Optimizing Surgical Care for Older Adults with the ACS Geriatric Surgery Verification Program

Understanding Delirium in Older Surgical Patients

• ICU environments can contribute to delirium due to constant noise and disrupted sleep patterns, highlighting the benefit of downgrading patients when intensive care is no longer needed.
• 💡 A multimodal pain management plan that limits opioids and emphasizes non-opioid analgesics, regional anesthesia, and non-pharmacological methods is crucial.
• 🚀 Early ambulation, facilitated by a multidisciplinary team including physical and occupational therapy, is key to patient recovery.
• 🧠 Measures like maintaining sleep-wake cycles, ensuring adequate light exposure, reorienting patients, and involving family can significantly help reduce delirium.
• ⚠️ Delirium increases hospital length of stay, leading to higher costs, increased risk of hospital-acquired infections, and a greater likelihood of needing post-acute care.

Pre-operative Assessment for Older Adults

• 🎯 Pre-operative screening is essential for surgical success, focusing on a patient's vulnerabilities, functional status, and cognition, rather than solely on age.
• 🩺 A comprehensive history and physical exam should include assessment of functional status (e.g., ability to climb stairs, activities of daily living) and baseline cognitive function.
• 💊 Reviewing medication lists for potentially inappropriate medications (PIMs), which can increase the risk of adverse events, is critical, especially when combined with post-operative pain medications.
• 🤝 Understanding a patient's baseline cognition and social support system can predict recovery and help combat risks like postoperative delirium.
• 📊 Functional status can be assessed using ADLs, IADLs, exercise capacity (METS), and tools like the Clinical Frailty Scale.

Optimizing Patient Health Before Surgery

• ❤️ For cardiac history, use the revised cardiac risk index (CRI), get cardiology input for poor METS or recent events, and carefully plan anti-platelet therapy.
• 💨 For COPD, maximize inhalers, encourage pulmonary rehabilitation, and promote smoking cessation.
• 📈 Aim for reasonable glycemic control (A1C < 8%) before elective cases, adjusting pre-operative insulin and holding certain oral medications.
• 🍎 Don't underestimate malnutrition; low albumin or recent weight loss can predict complications, and protein supplementation or nutrition consultation can help.
• 🤝 Prehabilitation involves optimizing controllable factors like blood sugars, medications, and nutrition, alongside cardiology risk stratification.

The Geriatric Surgery Verification Program (GSV)

• 🌟 The ACS Geriatric Surgery Verification Program aims to designate hospitals as centers of excellence for geriatric surgical care, improving independence and quality of life for older adults.
• 🏥 The program has three levels: Age-Friendly (demonstrating 6 standards for patients 65+), GSV Focused (30 standards for 25-49% of patients 75+), and GSV Comprehensive (30 standards for >50% of patients 75+).
• ✅ Verification entails an application, peer-review questionnaire, and site visit, focusing on core principles like goals of care, screening for vulnerabilities, intervention, and interdisciplinary post-operative care.
• 📈 Hospitals involved in the GSV program are showing improved outcomes, including reduced length of stays, lower rates of delirium, decreased morbidity, and higher rates of discharge to home.
• 💡 Even if not ready for full verification, implementing smaller processes can make an impactful difference in patient care.