Caring for Vulnerable Populations. An examination into emerging and effective care coordination practices for vulnerable populations through the example of Source: A Comprehensive Heart Failure Management
Editor who approved publication: As a catalyst to this review, we compared traditional risk scores eg, cardiac-focused to geriatric-specific risk measures from two older female patients seen in our preoperative clinic who were scheduled for elective, robotic-assisted hysterectomies.
Adequate screening of physiologic and cognitive reserves in older patients scheduled for surgery could identify at-risk, vulnerable elders and enable proactive perioperative management strategies eg, strength, balance, and mobility prehabilitation to reduce adverse postoperative outcomes and readmissions.
Here, we describe our initial two cases and review the stress response to surgery and the impact of advanced age on this response as well as preoperative geriatric assessments, including frailty, nutrition, physical function, cognition, and mood state tests that may better predict postoperative outcomes in older adults.
A brief overview of the literature on anesthetic techniques that may influence geriatric-related syndromes is also presented. ML An year-old woman presented to the preoperative assessment clinic PAC prior to an elective robotic total hysterectomy for biopsy-proven adenocarcinoma of the endometrium, FIGO grade 2.
She had a medical history of rheumatic heart disease, with a previous mitral valve replacement with a tissue valve, atrial fibrillation with chronic anticoagulation and pacemaker placement, and coronary artery disease.
She denied any cardiac symptoms except for mild shortness of breath on exertion. The patient was taking metoprolol, valsartan, aspirin, simvastatin, and warfarin. Her heart beat was irregularly irregular without murmurs.
Her lung sounds were clear. There was no pitting edema. Per the Revised Cardiac Risk Index RCRI for preoperative risk, the patient had one risk factor coronary artery disease with an expected risk of having a major postsurgical adverse cardiac event of 0.
Perioperatively, she was also bridged with low molecular weight heparin and unfractionated heparin. Her postoperative course was uneventful, and she was discharged on postoperative day POD 1 to home with home health services.
She returned to the gynecology clinic 1 month later for surgical follow-up and was found to be doing well without any overt complications. KM A year-old woman presented to the PAC prior to her scheduled robotic total hysterectomy for complex atypical hyperplasia of the endometrium.
Her medical history included benign essential hypertension, schizophrenia, gastroesophageal reflux disease, and irritable bowel syndrome. She was taking hydrochlorothiazide, labetalol, olanzapine, lovastatin, trazodone, lansoprazole, amlodipine, potassium chloride, and vitamin E.
She denied any cardiovascular CV symptoms. Her schizophrenia was well controlled on antipsychotic medications and, although she has received assistance from a social worker, she was independent on all her activities and instrumental activities of daily living ADLs and IADLs.
Her heart beat was regular without murmurs. Per the RCRI, the patient had no major CV risk factors and the expected risk of having a major adverse postoperative cardiac event was 0.
She underwent a robotic total hysterectomy, bilateral salpingo—oophorectomy, ureteral stent placement, and pelvic washing. The pathology later was reported as stage I adenocarcinoma grade 2.
Her immediate postoperative course was uncomplicated, and she was discharged, accompanied by her son, to her home on POD 2, without home health services. Unfortunately, on POD 32, she was admitted to the hospital after sustaining a fall in her apartment and was found to have an open tarsometatarsal fracture dislocation of her left foot.
She underwent a closed reduction and debridement, and was discharged to a skilled nursing facility. Discussion We describe the cases of two older female patients who underwent uncomplicated gynecologic—oncologic hysterectomies via robotic assistance.
While both patients were considered to have an American Society of Anesthesiologists ASA physical status of 3, per traditional cardiac risk assessment measures, the year-old patient ML was deemed to be at a higher risk than the year-old patient KM.
ML had other comorbidities that increased her Charlson comorbidity score to 6 compared to a score of 4 for KM. Even so, the length of stay LOS was 1 day longer for the younger patient and her postsurgical course was questionable.
Her high-sensitivity C reactive protein CRP was 0. Table 1 Geriatric-specific preoperative evaluation testsAbbreviations: Her frailty score was 3 and her MAT-sf score was Indeed, her history of schizophrenia and long-term use of atypical antipsychotics might have been the most compelling factor for her increased frailty and reduced mobility.
Prolonged intellectual disability ID and treatment with antipsychotics have been associated with the development of early frailty, 1 and this may be due, in part, to the metabolic symptoms, eg increased BMI, higher diastolic blood pressure, and elevated fasting glucose, that often develop following chronic treatment of ID.
Since the first scientific attempt to predict postoperative outcome, 4 multiple predictive scoring systems have been developed and validated. Since most of these variables can be obtained through the patient interview and the electronic medical records, these preoperative risk tools are very easy to use and have good accuracy in predicting perioperative complications.
However, none of these tools considers physiologic characteristics specific to elderly patients.Since the breadth of the vulnerable population is large, the committee focused its initial the patient and his/her family and caregivers at home, complement- 6 Caring for Vulnerable Populations Introduction “The moral test of a government is how it treats those who are at the dawn of life, the.
The surgical procedure was stopped, and the patient received mg of intravenous (IV) fosphenytoin. She continued to experience seizures and self-terminating runs of ventricular tachycardia. She was intubated and placed on a ventilator while receiving a neuromuscular blocker.
13% of the population of the United States, but account for one-third of inpatient FI, the more vulnerable the individual is to adverse outcomes (ie, the FI is strongly Rehabilitation of the Geriatric Surgical Patient or discharge to SNF (odds ratio, ).
The investigators defined frailty as an FI. Request PDF on ResearchGate | On Dec 1, , Jennifer Zinn and others published Surgical Patients: A Vulnerable Population. Great Neck, NY – With an aging Baby Boomer population and increasing numbers of childless and unmarried seniors, nearly one-quarter of Americans over age 65 are currently or at risk to become “elder orphans,” a vulnerable group requiring greater awareness and advocacy efforts, according to new research by a North Shore-LIJ geriatrician and palliative care physician.
Vulnerable Populations and Chronic Conditions As already noted, a key identifying characteristic of vulnerable populations is the presence of 1 or more chronic illnesses.