Fractures

InfectionsStaphylococcus aureusProphylactic antibiotic given within 1 hour of skin incision and continued for 24 hours after surgery

Dislocation after THA due to implant loosening

DVT and PE

Fractures

Minimally Invasive Surgery TKA Involves using a limited incision (4-7 in.) down

the midline of knee▪ Standard TKA involves 8-14 in. skin incision

Early retrospective results from other centers indicate positive results with this technique.

Computer-Assisted Navigation TKA Increases the accuracy of implantation Results in improved outcomes and faster return

to normal functions

Vincent Conti, MD, and Scott D. Lick, MD

Clinics in Geriatric Medicine. 2006;22: 559-574.

Cardiovascular disease remains the most common cause of morbidity and mortality in the US CAD and CHF most common in the elderly

Surgical procedures (CABG and cardiac valve repair and replacement) are the best options for many older patients to improve their QOL.

Primary Indication: Presence of symptoms that compromise the QOL when these symptoms are the result of the cardiac lesion to be corrected and likely to resolve or improve with successful operation

Other considerations: Limited life expectancy Dementia Multisystem organ failure Chronic liver failure Severe pulmonary disease Severe malnutrition

Coronary artery bypass operations traditionally have been performed using a median sternotomy incision.

Although recovery after median sternotomy in most patients is rapid and complete, the elderly tend to have more difficulties and recover more slowly.

Development of coronary artery bypass operations using a small anterolateral thoracotomy incision Some studies showed did not

improve outcomes and associated with more early postoperative pain

Valve replacement and repair have been done through smaller incisions

Aortic valve replacement partial sternotomy incisions

Mitral valve procedures right parasternal incisions

Mitral valve repair or replacement robotic techniques for minimal incisions

Transcatheter heart valve replacement Valve replacement without open heart surgery More studies needed

Aortic dissection occurs when a tear in the inner wall of the aorta causes blood to flow between the layers of the wall of the aorta and force the layers apart.

Patients who have acute ascending (type A) aortic dissection involving the ascending aorta should undergo urgent operation.

Patients who have dissections involving only the descending aorta (type B) are managed medically initially.

Operative risk increases with age in patients with Type A dissection and survival with medical therapy have improved. More elderly patients are treated medically

Occasionally is 0ffered to patients >70yo but rarely to those >75yo

Recipient age adversely affects 1-year survival after heart transplant OR = 1 at age 55 (P<0.0001) OR = 1.3 at age 65 (P<0.0001) No valid data beyond 65

All solid-organ transplants require lifelong medications to suppress the immune system But they can cause neuropathy, osteoporosis, HTN,

worsening DM, and renal dysfunction.

Recipient must not only survive the operation but also tolerate the side effects of postoperative medications.

Rishi P. Singh, MD, Hilel Lewis, MD

Clinics in Geriatric Medicine. 2006;22: 659-675.

Prevalence and disabling effects of eye-related illness increases as the population ages.

Recent research shows that vision impairment is associated with: Decline in QOL 2 or more falls in the elderly Increased rate of hip fractures and

decreased mobility

Clouding of the lens caused by clumping of proteins due to inadequate delivery of nutrients to deeper lens fibers

Results in blurry vision

Primary Goal of Surgery: To remove clouded lens

Innovation Impact LimitationsMicroincision Phacoemulsifi-cation Surgery

• Uses ultrasound and allows surgeon to operate through 1.4mm or smaller incision wounds to dissolve and remove damaged lens• Theoretically faster recovery, less postoperative astigmatism, and safer

• No randomized studies available

Phaco Chop Technique

• Uses ultrasound and a fine instrument, “cracker” or “chopper” - fragment cloudy lens into smaller pieces • Reduction in total ultrasound usage, faster surgical times, and safer

• Steep learning curve for surgeons to master • Requires use of nondominant hand

Multifocal Intraocular

Lens Implantation

• Implantation of intraocular lens • Allows near and distance vision without glasses• Increased patient satisfaction after surgery

• Some patients require glasses after surgery• Increased halo perception and decreased contrast sensitivity • Additional cost for lens

Condition that causes damage to the optic nerve due to increased intraocular pressure Caused by decreased or no drainage of

aqueous humor

Glaucoma causes irreversible loss of peripheral vision early and central vision later in the disease development.

Primary goal of surgery: To reduce intraocular pressure

Innovation Impact Limitations

Antifibrotics in

Trabeculectomy

• Trabeculectomy: reduce intraocular pressure by shunting the aqueous fluid directly through the sclera and conjunctiva fistula• Antifibrotic therapies: mitomycin C and 5-fluorouracil• Use of antifibrotic injection after surgery showed greater surgical success• Less need for glaucoma medications• Decreased need for reoperations

• Increased risk for postoperative infection and damaging hypotony (an intraocular pressure of 5 mm Hg or less)

Glaucoma Drainage

Device

• Intraocular fluid passes through a tube placed into the anterior or posterior chamber to a footplate sewed to the exterior scleral tissue.•Provides a surgical option for those with previous failure trabeculectomies and those at high risk for failures.

• High rates of postoperative hypotony• Diplopia can occur after implantation• Problems with long-term biocompatibility

Disease associated with aging that gradually destroys sharp, central vision. Affects the macula, the part of the eye

that allow you to see fine detail

Wet AMD Occurs when abnormal blood vessels behind the retina start to grow under the macula Loss of central vision occurs quickly Early symptom: straight lines appear wavy

Dry AMD Occurs when the light-sensitive cells in the macula

slowly break down Loss of central vision occurs gradually Early symptom: slightly blurred vision

Innovation Impact Limitations

Macular Translocation

• Surgical procedure which involves detachment of the retina and relocation of it to a healthier spot in the eye• Restores vision and improves quality of life• Only meant to treat wet AMD

• Steep surgeon learning curve.• Diplopia is common. • High rate of retinal complications.

Retinal Prosthesis

Implantation

• Implantation of a retinal prosthesis that restores “useful” vision in those with profound retinal disorders and blindness.

• Implantation is technically challenging. • Only crude shape recognition is possible currently. • Feasibility of device mimicking the retina is doubtful in the near future.

Diabetic retinopathy is a complication of diabetes that results from damage to the blood vessels of the retina.

Symptoms: blurred vision, floaters, trouble seeing at night, blindness eventually.

Many with early diabetic retinopathy have no symptoms before major bleeding occurs in the eye.

Surgical procedures for treatment:

Laser eye surgery (photocoagulation)▪ Creates small burns in the retina where there

are abnormal blood vessels in order to stop or slow the leakage of blood and fluid in the eye

Vitrectomy▪ Removes some or all of the vitreous humor

from the eye

Innovation Impact LimitationsPars plana

vitrectomy for persistent macular edema

• Pars plana vitrectomy: vitrectomy that is accomplished in the deeper part of the eye

•Successful in decreasing macular edema refractory to laser therapy and steroids.

• Can accelerate cataract formation and risk of significant retinal complications.

Vitrectomy for diabetic vitreous

hemorrhage

• Restores retinal anatomy quickly and allows treatment of proliferative retinal disease with laser.

• Despite anatomic success, visual outcomes may be poor because of long-standing ischemia.

Vitrectomy for retinal

detachments in diabetes

• Useful in the restoration of vision in cases of retinal detachments.

• Despite anatomic success, visual outcomes may be poor because of long-standing ischemia.

1. Hornick TR. Surgical Innovations: Impact on the Quality of Life of the Older Patient. Clinics in Geriatric Medicine. 2006;22: 499-513.

2. St. Clair SF, et al. Hip and Knee Arthroplasty in the Geriatric Population. Clinics in Geriatric Medicine. 2006;22: 515-533.

3. Conti V. and Lick SD. Cardiac Surgery in the Elderly: Indications and Management Options to Optimize Outcomes. Clinics in Geriatric Medicine. 2006;22: 559-574.

4. Singh RP and Lewis H. Innovations in Eye Surgery. Clinics in Geriatric Medicine. 2006;22: 659-675.

5. www.ncbi.nlm.nih.gov