Geriatric Challenges: Age shouldn’t determine treatment, experts say

If patients don’t have a list and don’t know their medicines, “I actually use that as a bit of a warning sign that they aren’t on top of their health and we really need to think, can they do all of the follow-up?” he said. In fact, difficulty taking medication can be one of the first signs of cognitive impairment.

At the University of Kentucky in Lexington, a preoperative anesthesia clinic allows anesthesiologists to consult with patients, especially the large numbers who are taking anticoagulants for cardiac conditions. Sanford M. Archer, MD, professor of otolaryngology-head and neck surgery at the university, said uncontrolled bleeding is clearly a concern during surgery, particularly for endoscopic techniques that don’t permit surgeons to cauterize or tie off blood vessels. In many cases, though, cardiac patients on anticoagulants can be switched to temporary medications to get them through surgery and then given another alternative like Lovenox until after they’ve recovered from the operation.

Surgeons also should pay special heed to a patient’s “functional reserve” or ability to bounce back from a surgery. One relatively straightforward way to do so is to assess a patient’s independent daily living activities. “Can they pay their bills? Can they get around their house? Can they make it to the store to buy groceries?” Dr. Dale said. “Those things are actually very tightly tied to life expectancy.” Additionally, the answers may help a surgeon evaluate whether patients sent home after big surgeries can take care of themselves.

Non-physician staff can administer a more formal test, a 13-point scale called the Vulnerable Elders Survey (VES-13), which highlights patients at risk for deteriorating health and functional ability. If necessary, geriatricians may conduct a longer evaluation known as a comprehensive geriatric assessment.

The mental competency of an older patient also demands a proper assessment. Dementia not only limits overall life expectancy, Dr. Dale said, but can also pose a significant risk immediately after a surgery. Given the added stress of surgery and anesthesia, patients who are cognitively impaired are at a much higher risk of becoming delirious, which can be a life-threatening condition on its own. In addition, patients who are not cognitively intact are less likely to follow up with the necessary postoperative care, thereby reducing their chances of recovery.

Overt dementia can usually be identified without screening tools, while offices can use rapid and straightforward methods like the Mini Mental State Exam to help sort out those patients who might require a more thorough examination. A newer test called the Montreal Cognitive Assessment (MoCA) helps identify milder forms of cognitive impairment.