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May marks Older Americans Month and AMA's Senior Physicians Recognition Month. In today’s AMA Update, Rachelle E. Bernacki, MD, MS, joins to discuss surgical care and improving health outcomes for senior patients. AMA Chief Experience Officer Todd Unger hosts.
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- Rachelle E. Bernacki, MD, MS, director, Care Transformation and Postoperative Services of Brigham and Women’s Hospital Center for Geriatric Surgery
Unger: Hello and welcome to the AMA Update video and podcast series. Today we're talking about surgical care for senior patients and how it can be improved to lead to better outcomes. I'm joined by Dr. Rachelle E. Bernacki, a geriatrician at Brigham and Women's Hospital and co-director of its Center for Geriatric Surgery in Boston. I'm Todd Unger, AMA's chief experience officer in Chicago. Welcome, Dr. Bernacki. It's great to have you today.
Dr Bernacki: Thanks so much, Todd. It's great to be here. I used to live in Chicago, so it's nice to see that backdrop there.
Unger: Yeah, you can see the real thing right behind me. Dr. Bernacki, when it comes to surgery, of course, there's always some level of risk. But that risk is often higher for senior patients. Let's just talk a little bit about how much more likely they are to experience complications from surgery.
Dr Bernacki: Sure. So when you're older, you are at more risk for complications, including infections, bleeding, those types of things, as well as needing more assistance afterwards. So potentially needing to go to a skilled nursing facility or a nursing home. There's also a really great study recently by Tom Gill that was published in JAMA Surgery that looked at community-dwelling older adults over 65 and it looked at mortality rates.
And they saw that one in seven had died within a year from any elective surgery. It was much higher for emergency surgery. So about one in three patients died when they had emergency surgery. It's also more risky if you're frail. And we'll talk more about that, but one-in-four patients died if they were frail. And if they had dementia, one in three.
So as you can see, there is quite a considerable risk. And I also do palliative care, so it's helpful in helping patients and families with those risks.
Unger: I find that those are really surprising numbers. So obviously, a huge area of concern. And kind of speaking to something you just brought up, at your health system, you conduct what you call a frailty screening on senior patients who are candidates for surgery. Tell us more about that particular practice?
Dr Bernacki: Yes, so we use John Morley's FRAIL Scale. And I like it because it's an acronym and that's really easy to remember. So the F is for fatigue. So if the patient is fatigued, like they take a nap every day, I might consider them as a positive point. The R is for resistance. So can they walk up a flight of stairs? The A is for ambulation. Can they walk a block? The I is for illness. Do they have more than five illnesses? And the L is for weight loss.
So we asked all our patients those five questions. And if they screen positive on more than two or three, then they get a full frailty assessment. So we were able to teach our surgical residents to do that screening in the trauma center or in the emergency room. And then we have a geriatrician that sees those patients. We've also now built it into our preoperative screening for elective surgeries.
And so then if those patients screen positive, then they see a geriatrician and we do a full frailty assessment in the preoperative center.
Unger: What if let's say that you do that particular process and there are scores across a number of different dimensions, what are you going to do differently?
Dr Bernacki: Yeah, great question. So there's something called pre-habilitation, which is important. And those center around things that we should be doing anyways, like exercise and nutrition. So people should be getting some exercise every day. And for older adults, really walking is probably the easiest thing.
And so if you're already walking, just walking more is better. And then for nutrition, of course we want you to eat whole foods. If you have trouble chewing or swallowing, some of the supplements are good. But particularly for surgery, protein is important.
So fishes, chicken, things like that. So those are the important things pre-operatively. The other things that I look for are any sort of medications that might put them at risk, like the common ones are benzodiazepines, or Ativan, or Valium. Those are medicines that cause people to fall when you're older, as well as have confusion.
So I try to taper those medicines off. And sleeping pills as well.
Unger: I love the term pre-habilitation. I have not heard that before.
Dr Bernacki: Yeah, pre-hab is the sort of short—and then the last thing I'd say is I think surgery can be a really anxiety-provoking experience. So trying to control your mind as much as possible. So doing things like meditating or there's an app that I sometimes recommend called Headspace. So just trying to feel calm and relaxed prior to the surgery. So those are the things that I think are the most important.
The other one that I think sometimes surprises me is I always ask about alcohol use. And sometimes, when you're older, you can't metabolize alcohol as well. So even if you only have a couple of drinks for a older woman, it's important that you sort of cut back on that as those also can make you at more risk for confusion or delirium following the surgery.
Unger: Well, those are great practices in the pre-hab arena that you're talking about. Let's go to the other end of this and talk about post-op. What are some of the best practices that you've implemented at your system around that part of the recovery process?
Dr Bernacki: So the best practices around post-op recovery are about preventing delirium or confusion. And I think that can be really frightening for loved ones, family, to see their mom, dad, whatnot, having confusion and not knowing where they are. And we know we can prevent it. And the ways that we prevent it are to do things that are normal, like get out of bed to eat, to walk.
We try to walk our patients three to five times a day. We also try to let them sleep, which is sort of an interesting concept in the hospital because we often wake people up. But we have a protocol and it's called the SSTEP pathway. It's Superior Surgical Treatment for Elders Pathway. And when we are on that protocol, we don't wake them up at night. We also give them melatonin to let them sleep.
The other things that are important are ensuring that they're not in pain. So we give scheduled Tylenol four to five times a day. And we also give low-dose opioids. And we have a sort of mantra in geriatrics, which is start low and go slow. So we give low doses of pain medicines.
The other thing that can happen when you take pain medications is that you can get constipated. And so we really keep an eye on that and we start bowel regimens very early. And so that's incredibly important.
Unger: In the materials before, I saw a term. You used geriatrisizing the environment. It is kind of interesting. I mean, I think parents are obviously familiar on the younger end with making sure the home is safe for young children. But on that other end, you talk about the need to make sure the environment is working for these patients as well.
Dr Bernacki: Yeah, I think simple things like having a whiteboard with a date, what the goals of the day are, where they are. So we do a lot of frequent reorientation, which, again, prevents people from being confused. Having access to natural sunlight is really important. And then non-slip floors. So all of those things kind of contribute to older adults being able to have a more normal experience following surgery and also leave the hospital as fast as possible.
Unger: And the kind of mental health aspects that you're pointing out here, apart from like the physical recovery from surgery, which is probably very difficult for seniors at some point, what about symptoms of post-operative depression? Is that something that you see more frequently in seniors?
Dr Bernacki: Yes, so for people over 65, 15% to 50% can have depression following surgery. And we know the best numbers from coronary artery bypass, where 30% to 40% of those patients experience depression. And that actually just recently happened to a friend of mine's father. And I think the important things about that are to know and look for it so that you recognize it early because we have really good treatments for it. We have medications that are effective and safe.
And so it's important that we get the people on those medications so that they can be on their road to recovery,
Unger: I mean, those numbers seem really high to me. What moldable of someone who's not a senior are we talking about? Because that's approaching half.
Dr Bernacki: Yes. Yes, and like I said, the estimates vary between 15% and 50%. So the best studies are in bypass, bariatric surgery and then spine surgery. And we know that patients that have revision surgeries are at higher risk.
Unger: Now, we know that one thing that complicates patient care for all ages is prior authorization. And this is something we're hard at work on at the AMA as our Recovery Plan for America's Physicians. Talk to us a little bit about how prior authorization complicates surgical care for your particular practice?
Dr Bernacki: Yeah, so I work mostly inpatient. And I am extremely careful not to put patients on medications that I won't be able to get a prior authorization to. Or if I do put them on those medications, then I make sure that our pharmacist—and I'm very blessed working at the Brigham that we have a team that can work on those prior to them going home. But particular medicines, like, say, Pregabalin or Lyrica, or say, OxyContin, which are pain medications, often need prior authorizations. And we have a whole team that actually works on that.
And when you think about it, there's so many other things that I'd rather have my team working on than that.
Dr Bernacki: So, I applaud the efforts.
Unger: And speaking of our recovery plan, one of the other key pillars is about supporting telehealth. It's got obviously a lot of potential to improve care for senior patients, especially after surgery. How have you implemented or use telehealth maybe differently than before the pandemic for your patients?
Dr Bernacki: I see most of my patients pre-operatively on Zoom. And I think patients—I really like it because I can see them in their home environment. And it's also often easier for their caregivers. So whether that's a spouse or a child, it makes it easier for them and more feasible.
One of the things that's challenging about it is it often does for older adults need like a daughter to come and set up the Zoom. Some of my very spry patients can do it themselves, but not everyone can. I think the other thing that's challenging is for patients that are out-of-state, they often have to come in because of the billing rules.
And I think that's really unfair because oftentimes it's hours and taking a day off work, et cetera. But overall, I'd love to see telehealth continue to work for us and even expand over time.
Unger: Dr. Bernacki, May also happens to be Senior Physicians Recognition Month. And with physicians of all ages leaving medicine in greater numbers, it's more important than ever to recognize those that are still practicing after all these years. What unique perspective would you say that senior physicians bring to caring for senior patients?
Dr Bernacki: Yeah, so first, I'd like to say for those that are practicing, thank you, because we've been very busy since the pandemic. And I really appreciate them continuing to work. But I think they bring they're in it themselves. They have their family, friends also experiencing surgeries and the anxiety surrounding that. And I think they really bring empathy in a different way.
And I'm getting there myself eventually. So my colleague Dr. Cooper and I continue to work on the systems at our hospital because we want to get the best care for ourselves one day and to be able to retire eventually.
Unger: That sounds—that sounds terrific. Good planning ahead. Dr. Bernacki, what a pleasure to talk to you today. Thanks so much for joining us. That's it for today's update. We'll be back soon with another episode.
In the meantime, if you'd like to learn more about AMA's Recovery Plan for America's Physicians, please visit our website ama-assn.org/recovery. We'll be back soon. In the meantime, thanks for tuning in and please take care.
Disclaimer: The viewpoints expressed in this podcast are those of the participants and/or do not necessarily reflect the views and policies of the AMA.