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GUIDELINES IN GERIATRIC CARE
Audio-Digest Family Practice
Volume 61, Issue 01
January 7, 2013

Surgical Concerns: Geriatric Syndromes – Michael E. Zenilman, MD
Update on Wound Care – William B. Greenough III, MD
Tight Glycemic Control and Chronic Sedentary Feasting – Thomas Finucane, MD

  
From The 57th Annual Philip A. Tumulty Topics In Clinical Medicine, Presented By Johns Hopkins University School Of Medicine
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The following is an abstracted summary, not a verbatim transcript, of the lectures/discussions on this audio program.

Family Practice Program Info  Accreditation InfoCultural & Linguistic Competency Resources

Guidelines in Geriatric Care

From the 57th Annual Philip A. Tumulty Topics in Clinical Medicine, presented by Johns Hopkins University School of Medicine

Educational Objectives

The goal of this program is to improve management of elderly patients undergoing surgery, wound care, and care for diabetes. After hearing and assimilating this program, the clinician will be better able to:

1. Predict surgical risk based on comorbidities and geriatric syndromes.

2. Perform specific tests to assess preoperative frailty.

3. Select and effectively apply appropriate dressings to assist wound healing.

4. Use effective antibacterial agents to minimize infection in pressure sores.

5. Weigh evidence about the effects of medications for tight glycemic control, and about the effects of tight control on outcomes.

Faculty Disclosure

In adherence to ACCME Standards for Commercial Support, Audio-Digest requires all faculty and members of the planning committee to disclose relevant financial relationships within the past 12 months that might create any personal conflicts of interest. Any identified conflicts were resolved to ensure that this educational activity promotes quality in health care and not a proprietary business or commercial interest. For this program, the faculty and planning committee reported nothing to disclose.

Surgical Concerns: Geriatric Syndromes

Michael E. Zenilman, MD, Professor of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, and Director, National Capital Region, Johns Hopkins Medicine, Bethesda, MD

Comorbid illnesses: with no comorbid illnesses, risk for death from surgery increases linearly with age (risk only slightly higher in older patients, compared to younger patients); with cardiac, lung, or renal disease, or diabetes, risk for death from surgery increases exponentially; no difference in death rates seen between younger and older patients when comorbidities matched

Risk assessment: revised Goldman criteria — cardiac risk factors include ischemic heart disease, use of insulin for diabetes, and preoperative creatinine; with 3 risk factors, risk for cardiac events after noncardiac illness nearly 10% (nearly 0% with no risk factors); preoperative β-blockers shown to decrease cardiac risk (controversial in abdominal surgery); control cardiac and pulmonary risk (with, eg, smoking cessation), renal disease (with, eg, control of creatinine level, hydration), and diabetes; need for emergency surgery triples or quadruples death rate

Surgery and geriatric syndromes: colectomy — morbidity rate in elderly patients (>50 yr of age) 33%; mortality rate 4%; mortality rate in patients <70 yr of age with 2 comorbidities not statistically different from that in patients >70 yr of age with 2 comorbidities; colon surgery safe in older patients; older patients had longer length of stay and higher hospital charges, but no difference in 3-yr survival for cancers (mortality risk predicted by disease stage and procedure); younger and older patients who underwent laparoscopic colectomy had differences in comorbidities but no difference in operative times, conversion rates, anesthesia times, hospital stays, or outcomes (procedure proven safe in elderly); laparoscopic vs open colectomy in elderly patients — study looked at patients >80 yr of age; conversion rate 6%; no difference seen in mortality or morbidity rates, but recovery times differed; laparoscopic surgery resulted in better postoperative independent status (ie, more patients discharged home [98% vs 82%; statistically significant] rather than to skilled nursing facility [SNF]); elective surgery vs emergency surgery — 83% of patients who underwent elective open surgery discharged home, compared with 42% of those having emergency surgery; outcomes driven by geriatric syndromes rather than comorbidities

Comprehensive geriatric assessment: consider polypharmacy, functional status, nutrition issues, and cognition; assess for geriatric syndromes, eg, delirium, dementia, incontinence, osteoporosis, risk for falls, failure to thrive, impaired activities of daily living (ADLs), alcoholism, and frailty; predicting mortality — study showed geriatric syndromes best predictor of mortality; overall mortality rate of 110 participants (mean age 70 yr) who underwent major procedures and stayed in intensive care unit (ICU) 16%; history of fall in last year major predictor of whether patient discharged to home or to SNF; more patients with dementia went to SNF than went home; according to results of univariate logistic regression for 6-mo mortality, signs of dementia on Mini-Cog test, albumin level, history of falls, hematocrit, and impaired ADLs associated with odds ratio of 13

Preoperative frailty assessment: disabilities; functional gait; history of falls; chronic illnesses; polypharmacy; elder abuse; alcoholism; use Charlson comorbidity index; use Beers criteria to recognize potentially inappropriate medications for older patients; use Katz Index of Independence in Activities of Daily Living (score <5 concerning); ask about history of falls (1 fall in last 6 mo concerning); check albumin; use Mini-Cog test and Timed Up and Go test (>10 sec concerning); check for weight loss

Postoperative effects: decrease in ADLs; recovery gradual (ask about ADLs, especially bathing and dressing); base decision to palliate or perform curative procedure on prediction of recovery (critical to discuss preoperatively)

Dementia and delirium: delirium — sudden; reversible; worse at night; associated with drugs more than dementia; dementia — gradual; not reversible; patients at high risk for delirium; patients who develop postoperative delirium at higher risk for 6-mo mortality; treatment of postoperative delirium — treat underlying cause; eliminate unnecessary medications; avoid restraints; room should be light or dark at appropriate times; antipsychotics (eg, risperidone, haloperidol) effective; avoid benzodiazepines

Surgery in patients from SNFs: speaker’s study — followed frail surgical patients in academic SNF and community geriatric center; dementia and coronary artery disease (CAD) most significant predictors of death in academic SNF, compared to sex and CAD in community geriatric centers (sex alone predictor of death in patients with congestive heart failure [CHF]); study of Medicare patients — looked at patients who underwent emergency cholecystectomy, colectomy, duodenal ulcer surgery, or appendectomy, and compared patients from SNFs to matched cohort of elderly patients; death rate higher in patients from SNFs for all those surgeries; propensity scoring analysis (ie, patients with similar illnesses matched) also saw higher death rates in patients from SNFs (operative mortality rate for emergency surgery for ulcer disease 41%, compared to 30%); patients from SNFs had more interventions (eg, ventilation, tracheostomy, feeding tubes) than non-SNF patients

Key points for surgeons: willingness to change goals (eg, comfort vs survival) important; case mix includes dementia, CHF, terminal diseases, and maintenance operations; help needed from dedicated medical professionals, ancillary support (from, eg, social workers), and relationships with referring hospitals

Update on Wound Care

William B. Greenough III, MD, Professor of Medicine, Johns Hopkins University School of Medicine

Assessment of skin: severity of subcutaneous injury not discernible by examining skin; blood supply to interstitial tissue poor and can be shut off by shearing and pressure; even small discolored blemish can have serious deep-tissue injury underneath that can lead to anaerobic sepsis and death; residual hair follicles and sweat glands allow skin to grow easily over injury; approach to wound dressing determined by presence of dermis and depth of injury

Function of skin: hydrophobic (avoid oily dressings for deeper wounds); enzymes of phagocytes (eg, collagenases, proteases) act on necrotic wounds during angiogenesis; newly grown blood vessels coated with mesoderm (involves sequence of growth factors)

Approach: removal of dead tissue crucial to avoid sepsis; assist wound healing — use dressing that encourages growth factors; do not disturb wound by, eg, stuffing with foreign bodies; protect against invasive bacteria; minimize infection — systemic antibiotics ineffective in wounds that have not been debrided; if initial wound care adequate, then systemic antibiotics usually unnecessary; every wound becomes colonized with bacteria once no longer under sterile conditions

How to choose dressings: general rule to use hydrophobic dressings when trying to grow skin (use, eg, petroleum jelly; oily and absorbent material helps prevent overgrowth of mesoderm [hypergranulation]); on deep wounds, use hydrophilic material such as starch (eg, calcium alginate [eg, Calginate]) to fill cavity; avoid disturbing growth factors or organization of wound healing; once wound clean, avoid changing dressing every shift; perform split-thickness skin grafting and apply dressing containing petroleum jelly and bismuth tribromophenate for skin growth

Antibacterials: invasive organisms include coagulase-positive Staphylococcus aureus and groups A, B, and G streptococci; organisms invasive regardless of sensitivities to antibiotics; Staphylococcus causes formation of abscesses (difficult to treat, particularly in wounds with dead tissue); silver — prevents proliferation of Streptococcus and Staphylococcus; nontoxic; inhibits main invasive pathogens

Pressure sores: occur when patient not moved; develop faster in hypotensive patients; risk factors include acute hospital setting (particularly ICU); mattresses with low-air-loss technology better than gurneys or hard mattresses but do not solve problem; stage I — no clotting of blood vessels; blanching occurs when skin pressed; if no blanching, document “suspected deep-tissue injury” or “unstageable”; stage II — injury through epidermis into dermis; stem cells present for new skin growth; heals in 2 to 3 wk; stage III — injury through skin into deep tissue with cavity formation; may take months to heal; stage IV — injury through subcutaneous tissue, usually down to periosteum and ligaments

Types of debridements: body produces enzymes that clean wound; in open wound associated with osteomyelitis, dead bone “spit out” before granulation; definitive treatment for osteomyelitis to remove dead bone and leave wound open (saucerization); gauze with oxychlorosene (Clorpactin WCS-90) or saline; collagenase from Clostridium histolyticum that distinguishes dead from live collagen (useful for superficial wounds but not as helpful for deep wounds); chemical enzymes not used

Problems: tunneling and undermining; incomplete debridement; hypergranulation; vascular and diabetic ulcers; negative-pressure wound therapy [eg, VAC system] for tunneling — tissue-friendly sponge with graded vacuum pressure packed into tunneling of wound; dressing changed twice weekly; failure to clean sloughed tissue and wound problematic

Products: iodine attached covalently to microbead — does not soak into tissue; kills bacteria; lasts for 36 hr; usually applied in wound cavity with calcium alginate; once wound clean, apply silver dressing (eg, Calginate-AG) or, for clean deep tunneled wounds, use VAC system

Optimal wound care: remove dead tissue and foreign bodies (eg, suture material); culture wound to look for invasive pathogens, and determine whether cellulitis present around wound or systemic antibiotics needed (eg, when patient febrile or has spreading cellulitis; use antibiotic directed at Staphylococcus or Streptococcus); obliterate dead space with wound matrix (eg, starch); absorb excess exudate; maintain moist wound environment under skin to prevent formation of eschar; protect wound from trauma; avoid transmission of infection by staff members; less frequent changing of dressings (and avoiding changing gauze in wound multiple times per day) now common

Tight Glycemic Control and
Chronic Sedentary Feasting

Thomas Finucane, MD, Professor of Medicine, Johns Hopkins University School of Medicine

Introduction: typical patient problem — overweight sedentary elderly woman with hemoglobin A1c (HbA1c) of 9%, with no symptoms of hyperglycemia; standard approach — metformin first-line drug; add any of several drugs “safely” to reach glycemic target

Chronic sedentary feasting: ingesting readily available calories with no requirement for physical activity; associated with many adverse effects (many can be reversed with physical activity and calorie restriction); tight glucose control — may not be appropriate to focus on hyperglycemia by adding one drug after another without clear knowledge of mechanisms of action or evidence of benefit

Studies of tight control in type 2 diabetes: 9 trials compare tight glucose control and usual care; up until mid-2008, no trial except United Kingdom Prospective Diabetes Study 34 (UKPDS 34) showed reduction in renal failure, myocardial infarction (MI), stroke, amputation, or death; UKPDS saw reduction in death and MI in metformin arm; in Steno-2 study, reduction in vision loss seen (multi-interventional arm; unclear which aspect reduced abrupt vision loss); randomized clinical trials (2008-2009) — 1) Action to Control Cardiovascular Risk in Diabetes (ACCORD) trial concluded that, compared with standard therapy, use of intensive therapy to target normal glycated Hb levels for 3.5 yr increased mortality and did not significantly reduce major cardiovascular (CV) events; findings identify previously unrecognized harm of intensive control in patients with type 2 diabetes; study stopped early due to clear signal of harm with glycemic goal of 6%; 2) Veterans Affairs Diabetes Trial concluded that intensive glucose control in patients with poorly controlled type 2 diabetes had no significant effect on rates of major CV events, death, or microvascular complications, with exception of progression of albuminuria; 3) industry-sponsored trial concluded that intensive glucose control involving drugs required to lower HbA1c to 6.5% yielded 10% relative reduction in combined outcome of major macro- and microvascular events, primarily as result of 20% relative reduction in nephropathy; no difference seen in macrovascular disease or death; advanced treatment regimen’s reduction of renal complications amounts to reducing number of incidents of renal complication only from 5 per 100 patients to 4 per 100 patients over 5 yr; no trials provide data about elderly (80 yr of age) patients; 4) large study looked at patients with type 2 diabetes treated with medications; risk associated with HbA1c of 6.5% to 7.0% similar to that with HbA1c of 9.0% (7.5%-8.0% preferred; 7.0% not recommended); negative effects of tight control more pronounced in patients on insulin (eg, if HbA1c 7.0% while on insulin, risk of dying substantially increased, compared to HbA1c of 8.0%); nearly all articles claiming that tight control of type 2 diabetes effective refer to benefits seen in Diabetes Control and Complications Trial (involving type 1 diabetes); higher glycemia in untreated patients associated with higher mortality (but co-occurring factors must be considered, eg, adipokine storm, hepatosteatosis)

Diabetes: level of glycemia above which adverse effects rise; in large untreated populations of nondiabetic patients, risk for diabetes-like events increases with HbA1c 4.5% and fasting blood glucose (FBG) >70 or 75 mg/dL; diabetes occurs with HbA1c of 5.0% or FBG of 80 mg/dL; FBG of 70 mg/dL preferable to 80 mg/dL; “legacy effect” or “metabolic memory” — in some trials that followed patients in standard care for years, HbA1c immediately coalesced; several years later, group in tight control arm appeared to have better outcomes on several diabetes-related measures; mechanism not understood

Summary: except ACCORD trial and UKPDS 34, no randomized clinical trial shows significant benefit in macrovascular effects (eg, MI, stroke, amputation), microvascular effects (eg, renal failure, blindness, neuropathy), or death; evidence about tight control limited; improving HbA1c with rosiglitazone increases risk for MI (debatable whether true with sulfonylureas); speaker argues that hyperglycemia marker for disease; diabetes associated with evolutionary challenge related to ingestion of “torrent of unusable calories”; one adverse effect of tight glycemic control in elderly patients is death

Acknowledgments

Drs. Zenilman, Greenough, and Finucane spoke in Baltimore, MD, at the 57th Annual Philip A. Tumulty Topics in Clinical Medicine at Johns Hopkins, presented May 7-11, 2012, by the Department of Medicine at Johns Hopkins University School of Medicine. Please visit http://www.hopkinscme.edu/ for information about upcoming courses from this sponsor. The Audio-Digest Foundation thanks the speakers and Johns Hopkins University School of Medicine for their cooperation in the production of this program.

Suggested Reading

Effect of intensive blood-glucose control with metformin on complications in overweight patients with type 2 diabetes (UKPDS 34). UK Prospective Diabetes Study (UKPDS) Group. Lancet. 1998 Sep 12;352(9131):854-65; Arzt H et al: Which medical device and/or which local treatment are to be used, as of 2012, in patients with infected pressure sore? Developing French guidelines for clinical practice. Ann Phys Rehabil Med. 2012 Oct;55(7):498-507; Bonds DE et al: The association between symptomatic, severe hypoglycaemia and mortality in type 2 diabetes: retrospective epidemiological analysis of the ACCORD study. BMJ. 2010 Jan 8;340:b4909; Eardley WG et al: Extremity trauma, dressings, and wound infection: should every acute limb wound have a silver lining? Int J Low Extrem Wounds. 2012 Sep;11(3):201-12; Gerstein HC et al: ACCORD Study Group. Glycemia treatment strategies in the Action to Control Cardiovascular Risk in Diabetes (ACCORD) trial. Am J Cardiol. 2007 Jun 18;99(12A):34i-43i; Health Quality Ontario: Management of chronic pressure ulcers: an evidence-based analysis. Ont Health Technol Assess Ser. 2009;9(3):1-203; Jiang B et al: Dual delivery of chlorhexidine and platelet-derived growth factor-BB for enhanced wound healing and infection control. Acta Biomater. 2012 Oct 11 [Epub ahead of print]; Marcantonio ER et al: A clinical prediction rule for delirium after elective noncardiac surgery. JAMA. 1994 Jan 12;271(2):134-9; Reaven PD et al: Veterans Affairs Diabetes Trial. Intensive glucose-lowering therapy reduces cardiovascular disease events in veterans affairs diabetes trial participants with lower calcified coronary atherosclerosis. Diabetes. 2009 Nov;58(11):2642-8; Robinson TN et al: Redefining geriatric preoperative assessment using frailty, disability and co-morbidity. Ann Surg. 2009 Sep;250(3):449-55; Schwartz AV et al: Intensive glycemic control is not associated with fractures or falls in the ACCORD randomized trial. Diabetes Care. 2012 Jul;35(7):1525-31; Schwartz AV et al: Health, Aging, and Body Composition Study. Diabetes-related complications, glycemic control, and falls in older adults. Diabetes Care. 2008 Mar;31(3):391-6; Stubbs N et al: The development, implementation and evaluation of a cross organisational clinical guideline for the management and prevention of wound infection. J Tissue Viability. 2012 Nov;21(4):112-4; Zenilman M: Geriatric surgery: past, present, and future. Arch Surg. 2012 Jan;147(1):10; Zenilman ME et al: New developments in geriatric surgery. Curr Probl Surg. 2011 Oct;48(10):670-754; Zenilman ME: Surgery in the geriatric patient: aging, the heart, emergencies, and us. Arch Surg. 2007 Feb;142(2):109-10; Zenilman ME et al: General surgical care in the nursing home patient: results of a dedicated geriatric surgery consult service. J Am Coll Surg. 1996 Oct;183(4):361-70.


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