Geriatric Surgery

Podcast Transcript

Dr. Scott Steele: Butts & Guts, a Cleveland Clinic podcast, exploring your digestive and surgical health from end to end.

Hi again everyone, and welcome to another episode of Butts & Guts. I'm your host, Scott Steele, the chair of colorectal surgery here at the Cleveland Clinic and beautiful Cleveland, Ohio. Today I'm super thrilled to have Dr. Mark Horattas, who's the chairman of the Department of Surgery at Cleveland Clinic Akron General, and Kelly Bahr, RN, who's the Geriatric Surgery Coordinator in the Department of General Surgery at Cleveland Clinic, Akron General. To the both of you, thank you so much for joining us on Butts & Guts.

Kelly Bahr, RN: Thanks for having us.

Dr. Mark Horattas: Thank you.

Dr. Scott Steele: Fantastic. Mark, we'll start with you and then Kelly over to you. For all our listeners, give us a little bit about your background. Where'd you train, where were you born and from and how did it come to the point that you're here at the Cleveland Clinic?

Dr. Mark Horattas: I trained locally at Akron General and had a longstanding career here at Akron General until we merged with the Cleveland Clinic and been in practice now for 34 years. Probably almost a geriatric surgeon myself now.

Dr. Scott Steele: Fantastic. Kelly?

Kelly Bahr, RN: I graduated in 1991 from Fairview Hospital School of Nursing. My first 10 years were at Fairview Hospital, and then I came to Akron General in 2001, and have been here since.

Dr. Scott Steele: Well, we are super excited to have the both of you with us. Today we're going to talk a little bit about geriatric surgery and how surgical care specifically evolves as we age. To start, Dr. Horattas, can you share a little more about the patients who are considered geriatric?

Dr. Mark Horattas: Generally, for the College of Surgeons in their geriatric verification program, they consider all patients over the age of 75 undergoing surgery, a geriatric surgery patient. The population is expected to double over the next 40 years from 45 million to 98 million. The geriatric population will likewise probably need increasing care for their healthcare needs including surgery.

Dr. Scott Steele: Mark, can you tell us, are all surgeons geriatric surgeons?

Dr. Mark Horattas: Probably very few are geriatric surgeons, but almost all adult surgeons are increasingly caring for geriatric surgical patients as part of their practice.

Dr. Scott Steele: Kelly let's jump over to you real quick. First of all, give us a little bit of a feel for what does a geriatric surgery coordinator do when you're evaluating these patients and what are some of the major risk factors of surgery that you look for or try to mitigate when it comes to these older patients?

Kelly Bahr, RN: When the patient gets scheduled for surgery, we're doing some vulnerability screens to see if they have any malnutrition issues, any mobility issues, any cognitive issues. We try to remediate those issues prior to surgery to make sure the patient is overall as healthy as they can be to withstand the stress of surgery. As a coordinator, we have a surgery optimization clinic where the patients come if they need to be optimized. I do follow up phone calls with those patients every couple weeks to make sure the patient is following the regimen to help get them healthier. While they're in the hospital, I continue to see them, make sure they have everything they need at discharge, and get anything ordered from the providers that may be needed while they're here to make sure they have a good outcome.

Dr. Scott Steele: Well, that's fantastic. There seems to be a lot of discussion around a person's chronological age versus their physiological age. Can either of you explain this concept and how it may impact a surgical outcome?

Dr. Mark Horattas: I think I could probably add a little bit more to what Kelly said. The impetus for moving on geriatrics was looking at some of the modifiable risk factors that we could improve a patient's chances of going through surgery without a complication or problems. Generally chronological ages alone, a patient that's 75 probably has a 10-year life expectancy and a 85-year-old, probably a five to six year life expectancy. All the patients that we're looking at, at our geriatric verification program are patients who are 75 and older or who've probably already exceeded what was an average lifespan in the United States.

These patients tend to have a high risk of other problems such as nutrition or deconditioning or preexistent anemia or other modifiable risk factors related to mental status or delirium risks. We go through a series of assessments and trying to look at each of these modifiable risk factors that a particular patient might have, and actually try to change them specifically one at a time. Adding boosts for nutritional supplementation given the patient's pedometers for deconditioning, and Kelly works with them to get to a goal of a certain number of steps. Comparatively correcting their anemia with iron supplementation. Additional focus education with their advanced directives and medical optimization. The patients are just not all the same when they become that age compared to our younger population. It's not just a chronological age, but the other things that go along with getting older.

Dr. Scott Steele: Fantastic. Little things like glasses and even hearing aids, they're often overlooked when prepping patients for surgery. Can you share a little bit more about why these items matter to geriatric patients?

Kelly Bahr, RN: I'll take this one. Our geriatric patients are more likely to develop delirium just because of the anesthesia, the stress of the surgery, the pain medications that we give them while they're in the hospital. Taking away your senses by not having your glasses or your hearing aids, can put you at much higher risk to develop delirium. As part of our geriatric surgery verification, our patients are now allowed to keep those sensory aids on them until they get put to sleep. They can wear their hearing aids to the operating room and their glasses as well, which a huge change from what we had been doing in the past where we made them leave them in their rooms.

Dr. Mark Horattas: Just to expand on what Kelly said. When you think about it, we were trying to take their glasses and their hearing aids and other personal items to protect them and lock them up when they came into the pre-surgery unit and didn't give them back to them until after they left the recovery room. What we were inadvertently doing was potentially having some of these patients be technically blind and deaf as they go through a very stressful process of going to sleep, waking up, and all the focus care that goes on with communicating with these patients. With this special program, we're able to have a special designated box, a tackle box program we called it. It has been very successful and anesthesia, the nurses, and everyone now keeps all of these sensory aids with the patients through their entire process all the way through going to sleep, waking up. It's been a tremendous help for stress reduction in educating the patients and something we didn't really think about before we started this program.

Dr. Scott Steele: Truth or myth, truth or myth, surgery for those over 75 years old should be avoided at all costs.

Dr. Mark Horattas: I think that everyone would agree that those over 75 are becoming an increasing part of our daily surgical population. A definite myth that's not just age related. I had a 90-year-old patient come in for an emergency bowel obstruction with all sorts of health problems, heart failure, pulmonary failure, on oxygen, renal failure, and the patient was anxious to consider having a surgery at two in the morning. That's definitely a myth these days.

Dr. Scott Steele: Kelly, you see a lot of these patients not only preoperatively and manage their expectations, but you also get a lot of the calls postoperatively. How does age impact that recovery time?

Kelly Bahr, RN: It all depends on how healthy they're coming in. If we get a healthy patient, we've had a couple of people in their mid-eighties who have done very well and gotten out of the hospital in a couple of days, but even some of our younger 70-ish patients, if you're coming in not healthy to start with, of course your recovery is going to be a little more complicated. The things we can do while you're in the hospital to try to optimize you and make sure you're going to have a good outcome.

Dr. Scott Steele: That's fantastic. Kelly, sticking with you outside of the medical procedure itself, there's many potential vulnerabilities that may impact patient outcomes. Can you tell a little bit more about planning for those vulnerabilities?

Kelly Bahr, RN: Yeah, so Dr. Horattas mentioned some of those things we do preoperatively. The patient is giving a pedometer, we're asking them weekly to increase their steps. By the time they come in, we have already increased their mobility from where they were prior to scheduling surgery. We're checking swallow evaluations prior to surgery to make sure there are no swallowing issues. We're making sure that there's no malnutrition involved and if there is, we try to treat it either with just giving supplements to drink before surgery or even possibly a nutrition consult. Palliative care if that's an option, we'd consult palliative care prior to surgery to make sure that avenue has been discussed. Lots of things we can do before surgery to make sure that they're coming in as healthy as they can be before surgery.

Dr. Scott Steele: A major part of recovery is oftentimes the support structure around patients. How can a family member or caregiver advocate for geriatric patients who may be considering or about to undergo surgery?

Dr. Mark Horattas: I think Kelly does a lot of this, but it's truly multifactorial. They can make sure that patients understand some of the complicated questions and answers that are being posed to them. Their family member express their personal goals of healthcare, help with the stress relief, going through a whole surgical procedure and tremendous amount of education both before and after the surgery that can be reaffirmed by the family members. I think a family member is a critical part of the whole process for these patients.

Kelly Bahr, RN: I will add to that to make sure that the family is having some advanced directive conversations, make sure their advanced directives are in place, that they have a living will, a healthcare power of attorney just in case that needs to be relied on while they're in the hospital. Families can ask for a geriatric consult prior to surgery. The geriatrician can help make sure the patient is not on any medications that are having interactions with each other to make sure there's nothing else that they need to be assessed. They can ask for physical therapy, occupational therapy, nutrition consults, or ask their physician for a consult to the surgery optimization clinic.

Dr. Scott Steele: Cleveland Clinic Akron General recently received a level one geriatric surgery verification from the American College of Surgeons. To the both of you, what are the benefits of working with the care team with this verification?

Dr. Mark Horattas: I think probably clearly has been the cultural changes that we have been able to see. This is a program that we started about four years ago, both with all of our physicians and surgeons, general surgery, orthopedic surgery, trauma surgery, our surgical intensivists, emergency room physicians, our emergency general surgery service, and then work side by side with all our support people, geriatrics, nursing, anesthesia, physical therapy, occupational therapy, speech therapy, pharmacy, QI, the palliative team. We even had two community volunteers that voluntarily worked on the whole project for lay people. Working through this whole process trying to meet these 30 standards, we changed a lot of things, how we approach caring for these patients and dealing with their special needs. It allowed us to change how all these different departments approach this specific patient population. I'd probably say that the most impressive thing is the whole team approach and the cultural changes in dealing with this special population.

Kelly Bahr, RN: Correct. The team as a whole has learned all about these geriatric vulnerabilities. Right across the street we have a children's hospital to take care of children's, but we don't have a geriatric hospital. We are focusing on the vulnerabilities that our older patients have and making sure that we do well by taking care of them with their special needs.

Dr. Scott Steele: Fantastic. Are there any advancements on the horizon when it comes to geriatric surgery?

Dr. Mark Horattas: I think some of them that we've been able to see is just improvement in preparing them for surgery with our surgical optimization clinic has been great. Some of the tools to prevent, recognize, and treat delirium have been very helpful in reducing patient falls and some of the complications. We've seen an improvement over the past two or three years with that. Redesigning some of our rooms in the facility to help with patients who might be visually impaired or have mobilization issues. Having a dedicated geriatric APP to help coordinate the special needs and care has been a great help. I think there's a lot of small things, but collectively when you put them together, they make a pretty significant impact.

Dr. Scott Steele: Fantastic. Now it's time for our quick hitters, a chance to get to know each of our experts a little bit better. First of all, to each of you, Mark, we'll start with you, what's your favorite food?

Dr. Mark Horattas: Well, I don't know if I have a favorite food, but I'm partial to Greek food being Greek. I guess I would say Greek food in general.

Dr. Scott Steele: Kelly?

Kelly Bahr, RN: I would have to say pizza even though I'm not Italian.

Dr. Scott Steele: Fantastic. Kelly right back to you, what was your first car?

Kelly Bahr, RN: A Plymouth Duster, 1976, blue with white interior.

Dr. Scott Steele: Nice. Mark?

Dr. Mark Horattas: It was an old, dilapidated Audi Fox that I had to rebuild from the ground up. Occupied a lot of my high school years fixing it.

Dr. Scott Steele: Fantastic. Mark, sticking with you, what is one of your favorite trips or a place that you'd like to go to?

Dr. Mark Horattas: Probably Florida in the wintertime. Winters in Cleveland and Akron get pretty old after January, so think everyone needs a boost of sunshine so that's my primary go-to place.

Dr. Scott Steele: Kelly?

Kelly Bahr, RN: On my bucket list, we have Alaska and Hawaii.

Dr. Scott Steele: Fantastic. Rounding out, Kelly, we'll start with you. Looking back, what did you think you were going to be when you grew up?

Kelly Bahr, RN: I started this venture in nursing when I was 16. My very first job was in a nursing home as a nurse's aide. I have no idea why I started there as a nurse's aide, but it led me to my career. I didn't have many other plans after that.

Dr. Scott Steele: Mark?

Dr. Mark Horattas: Might laugh here, but when I was in first grade, I thought being a garbage man was a pretty cool thing going through the neighborhood, picking up for everyone's stuff. I think probably from grade school on, I was pretty set on being a doctor after that, specifically a surgeon.

Dr. Scott Steele: That's fantastic. Kelly, we'll start with you and then Mark, what are as a final take home message for our listeners regarding geriatric surgery?

Kelly Bahr, RN: I would say make sure you're having family discussions about what your goals are, goals of care, what your wishes are if anything happens in the hospital and you take a turn for the worst to make sure that your family is aware of what your wishes are so that your wishes are carried out and we're not just relying on someone else making those decisions for you.

Dr. Scott Steele: Mark?

Dr. Mark Horattas: I would echo Kelly sentiments. Our older patients who may need an operation are different from our average younger surgical patients when we often are focusing only on an isolated problem that needs to be fixed. I think our geriatric surgical patients have special needs and increased perioperative risk factors, as well as their own unique personalized goals for their care. Recommend for the patients to have a candid conversation with your surgeon and care team about what a major operation may specifically mean for you and share your personal overall health goals them to help decide whether a surgical solution is truly right for you, and if so, what is the safest and best way to help you get through the process.

Dr. Scott Steele: That's fantastic. To learn more about the Akron General Geriatric Surgery Program or to schedule an appointment, please call 330.344.7874. That's 330.344.7874. You can also visit our website at akrongeneral.org/geriatricsurgery. That's akrongeneral.org/geriatricsurgery. To the both of you, thank you so much for joining us here on Butts & Guts.

Kelly Bahr, RN: Thanks for having us.

Dr. Mark Horattas: Thank you, Dr. Steele, for having us and taking the time. Much appreciated.

Dr. Scott Steele: That wraps things up here at Cleveland Clinic. Until next time, thanks for listening to Butts & Guts.