Knowledge, attitude, and practices of Indian anesthesiologists regarding the comprehensive preanesthetic assessment of geriatric patients: A cross-sectional survey

Pallavi Ahluwalia; Bhavna Gupta

doi:10.4103/bjoa.BJOA_26_21

ORIGINAL ARTICLES

Year : 2021 | Volume : 5 | Issue : 4 | Page : 246-251

Knowledge, attitude, and practices of Indian anesthesiologists regarding the comprehensive preanesthetic assessment of geriatric patients: A cross-sectional survey

Pallavi Ahluwalia¹, Bhavna Gupta²
¹ Department of Anaesthesia, Teerthanker Mahaveer Medical College, Moradabad, Uttar Pradesh, India
² Department of Anaesthesiology, All India Institute of Medical Sciences, Rishikesh, Uttarakhand, India

Date of Submission	22-Feb-2021
Date of Decision	21-May-2021
Date of Acceptance	03-Jun-2021
Date of Web Publication	24-Nov-2021

Correspondence Address:
Dr. Bhavna Gupta
Department of Anaesthesiology, All India Institute of Medical Sciences, Rishikesh, Uttarakhand.
India

Source of Support: None, Conflict of Interest: None

DOI: 10.4103/bjoa.BJOA_26_21

Abstract

Background: Comprehensive preoperative geriatric evaluations, including frailty, diet, mobility aid use, physical activity, cognitive testing, and mood state assessment, help predict perioperative outcomes in elderly patients. Material and Methods: An online questionnaire-based Google survey was prepared to assess preanesthetic checkup (PAC) in elderly patients by practicing anesthesiologists over 3 months. Data about respondent demographics, knowledge about preoperative investigations, and utilization of validated tools for risk assessment in geriatric patients were collected and analyzed descriptively using different percentages and frequencies. Results: The invitation was sent to 500 anesthesiologists. One hundred and fifty-six recipients responded to the e-mail invitation producing an overall response rate of 31.2%. About 47.4% and 42.4% of anesthesiologists had an equal preference for regional/general anesthesia in conducting elderly elective cases for surgeries, the choice of anesthesia was mainly regional anesthesia in cognitively impaired elderly patients. Nearly 88.5% and 78.2% of practicing anesthesiologists were well aware and conducted the functional assessment and mini—mental state examination in geriatric patients, but only 48.7% were aware of frailty scoring, 30.8% were aware of Charlson comorbidity scoring index, and 24.4% were about Elderly Mobility Scale (EMS). Conclusion: Surgical results are strongly influenced by the general health, work, and life expectancy of patients. A comprehensive preoperative geriatric evaluation of patients must be extended beyond an organ-based or disease-based evaluation. We support the inclusion in the PAC of geriatric patients of validated score systems, including frailty score, Charlson comorbidity score index, EMS, functional assessment, and mini—mental state assessment.

Keywords: Geriatric anesthesia, preoperative checkup, questionnaire, survey

How to cite this article:
Ahluwalia P, Gupta B. Knowledge, attitude, and practices of Indian anesthesiologists regarding the comprehensive preanesthetic assessment of geriatric patients: A cross-sectional survey. Bali J Anaesthesiol 2021;5:246-51

How to cite this URL:
Ahluwalia P, Gupta B. Knowledge, attitude, and practices of Indian anesthesiologists regarding the comprehensive preanesthetic assessment of geriatric patients: A cross-sectional survey. Bali J Anaesthesiol [serial online] 2021 [cited 2022 May 28];5:246-51. Available from: https://www.bjoaonline.com/text.asp?2021/5/4/246/330945

Introduction

Patients scheduled for elective surgery are assessed preoperatively in clinical practice to evaluate their underlying medical condition and estimate the likelihood of adverse postoperative outcomes. In almost all organ systems, there is a gradual decline of the functional reserve with aging, to a varying degree. With a growing dearth of patients with multiple comorbidities, perioperative management is also becoming complex.

Age-related adjustments are typically reasonably compensated for a routine life, but there is a physiological reserve constraint and is apparent during stressors such as the perioperative period. The risk of anesthesia is more closely linked to the prevalence of coexisting illnesses and patients’ rising age. Therefore, it is essential to evaluate the physical, emotional, and cognitive state of a patient and estimate the physiological reserve during the preanesthetic checkup (PAC). The optimal PAC decreases the risk of perioperative morbidity and mortality and reduces the need for complicated testing and consultation.^[1] Such advantage also includes eliminating cancellations and delays in cases and reducing the duration of hospital stay.^[2] The goal of this study was to obtain information from the participants about the conduct of PAC of elderly patients.

Materials and Methods

It was a prospective, cross-sectional survey of practicing anesthesiologists in North India, conducted over 3 months after getting institutional approval (#AIIMS/IEC/21/65, dated 12/2/2021). Our questionnaire was adapted to assess the attitude and behavior of practicing anesthesiologists and knowledge regarding validated tools during PAC assessment of elderly patients. Before sending the final version to participants, we initially created a print version of the first draft. For testing the draft questionnaires, it was distributed to ten anesthesiologists, five each at our respective institutes, and shortcomings in the questionnaire were noted, and necessary changes were incorporated. The final online questionnaire-based Google survey validated by experienced anesthesiologists was then sent to 500 known anesthesiologists in India over 3 months.

The survey questions were generated online in Google Forms and were circulated electronically through social media to groups of residents and anesthesiologists from different hospitals. A message of intent, describing the survey’s objectives and ensuring anonymity and confidentiality of all responses, was sent to all participants. The survey was in a checkbox layout and included a free text field that required more direct information and descriptions for each category of searched objects. Respondents were free to conceal their identity.

The invitation was sent twice (with a 3-week gap) to ensure that all the members received the message and that they had an opportunity to respond and to raise the response rate. Only one reply from each e-mail address was permitted by the web platform, thereby avoiding multiple answers from a single user. At the end of the 3 months, the survey was closed. After completing the study about respondent demographics, the practice of PAC characteristics was collected. Data were downloaded and entered into a Microsoft Excel sheet. Data about respondent demographics and practice characteristics were collected and analyzed descriptively using different frequencies and percentages. Descriptive statistical testing to test participant’s knowledge and routine usage of validated tools was evaluated using software package IBM SPSS 23 (IBM Corp. Released 2015. IBM SPSS Statistics for Windows, Version 23.0. Armonk, NY: IBM Corp.), using Chi-square test for categorical variables. The P value was considered statistically significant at <0.05.

Results

The invitation was sent to 500 anesthesiologists and 156 recipients responded to the e-mail invitation producing an overall response rate of 31.2% and included 48.7% postgraduates, 14.1% senior residents, and 28.2% faculty respondents. Nearly 96.2% of the respondents worked in tertiary care hospitals, of which 61.5% and 38.5% were, respectively, from government and private setup. About 19.2% had <1 year of experience, 44.9% had 1—5 years of experience, and 29.5% had more than 10 years of experience as anesthesiologist [Table 1]. [Table 2] depicts the relationship of responses to questions asked regarding the devotion of time in PAC conduct with experience of anesthesia (P = 0.234), which indicates that there was no difference in the conduct of time concerning the experience of anesthesiologists.

Table 1: Demographics of participants, mode of preferred anesthesia, investigations, comorbidity, and type of surgery encountered and awareness of participants to various validated scores

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Table 2: Relationship of responses to questions asked regarding devotion of time in conduct of preanesthetic checkup with experience of anesthesia, and difference was statistically in significant

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The choice of anesthesia was mainly regional anesthesia (39.7%) in conducting a case in cognitive impaired elderly patients. Participants’ encountered following surgeries in decreasing order including orthopedic, urological, oncological, abdominal, and neurological surgeries in elderly patients. Most of the participants responded that they get chest X-ray, complete blood count, electrocardiography in all geriatric patients, but echocardiography or CPET only in selected cases. The common comorbidities encountered in PAC of geriatric patients mentioned by participants included hypertension, diabetes, coronary artery disease, chronic kidney disease, valvular heart disease, a neurological decline in decreasing order.

As many as 48.7% were aware of frailty scoring, 30.8% were aware of Charlson comorbidity scoring index and only 24.4% about Elderly Mobility Scale (EMS).^[3],[4],[5] Almost 88.5% and 88.5% of practicing anesthesiologists were well aware and conducted functional assessment and mini—mental state examination in geriatric patients.^[6],[7] Nearly 67% of participants felt a lacuna in the current knowledge regarding proper PACs of geriatric patients while 18% were unsure.

The cross-tabulation table [Table 3] reflects participants’ knowledge and actual usage of validated tools during PAC examination, and significance can be seen with Charlson comorbidity index (CCI), Mini Mental State Examination (MMSE), EMS, and frailty score (P < 0.05). This also indirectly reflects, though the participants know various validated tools, they are hesitant to use during PAC assessment. When they were inquired whether they knew about the tools and used them, the results were surprising. None of the tools, CCI, MMSE, frailty, EMS, were being used except METS scoring (P < 0.001).

Table 3: Cross-tabulation table reflects the knowledge of participants and actual usage of validated tools

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Discussion

Life-saving interventions (e.g., cancer resection) are some of the surgical procedures carried out in older adults, while other operations are conducted to improve the quality of life (e.g., joint replacement). The risk of postoperative complications, prolonged hospital stays, and delayed or diminished functional recovery is increased in geriatric patients. In both the Acute Physiology and Chronic Health Evaluation and Physiological and Operative Severity Score for Mortality and Morbidity frameworks and their modifications, advanced age provides a risk factor for adverse results.^{[8],[9],[10],[11]}

Preoperative geriatric evaluations, including frailty, diet, physical function, memory, and mood tests, can help predict postoperative outcomes in elderly patients. Proper evaluation during PAC is an essential part of patient care. Preanesthetic screening requires taking a proper history, appropriate physical examination, and laboratory investigations. The PAC goal is to optimize the patient before surgery to minimize the risk of anesthesia and surgery and to maximize the outcome as far as possible. It also offers an opportunity for the patient to address any anesthesia-related issues or concerns. It is well documented that both the patient’s preoperative physical health and the surgical procedure affect morbidity and mortality during surgery.

The survey was done to assess the attitude and behavior of practicing anesthesiologists regarding PAC assessment of elderly patients and knowledge regarding the use of validated tools in PAC assessment in elderly patients. Kluger et al.^[12] examined the Australian Incident Monitoring Study database and reported that out of 6271 reports, 478 did not have a correct preoperative assessment, while in 248 patients, there was inadequate preoperative preparation. They reported that insufficient preanesthetic management resulted in an increase in mortality by six-fold.

A significant aspect of the evaluation of preoperative surgery is cardiac risk assessment. Postoperative myocardial infarction leads to significantly higher levels of in-hospital mortality. A strategy has been developed by the American College of Cardiology and the American Heart Association to help doctors assess cardiac risk before noncardiac surgery. The guideline suggests that preoperative cardiac monitoring should be used appropriately. Testing should be required only if clinical management changes the findings.^[13] Postoperative pulmonary complications can increase hospital stay by 1 to 2 weeks and lead to functional decline and increased morbidity and mortality. Risk factors leading to increased pulmonary complications include age >60 years, underlying lung disease, current smoking, delirium, functional dependence, weight loss, and surgical factors such as extended or emergency surgery, general anesthesia, and neuromuscular blockage.^[14]

This survey contributed to the assess awareness and evaluation of these assessment tools used during PAC by geriatric patients posted for elective surgery by anesthetists. About 88.5% and 78.2% of practicing anesthesiologists were well aware of and administered functional assessment and mini—mental state assessments in geriatric patients. Still, just 48.7% were aware of frailty scores, 30.8% were aware of Charlson comorbidity scores,^[4] and only 24.4% were mindful of EMS scores. Proper risk stratification significantly affects intraoperative management. The Charlson comorbidity score index predicts 10-year survival in patients with multiple comorbidities. It indicates a 10-year mortality rate of patients presenting with one or more conditions in the model.

A 30-point questionnaire commonly used in clinical and research settings to determine cognitive disability is MMSE. It helps to estimate the degree and growth of mental disorders and monitor the cognitive changes in people over time, making it a meaningful way to document the person’s response to treatment. In assessing cognition, delirium, dementia, and depression are important factors, as sensory dysfunction is associated with a higher risk of postoperative complications and mortality.^[15] There are many tools for screening for cognitive impairment, including the Mini-Cog, a fast screening method for outpatients.^[16],[17]

The heart’s functional capacity is typically reflected in metabolic equivalents (METs). More than 7 METs of activity tolerance are considered outstanding, whereas <4 METs are regarded as low activity tolerance. Patients with functional disability have a greater risk of postoperative complications, including functional impairment and institutionalization.^[18] Rehabilitation involving multimodal therapies has strengthened postoperative functional performance, including home activity, nutritional evaluation, relaxation techniques, and pain management.^[19],[20]

The EMS is a valuable and validated instrument for assessing vulnerable elderly adults’ roles. This assessment method provides a standardized means for measuring mobility in elderly patients. EMS can be used for tracking status before and after any physical therapy to preserve or achieve independence from activities of daily living. Limitations in independence in older adults are common and are associated with depression, social alienation, and poorer quality of life.^{[14],[21],[22]}

Frailty is typically characterized as an increase in resilience due to age-related reductions in body capacity and functionality across various physiological processes to impair the ability to cope with day-to-day or acute stressors. Preoperative fragility assessment, as well as short-term and long-term outcomes, may increase patient safety. If frailty is known and time permits, it is possible to pursue interventions to reduce frailty before surgery.^[23] Interventional studies have been done on how best to do this, including Vitamin D supplementation, protein supplementation, and exercise programs; however, it remains controversial to generalize the use of different supplements to treat frailty.^[24]

In 2002, the prevalence of dementia and cognitive decline without dementia was estimated to be 13.9% and 22.3%, respectively, in those 71 years of age and over in the United States.^[25] Dementia is a known risk factor for geriatric population morbidity and mortality. With reported incidence rates of 32%—42%, postoperative delirium is a common postoperative complication.^[26] A specific problem for geriatric patients is postoperative cognitive dysfunction.^[27] Although some of the risk factors for early postoperative cognitive dysfunction are preoperative cognitive impairment, blood loss, sleep deprivation, infection, and electrolyte disruption (especially hyponatremia), the multivariate analysis identifies age alone as a single long-term risk factor for sequelae.

The limitations of the study are that the participants of the study were from a relatively smaller number of institutes from India. Anesthesiologists’ practices cannot be generalized to the entire population.

Conclusion

A comprehensive preoperative geriatric evaluation of patients must be extended beyond an organ-based or disease-based evaluation. During preoperative evaluation, the expectations and desires of the patient need to be assessed and whether the advantages and complications of surgery are consistent with those goals and intentions. There is a substantial loss of frailty, autonomy, neurological, and cognitive function in elderly patients, which needs testing during preoperative assessment. We support the inclusion in the PAC of geriatric patients of validated score systems, including frailty score, Charlson comorbidity score index, EMS, functional assessment, and mini—mental state assessment.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

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