Preoperative Evaluation of the Older Surgical Patient

Abstract

Beginning in 2012, nearly 10,000 Americans will reach age 65, each day [1]. The number of older Americans is expected to increase from 35 million (12.4% of the total population) in 2000 to 71 million (19.6% of the total population) in 2030 [2]. As demonstrated in Fig. 22.1 [3], the proportion of adults who are ≥65 years of age is increasing, while the proportion of persons  <  age 55 is decreasing. In fact, individuals over age 85, dubbed the “oldest old,” are the most rapidly growing segment of the population, and their number is expected to increase fivefold to almost 19 million by the year 2050 [2].

Appendices

Appendix 22.1 Mini-Cog Screen for Dementia

Administration

1.Make sure you have the patient’s attention. Instruct the patient to listen carefully to and remember three unrelated words and then to repeat the words back to you (to be sure the patient heard them)

2.Instruct the patient to draw the face of a clock, either on a blank sheet of paper, or on a sheet with the clock circle already drawn on the page. After the patient puts the numbers on the clock face, ask him or her to draw the hands of the clock to read a specific time (1:45 or 11:10 are commonly used). These instructions can be repeated, but no additional instructions should be given. If the patient cannot complete the clock-drawing test (CDT) in 3 min or less, move on to the next step

3.Ask the patient to repeat the three previously presented words

Scoring

Give 1 point for each recalled word after the CDT distractor. Score 0–3 for recall

Give 2 points for a normal CDT, and 0 points for an abnormal CDT. The CDT is considered normal if all numbers are depicted, once each, in the correct sequence and position, and the hands readably display the requested time. Add the recall and CDT scores together to get the Mini-Cog score

0–2 positive screen for dementia

3–5 negative screen for dementia

Source: Data from [60]

Appendix 22.2 St. Louis University Mental Status (SLUMS) Examination

1.What day of the week is it?				1 point
2.What is the year?				1 point
3.What state are we in?				1 point
4.Please remember these five objects				I will ask you what they are later
Apple	Pen	Tie	House	Car
5.You have $100 and you go to the store and buy a dozen apples for $3 and a tricycle for $20
How much did you spend?				1 point
How much do you have left?				2 points
6.Please name as many animals as you can in 1 min
0–5 animals				0 points
5–10 animals				1 point
10–15 animals				2 points
15+ animals				3 points
7.What were the five objects I asked you to remember?				1 point for each one correct
8.I am going to give you a series of numbers and I would like you to give them to me backwards. For example, if I say 42, you would say 24
87				0 points
649				1 point
8,537				2 points
9.This is a clock face. Please put in the hour markers and the time at 10 min to 11 o’clock Hour markers okay Time correct				2 points 2 points
10.Please place an X in the triangle
Which of the above figures is the largest?
11.I am going to tell you a story. Please listen carefully because afterwards, I’m going to ask you some questions about it Jill was a very successful stockbroker. She made a lot of money on the stock market. She then met Jack, a devastatingly handsome man. She married him and had three children. They lived in Chicago. She then stopped work and stayed at home to bring up her children. When they were teenagers, she went back to work. She and Jack lived happily ever after
What was the female’s name? 2 points			2 points
What work did she do?			2 points
When did she go back to work?			2 points
What state did she live in?			2 points
Scoring
High school education			Less than high school education
27–30		Normal		20–30
20–27		Mild cognitive impairment		14–19
1–19		Dementia		1–14

Source: Available at http://www.medschool.slu.edu/agingsuccessfully/pdfsurveys/slumsexam_05.pdf. (See also 64)

Appendix 22.3 Michigan Alcoholism Screening Test: Geriatric Version (MAST-G)

1.After drinking have you ever noticed an increase in your heart rate or beating in your chest?	Yes	No
2.When talking with others, do you ever underestimate how much you actually drink?	Yes	No
3.Does alcohol make you sleepy so that you often fall asleep in your chair?	Yes	No
4.After a few drinks, have you sometimes not eaten or been able to skip a meal because you didn’t feel hungry?	Yes	No
5.Does having a few drinks help decrease your shakiness or tremors?	Yes	No
6.Does alcohol sometimes make it hard for you to remember parts of the day or night?	Yes	No
7.Do you have rules for yourself that you won’t drink before a certain time of the day?	Yes	No
8.Have you lost interest in hobbies or activities you used to enjoy?	Yes	No
9.When you wake up in the morning, do you ever have trouble remembering part of the night before?	Yes	No
10.Does having a drink help you sleep?	Yes	No
11.Do you hide your alcohol bottles from family members?	Yes	No
12.After a social gathering, have you ever felt embarrassed because you drank too much?	Yes	No
13.Have you ever been concerned that drinking might be harmful to your health?	Yes	No
14.Do you like to end an evening with a nightcap?	Yes	No
15.Did you find your drinking increased after someone close to you died?	Yes	No
16.In general, would you prefer to have a few drinks at home rather than go out to social events?	Yes	No
17.Are you drinking more now than in the past?	Yes	No
18.Do you usually take a drink to relax or calm your nerves?	Yes	No
19.Do you drink to take your mind off your problems?	Yes	No
20.Have you ever increased your drinking after experiencing a loss in your life?	Yes	No
21.Do you sometimes drive when you have had too much to drink?	Yes	No
22.Has a doctor or nurse ever said they were worried or concerned about your drinking?	Yes	No
23.Have you ever made rules to manage your drinking?	Yes	No
24.When you feel lonely, does having a drink help?	Yes	No

Scoring: Five or more “Yes” responses are indicative of an alcohol problem

Source: from [67]

Appendix 22.4 The Geriatric Depression Scale (Short Form)

Choose the best answer for how you felt over the past week.

Answers in bold indicate depression and receive one point. Scores greater than five suggest the presence of depression. Source: material available at http://www.chcr.brown.edu/GDS_SHORT_FORM.PDF. See also Sheik and Yesavage [70]

Appendix 22.5 Cardiac Evaluation and Care Algorithm

Reprinted from Fleischer et al. [43]. Copyright 2007, with permission from Elsevier