Should your Patient have that Cardiac Intervention? - #26
Take QuizUse geriatric assessment tools to determine appropriateness of invasive cardiac interventions.
General Principles
- Due to physiologic changes with aging:
- Many diseases present atypically.
- Interventions (medical and surgical) may have unintended consequences/effects.
- Medical problems are frequently multifactorial (physical, cognitive, functional, social), with diagnosis/management best approached through multifactorial interventions.
- Diagnostic testing and treatment are determined based on ability to improve disease process or quality of life/goals of care.
Patient Assessment
- Gather in-depth information of both physical and cognitive health.
- Evaluate functional status by screening:
- Activities of Daily Living (ADL)
- Instrumental Activities of daily Living (IADL) http://consultgerirn.org/uploads/File/trythis/try_this_23.pdf
- Use the American Society of Anesthesiology (ASA) Physical Status Classification as a reliable and accurate predictor for surgical mortality.
The American Society of Anesthesiology (ASA) Physical Status Classification Class I A normal healthy patient for elective operation Class II A patient with mild systemic disease Class III A patient with severe systemic disease that limits activity but is not incapacitated Class IV A patient with incapacitating systemic disease that is a constant threat to life Class V A moribund patient not expected to survive 24 hours with or without operation - Generate approximate prognosis of life expectancy
- Determine patient’s and family’s values and preferences regarding care
Considerations Regarding Prognostication
- When life expectancy is more than 10 years, it is reasonable to consider prevention, testing, and treatment as in younger patients.
- In patients with a single primary disease process, prognosis can be estimated with a disease-specific instrument.
- When multiple diseases alter the patient’s health status, prognosis can be estimated by considering general health (number and severity of co-morbidities), age, cognition, and function.
- Prognostic tools have been developed to guide the estimation of life expectancy in older adults with multiple comorbidities
http://www.eprognosis.org/p/calculators.html
Normal physiologic changes with age that may affect perioperative and postoperative outcomes:
| Effects | Physiologic change with age |
|---|---|
| Change in pharmacodynamics |
|
| Complex fluid management (Risk for fluid overload and depletion |
|
| Decreased pulmonary reserve (Higher risk for pneumonia) |
|
| Increased risk of hyperthermia |
|
| Higher risk for delirium |
|
Elderly patient with cardiac disease indicating invasive intervention.
Determine appropriateness of invasive cardiac intervention in the geriatric cardiology patient through assessment of their overall physical health, cognition and function and social situation.
Not applicable
Science Principles
- List geriatric assessment principles to help identify patients who may benefit from invasive intervention.
- Identify factors that may increase morbidity and mortality in older adults with heart disease.
- Formulate appropriate prognosis of life expectancy.
Review of Systems (ROS)
Geriatric Topics
ACGME Compentencies
Science Principles
- Schonberg MA, Davies RB, McCarthy EP, Marcantonio ER. Index to predict 5-year mortality of community-dwelling adults age 65 and older using data from the national health interview survey. J Ger Intern Med. 2009;24(10):1115-1121. http://www.ncbi.nlm.nih.gov/pubmed/19649678
- Fleisher LA, Beckman JA, Brown KA et al. ACC/AHA 2007 guidelines on perioperative cardiovascular evaluation and care for non-cardiac surgery. Circulation. 2007;116(17):e418-e499. http://www.ncbi.nlm.nih.gov/pubmed/17950159
- American Society of Anesthesiologists. New classification of physical status. Anesthesiology 1963;24:111.
- Bowie MW, Slattum PW. Pharmacodynamics in older adults: a review. Am J Geriatr Pharmacother. 2007;5(3):263-303. http://www.ncbi.nlm.nih.gov/pubmed/?term=pharmacodynamics+in+older+adults+a+review+bowie
- Walter LC, Lewis CL, Barton MB. Screening for colorectal, breast, and cervical cancer in the elderly: a review of the evidence. Am J Med. 2005 Oct; 118(10):1078-86. http://www.ncbi.nlm.nih.gov/pubmed/16194635
Users are free to download and distribute Geriatric Fast Facts for informational, educational, and research purposes only. Citation: Gabriel Manzi MD, Catherine Malmsten MD, Guru Krishnan, Nicholas Dreger, Kathryn Denson MD, Fast Fact #026: Should your patient have that cardiac intervention? April 2013.
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