Accurate assessment and management of elderly patients with perioperative debilitation

Authors: Wang Lan, Zhu Rui, Gu Weidong, Department of Anesthesiology, Huadong Hospital, Fudan University

Debilitation is a state
of decreased health in the elderly characterized by weakness, weight loss, easy fatigue, decreased exercise endurance, and cumulative comorbidities.
In the U.
S.
population over the age of 65, the incidence of debilitation is about 15 percent
.
Due to the high risk of adverse outcomes such as postoperative complications in frail elderly patients, in recent years, medical staff have paid more and more attention to how to accurately identify this special group of
debilitated elderly patients.
In this review, we review the assessment methods of debilitation, the relationship with postoperative adverse outcomes, and the progress of perioperative management, and provide a reference
for the surgical evaluation and management of debilitating elderly patients.

1.
Methods of assessment of debilitation

According to the American Geriatrics Association, older adults > 70 years of age, have multiple chronic diseases, or lose more than 5% of their own body weight within one year should be screened for
debilitation.
There are many types of debilitation assessment scales, but there is still no gold standard for debilitation assessment, and it is recommended to select appropriate assessment scales
based on the characteristics of the test population and clinical use.

Commonly used assessment scales include the Fried Phenotypic Frailty Scale, the FRAIL Scale, the frailty index based on the comprehensive geriatric assessment (FI-CGA), and the care partner derived frailty index based upon Comprehensive geriatric assessment, CP-FI-CGA), CLINICAL FRAILTY SCALE (CS), COMPREHENSIVE FRAILTY ASSESSMENT INSTRUMENT (CFAI), Edmonton frail scale (Edmonton frail scale, EFS), Tilburg frailty index (TFI), Groningen frailty indicator (GFI), and PRISMA-7
.
Among them, the better reliability is the FRAIL scale, CP-FI-CGA and CFAI, and the higher validity is the FRAIL scale, CP-FI-CGA and GFI
.
With the exception of FI-CCA, all other scales can be completed
in about 15 minutes.
CP-FI-CGA and EFS are often used in the evaluation
of debilitation in hospitalized patients.

The clock drawing test, grip strength test, and stand-up walk test in the debilitating assessment scale need to be done
with the cooperation of the subject.
Evaluation criteria for the clock drawing test: (1) Draw the closed circle as 1 point; (2) Place the numbers in the correct position for 1 point; (3) The dial includes all 12 correct numbers for 1 point; (4) Place the pointer in the correct position for 1 point
.
A total score of 3 to 4 indicates normal cognitive levels, and a score of 0 to 2 indicates a decrease in
cognitive levels.

During the grip strength test, the subject kept his body upright, his feet apart, his upper limbs naturally drooping, and he held it to the maximum and maintained it for 5 seconds
.
The grip force gauge should not come into contact with the body and clothing during the test, and the use of instant impulse should be avoided
.
Repeat the measurement twice, with a 30s break between 2 measurements, and record the maximum reading value for scale evaluation
.

When the evaluator issues the "start" command, the patient stands up from the back chair and walks according to the usual walking gait, walks forward 3m to the mark point and turns back to the chair to sit down again, recording the time it takes for the patient's back to leave the back of the chair to sit down again, 0 to 10s is 0 points in EFS, 1 point for 11 to 20s, and 2 points
for >20s.

2.
Debilitating and perioperative adverse outcomes

In recent years, a large number of clinical studies have found that the postoperative complication rate and all-cause mortality rate of debilitating elderly patients have increased significantly
.
The results of a recent systematic review of 56 studies showed that the incidence of complications in debilitating elderly patients at 30 days after surgery increased by 2.
39 times (RR 2.
39, 95% CI was 2.
02 to 2.
83), and the risk of death in one year increased by a factor of 3 (RR=3.
40, 95% CI was 2.
42 to 4.
77).

There is a significant correlation between debilitation and postoperative morbidity and mortality
.

The more severe the preoperative debilitation in elderly patients, the higher the incidence of postoperative complications and the greater the risk of complications-related death
.
Harland et al.
collected clinical data of 260 patients who proposed intracranial tumor surgery, which were divided into debilitating group and non-debilitating group after debilitating assessment; The results showed that the incidence of postoperative complications (pneumonia, urinary tract infection, deep vein thrombosis, pulmonary embolism, new neurological dysfunction, cerebrospinal fluid leakage, wound cracking or infection) was 18.
0% in the non-debilitating group and as high as 30.
3% (P=0.
035)
in the debilitating group.

Liao Bingyao analyzed the postoperative complications of 148 patients undergoing surgery due to spontaneous intracerebral hemorrhage in the elderly, and after correcting the mixed factors such as sex, age, marital status, alcohol consumption, and smoking, the elderly patients with debilitating age were more likely to develop urinary tract infections (OR=3.
678, 95% CI 1.
163-11.
631), lung infections (OR=4.
054, 95% CI 1.
737-9.
457) after surgery, and lung infections (OR=4.
054, 95% CI 1.
737-9.
457), Electrolyte abnormalities (OR=6.
236, 95% CI 1.
348 to 28.
851) and hypoproteinemia (OR=2.
450, 95% CI 1.
085 to 5.
530).

3.
Perioperative management of debilitating elderly patients

The perioperative management of debilitating elderly patients can be intervened
from three aspects: preoperative assessment and pre-rehabilitation, intraoperative management and postoperative rehabilitation.

3.
1 Preoperative evaluation and pre-rehabilitation

If there are treatable comorbid diseases in debilitating elderly patients before surgery, they should be actively treated to improve
the overall state of the body.
Preoperative laboratory tests should include blood count, liver and kidney function, vitamin D, vitamin B12, and thyroid-stimulating hormone
.
Pay attention to improving lung function, electrocardiogram, and cardiac ultrasound
.
Clinicians should work together to make and optimize surgical decisions
.

Exercise is one of the main intervention methods for preoperative pre-rehabilitation, which can reduce the occurrence
of falls by increasing the muscle strength and coordination of debilitating elderly patients, increasing the flexibility of limb activities and improving bone density.
Studies have found that exercise training twice a week improves postoperative outcomes
in debilitating elderly patients.
For severely debilitating elderly patients with severe limitation of motor function, starting with a 5-minute walk every 2 days can also significantly improve the motor function
of such patients.

In older patients with severe debilitation, there is no need to force them to achieve the target amount of
exercise.
The results of the study show that although the amount of exercise is less than the target amount of exercise, as long as the preoperative training is adhered to, the prognosis of the elderly patients with severe debilitation can still be improved and the purpose of
pre-recovery can be achieved.

3.
2 Intraoperative management

The incidence of malnutrition in debilitating elderly patients is high, and it is not advisable to fast and drink
for a long time before surgery.
In addition to patients at higher risk of reflux aspiration, moderate preoperative carbohydrate intake reduces insulin resistance, improves perioperative nutritional status and discomfort, and reduces stress in
debilitating elderly patients.
Debilitating elderly patients are often accompanied by delirium and risk factors for the development of postoperative cognitive dysfunction (including advanced age, stroke, weakness, malnutrition, previous cognitive dysfunction, etc.

).
Therefore, for debilitating elderly patients, surgical trauma should be reduced as much as possible, thereby reducing the inflammatory response, while avoiding the use of benzodiazepines during surgery to prevent delirium and postoperative cognitive dysfunction
.

Debilitating elderly patients should be individualized during the operation, maintain a good depth of anesthesia, pay attention to the characteristics of drug metabolism slowing down in elderly patients, maintain the stability of the respiratory system and circulatory system during surgery in elderly patients with debilitation, reduce the stress response caused by endotracheal intubation and extubation, improve perioperative analgesia, avoid heart rate and blood pressure fluctuations caused by pain and other adverse stimuli, and the inhibitory effect
of large doses of analgesic drugs on the respiratory system 。 Debilitating elderly patients are more likely to develop hypothermia than general patients, intraoperative hypothermia can increase the risk of complications during and after surgery, therefore, attention should be paid to intraoperative insulation to avoid hypothermia
.

3.
3 Postoperative rehabilitation

During the postoperative recovery of debilitating elderly patients, clinicians should pay attention to the treatment of their comorbid diseases and strengthen nutritional support
.
Studies have found that perioperative use of immunonutritional modulators and vitamin D helps improve clinical outcomes in patients and reduces the incidence
of postoperative wound infections.
In addition, early limb motor rehabilitation training (30 minutes of moderate-intensity walking) and respiratory function exercises (respiratory trainers) in debilitating elderly patients helped to reduce the incidence
of postoperative adverse events.

The incidence of perioperative accidental falls in debilitating elderly patients is significantly higher
than that of non-debilitating elderly patients.
The results of a multicenter prospective cohort study showed that the incidence of falls in frail elderly patients was 3.
0 to 3.
6 times higher
than in non-debilitating older adults.
Measures to prevent perioperative falls in elderly patients are as follows
.
(1) Appropriate preoperative strengthening of skeletal muscle function exercise
.
Studies have found that regular tai chi exercises in the elderly can effectively reduce the incidence
of accidental falls in daily life.
(2) Pay attention to perioperative medication
.

Elderly patients are more sensitive to anesthetic drugs and their metabolism slows down, so anesthetic drugs tend to accumulate
in the body.
At the same time, due to the influence of residual anesthetics and sedatives, patients may have decreased blood pressure or orthostatic hypotension
.
Therefore, after the elderly patients wake up from anesthesia, family members and clinical medical staff should still be closely observed
.
Pay attention to avoid the occurrence of adverse events such as sudden wake-up induced dizziness and accidental falls
.
Debilitation is an age-related senile syndrome
.

At present, there is a lack of unified diagnostic criteria for debilitation at home and abroad, but various debilitation assessment scales based on debilitating phenotypes and defect accumulation models have been validated
in a large number of population cohort studies.
The incidence of perioperative complications in elderly patients with debilitating elderly patients is high, and the incidence of adverse events such as postoperative all-cause mortality and accidental falls is significantly increased, so clinical medical staff should strengthen the early identification, preoperative pre-rehabilitation, nutritional support and exercise training of elderly patients with perioperative debilitation, so as to reduce the incidence of perioperative adverse outcomes in elderly patients with debilitating elderly patients and improve the quality
of postoperative recovery.

Source: Wang Lan,Zhu Rui,Gu Weidong.
Precise assessment and management of elderly patients with perioperative debilitation[J].
Shanghai Journal of Medicine,2022,45(03):198-200.