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[00:00:00] Hello, and welcome to Behind the Knife. I'm Nicole Peka and I'm joined here by Agnes Prim Kumar. We're both behind the Knife Surgical Education Fellows and excited to be here. In today's episode, we'll be discussing surgical care for the older adult. It's a broad topic, but we hope to provide a quick look into the unique challenges and considerations to remember while caring for this vulnerable patient population.

So we'll also discuss a new verification program by the American College of Surgeons that's titled The Geriatric Surgery Verification, or the GSV program. Much like obtaining trial verification, hospitals can be distinguished as a center for excellent geriatric care. And we're so pleased to be joined by Dr.

Carolyn Smokin, who's a general surgery resident working with the A CS and the GSV program. And Dr. Marsha Russell, who's the chair of the a CS committee on the geriatric surgery, and she's heavily involved the creation and the implementation of the GSV program. So without further ado, let's get started.

How did you both get interested and involved in this topic? So I actually got involved with [00:01:00] this as a research resident. Um, Dr. Clifford Coe was my mentor at the time, and, uh, I was interested in outcomes research and he had a grant from that National Institute on Aging to look at quality issues for older adults undergoing surgery.

And at that time my grandparents were having some health issues. My grandfather actually had an urgent cabbage and my grandmother had fallen and broken her hip. So the need for optimal care for older adults undergoing surgery was particularly, um, prominent, uh, thing I was thinking about at that time in my life.

And then I was lucky enough to, you know, do research for several years with Dr. Co and then as an attending, you know, had the opportunity to work further with the a CS. Uh, with the Coalition for Quality on geriatric surgery, which ultimately turned into the geriatric surgery verification program. Thanks, Dr.

Russell. Caroline, what about you? So, as a resident [00:02:00] who, like many others isn't quite sure what surgical specialty I want to enter yet, I felt that the geriatric population is one that is. Represented in all surgical specialties, and I felt that it's a population that needs protecting as a vulnerable population and something that residents should really start thinking about early in our careers.

Thank you for sharing. You brought up some really important points. I think when you guys first reached out about doing an episode on geriatric surgery, I wasn't really aware that there was a group of surgeons who are interested in this, so it's been very exciting to learn about the different stuff you're doing and kind of what geriatric surgery all entails.

And like you guys both brought up, it's a field that really touches any subspecialty of surgery. And also it's a field that's really close to us as many of us have aging. Grandparents or parents, and eventually they're gonna come into contact with healthcare. So I think this is a really exciting opportunity for residents and surgeons around the country to get involved.

So on that note, let's get into our [00:03:00] first case. You're rounding in the surgical ICU overnight. When you see an 84-year-old female patient who was admitted after a ground level fall, she suffered multiple rib fractures. Initially, she required better pain control and supplemental oxygen, but she's since been weaned to room air and is able to maintain her airway with a strong cough.

She's now awaiting transfer to the floor. However, she starts to show signs of confusion, difficulty focusing, and restlessness. Your attending asks why the patient hasn't been downgraded yet, is they are now concerned. The patient has delirium as the resident on service one of the care team members asks you what factors contribute to delirium and how would downgrading the patient help?

That's a great question. Um, there's a lot of factors here in this case that could contribute to the patient developing delirium. Uh, first and foremost, they're being cared for in the ICU. The ICU is not a quiet place. There are noises constantly. The patient is overstimulated by that noise. Um, they're not sleeping.

The nurses [00:04:00] are frequently checking on the patient or waking them up. Um, from sleep in the middle of the night, uh, due to the level of care that they need. So it is really important then, when the patient no longer needs that intense level of care, you know, downgrading them can be beneficial just by eliminating some of the noise, uh, letting them sleep better.

And that in and of itself can be preventive towards development of delirium. Thanks for bringing that up. I think many of us don't think of downgrading as a way to reduce delirium, but um, that's something that I'll definitely keep in mind moving forward. Also in all geriatric patients, and definitely in trauma patients, it's important to consider and emphasize a multimodal pain management plan that limits opioids and emphasizes non-opioid and analgesics.

Opioids can contribute to delirium, so limiting. Opioids when possible, but also ensuring that the patient's pain is appropriately controlled is important. Some examples [00:05:00] include non-opioid analgesics, use of re, regional analgesia and non-pharmacological modalities to help. With pain control. Also, early ambulation is key regardless of the unit the patient is currently admitted to.

That's why a multidisciplinary team is very important. We need our colleagues in physical therapy and occupational therapy to work with us to provide the best possible care for these patients. And of course, the other well-known measures. Such as opening the blinds, reinforcing sleep wake cycles with appropriate lights on and off, which Dr.

Russell mentioned frequently reorienting patients to date and time and also being surrounded by, uh, family members can help with reducing delirium. Those are some great tips. Even just like focusing on some of the very small aspects like sleep, wake cycles, turning the lights on, turning them off at night, trying to get their family there, helping the patient get reoriented.

These can really make a big difference in the, um, rate that patients experience delirium. But you [00:06:00] know, as we were going through this, I was thinking a little bit more, and as a follow up question, why is delirium such an issue for the hospitals and the patients? That's another excellent question, Nicole.

We know that delirium increases patient's length of stay in the hospital, and the longer they stay in the hospital, the more likely they're to develop other complications and then potentially need, uh, discharge to a skilled nursing facility, for example. So when patients get delirium, they stay in the hospital longer.

That length of stay is longer, more costly to both the patient and the hospital system. And in addition, the longer they're in the hospital, the more likely they are to get hospital acquired infections and sort of other potential complications like a deep venous thrombosis, for example, which just contributes to, you know, further, uh, decline and other medical issues and makes it much less likely that they're gonna be discharged to home and may require post-acute care.

So in order to really provide optimal care for this vulnerable population, we want to, uh, [00:07:00] prevent as many delirium episodes as possible and also minimize, you know, the severity of any delirium episode that does occur by promptly recognizing it and intervening. Awesome. Thank you for that. And these are all really helpful guidelines and we all definitely cared for surgical patients with similar story, and we've heard the importance of delirium prevention in this population.

But these are just great practical tips that we can implement as we're rounding each day. Alright, let's do another quick chase. So, Mr. L is a 79-year-old man who comes to the clinic, uh, complaining of symptomatic gallstones. He's had three bouts of biliary colleague in the last two months alone, and his primary care doctor is worried about progression of his symptoms.

SC cystitis for his medical history, he has coronary artery disease with a stent that was placed two years ago. He has type two diabetes with an A1C of 8.1. He has COPD with exertional dyspnea and mild cognitive impairment. He lives alone, but he gets some help from his daughter who's in the area. So what are some initial thoughts that you have, [00:08:00] Carolyn, when you think about the scenario?

Right. So this is a classic scenario that I think many residents and attendings experience. Uh, we're not just deciding can we do a chole cystectomy? We're deciding if we should, and if so, how do we get this patient safely ready for the or? This is where preoperative screening is really a key to the patient's success.

Screening includes investigating the patient's vulnerabilities and includes assessment of their function and cognition. So I feel as though many times the patient's age screams louder than the rest of the presentation, but we really don't want age alone to be a reason not to offer operation as that's not the pres best predictor of surgical risks.

So what are some other things we can refer to Nicole to see if our patient is an appropriate candidate for surgery? As we say in every oral board scenario, the first step is always a comprehensive history and physical exam, but in our geriatric patients, you need to expand the lens. Not [00:09:00] only do we need to ask about comorbidities, but we also need to consider his functional status in this patient In particular, we're interested in knowing if he can climb a flight of stairs or does he do his own activities of daily living.

These functional questions are gonna help us understand more about his surgical readiness. Furthermore, we need to understand his baseline cognitive function. We're looking for risk factors that may put him at risk for postoperative delirium so that we can try to prevent that once we complete our history and physical.

We need to look at the patient's medication lists as we do for all surgical patients. In particular, we're looking for medications like anticoagulants and antiplatelets, but it's also important to check for potentially inappropriate medications, also known as pims. In our geriatric patients, these are medications that can increase the risk for an adverse event with or without surgery.

For example, a low toose benzodiazepine might have been prescribed for anxiety while the patient was younger, but as they age, this can increase the risk of confusion and falls. So especially when these medications are combined with postoperative pain medications, [00:10:00] we need to be able to identify these inappropriate medications and then have our patients safely stop them in the perioperative period or after if it's needed long term.

So I just wanna emphasize how important it is to really understand the patient's baseline cognition as well as their social support. These can really predict how well someone recovers postoperatively. Patients with preexisting dementia or mild cognitive impairment are at increased risk for postoperative delirium.

And sometimes you can help combat this by involving their support system early, having the family be at the bedside and spending time with them while they're in the hospital. But it's really important to understand, uh, what their baseline is so we can recognize changes as they're recovering from surgery.

Caroline, how do we assess how functional they are? For functional status, we consider the ADLs or IADLs. As you mentioned previously, exercise capacity can also be assessed with mets less than four mets, meaning they can't [00:11:00] walk two blocks or climb stairs without symptoms. It's typically a red flag. We should also judge their frailty by using simple tools like the clinical frailty, scale based on mobility and independence.

Even a score of five, which equates to mildly frail is associated with higher postoperative complications and something we should be aware of. Perfect, and if you have more time, there are standardized tools that can help you screen for frailty. I would advocate that doing any screen for frailty is better than none, so choose the tool that works best for you.

Once you've screened for frailty, you can move into comorbidity assessment. Let's go ahead and break those down next. Absolutely for assessing their cardiac history. You can use the revised cardiac risk index, RCRI. Get cardiology input if poor mets or recent cardiac events. And plan carefully around anti-platelet therapy for prior stents for COPD.

Maximize inhalers, encourage pulmonary rehab and push [00:12:00] smoking cessation. Even four weeks of quitting helps high-risk patients may benefit from pre-op incentives, spirometry teaching. Then for glycemic control, aim for reasonable control, ideally, A1C less than 8% before elective cases. Poor control of A1C increases infection and delayed wound healing.

Remember to adjust pre-op insulin and hold certain oral medications. Another component to focus on is nutrition don't under underestimate malnutrition. In an older adult, a low albumin or recent weight loss, uh, can predict complications, and even a short course of protein supplementation or nutrition consultation can help optimize them for surgery.

So how do we put this all together for Mr. L first? Optimize what you can control his blood sugars. Adjust medications and support nutrition. It looks like he is not on any anticoagulation, but given his heart surgery in the past, I would ask for help from my cardiology colleagues to risk stratify him and see if any other medication [00:13:00] changes need to be made.

All of this goes into Prehabilitation to get the patient in the best possible shape for surgery. I think the last piece is also to have shared decision making, which we talk about regularly. Sometimes for the patient, the right answer isn't surgery. So for Mr. L, maybe we consider non-operative management if the risks of undergoing surgery outweigh the benefits.

But if surgery is needed, we need to make sure that he's optimized and can prepare him for him and his family for realistic expectations, um, of not only what time in the hospital might look like, but also his recovery. Afterwards when he gets home, what can that look like for him and what life will can he lead moving forward?

Exactly. I wanna emphasize how important the transparency is to really help the patients and their families balance the benefits, risks, and patient goals. And we wanna make sure that the surgical care that we provide to older adults is aligned with their, uh, goals for their care. This [00:14:00] is also great, and individual providers can make it a point to provide patient-centered care and keep all these factors in mind.

But we all know real change often needs to be implemented at the system level, and that's where the geriatric surgery verification program comes into play. Great point. Caroline Hospitals can apply for GSV designation to show their commitment to specialized care, to allow elderly adults to maintain independence and quality of life after surgery.

This program was born out of a need to target the highest community, need the older population that is rapidly going and is also high risk and high cost. That's fantastic. I know the a CS has done incredible work through its other verification programs, and I'm really excited to see what's to come from this program as it continues to expand.

But if a center is interested in getting verified, what exactly does verification entail? Sure. There's actually three levels of verification now. In 2025, the Center for Medicare and Medicaid Services implemented an age-friendly hospital [00:15:00] measure tied into hospital reimbursements. As a result, the a CS released a new age-friendly verification level, which is.

For hospitals demonstrating six of the GSV program standards across surgery patients age 65 and older. After that, there's the GSV focused and GSV comprehensive levels, which are for hospitals demonstrating 30 GSV program standards for either 25 to 49% or greater than 50% of their surgical patients, aged 75 and older, respectively.

If a hospital is interested in verification, there is an application, a peer review questionnaire, and site visit to put it simply. So the standards for the GSV program are based on some core principles, including goals of care discussions to ensure the patient's goals are aligned with the surgical care screening for geriatric vulnerabilities intervention, where there are vulnerabilities identified and interdisciplinary postoperative care.

Awesome. And if my hospital wants to [00:16:00] pursue geriatric surgery verification, how do we start? Well, it really starts with the hospital or health system interested in seeking outpatient oriented change. And the first place to start is to really ensure that you have a dedicated team that is interested in implementing this program, and you wanna have all the necessary stakeholders at the table.

The hospital team works together to ensure that all standards are met and implemented at their center. And when these teams see better outcomes, such as improved mortality, decreased length of stay, and other cost savings programs continue to implement change and move the needle forward even further, it is important to preface that is really critical to have leadership engagement as well as support from it as implementation of the GSB program does rely on modifying the electronic health record as well as collecting some data.

That all sounds great. So I wanna take what we've been talking about and put it into the perspective of a case. So let's say that we're at a hospital and our hospital is connected to a CS and the geriatric surgery verification program. [00:17:00] And as part of that, we've noticed a trend over the past few years that a lot of our patients who are over the age of 75.

Come in from home when they come to get surgery. However, they're discharging to acute care rehabs and skilled nursing facilities. And we wanted to start a quality improvement project to help more patients discharge back to home where they came from and decrease our rates of discharging to these, uh, skilled nursing facilities.

So what would we do next? The key is to dig deeper and see why these patients aren't going home. Assume that the center dug deeper and saw that a large majority of these patients are diagnosed with delirium during their hospitalization, which is often what we see in non GSV hospitals. In this case, it's really important to address delirium before it happens.

So this includes identifying patients that are high risk for developing postoperative delirium, putting standardized delirium prevention bundles into play. Uh, simple things like returning [00:18:00] their personal sensory equipment like glasses and hearing aids, uh, as soon as possible in the recovery room. Using opioid sparing pain management to make sure their pain is, uh, optimally controlled.

And other, uh, interventions to prevent delirium that we touched on earlier, like, uh, sleep hygiene, for example. You've both mentioned collecting data from hospitals that are involved with the GSV program. Um, has there been data to show that these processes have shown improved outcomes for patients?

Absolutely. Uh, GSV hospitals are showing reduced length of stays, reduced rates of delirium, decreased morbidity, and higher rates of discharge to home, uh, just to name a few of the benefits that we're seeing. Well, this has been a great discussion on the care of older adults within the surgical patient population, and really provided some useful tips and resources available to hospitals to meet the needs of an aging patient population.

Caroline, can you give us three take home points for our listeners? Sure. First, the [00:19:00] older population is the fastest growing patient population, and it's important we focus on patient-centered care for this population. It's a patient population that all of us will engage with regardless of what surgical specialty we're in.

Second, if you or your hospital isn't prepared to get verified yet, there are still small processes. That can be implemented to make an impactful difference in your patients. And lastly, the geriatric surgery verification program is at the cutting edge of quality improvement. Like all other verification programs like Trauma bariatrics, just to name a few patients will soon seek out these centers that can best address their personal.

Thanks, Caroline, and that's a wrap on today's episode. If you'd like to learn more about the a CS Geriatric Surgery Verification program, or dive into some of the literature we discussed on caring for older adults, be sure to check out the resources linked in our show notes. Caroline and Dr. Russell, thank you so much for joining us today and for sharing your expertise.

We really [00:20:00] appreciate the practical tips and insights that you've provided. It'll be really interesting to see how this unfolds in the coming years. And of course, thank you to our listeners for always tuning in. Until next time, do.