All right. This will be our final talk for the morning before we break for lunch. And it's my pleasure to introduce a gentleman that I've gotten to know, having worked with him a few times on some courses that we did, Gentle Sentil, or Sentil Ranakrishnan. Prior to becoming a physical therapist, he was a physical therapist and decided that he wanted to do more. He graduated from the Wayne State PA program in 2004 and then completed the postgraduate PA surgical residency at Duke. He then decided to stay on at Duke. And since 2005, he's been working in neurosurgery. He's currently the administrative chief clinical neurosurgical PA at Duke and also the program director for the Duke Surgical PA Residency Program and a guest lecturer at the Duke PA Program. He's going to speak to us on something that I'm sure we all encounter in our clinic, which is the geriatric patient in neurosurgery. Good afternoon, or good morning still. When I was 10 years old, my father was 40 years old and I thought he was old. When I became 20 years old, my father was 50, but he didn't seem old anymore. My grandfather was 70, seemed older to me. So as we age, our definition of old, who's old, changes. Now in my 40s, I don't think 70 is old anymore. So we can see patients are also getting older in our practice. The number of Americans ages 65 and older is projected to more than double from 46 million today to over 98 million by 2060. So people are living longer. As they're living longer, they're also being more productive. 65 was a retirement age before, but it's not anymore. They are working longer, which means they're more productive members of the society and they're still being very active, and which means if they get sick, they still want some treatment, which is not going to be as conservative treatment, and they're seeking more surgical options. People are also getting smarter. Most recently, I had a grandmother who was about 86 years old, was coming in for brain surgery, and I was putting fiducials on her head for a pre-op brain lab MRI. As soon as I finished, she took a selfie and uploaded her picture to her Facebook profile picture. And I was stunned. You can use technology so much, and you're so old. She said, my grandkids don't call me anymore. We interact only through Facebook. So I had to keep up with technology. And she also had a master's degree, a double master's degree, when she was 86. So people who are in the older age are much prone to have finished college. And if you look at the Population Reference Bureau, it was published in 2016. About in 1965, only 5% had completed a bachelor's degree. By 2014, the numbers had increased about 25%. And the longevity has also increased. Life expectancy has increased. So what does it all affect us? The increase in life expectancy, increase in education level, increase in productivity. How does it affect clinicians? Because they're all seeking more invasive treatments, even at their older age. But treating older population comes with their own risks. Obesity is rampant in the United States, given the nutritional changes and the way our food pyramid system is structured. 40% age 65 to 74 years old in 2009, compared to 2012. The longevity has also increased the number of divorce rates. People who are older seem to be falling under more percent of divorce rates. And I can tell you, it was 3% in 1980, and it jumped up to 13% in 2015. And for men, about 4% to 11% during the same period. The longer people live, and the people who actually need more support seem to be living alone these days. And we've got to take that into consideration when we are planning any kind of big invasive surgical treatments. Because what is their support system once they leave the hospital, or can they leave the hospital after you finish surgery? Some of the other challenges are increase in nursing home care. If you finish, even if you have a successful outcome from surgery, but if they cannot go home because of the social support, the number of residents in skilled nursing care is actually increasing. And there's going to be a time when we're going to be running out of nursing homes, or we have to open more. Alzheimer's units have opened up a lot. Again, the more people live longer, the more problems they get. It affects the cognitive status, and it affects your surgical outcome as well. So what is aging? All people don't age at the same level, right? I have an 80-year-old grandpa who had tumor resection and went home the next day from the ICU, post-EV1, got discharged. Was up and wanted to fully catheter out. As soon as he woke up, he wanted to fully catheter out, and he wanted to get up and walk in the ICU. And I had a 35-year-old gentleman who had a brain tumor resection and was just crying and whining. And like, I can't get up. I can't do this. So people don't age the same. And you have to take that into consideration as well when you're designing a treatment plan, right? Gone are the days when if somebody 75 years old has a brain tumor, we'll watch and wait, or we'll do conservative therapy. We'll do a brain biopsy and then treat you with radiation or chemotherapy. When it comes to spine, we didn't do multi-level fusions on somebody who was really old. But these days, the oldest patient that we've had at Duke Hospital for a brain tumor resection was 93. It was even a GBM. It wasn't just a meningioma. And for spine, I would say it was like an 83 for a spine fusion. I had like a four-level spine fusion, right? So what are the challenges that we face when we treat older people, right? Organs, even though they're physically functioning well, their organs age, and the organs age at different rate, right? And this graph will tell you, on the x-axis, you have age in years, and in the y-axis, you have percentage of organ function. You can see how it affects each organ, be it the major vital organs, your heart, your lungs, your liver, your kidney, which all are going to dictate how the patient recovers after the surgery. There's something called a functional reserve. Your basal functional rate of an organ versus at a maximum intensity, you're running a sprint or you're having stress with surgery, what threshold do you have? The people who have a higher threshold, even after you knock them out of surgery and the stress of surgery, they tend to bounce back a little better than somebody who has a very small functional reserve. So surgery in elderly, as I said before, we are operating a lot more number of people than we did before. Nearly one third of surgical procedures occur in people greater than 65 years, a group that is equal to 15.2% of total US population. The problem is older people have more post-operative complications. If you look at our M&M rounds, you can see that relatively, the number of people that fall under that list are older people. The increase in the length of stay, it increases your readmission rates. It increases the number of people you send to rehab or nursing home compared to home. So given the problem that you're facing now, what should we do? How can we screen this patient better? Or how can we optimize them for a better outcome? I'm talking about elective surgery. If somebody comes through the ER as a trauma, you don't have the luxury to screen them properly. Or you do not have the luxury to optimize their health before you take them to the OR. But for elective cases, you have the time. And you should invest the time to make sure that you set up that patient for success and not a failure. So in this picture, who do you think is going to have a better outcome? The lady on the left, they're both having the identical same surgery. And they're both the same age. It's pretty obvious, right? The lady in the motorcycle, the biker mama is going to have a better outcome than the lady in the walker, just by intuition. And why do you think that is? She's got a better functional reserve than the lady on the right with the walker. So when we talk about clearing a patient for surgery, until, I want to say, eight years ago, because that's when a POSH program came to Duke Hospital. It's Perioperative Optimization of Senior Health. It's a separate department that opened in geriatrics. Before that, if I talk about clearing a patient for surgery, get a cardiac clearance, get a PFT. What is their creatinine? Is their liver function OK? So it's basically these big organs that we targeted or looked at and said, is that functioning OK? If the blood pressure is OK, if they're not in AFib, their cardiac rate is OK, if their creatinine is OK, if they're sat in more than 90% room air, yeah, we'll take the patient to the OR. But now for geriatrics, we have a little more different score or different method of evaluation. One of the main things we want to focus on, what is the activities of daily living? Do they live by themselves, or do they live already in a nursing home, or do they have enough support system? Because after discharge, you don't want to take a patient to the OR, do a multilevel spine fusion, and now say, well, you can't go home. Or we're ready to discharge the patient, and the patient says, I live alone, I cannot manage. So it's not that time where you try to figure out, OK, where am I going to send you? Heaven forbid if the patient doesn't have proper insurance, then they're stuck in the hospital. I've had patients who have been in the hospital for 360 days because they didn't have a proper disposition, didn't have any funding to go. You also want to evaluate the cognitive status. The mini-mental exam was pretty widely used. Some people will advocate the MOCA, which is the Montreal Assessment for Cognition, because it can pick out subtle differences when it comes to a mental exam or cognition. You want to also figure out what the nutritional status is. Do they have any unintentional weight loss? What is their albumin level? And what is their hematocrit? A hematocrit of less than 35 is accepted as to be anemic, and you want to make sure you figure out why the patient has that, because these have been shown to be predictors of outcome in recovery. If you're trending the nutritional level, albumin level gives you a screenshot of what your nutritional level is. But if you're going to trend or see the progress in clinic, you want to check the pre-albumin level. That's a little more final predictor of their nutritional status. And then you also want to check into the Charleston index, which takes about 14 different functions of the body systems and assigns them a certain score. The cumulative rate for geriatrics, it'll tell you what their score is in terms of recovery. The American Society of Anesthesiologists score will also give you a predictor of morbidity and mortality after surgery. And also check their polypharmacy. If they are taking different medications, see if you can consolidate them or figure out why they're taking what. Sometimes the patient has not seen a primary care physician in a while. What medication was prescribed like three years ago, they've still been taking on it. I've seen patients on Coumadin who didn't have to be on Coumadin. If they had a DVT a long time ago, they've been treated for more than six, seven years. That's the only indication they're on it. So you want to make sure you check why the patient is on a certain medication. And if you can get them off it, try to get them off of it before you take them to the OR. So apart from the regular physiologic status of the patient's organs, you want to evaluate the functional mobility, you want to evaluate the cognition, the nutrition, and what is their chronic disease burden. That will tell you what your outcome is going to be when it comes to treating older patients. So when you're evaluating pre-operative risk factors in elderly, check multiple chronic comorbidities, check their polypharmacy. Look at the higher American society of anesthesia classification. Where do they fall? How do you stratify their risk? High risk of emergent surgeries. Again, we're talking about more elective surgeries, but in situations where you are ending up taking the patient to the OR because they came through the ER or they're dying, then you try to address them as soon as possible. Check their functional status. One of the easiest way to check the functional status is what we call get up and go time. How long it takes for the patient from sitting to standing, walking about 10 feet, turning back around, coming back and sit down. That is a very good predictor of what the functional status is going to be. You don't have to put them through a Ninja Warrior drill to see are they going to do well or not. A simple test is plenty enough. Cognition, three-word memory, remembrance in one and three minutes, and also drawing a face of a clock. You'd be surprised how much you can pick up in just those two tests. Nutritional status, like I said, check for any unintentional weight loss. Check for your albumin and prealbumin levels. Mobility status, one of the simplest questions that I ask my patients when I evaluate them is, have you had any falls recently? And if they said, yes, I have fallen, then you try to ask further questions like, why did you fall? Was it a mechanical fall? Did you trip on a loose rug and you fell? And all you have to do is have a home physical therapy evaluation and then check their safety settings and make sure there are no loose rugs or they fell because they're just generally weak. So like I said, a simple. So we talked about the American Society of Anesthesiologists score. We talked about the Charlson index. There's something more recently that's called a frailty index score. This checks not just your organ function, but it also checks your mobility status, your cognitive status, how much it takes for you to get up and walk like 10 feet and sit back down. It takes about nutrition status. It takes about your anemia. And it takes about your breathing status as well. So there are about seven scores in a frailty index that takes into consideration when you're going to decide whether you're going to operate or not. And don't just ask for a cardiac clearance or see if their lung function is OK or if the kidney function is OK. OK. So frailty index falls under the global physiologic compromise pertaining to a patient as a whole. You take their living situation. You take their mobility. You'll take their fall history. You take their nutritional value. You take their fall mobility risk and see what even their living condition is, if they're living alone by themselves or if they have a good social support. OK. So a recent Robinson et al. had done a wonderful study and it's been published over the last few years in 2009, 2011, and 2011 twice. It tells you the risks of postoperative complications. And you can see patients who doesn't fall under the frail category, their postoperative complications are much lower than somebody who falls under the frail category. It's pretty self-explanatory when they look at it. And hospital length of stay. Again, you'll see a big difference between patients who fall under the non-frail category and patients who fall under the frail category. Most of this data is extrapolated from surgical specialties across the board. This is not just unique to neurosurgery. One of my residents, Dr. Eric Sankey, he's been working on frailty scores and he has designed a frailty score just for spine fusions. And it was recently accepted one of the best papers in the regional spine conference. And he has a formula that he's working on trying to figure out a frailty score for every subspecialty of neurosurgery. Whether it be somebody going for an aneurysm surgery, somebody's going for brain tumor resection, or somebody's going for a shunt. So he's trying to work on a formula for predicting what the frailty score is going to be for each subspecialty. So you can look them up, Dr. Eric Sankey, S-A-N-K-E-Y. 30-day readmission rate. Again, this is also higher in, it's like I sound like a broken record. You see that the big difference between patients are non-frail and patients are frail. So this should at least impress upon you how important it is, not just worrying about the cardiac status or the pulmonary status or the renal function. Even though they're all important, you want to change your focus into more, a little more detail, you know, right from their nutritional value to their fall risk or fall assessment. Okay. So this slide kind of generally gives you a difference between what am I talking about when I say non-frail and frail. Right? When it comes to non-frail, you have a better surgical outcome because they have normal function. When I say normal function, I include both their organ function and their physiologic function. No geriatric syndromes. This includes a fall, unintentional weight loss, normal cognition. Again, that plays a big role when they come to recovery, especially if somebody already has delirium or is confused and you take them to the OR and put them in the ICU for two days. The outcome is going to be much, you know, their length of stay is going to get much longer just because they're so confused. They're not able to participate in other therapies or even getting up out of bed to mobilize them. Or they get so agitated at night and, you know, you end up sedating them. And the next day morning, their sleep cycle is disturbed. The circadian rhythm is off. So you can see how the complication can keep piling by simple decrease in cognition. And nutritional value. Make sure they have not had any recent weight loss. Make sure their albumin, prealbumin levels are good. So this tells you the risk scale tips in your favor. Patient has a better outcome, they end up going home. Or their length of stay, post-op complications, readmission rates are all to minimum. Compared to the other side where you tip the risk of scale against your favor and more importantly against the patient's favor and you have a poor outcome. If they have poor function, if they have impaired cognition, positive geriatric syndromes like, you know, they've had falls in the before, they live alone or they have cognitive deficiencies. And then poor nutrition, unexplained weight loss and stuff like that. Okay. So having talked about organ systems, what are the screenings that you can do when you're trying to evaluate a patient for surgery and it starts even before they come to the hospital for surgery? In your pre-anesthesia visit, because anesthesia plays a big role in their recovery, you know, and anesthesia affects your cardiac status. It affects your pulmonary status. Airway management could be a problem. The patient can open their mouth wide, you know, intubation. So the anesthesia checks all this before they even come to you. What is a normal renal liver function? Because some of your medications that they're going to administer to your patient is going to affect, your dosage is going to affect. Because, you know, you get in the habit of knowing what dose you want to give, right? At Duke Hospital we use Lyrica 150 milligram twice a day for brain tumor patients when they have craniotomy. We start the dose when they get admitted the night before, right? Studies have shown, there's a paper from Israel that shows that if you use Lyrica 150 milligram PID, start the day before surgery and continue for 72 hours, the amount of narcotics used is way less than patients who have not done that study. So I've got a habit of writing that Lyrica 150 milligram twice a day, and I get a call from the pharmacist, hey, you want to reduce this dose in half because this patient's liver function or kidney function is poor, so you want to change the dose. So you want to know that beforehand so that you can, because it affects what, it affects your medication choice, it affects your dosage, and how long can you give them. Body temperature regulation is, you can get malignant hypothermia, even though it's a very rare complication, it's happened before. So they want to, you know, the anesthesiologist pay attention to all those in detail. And finally, cognition, because it's going to affect your recovery time in the hospital. So what happens in cardiovascular status? What important things you're trying to figure out? Now, vasoconstriction increases sympathetic activity at rest. But as you age, there's an uptick in your sympathetic activity, right? So patients tend to write higher blood pressure normally. That's your norm. And you take them to anesthesia, and all agents that you give them, anesthetic agents, narcotics, all that tend to drop your blood pressure. So if somebody is already writing on a higher sympathetic tone, and they use it at higher blood pressure, even though it forms under the normal value, they kind of write it, you know, for them it's higher, and then you drop them down to a normal range, you're going to put them in trouble. Right? They're prone to more hypotension, because all medications tend to lower sympathetic tone. Arthrosclerosis is normal age, and so patients' response to medications or their peripheral vascular resistance could be increased. Ventricular hypertrophy, as, you know, as you age, your cardiac contractions may slow down, but the strength will still try to be preserved or remains the same. And so you get ventricular hypertrophy, and that's, again, going to impair diastolic filling. Cardiac muscles die over time, but they're not replaced by other cells. They don't regenerate. You get scar tissues there. And then there's decreased ventricular contraction. So all this, you want to take into consideration when you're planning a patient to surgery, because this is what's going to happen, is happening to them normally in their physiologic state, and all the intervention that you give, right from anesthesia to your medications postoperatively, is going to affect them. You know, this is a picture of the Starling curve that shows you what happens with younger patients and what happens in elderly patients, and how their end diastolic volume and how they're filling pressures is going to affect their cardiac output. Aging and contractility, you see elderly patients, they have at rest, they have decreased contractility, and if they do a maximal resistant exercise or they're under stress, they have a slight increase compared to a younger population. So their cardiac function is already compromised, and now you're putting them to big surgeries, whether it be brain tumor resections or whether it be spinal fusions. You are putting them to a significant risk in compromising their cardiac status. Okay. Anesthesia can also cause low blood pressure. They can be high one time, low the other, so you're trying to fine-tune, because they already come on high blood pressure medications. We tend to hold their home medications preoperatively and try to manage with IV blood pressure medications like hydralazine or labirinol, just to make sure that you have some flexibility and you don't drop them too much. Some people are really high, and we tend to start their home medication back at time of discharge. We try not to start anything new, because who knows what happens when they go home and they go back to their regular diet, their regular sleeping habits, their regular environment. So you want to make sure they have a very close follow-up when it comes to changing blood pressure medications. Decrease in sympathetic tone, like I said, which happens with any induction with anesthesia and the medication that you give. They have a direct effect. When cardiovascular status, it affects your contractility. It affects your peripheral vascular resistance, as well. Some of the patients who do really well from a brain tumor surgery standpoint are patients who have awake craniotomies, who go through very little anesthesia. They do really well. So sometimes my surgeons, if it's possible, and they can do an awake craniotomy on an elderly patient, they would favor that, because they do really well from a recovery standpoint. Obviously, you can't do that in a big spine fusion, but in brain tumors, sometimes it's possible. So next is your pulmonary status. You want to make sure that are they breathing in room air before the surgery. If somebody has chronic COPD and they're already on supplemental oxygen at home, you want to make sure that you pay closer attention while they're here. If they are smokers, you want to make sure that you pay attention to that, as well. Ideally, if it's an elective surgery, you would ask them to quit smoking before. But it takes a while. They just can't stop cold turkey. But the best part of pulmonary function is you can give supplemental oxygen. They respond well, whether it be because of biomechanics, whether it be because of COPD. If it's COPD, you want to make sure that you don't want to make them normal, because the increased hypercarbia they have is the driving force for their ventilation, and you don't want to take that away. So you have to be judicial in seeing who gets supplemental oxygen, and how much, and how long. When we talk about pulmonary status, we also talk about vocal cords, because that can be affected, and they can have increased risk of aspiration. They can have increased risk of atelectasis. These are the patients you want to try to mobilize them as soon as possible. And even intubation. Older people have arthritis, and they have decreased range of motion of the spine. They have poor dentition. They could have TMJ problems that could be affected with intubation. Again, these are not specific to neurosurgery. These are specific to any surgery that involves a geriatric patient. Lung volumes. This graph tells you what happens to lung volumes as you age. Hepatic and renal function is something that you want to pay attention to, because most of your drugs are cleared this way, for one reason. And two, again, if the patient's hypotensor can affect your renal function, if they drop their pressure too quickly, too fast, and it also affects their nutritional status. You want to make sure your hepatic function is optimal and your renal function is optimal, because they all increase your CNS drug sensitivity. The drug is not cleared. If NSC is not cleared from your system, they kind of linger on your body for too long, and the patient is groggy to wake up. It takes longer to get them extubated. So cognitive disturbances. Postoperative delirium is very common in an elderly patient. You've taken somebody who already has some mild cognitive impairment. You put them through a long surgery under anesthesia, and they wake up in the ICU in a completely unfamiliar environment, and they don't know if it's day or night. The circadian rhythm is off, and they get agitated. And the treatment for agitation is a lot of the, I don't want to say just the residents, even the PAs, they would go to Benzos to try to calm the agitation, because they don't want to hurt the patients. They put restraints on the patient, right? So this only makes the problem worse. As a rule, we try to avoid Benzos in older people. Haldol is probably a better drug to treat delirium in the acute setting. It occurs in 10% to 15% of elderly patients, especially if they're in the ICU. It increases the length of stay, which in turn can cause worsening of the delirium. If the patient has cognitive disturbance to begin with, it's again highlighted in the hospital stay. Polypharmacy can cause a problem, impaired memory, metabolic disorder, visual and hearing disturbances can all have problems when it comes to delirium. In our hospital, or at least I, if a patient is an alcoholic who's been drinking at home, and they come to have elective surgery, there's a CIVA protocol that they use to make sure that they don't go into agitation. Now, they get Ativan, either scheduled or PRN as much as possible, or according to the level of severity of their agitation. And the nurses can titrate that. My practice or my philosophy is if they're drinking, give them the alcohol they've been drinking. I tell the family, if your grandma's gin is her favorite drink and she's been taking three, four drinks a night every day, bring that to the hospital. I can, from the dietary, I can get beer. I used to get vodka, but they don't give it to me anymore. I can get beer, but that's about it. But a lot of the patients, beer, it's a lot of volume to drink, and that's how they're not drinking every day at home. They take a couple of shots of whiskey, or it's usually hard liquor that they take. And I tell the family, bring it. And I ask them to take it, even for awakening anatomy, the night before, if they're alcoholics, I'll let them drink whatever they're drinking. Nurses look at me weird. They say, are you sure? I said, I'll put an order in the mail, I'll put a nursing comment, patient can have two drinks tonight, right? It's much better than giving them benzos. The outcome is better, they tolerate better, and they're happy that they can get their alcohol, because that's one of their worries, they're going to withdrawals postoperatively. And when I do a history, I ask them very specifically, do you drink? How much do you drink? And usually people are pretty straightforward. And the answer, if I have a sense of, and the families are there, and they shake their head this way or that way, and there's some conflicting information you get, usually multiply by two what the patient tells you, and divide by two what the family tells you. Because the family tends to over-exaggerate or exaggerate how much their loved ones drink, and the patient themselves try to underestimate how much they drink. And we have a nursing protocol that we have devised in our hospital where we reorient the patient every few hours. We tell them, you're at Duke Hospital, this is the date, this is the year, right? We try not to do, if the patient's stable, we try not to do a routine vital sign exam from 10 p.m. to 6 a.m. So we try to get them this way. We start them on melatonin, they get an 8 o'clock dose, usually 3 milligram works well. So you want to make sure that you pay attention to all the little details that helps the patient. Post-operative cognitive dysfunction is a separate entity, and this can increase the length of stay, it can increase other complications. I've had patients who develop bed sores because of cognitive dysfunction. You know, they're agitated, they're combative, the safety of the bed is poor, so they tend to spend in the bed longer time, and they've had bed sores because of that. So you can see, not only affects your cognition status, but it can affect your general function as well. According to a recent study, about 40 percent of all surgical patients greater than 60 have had some form of post-operative cognitive dysfunction at the time of discharge, and about 10 percent have post-operative cognitive dysfunction at three months or later when they come back for clinic. Munk et al. did a study that documented the presence of your cognitive dysfunction on discharge from the hospital after major surgery other than cardiac surgery, and then after three months, 12.7 percent of these patients greater than 60 years old still had cognitive dysfunction. So you take somebody who already has a lower reserve when it comes to cognition, you put them through surgery, and then they still have difficulty even three months later down the road. It tells you patients what is their one-year mortality rate, and it's not shocking that patients who have cognitive dysfunction have a higher mortality compared to patients who didn't. This is a slide, I'm not going to read you the slide of the differential diagnosis that you can see for post-operative cognitive dysfunction, but broadly speaking, delirium, central anticholinergic syndrome, dementia, achondric crisis, they can all kind of mimic, and it all depends upon the timing of onset and how you diagnose them. Usually, if you do a thorough preoperative exam and you vet these patients and you figure out what their baseline cognitive dysfunction is, you can pretty much then tease out what happened after surgery or this is the patient's baseline. We exactly don't know how post-operative cognitive dysfunction occurs if the patient is fine before the surgery, but it depends upon, you know, the anesthetic agent, it depends upon how much time they spent under anesthesia on the table, it depends upon what their physical recovery is in the hospital, how they cleared their drugs from the system. So it's a combination of multi-system function and not just pinned to one psychological status. But they've identified certain risk factors of the patient who usually tends to have this post-operative cognitive dysfunction, and usually advanced age, that's what we're talking about, we're talking about a geriatric patient. Somebody has pre-existing cerebral or cardiac disease. Again, we do a, that's why we do a preoperative screening where you do a mini mental exam or your MOCA test to document what the patient's cognitive level of function is. education level plays a role, history of alcohol use, that plays a role again, and the type of surgery, how big the surgery is, how long the surgery is, and what is their mobility status right after surgery. So how do you combat delirium? We talked about early reorientation protocols. But that doesn't mean you go and wake up the patient. We talked about breast caning survey earlier, we talked about pain scale. I've seen patients when I've been on call at night, 12 o'clock, a patient is sound asleep. They wake the patient up, hi there, you okay? Do you have any pain? Patient is sleeping, leave them alone, right? So if the patient is not delirious, you would cause them delirium by being a very good nurse. Nothing against nurses, I love my nurses, and they do really good care. It's the protocol that's in place, right? So sometimes if I know a patient is prone to develop delirium, and if I know they're stable, I will write an order in the computers in my Epic saying, please, no vitals, turn the lights off at 8 o'clock at night, no TV, nothing. The room is dark, and then turn everything back at 6 a.m. in the morning. We're trying to establish the circadian rhythm. Whether the patient has sleeping difficulty or not, I put them on melatonin. Again, you don't want to give it too late. I try to avoid any benzos, I try to avoid any sleeping medications. Even in the agitated, like I said before, Haldol is a much better choice than a benzo. Do not use Valium, do not use Ativan. Try to maintain a higher blood pressure, greater than two-thirds of their baseline. Maintain the oxygen saturation greater than 90%. I tell them, make sure the patient doesn't eat in bed. I don't want any aspirations, make sure they're out of bed, sitting in a chair to eat, or if they're not that mobile, most of the beds in the hospital you can actually bring into a sitting position. So they are trying to avoid every little thing that can go wrong you want to pay attention to. Early mobilization, as soon as possible we try to get them out of bed, and provide appropriate environmental stimulation at appropriate times. 6 a.m. to 8 p.m., everything's on. Don't turn the light off, don't put the curtains down. Bring the family in, ask them to come during those times. Have the TV on. Any stimulation you can give them, so letting them know. Because in the hospital, it's 24-7, it's 72 degrees, and it's bright. You want to make sure that they know it's day, it's night, and stuff like that. You want to avoid anticholinergics. I try to not use Copalamin patch for older patients. I try not to use Phenergan. Anything that is anticholinergic you want to try to avoid because these are known or are shown to cause delirium. Ketamine, try to avoid medication that can cause a patient to go into delirium. I have patients who had big spine fusions, and to avoid narcotics, the pain team puts them on a ketamine drip, and the nurse will come and tell you, you need to come and talk to your patient. And this patient will tell me, there are leprechauns under my bed. Can you get them out? They're keeping me awake. They're bothering me. Stuff like that. So sometimes you induce delirium, and you want to make sure you pick medication that does not affect the cognitive status. Stuff that we don't think about are going to affect their cognition. Usually Copalamin patch can, too. Avoid large doses of barbiturates and anesthesia types. Avoid or minimize the use of propofol. Maintain circadian rhythm. We talked about sleep cycle and awake cycle. Avoid restraints. One of the first things, you know, nursing, because they want to avoid falls. If a patient falls in the hospital, you know, it counts against you. It's bad for your reputation. A patient can come with one injury and go with another injury, so you want to try to avoid all that. If somebody's agitated, the first thing they do is put them on restraints. Luckily, most of the hospitals, you cannot put them on restraints forever. Short periods, yes. But you try to get them out of restraints as soon as possible. And medication like Risperdal works really well for somebody who's agitated. One of the things that we try to do as fast as possible is, if somebody's agitated and confused, and overnight I come back in the morning and I see a patient in restraints, I'll talk to the nurse and say, why is this patient in restraints? Well, last night they were trying to climb out of bed. I had five patients that I was taking care of, and, you know, this patient, I was really worried that they were going to hurt themselves, so I put them on restraints. If they get a sitter to sit with the patient, that way they're off restraints or start them on a low-dose Risperdal at nighttime, if that's the only time they're getting agitated, and you can wean them off. Do not send them home on Risperdal if they're going home. If they're going to a nursing home, I write down a taper plan for my Risperdal dose. Within a week, I want them off of Risperdal. You don't want to keep them on for too long. Adequate pain control. All my patients are 975 milligram of Tylenol, Q8 hours scheduled. Whether they are in pain or not in pain, any postoperative patient, they get scheduled Tylenol. We get a geriatric consult in our hospital, especially for spine surgeries. If it's an elective spine surgery, they go through the perioperative optimization of senior health. It's a separate branch of geriatrics where the anesthesiologist evaluates the patient. There's a general physician that evaluates the patient. There's a nutrition dietician that evaluates the patient. A psychologist evaluates the patient. It's a comprehensive plan, and they come up with a postoperative plan. A note is established in the chart, and when the patient comes after surgery, we usually have all these recommendations to do. If the patient has not gone through the post-clinic and they come to the hospital, usually not much for brain surgery, but usually for big spine fusions, we get a geriatric consult in-house. And I can tell you with ISTO, the first thing they're going to do is Tylenol, stool softener. Constipation can cause delirium, believe it or not. The nurses can tell, oh, you've got a geriatric consult. I know what they're going to write. They're going to schedule Tylenol. They're going to write Seneca BID. They're going to write sleep aid. Usually your melatonin, 3 mg at bedtime. They're going to say turn off the lights at 8 p.m. So these sounds very simple, but the only thing which I've seen that was unique for them is, you know, we try to avoid narcotics on all the people, but they will start them on 2.5 mg of Oxycodone Q4 scheduled. You don't want them to be in pain, especially after big spine surgery, and then try to treat them with IV pain medications or give them more oral pain medication. Give them a small basal dose of 2.5 mg in a Q4 or Q6 hours, and then another 2.5 Q8 PRN if needed. And you see these patients tend to mobilize more. They get up and walk faster, and they get rid of the catheters. They are up and walking in the hallway. Compared to somebody, I'm very strict in saying I'm going only Tylenol and no pain medicine because you're old. And you're going to get not worried about more addiction, more worried about the depression, the cardiac respiratory function, or in their awake status. But a very low dose basal Oxycodone goes a long way. Then you're trying to deal with the PRN with a much higher dose. Treat identical causes of hypoxia. Everybody gets an incendiary spirometer. You don't want hyperglycemia as bad, but hypoglycemia can kill you. Electrode abnormality, they get scheduled BMP and magnesium checks to make sure their potassium and magnesium is supplemented. We even have a nursing protocol. They don't have to call the resident or the PA. The nurses can titrate their magnesium and potassium supplement accordingly. You want to make sure they're hydrated properly. Fever, pain, sepsis, you want to treat them because they all can hinder recovery. So to operate or not to operate if the patient is older. 70-year-old, 80-year-old comes to the hospital. You're trying to operate for spine pain. It's an elective procedure. So you have time to introduce the patient to the POSH service. This was a recent, as early as January 3, 2018. The Duke POSH program was featured in the JAMA study. They published their study, so you can take a look at this article and see how they have made a big difference in recovery and preparation of pediatric patients when it comes to complex surgeries. They try to address all risk factors. They pay attention to their blood pressure. They pay attention to their blood sugars, diabetes, osteoporosis. Have they used, have they depended on any drugs, whether it be tobacco or alcohol? What is their nutritional status? It plays a very important, vital role. Obesity, how, you know, is that because that's going to affect wound healing, that's going to affect their mobility status, that's going to affect their lung function. I know I put osteoporosis twice. That's important to this when it comes to spine fusion. Psychiatric counseling, consult all their medication, discontinue inappropriate medications because sometimes grandpa or grandma has not had time to go, or they live alone and they don't have time to go to their, or means to go to their primary care physician, and they've been continuing the medication they've been taking for a long time. Like I said, one of, I don't see it that often, but I've seen it enough number of times to remember this, that patients have been on Coumadin that didn't have to be on Coumadin at all because they had a DVT like 10 years ago. And these patients, they're coming up with a small fall, and they have a big bleed in the head, and now you're faced with a dilemma, like do I take this patient to do a big craniotomy to get the subdural out, or do I have a family discussion with them? And that could have been totally been avoided because they didn't have to be on Coumadin. Boost their physiologic reserve. Again, if it's an elective surgery, you can ask them to lose weight, you can ask them to come off of tobacco or try to wean them off of alcohol. You can improve their functional status, put them on a PT regimen, physical therapy, ask them to go see if they can improve their functional status before they can come. Again, all these are out of the window if it's an emergent surgery, but if it's an elective surgery, you can really make a difference by paying attention to your geriatric recommendations. This is a pretty big slide, but most importantly, if a patient was going to go to an elective spine surgery, what would you do? And you want to pay attention to detailed history. You want to make sure that you get a lab that shows you what your CBC is, especially your hematocrit. You want to make sure they're not anemic. You want to make sure you pay attention to their quag panel. And I've listed a bunch of papers that were recently published on how age affects surgery and how you can play an important role, because you cannot reverse age. You cannot make a patient younger to suit the surgery, but you can definitely optimize them to make sure they have a better outcome. These are the labs and tests you want to do before surgery. Again, some of them are self-explanatory. Definitely everybody gets an EKG. You want to make sure what their cardiac status is. Definitely everybody gets a CBC. You want to make sure their burean creatinine ratio is okay. You want to make sure you get your LFTs. Your quag panel is okay. You'd be surprised. Urinary tract infection can be one of the biggest causes for delirium. You want to make sure you figure out what the drug levels are in case they're taking drugs that can be measured and their bleeding time and stuff like that. But most importantly, for our purposes, you see diabetes plays a very big role because you want to make sure the blood sugar is under control, because it can. And don't just go by the blood sugar. Make sure you check a hemoglobin A1c, because they could come to you with a blood sugar of 150 or 120. But if you look at the hemoglobin A1c, it's like 10.3. Those patients are optimized, and you want to make sure you pay attention to them. So frailty index, like I said before, make sure you – this is one of the biggest things you want to – if you go back home and you're doing an elective surgery and your surgeon has scheduled a patient who is, like, 80-year-old for a three-level spine fusion or for a meningioma resection, you want to sit down and talk to them and say, let's make sure what their frailty index is, and let's check and see, will I be able to get this patient safely out of the hospital? So make sure you get a thorough history. And again, this is a very important paper that came for adult spine deformity surgeries, and it helps you predict what the outcome is going to be. And it's pretty fairly right on the money. So what are the variables that you would use? Are they able to do all the activities of daily living by themselves? Brushing, cleaning, bathing, history of diabetes, if they have any pulmonary history disease, congestive heart failure, if they have any previous history of MI, and this goes on and on. And most of them are pretty self-explanatory and pretty common sense that we should be screening all our patients to, but it makes a big difference in a geriatric patient. This is another paper that came out in Journal of Neurosurgery Spine, Use of Modified Frailty Index to Predict 30-Day Morbidity and Mortality from Spine Surgery. And it also shows the higher your frailty index, the higher your complication rate, the higher your length of stay, the higher the incidence that they end up going home and they have to need placement. And when infection falls in place, again, you'd see an uptick in the wound infection rate on patients who have had a higher frailty index. And you can ask, because they could be obese, they could be having poor nutrition, they could be diabetic, they could be not having a, they could have a decreased morbidity index as well. Again, most of the stuff, the slides that are following probably would have talked about it, but diabetes is very important, you want to make sure. We have canceled elective cases on patients who come with a blood sugar of 400 for their elective spine surgery. It was a brain tumor resection and its time was of essence. I put them on an insulin drip, get an endocrine counsel while they're in-house and send them home on insulin and not just their metformin that they were taking at home. And there's lots of studies that have proven diabetes can cause bad outcomes. Again, good blood pressure control. The goal is to keep them less than 160. You don't want to drop them too much, too fast, too down, because, again, you can have perfusion injuries. Smoking, very important because they can affect wound healing and bone growth. And there's lots of studies that proves that. Renal function is very important because of clearance of drug and it can affect the other systems too. Nutrition, you want to make sure your albumin level is intact or while their BMI is addressed. Psychiatric, if they have any depression, anxiety, you want to make sure that's addressed because that can affect their recovery phase as well. It affects their quality of life, and if they don't feel like they're doing well, it's kind of a downward spiral. In the interest of time, I'm going to skip a lot of these studies. If anybody's interested, just e-mail me and I'll send you this PowerPoint, because it's a very good read and it gives you a reason why you're doing what you're doing. Bone density is very important, especially for spine surgeries. There's a lot of study that's proven, and you can treat them or try to get them ready before surgery. But you'll see the duration of treatment. There are some medications that take about three to five years to make sure they make a really good difference in the bone density studies, so you really want to make a headway before you do any big spine surgery or spine fusion. In conclusion, no surgery is without any risk, but your goal is to make sure that you prepare a patient optimally, you try to improve the outcome by paying attention to smaller details, and that will help any older patient come through your practice and get out of the hospital safely. Don't forget their social history. Don't try to plan their discharge after you've done the surgery. Try to plan their discharge before. Make sure they have a good social support. Make sure you know where they're going to go after their surgery. And if there's any questions, I'll take them, or I can stay back a little later because in the interest of time, I think I'm pretty much done with my slotted hour. Any questions? All right, thank you. Thank you.

geriatric patients

neurosurgery

elderly patients

pre-operative evaluation

frailty index scores

post-operative complications

optimizing care

surgical decisions

geriatric consultation