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The University of Florida College of Medicine is accredited by the Accreditation Council for continuing medical education, ACCME to provide continuing medical education for physicians. The University of Florida College of Medicine designates this enduring material for a maximum of 0.25 AMA PRA category one credit. Physicians should claim only the credit commensurate with the extent of their participation in this activity. Welcome to UF health med EdCast with UF health Chan's hospital. I'm Melanie Cole. Joining me today is Dr. Basma Mohamed. She's an assistant professor in the department of anesthesia and the divisions of perioperative medicine and neuro anesthesia. At the University of Florida college of medicine, Dr. Mohamed practices at UF Health Shands Hospital.

Melanie Cole: Dr. Mohamed, I'm so glad you could join us today to highlight Perioperative optimization of the elderly spine surgery patient. So can you start by discussing unique aspects of orthopedic care in elderly patients? What makes this group of patients unique for this type of practice? Some of the issues that surround them when they are experiencing spinal issues?

Basma Mohamed: Hello. Yeah. Thank you so much for inviting me to this podcast. So we have noticed over the last years that the population's aging and more and more patients are presenting to the spine surgeons with more symptomatic spine disease. What's really interesting is that the spine surgeon is always coming to the anesthesiologist and asking, well, this patient's elderly and high risk will be able to offer surgery without having a lot of complications. Afterwards, what we noticed that is very unique about this population is the fact that not just the list of comorbidities that they're experiencing, many of them have a list.

Medical problems that they need care for, but also what was not noticed from the anesthesia and also preoperative care standpoint, how functional they are, how much nutrition they take, how much social support they have. And from a psychological standpoint, many of them experiencing anxiety and depression. And on top of all of that, the cognitive status that they have, this might go unnoticed as well. And from the spine pathology itself, you have experienced a lot of pain issues. Over the years. And by the time you are surgical candidates, you're really suffering so much from pain.

So as a result of this, I think a preoperative evaluation that focuses only on medical optimization is not enough for that population. And that's why we decided to group together and just look at literature and look at this patient population, how unique they are and offer them different options for different aspects that I've talked about.

Melanie Cole: That's so interesting, and it really is. An exciting time to be in this field because of this aging population. Now, Dr. Mohamed, it's interesting for perioperative in that it involves that entire timeframe from pre two post surgery. And you just mentioned how pre is just really not enough, but before we get into the elements that define these periods, can you discuss what ties them all together? The unifying goal of the perioperative optimization of the elderly patients.

Basma Mohamed: So the goal is first to make sure that we optimize every aspect that I've talked about. In addition to the medical comorbid optimization. At the same time, we need to provide the adequate evidence based clinical care during the surgery, and also after the surgery to expedite the recovery and hopefully discharge them home and not really needing any skilled nursing facility or anything like that.

Melanie Cole: So tell us about a comprehensive preoperative evaluation what's involved in that. And what are some of those quality of life considerations you mentioned before when you're considering the treatments for these patients?

Basma Mohamed: Great. So currently at UF Health Shands Hospital, when the spine surgeons decided the patient is high risk, and also they will benefit from having spine surgery. They refer them specifically to the anesthesia preoperative clinic in a form of anesthesia consult. During that consult, we pay so much attention to their medical comorbidities, but we also assess the functional status using a six minute walk test and afer assessment test. We also like to evaluate their nutritional status using preen as a lab test. We do preoperative cognitive screening.

And we have a wonderful group of neuropsychologists who dig deep in that population and evaluate them through extensive neuropsychology testing to predict their risk of delirium. Afterwards, in addition, they also offer psychological evaluation and in some situations they were able to tell us if this patient has an undiagnosed anxiety or undiagnosed depression that will need further optimization before we proceed with surgery. We also evaluate the level of social support and we provide them with a patient education material that can help them through the entire preoperative continuum.

Melanie Cole: Can you expand just a little bit? And you mentioned the frailty assessment and the importance, the methods that we're seeing in the literature today, what do they say about that?

Basma Mohamed: Surprisingly frailty assessment has been extensively studied in the general surgery population, but if you look at the PubMed recently in the last couple years, there's a huge number of studies and thematic reviews that have focused so much on feral in that population, fine surgery population. Every study category, they will focus on patients that are really either high risk from a medical standpoint or from a surgical standpoint. The focus really on fertility is it's mainly, it's an age related kind of decline in the patient physiological function to the point that they really become vulnerable to stressors.

So at this time there are so many, I mean, there are between 11 to 28 different frailty assessment tools that have been tested, validated, and modified based on the clinical feasibility and applicability in a clinical setting. However, the main focus on frailty is the combin. Impact of multiple comorbidities and the function status of the patient. I can explain a little bit more by explaining that, for example, at our institution, what we do with through assessments that we assess their ability to being physically active, their walking speed, the self-re exhaustion whether they lost weight over the last six months or not.

And then we finally, we test their weakness or the strength of their hand grip. These are five different elements that focus so much on one domain, which is the functional status. And it gives you an idea about overall how functional they're gonna be now and how functional they're gonna be afterwards. And for frail patients, we offer some opportunities for optimization, which I can talk about a little bit later.

Melanie Cole: Well, that's what I would like to talk about is those opportunities for optimization. And one of the words we hear now much more often is pre rehabilitation. So for frail elder patients in preperation of spine surgery. How is this improving clinical outcomes? How does it benefit the patients speak if IRO is involved and how this type of program really assesses and prepares older adults prior to surgery?

Basma Mohamed: Yes. So, we have a unique collaboration with the physical therapy group at our institution. So back in 2017, we decided to gather and look at the literature of the general surgery population and see what really was done so far in the frail elderly population. They help us design a prehab rehabilitation program where it's focusing on the core strengths in addition to some ideas for aerobic exercise. But the whole idea is core strength for that population. So they can prevent any kind of postoperative complications, which I'm gonna elaborate a little bit more.

So those patients are really are frail, so they fail the frailty test and we get them up and get them walking for six minutes. And if they read below 50% predicted of their six minute walk test. Then we send it to prehab. They get evaluated one time by our physical therapist and they design a program that is really progressive over a period of eight to 12 weeks. I have to tell you, we have some success stories where patients, when they came back, their frailty score was really lower and the six minute walk test could go from like single digit to like 90 plus percent predicted, which is very, very helpful to understand that prehab could be really a potential benefit for those patients.

At this time during once they get optimized through prehab and through all the other elements that I mentioned earlier when they get scheduled for surgery, we follow an enhanced recovery after surgery protocol for the entire surgical encounter. So intraop, we focus on optimizing fluid intake, optimizing P manage. If the patient needs blood transfusion, we focus on patient blood management protocols if needed. And then afterwards, which is a key element postoperative phase. We focus so much on early ambulation participation, physical therapy, early nutrition. And then we found out that at least there was a decrease of one or one and a half day in the hospital length of stay. And the increased instance of ICU stay in those patient.

Melanie Cole: While we're thinking about prehabilitation. What do you feel? Dr. Mohamed is important to note about discharge planning for patients undergoing orthopedic and spine procedures. What's important to note as far as geriatricians and other providers, where they fit into this continuum. What's involved in this geriatric co-management? Rehab social support, you've mentioned a couple of times, as well as ongoing adjuvant therapy. How do you weave all of these elements together? Because that's really what gives us the best outcomes.

Basma Mohamed: Absolutely. I think coordination of care with different champions in different cases of care is very essential. Many times, especially for patients that don't live or don't pro get their care within the UF Health Shands Hospital. We try to communicate with their primary care physician to give them a heads up. Hey, by the way I'm referring this patient for prehab, it goes for prehab is this is, and that this patient's undergoing such and such surgery expect post care to be such and such. We predict that this patient will require rehab facility afterwards or being discharged home or any of these things that we try to predict for them.

But at the same time we are trying to improve our own hands on care for postoperative care for those patients. But as you can imagine for anesthesiologist, I have such a good grip on the preoperative and intraoperative phase. And then for postoperative concerns, I communicate all the time with the spine surgeons without any.

Melanie Cole: Well, I think that communication is really so important. As you said, give us your final thoughts for other providers on the perioperative optimization of the elderly spine surgery patient, and what. You would really want them to know when they're trying to build these types of programs.

Basma Mohamed: Great. Yeah, there are tons of resources currently online. There was a very nice recent article that I can eventually maybe send you a link to that. But what I would highly recommend is that the fact that caring for the elderly population in the form of only optimizing their medical comorbidities is not enough. We need to have a way of standardizing. Regular primary care in a way that identifying fairly early identifying cognitive impairment really early and trying to optimize them from a primary care standpoint. So by the time they come to us, you don't have to wait for surgery for like three months or so, because. By the time the patient gets referred to surgery, they took a lot of time from primary care to pain interventions.

And then finally coming to us for the surgeon to tell them, no, you cannot have surgery until you get prehab. That's really difficult. I really wanna emphasize the fact that up until now, prehab is not really considered as a standard of care to pre-op optimized patients, but that's what we're aiming for. We're trying to track and do research on those patients where in a way that we need to prove that prehab can improve them or can help optimize their post-operative outcomes. And hopefully we can change the guidelines and the recommendations to include it as part of the recommendations.

Melanie Cole: Well, thank you so much. And I hope you'll come on and join us again and update us as things work around and improve. And thank you so much for joining us again, to refer your patient or to listen to more podcasts from our experts. Please visit UFhealth.org/medmatters. That concludes this episode of UF Health Med EdCast with UF Health Shands Hospital. I'm Melanie Cole. Thanks so much for joining us today.