Pre-Operative Geri Assessment: Vicky Tang and Houman Javedan

Eric 00:16

Welcome to the GeriPal Podcast. This is Eric Widera,

Alex 00:24

This is Alex Smith.

Eric 00:26

And Alex, who do we have with us today?

Alex 00:28

We are delighted to welcome Houman Javedan, who is a geriatrician and director of inpatient geriatric medicine at the Brigham and Women’s Hospital where I trained and associate program director of the Geriatric Fellowship at Harvard Medical School. Houman, welcome to the GeriPal Podcast.

Houman 00:48

Thank you. This is very exciting for me. I’ve been listening to this podcast for a while.

Alex 00:51

We love to hear that. We’re also delighted to welcome back Vicky Tang who is a geriatrician, researcher and coach. Listen to our prior podcast with Vicky about coaching and she is at the University of Texas Houston where she is the Roy M. And Phyllis Gough Huffington Chair in Gerontology. Vicky, welcome back to the GeriPal Podcast.

Vicky 01:15

Thank you.

Eric 01:17

So we’ve got a lot to talk about. We’re going to be talking about perioperative or preoperative assessment in older adults. But before we get into that topic, we always do a song request. Houman, I think you have a song request for Alex.

Houman 01:28

Yeah, there’s a song by Alex Kuba called Aura, which I mean there’s two reasons I explained I really like this song. The first phrase says I’m loyal to the life that I have chosen, which I think represents sort of the feeling a Jurition has mid career and onwards. And the second, which was interesting was Alice Kuba Houmanself said it took Houman 13 years to complete this song because he sort of learned to be present in the time and sort of appreciate that sort of geriatric wisdom about the now and not being worried about the future.

Alex 02:01

Beautiful message.

Eric 02:02

Have you been practicing the song for 13 years, Alex?

Alex 02:05

I have not, but I did record it for those of you who are listening to the audio only with my son’s Kai on ukulele and Ren on bass. And here I’m going to try it on guitar. We’ll see what happens.

Alex 02:15

(singing)

Eric 03:37

That was great, Alex.

Houman 03:38

Thank you. Wow. Well done. I’m impressed

Alex 03:39

I apologize to those of you watching on YouTube.

Eric 03:43

I kind of want to hear the ukulele version.

Alex 03:45

Yeah, it’s much better. Listen to the audio only.

Eric 03:47

Who’s playing the ute?

Alex 03:48

Kai’s playing the ukulele and I forgot to bring my ukulele to work. You forgot your notes. We’re winging it today. We are winging it.

Eric 03:55

Let me try them out again. Preoperative assessment. I got a question. And we actually got some questions from our listeners, but I think the biggest one is why do we even bother with this? Why do we do preoperative assessments? Is it just like a legal formality? We’re just saying, hey, we’ve cleared this person for surgery, or is there more going on here? Houman, I’m start off with you, your thoughts on this.

Houman 04:21

Yeah, so I guess I’ll sort of need to share that. I started life as a surgeon, right. And. And I need to share the couple of anecdotes, the sort of. I, I love geriatrics in med school. Then people said, no, you don’t want to do that. And then I really enjoyed the teamwork on surgery and being in the or, and then started life as a, you know, my basic surgical training was in Scotland, so netting, mercury and Glasgow. But it was always the older patients where I felt like people were. It didn’t, it didn’t make sense. People were missing things and people were very binary about it. In my days, it was this attitude of like, you don’t operate on anybody over 85 or you do absolutely everything and if they don’t do well, well, they were old. And I specifically remember one case where it’s. Maybe it’s, you know, was.

Was a little bit traumatizing. There was a general surgeon in Glasgow who would sort of haze his fellows by bringing in sort of terminal patients and they wouldn’t last very long. And I broke rank. I broke rank and confronted Houman and he said, well, they were old, they’re going to die anyway. So, like, what’s, you know. And something just sort of in me said, no, that’s it, I can’t do this. That’s not a good enough answer anymore. So I really sort of leaned into aging and sort of geriatric assessments for surgical patients. And 13 years later, that’s kind of my career to. Basically, the answer to your question is it’s not just a legal thing. It’s actually identifying the amount of aging and disease a patient has before you subject them to surgical insult so that you can have the best outcome. And that is the core of all of it, it’s sort of like it’s taken me 13 years to be able to come and say this in a podcast, but that is really the answer is surgeons just don’t know.

Like nobody has that training and skill. The geriatricians to, to quant, you know, to really assess the amount of aging and disease that a patient may have. So they can then decide what the surgical insult will do and if it’s appropriate, inappropriate, and how to modify it. Which is what I’m more interested in going forward is how do we do it better?

Eric 06:38

So should we do surgery or should we not? But even more like if we go ahead with the surgery, how do we actually improve their outcomes? By thinking about it beforehand.

Houman 06:46

That’s right. And there’s a lot you can do in the or there’s so many things you can do. Like there are surgeries that may be appropriate for a 50 year old, but inappropriate for the same functional outcomes in a frail like 85 year old. Like, you can get the same functional outcomes, but the actual surgery and interventions are different to get the same outcomes.

Eric 07:08

Vicky, you’ve done both outpatient preoperative assessment in older adults. You’ve done inpatient or doing inpatient preoperative assessments in older adults. How do you think about the why question? Why do you do it?

Vicky 07:21

Yeah, so I’ll actually share. What my surgical colleagues tell me is they feel very uncomfortable doing surgery on older adults and not being certain that they’re going to get the outcomes for the patient that the patient would want. Right. And so they’re not sure how to have these conversations. A lot of surgeons will, you know, are the ones that were referring to me in the pre op select group.

Eric 07:52

Of people who are referring to you?

Vicky 07:54

Yeah, they’re like, you know, I don’t think the outcomes are going to go well. I don’t really know how to assess, you know, what’s going to happen to this older adult. So I’m just going to refer to geriatrician and geriatrics will, you know, kind of suss it out. And so, and so I’m like, yeah, sure, thank you. You know, and using that opportunity to like what human was saying, you know, there’s a lot of stuff we can optimize before surgery so that we can increase the likelihood of a positive outcome in older adults, or slash and have the conversation about, you know, what’s most important to the patient and how does this surgery potentially impact that?

Does it actually fit with, you know, what the goals of the patient is and deciding, hey, Maybe surgery is not the thing to go. Maybe there’s something else to offer. So, yeah, that’s what I would say.

Eric 08:55

Maybe for our audience we can take a step back. Probably a lot of people have, you know, either done or seen kind of preoperative assessments. What’s different in older adults when we think about the preoperative cooperative assessment, human. I’ll start off.

Houman 09:10

Do you want me to go first? Yeah. So it actually kind of tags along beautifully from. Sorry, I’ve listened to a number of your podcasts, but the comprehensive. I’m going to plug it. Whoever didn’t listen to the comprehensive geriatric one, go back and listen to that one. Because the comprehensive geriatric assessment, I think, is critical to the role of elucidating the value of the knowledge base of geriatrics and geriatricians. And the key element, I think, is this.

I’ve sort of had the privilege of working with Ken around developing our frailty index, where I view it as a Trojan horse for a cga. Basically, if you can sort of come up with an algorithm for a CGA on your sort of deficit accumulation frailty, it’s a way of sort of communicating to others your CGA in a numeric manner.

Eric 09:56

And for all our listeners, CGA is comprehensive geriatric assessment.

Houman 09:59

Yes. Thank you. Sorry. To be honest, I think it’s the multi domain evaluation, which includes function, cognition, comorbidities. And then I would say that in the case of surgical assessment, what you really want to know is how much are those comorbidities actually subtracting from the physiological reserve of the patient? The ultimate answer when you finish is what is the physiological reserve of the person in front of you and how much of that reserve is determined by a disease process and how much it is determined by their unique aging and where they are in that sort of physiological journey. And once you have that, then you can look at, okay, what sort of insults can this person tolerate?

And it fits in with a lot of these notions about with frailty we have notions of resilience, which is recovering from injury, and then the robustness, which is sort of the antonym of frailty. Like, are you robust enough to tolerate? And then what you can do is choose the surgical options that are there. You can take some surgical options maybe are beyond, like, I’ll just talk about orthopedics, which I know best. So a good example is someone may need a revision surgery, or someone may just need sort of an open reduction and fixation with plates and screws, which ends up with a much less sort of surgical insult compared to a major revision, which would be you have to hammer all the hardware out, you know, re sort of align everything and hammer everything back in and cement it in place, which is a much bigger insult.

So I would say in the most simple way that is sort of what the geriatric assessment does. But I do want to say that the downstream it can’t sit on itself in isolation. I have a very close relationship with my surgeons and we both speak our language now of once you do the assessment, they tell me what the surgical sort of variety and options are and we come together to understand what’s best for the person.

Eric 12:05

So it’s not just you’re cleared for this surgery. No, the word ongoing discussion.

Houman 12:10

I know clear is a term that I talk about. Yeah. Clear is a term I recommend everybody stay away from.

Eric 12:18

Yeah.

Vicky 12:19

Though I do worry that it will end up being that way as you know. Right. Like, so right now we’ve got these surgeon partners. I mean, who, man, I’m sure the folks I refer to you are like really into it. They believe it, they buy it. But I’m sure, you know, pre op care used to be that way too until it became, you know, required in a way. And so I don’t, I’m just saying it shouldn’t be a legal thing. And it may become that way with all the kind of regulations that are happening with geriatric surgery verification program or like Medicare measure happening, you know, we’re.

Eric 12:58

Going to talk about the geriatric surgical verification program. But before we go do that, I’m just trying to put my head around the concept of this preoperative assessment. Does, does every surgery that an older adult goes through need a preoperative assessment? Like if they’re getting cataract surgery, which this is exceptionally low risk surgery, do they even need any of this or should everybody. Independent of what they go through this.

Houman 13:27

Yeah. So the answer is no. And I think when you talked about, you asked this question in the CGA podcast too, and we actually agree we have screening processes in place. So we actually have early sort of like frail screening processes. So if someone’s a robust 85 year old, to your point, but, but then no, no, they don’t, they don’t need. And it’s all about what is the insult that they’re going to withstand. So like to your point, cataract surgery, but it depends on how frail they are and what the risks are. Right. So what you need to do is you need to have that Frailty screen in place because we know that you can’t eyeball it. You’re, you know, 30% of the time. They did a study beautifully. Got to go back to the study and like, it was in 2005, where I think surgeons were right 30% of the time, which isn’t great about whether.

Eric 14:16

Or not they’re frail. Is that the question?

Houman 14:17

Yeah. And we’re actually doing a study right now, the eyeball test. We’re doing another eyeball test with video between the US And Holland. We’re in the process doing the study of giving essentially the history and a video of a patient to orthopedic surgeons and geriatricians here and in Holland and see how well they can eyeball it just. And what they anchor on.

Alex 14:38

I gotta ask, why Holland?

Houman 14:41

Because our researchers in the ortho geriatric trauma are from Holland.

Alex 14:49

It’s not that you have a hypothesis that in Holland. Oh, that is so much better at the eyeball test.

Eric 14:55

We got better eyeballs in Holland.

Houman 14:57

No, it was just. It’s also a different medical system, which I think is important to look at as well, because there is. I mean, let’s be honest, there is a pressure for people to do as much surgery as possible as well. Surgeons are under the gun to like or time is the most valuable amount of time in the system. And I think that you also had a fantastic podcast with Victor Monteri about the industrialized medical health care system, and I think this feeds into it very, very well as well, is that those pressures are particularly harmful to, I think, the aging population. Right?

Eric 15:36

Yeah.

Houman 15:36

So that’s the other part of this element is you need screens in place, you need to identify the right patients, and then you need to do the more extensive evaluations. And that’s what we’ve done in our system.

Alex 15:48

And just to make explicit, what you were just talking about in the podcast with Victor Montori is that there’s a potential. And what’s happening is beyond potential. It’s happening now. The industrialization of our system and within that industrialization, the surgical time is one of the most valuable commodities for making money for each healthcare system. So there’s a tremendous profit incentive. And we are one of the checks on that system. And we can be. And we can be agents of change.

Eric 16:18

Czechs or cogs.

Alex 16:19

Ah, we’re both. We are cogs. We can be Czechs.

Houman 16:25

We’re strong cogs, Eric. We’re strong Cox.

Eric 16:29

So real quick, so all older adults in your system, do they go to surgery? Do they get a Frailty screen.

Houman 16:36

Yeah. So on the orthopedic side, when they come to see the orthopedic surgeon, they get that quick sort of fr. We’ve sort of melded all these different tools. We just happen to use the frail screen that John Morley came up with a while ago. And primarily, it’s also primarily because it was. Trying to get another screen into a busy surgical clinic is hard. And that one was relatively easy to train everybody to do. And we also tested it in our hip fracture population, and it did a great job of separating robust from non robust, but didn’t do a great job of separating degrees like, from pre frail to model it or severely. It didn’t do a very good job of separating frailty, but it did isolate the robust patients really well.

Eric 17:21

And that’s not. The frailty screen is not should I or should I not do surgery? It’s should I or should I not do a more comprehensive geriatric assessment.

Houman 17:31

Exactly.

Eric 17:31

Get the geriatrician involved.

Houman 17:33

Exactly.

Eric 17:35

Vicky, do you do a similar thing? How do you think about the preoperative assessment in older adults?

Vicky 17:40

You know what’s so funny? I feel like human and I are both thinking, correct me if I’m wrong, but in my mind it’s like, oh, this is such a Trojan horse to do the cga. Like, this is. Exactly. And so when the Jerry fellows called me, like, hey, oh, my gosh, I have to do a. I have to start a pre op, you know, clinic, or, you know, what am I? How do I do it? I was like, look, this is all just so that you can do a geriatric assessment on the patient. And so however you want to couch it, that works for the surgeon, like, do it. So for me, what I like to do is say, like, look, these older adults, they can have their high risk of delirium. And if you do the delirium, I mean, all the things that can cause delirium, it’s essentially a cgi, Right.

So do hearing, vision, cognition. Right. Geriatric syndromes. So I do the delirium screen. I mean, that’s my delirium assessment and how to optimize potentially. And then a huge component of what I think is important to talk about is the goals of care. What’s the surgical goal here? How does that fit within the bigger picture of this person’s life?

Eric 18:53

So, like, why do you want the hip replacement? People just don’t want the intervention. They want the outcome. Maybe it’s so they can golf again, kneel down to be with their grandchildren.

Vicky 19:05

That’s exactly right.

Eric 19:06

But it’s also important to do that assessment because if before they weren’t getting out of bed at all, I’ve had.

Vicky 19:14

Patients where I’m like, hey, what are you hoping to get out of this intervention, this surgery? They’re like, oh, I want to run a marathon again. I’m like, but you were. This is not the. Even the surgery related to, you know, that that’s not going to get. So then I’m like, hey, surgeon, you know, colleague. Like, this is what they’ve told me. I think we need to have a group conversation about, you know, I mean, and the other pitch that is like, hey, you know, you’re getting knee surgery. Great. It’s not going to kill you. Let’s talk about acp. This is the perfect time.

Eric 19:46

Advanced care.

Alex 19:47

Advanced care plan.

Eric 19:48

Yeah, sorry, it’s not the American College of Physicians.

Vicky 19:50

Sorry. No, no.

Alex 19:52

So I’m hearing a lot of concepts here, and you reminded me of another that has gone unsaid. But I think I’ll say it. Comprehensive geriatric assessment is one sort of framework. I just heard advanced care planning as another sort of framework. I heard frailty, pre frailty, robust, different levels of frailty. And also what you just said about, like, what their goals are reminds me of the 4ms. Framework and the what matters most. And I wonder. That’s a lot of frameworks for people to hold onto. And I like how you’re linking them conceptually. And I also just want to make sure our listeners don’t get lost in this. In all these concepts, how do you think about the forums or do you in relationship to preoperative assessment?

Eric 20:39

Because the forums kind of makes us more accessible. Right.

Alex 20:42

I think that was the goal is like, we have all these concepts. Let’s simplify it for people. Four M’s.

Houman 20:48

Yeah. Yeah. But to be honest, I think forums is geriatrics for non geriatricians. Right. Yeah. I mean, honestly, from my perspective, the other thing I would say, and you know, I’m a little controversial, but I’ll.

Alex 20:59

Be honest with you, like, we like controversy.

Eric 21:02

Sorry.

Vicky 21:03

I love it.

Eric 21:04

This is going to be on our great talk.

Houman 21:06

Yeah. So forums is a wonderful way to try to sort of dumb it down for non geriatricians. And that’s great and I love it. And I’m all about age friendly and I’m all about bringing about the domains of sort of understanding and aging that we need to pay attention to. But I would say this, and Vicky, and maybe you can back me up on This a little bit is always when it comes to surgical. And maybe this is the surgeon side of me coming out is when it comes to going under surgery, you need a lot more granular sort of assessment because you, this is not, this is not like this. This could ruin your life if you’re not. If someone.

My point to you, it’s like saying there are times you need an MRI and there’s times you need an X ray. Right. And surgery is one of those things where you need a very granular idea of what your physiological reserve is, especially in the context of aging. And it brings me back to that sort of my early experiences as a surgeon where everybody sort of just had this, sorry, I know it’s a little bit rough, but it’s true. They had sort of a sort of mercenary approach. I grew up in a world where there were a lot of people from like, you know, they used to subscribe to these mercenary magazines and they had this slogan that said shoot them all and let God sort them out. And that approach to surgery is not correct.

Alex 22:30

Right.

Houman 22:31

That is not the way to go about it. And also, with all due respect, the Forams just doesn’t cut it. The fifth M matters. But even more than that, you need an actual person with sort of rigorous understanding of aging versus disease to know whether your blood pressure lability is due to bad blood pressure management or is it actually sort of advancing cardiovascular frailty and stiffness that is causing this lability that may or may not be clinically relevant.

Alex 23:02

Yeah, I appreciate that spirited defense of the geriatrician’s role here. Vicky, anything you want to add?

Vicky 23:08

I hear you Humen as a legit, you know, card carrying geriatrician for sure. And I also want to make sure that as many older adults can get the care that they should be getting gets it. And so even if they don’t have.

Eric 23:26

Access to a jar, even if they’re.

Alex 23:28

Seeing a nurse practitioner. Nurse assistant, family practice. Yeah, yeah.

Houman 23:33

But we, that that’s a systems issue that we can solve.

Eric 23:36

Yeah.

Houman 23:37

And we can get into like we can get into. I mean let’s be honest that that’s a financial issue.

Eric 23:42

Yeah.

Houman 23:42

More than I think a, a geriatrician issue.

Eric 23:47

That’s a separate podcast we could talk about.

Houman 23:49

I know, I warned you guys. You guys have already brought me on and I’m like building these programs so.

Eric 23:56

When we think about the four M’s you have mind. So it’s one thing just to do a brief screening test for a mini cog on somebody mind it’s another to think rationally about preoperative assessment. What does it mean to have some cog impairment? Did they have delirium in a past hospital stay? Because that’s the strongest marker whether or not they have a delirium in the next one. All of those things which is part of that real comprehensive preoperative assessment. Am I getting that right?

Houman 24:25

So, Eric, I’ll come back at you as a surgeon on that. What do I do with these four ends? Yeah, that’s the surgical. The surgical approach is give me something I can use that will tell me how I can proceed with my surgery and the management of that patient around surgery. It’s a very different mentality than the sort of. The more medical approach, where if you’re approaching a hospitalist, the 4N 5M approach may be more helpful and it’s gentle and it’s sort of more sort of. It doesn’t insult them and sort of gets them going down the rain.

But when it comes to surgery, you got to get surgical. And when they get surgical, they want to be like, dude, what do I do? Like, like, tell me what needs to be done for this person. That’s the surgical approach, and it’s very different. And the truth is, when people are that abrupt, you need the, like, you really need the strongest granular assessment to give them a very clear idea of what to do. Because if you get surgeon forums, they’re just going to, like, look at it and think of it as check and move on.

Eric 25:27

Check, check, check. Frailty assessment. Check, check.

Alex 25:30

Right. Yeah.

Eric 25:31

So then what do you do? So you do a frailty assessment. You.

Vicky 25:35

I’ll push back.

Alex 25:35

Yeah, please, please. We love. We love disagreement. We welcome.

Vicky 25:40

You know, I’m in Texas now, so, you know, I’m not sure that’s. That’s entirely true. I mean, you have protocols, right, that you can follow. It’s not necessarily a check. Right. Like, ultimately, who Men. You’re like, oh, yes, this person’s frail. This is a percentage or this is a thing. So then you can say like, hey, based on this, this is your likelihood of risk of having a bad outcome post op. So I think it’s still. While we want to make it sound, I guess my concern is like, well, we want to make. I am pro geriatrics for sure. Yes. We should all do fellowships if you want to do geriatrics, you know, so on and so forth.

But I don’t want it to be over complicated. It doesn’t need to be for most cases. And my concern is then we make it unaccessible to people. So it’s like, yeah, you do what matters most. Okay, well, if, you know, somebody says I want to, you know, be able to do a marathon again and the surgery is not going to accomplish that, then no, you’re not having surgery. We’re going to do something else. Right. If they have a high delirium risk. Okay. We’re going to have a conversation. You okay with that patient. We’re going to proceed like this is what might happen. Yes. Okay, well, we’re going to set measures in place to, you know, prevent delirium from happening or if delirium is happening, then we’re going to put in all the things that we can do to minimize bad outcomes from this patient. You know, kind of like. So I do think that with the 4Ms, yes, it’s not like very granular, but we can still have actionable items come out of that assessment.

Houman 27:27

So the problem with that from a surgical perspective is you can give the surgeon all of that and they’re going to come back with, so can I operate on them or no. And sorry, I’ll just, I need to.

Vicky 27:39

I can answer that for the most part though.

Houman 27:43

Yeah, I mean, but so, yeah, I mean, but that, what I’m saying is that’s probably what they’re looking for. Yeah, but in all fairness, as a geriatrician, for me to answer that question with sort of more certainty, I need a comprehensive geriatric assessment to get a sense of where their deficits are and whether those deficits are going to put them in at harm for the type of insult that is planned for them. I’m not, and don’t, don’t get me wrong, I’m not saying the forums are wrong and I’m not saying. And also maybe, you know, and the robust 85 year olds, like there’s certain pathways we need to put in place. Right. There’s certain things that need to happen. Like the 24 hour opiate dosing has been well known. Frank Sieber published it like years ago, but it’s not well known to everybody.

But there are other fine tuning things like the prostaglandin mechanism of free water excretion and the collecting documents may not be something people will know and they don’t realize that NSAIDs, right, NSAIDs and all these things around surgery can be a lot more harmful than you think. Toradol may not be such a safe med around surgery in older patients. And that level of detail and understanding is something that I think also gives us A little bit of credibility, like, you have skill, I have skill. And the idea is together we can take care of this person. And Eric, I actually agree with you when you said the very severely frail probably, like the reserve is so gone that probably your dosing is not going to make a difference. And your robust, probably with just a simple checklist of don’t do dumb things due to basic acing changes will work. You don’t need the whole CGA or a geriatrician involved. But it’s that middle group, it’s that sort of moderate to severely group and that sort of mild to moderate group where that’s where the geriatrician has its value.

And the idea of where do you deploy geriatricians? That’s where you deploy geriatricians. That’s where the value is. And then other people can do the rest. And by geriatricians, by the way, we are teams like geriatric MPs, geriatricians, people who are. My point is, my answer to everybody is, and especially when it comes to geriatrics, I’m like, how rigorously do you know the physiology of aging? And do you know it well enough that you can make medical decisions based on that understanding so that you can have different clinical outcomes in the person in front of you? If we ask that of a pediatrician, nobody would question that a pediatrician was appropriate for children. Imagine having doctors who know nothing about normal growth treating kids. Come on.

There’s a point where we got to draw the line and say that, listen, the knowledge base and skills of aging is required and needed. And if we can, if we can develop cath labs in every hospital over the course of five years, I think we can solve the need for training geriatricians in the country. And with virtual care, we can, we can, we can find the transition to get there. I just, I’m tired of these naysayers because I’ve done it. I’ve done it. When I went, sorry, I shouldn’t be saying this, but 13 years ago when I went into my hospital, there were no geriatricians. They didn’t even know geriatrics was a.

Alex 30:54

Specialty, right When I trained there, no geriatricians.

Houman 30:56

That’s right. There was no geriatric. They didn’t even know. Now they can’t imagine functioning without geriatricians.

Eric 31:03

I got a question. This is all, I love your passion. It makes a lot of sense to me, but do we have any data that doing these comprehensive geriatric assessments before surgery improves outcomes yes, thank you for asking, Eric.

Houman 31:20

I knew you’d be asking me. All right, so which data do you want? The first Data I did 10 years ago in my group was we showed the utility of mini cog in fracture patients. When I first did the mini cog on the inpatient side, all the geriatric. Everybody that neurologists want to kill me. Why are you doing a mini cog in the acute setting? I’m not using as a dementia screen. I’m doing it as a cognitive stress test on my patients to get an idea of what their level of cognition is.

Eric 31:45

It’s like the treadmill test you’re using.

Houman 31:47

That’s right. Just as we. I guess what we published that it’s a great test for assessing cognitive vulnerability in delirium. But we also sort of threw in there the fact that since we got a geriatrician, our mortality rates dropped to 18% and our delirium rates dropped to 10.5%. They used to be 25%, and now there is. There’s a recent study that came out of the UK which showed that if you get a geriatrician involved in trauma patients, the mortality significantly decreases in the care of those patients. Well, you did it in hip fractures, but can you do it?

Or can you do it in this hospital? Can you do it everywhere in the world? This is pretty much ortho. Geriatrics has demonstrated that you bring the concepts of geriatrics to this. The other one is, then we did elective joints, then with elective joints, what we showed. By the way, I’ve been very lucky, and this is the interesting. I’ve been very lucky because the orthopedic surgeons I work with are very clever and very resourceful. They have the resources.

Vicky 32:43

Right.

Houman 32:44

But they actually looked at, if you saw geriatrician, within 90 days of the surgery, your ED readmissions drop. And we published that, and that was with Antonia Chan. And by the way, the problem is most of this literature is in the Journal of Orthopedic Trauma. It’s in trauma. It’s an injury. It’s in all the surgical journals. So a lot of people may not be as aware, but I got to be honest, it’s just easier to get this stuff out there in the surgical journals and the resources that people have on surgery to show these outcomes are greater. So I’m in the middle of the authorship, huh?

Vicky 33:18

I was gonna say I publish all my stuff in surgery journals. It’s fine. That’s your audience, you know.

Alex 33:23

Yeah, right. That’s Your audience. Vicky, what evidence would you add for Prehab and other elements of the comprehensive geriatric?

Vicky 33:31

So I really wanna be like I’m, I love humans energy. So we recently did a systematic review with the ASA group and looking at Prehab. So I’ll talk about Prehab.

Alex 33:47

So it’s American Society of Anesthesia.

Vicky 33:49

Thank you.

Alex 33:49

Go ahead, go on, go on.

Vicky 33:50

Vicky, I was forgetting.

Houman 33:52

Yeah, yeah.

Eric 33:53

What is Prehab?

Vicky 33:55

So Prehab is essentially the idea is for elective surgical cases you can pre habilitate, which is like, kind of like rehabilitate, but before they decline and basically build up or optimize either their functional level, their cognitive level, their nutrition status so that after surgery, when they take that hit of surgery, they have more kind of reserve to I guess use up, you know. And that’s I guess what I think of when I think of Prehab. So the literature has been mixed.

Everybody’s got a different definition of Prehab. And so it’s kind of left a question as to like does it work, does it not work? And which patient population versus not. I’m always in the pro Prehab world. I think, I also think that everybody would benefit from a geriatrician. We can always find something to help and optimize. So that’s the short answer for Prehab. It’s plus, still pending a really good large study where there’s a good definition of Prehab.

Eric 35:09

And let me ask you this because it does feel like the tide is changing as far as surgeons because I feel like there is a lot of interest in things like frailty from the surgical side. Yeah, I’ve started to hear about this geriatric surgical verification kind of like this age friendly movement that we’re seeing everywhere but in surgery. Do you feel like that there is this change in the absolute.

Vicky 35:35

Yeah, absolutely. And I’m happy to speak to that. So the geriatric surgery verification program was developed with the American College of Surgeons with the support of John A. Hartford back in 2019. They started right before the pandemic. And the idea here was that hospitals that applied to be a geriatric surgery verified program would need to meet certain criteria really around pre op assessments. What we’re, we’ve been talking about making sure what matters most is asked, making sure we have function, function assessment and physical like PT assessment after surgery, before surgery, when possible.

And so now we’re up to 80 hospitals that have signed up for the Geriatric surgery Verification program nationally. And it fits very well with the CMS medical care measures and the 4Ms. As well. But their big sell is, you know, hey, we’re gonna help your hospital system meet this Medicare measure. We’re gonna help decrease the rates of delirium post op. And I think that really the most awesome part to me about it is this requirement to have goals of care discussions with patients and their family members, making sure advance care planning is done. And yeah, that’s great.

Alex 37:05

Thank you.

Eric 37:05

We’ll have a link to the geriatric surgical verification website, the great website I was looking at yesterday.

Vicky 37:14

Sorry, can I also do a quick pitch too? So ACS has nisqip, the National Surgical. I don’t remember exactly. Nsqip. Yeah. And so the folks that did gsv, they’ve put in some outcomes that older adults would be interested in. Like given, you know, all these risk factors you plug in, you know, after surgery for this type of procedure, what is your likelihood of going to a skilled nursing facility or a nursing home after?

Eric 37:45

Yeah, so they prognostic index for pre, for the pre surgical.

Vicky 37:52

Yeah. Conversation for older adults. Yeah. So that’s been really neat to see.

Eric 37:57

We’ll have a link to that on our show notes too. Uman, you were going to say something?

Houman 38:01

No, I think what I would say to people is having sort of been the first acumen center to try to implement GSV is don’t be discouraged. I mean, I think the first pass of GSV has a huge, hugely demanding sort of bar. And may I say that, you know, the only feedback, I would say it’s slightly too academic. I think that a lot of the backlash is that it makes it look like that there’s all these incredibly sort of demanding, resource intensive things that you have to do.

While in reality what it just boils down to is you need a geriatrician to know about aging and disease. And then you can use the GSV outline to sort of move the bar forward in terms of your protocols and outlines of your institution so that older patients can be assessed and risk stratified correctly with the right perioperative and post operative management so that they can have better outcomes. And GSV is done in almost exhaustive sort of, you know, I think it’s.

Vicky 39:00

There’s a mini version now. There’s a mini version.

Houman 39:05

Someone who’s actually been involved and you know, and I’m the one that’s advocating. But I would say like, I think the GSV is fantastic, but it’s exhaustive in the sense that I think people should look at it. I would say invest in the people who want to actually focus and care about older surgical patients and use GSV as an outline. And then the nice thing about it is that it gives you credit if you put the resources in place. And that’s a whole nother podcast is the finances of all of this and the industrial complex of all of this.

But having said that, Vicky, I think it’s very important to be positive that surgery is actually a space which is a revenue generating space where Trojan Geriatrics is exactly the term I use. Vicky has demonstrated its efficacy and its clinical validity. And I think we should use that in the United States as one of the ways which sort of we can lift geriatrics up in our country. I genuinely do. I feel like it’s a fantastic opportunity.

Eric 40:08

Okay, well, Alex sets up real quick. I have one last question. If you had a magic wand you can change anything that happens around the preoperative assessment for older adults or the perioperative management, what would you use that magic wand on? One thing that our listeners could think about, Vicky, go to you first.

Vicky 40:26

I feel like I’m going to use Human’s line is everybody needs to get geriatricians in their hospital doing pre op assessments today. Do I get it?

Houman 40:35

Yeah. So, Eric, I would answer that because recently I had a procedure and I guess when you come out of anesthesia very lucid. But for me, my new mission is I’ve reached a stage where I want every older patient to have access to someone with the knowledge base and skill for aging so they can get the care they deserve.

Eric 40:54

And that’s beautiful.

Houman 40:55

That’s really it.

Eric 40:56

That’s much better. Last time I had a procedure, I think I was talking about surgery in the post. The pacu. Sorry, Sushi. Sushi. That’s much deeper than my.

Alex 41:06

He was talking about sushi.

Eric 41:07

Yeah, that’s not a thing. Well, Alex, you want to finish us off?

Alex 41:11

Okay, here’s a little bit. (singing)

Eric 42:34

Vicky Human, thank you for joining us on this GeriPal Podcast.

Houman 42:38

Thank you for inviting us. This was fun.

Eric 42:41

And to all of our listeners, thank you for supporting the GeriPal Podcast.

This episode is not CME eligible.