1 Assessing the Aging Patient
Due to current demographic developments, more older adults will seek care for spine related diseases. This chapter emphasizes key geriatric concepts and approaches that will better equip spine health providers to deliver optimal care to this population. These approaches keep the patient’s goals of care at the center, reduce complications of therapy yet can be delivered efficiently. First, epidemiological data and pathophysiological models are reviewed and an overview of geriatric syndromes is presented. Next, the structured geriatric assessment is highlighted as a way to systematically evaluate an older adult, and examples are given on how to perform such an assessment. Lastly, evidence-based examples of perioperative management of geriatric syndromes and society guidelines on the topic are discussed to emphasize the merits of endorsing and applying such an approach.
The expanding demographic of older adults will lead to greater numbers of persons seeking care for spine disease and related conditions.
Seniors may have different care preferences and goals of care that revolve more around function than longevity.
Age-related changes in physiology lead to greater vulnerabilities and chances for decompensation in health and functioning.
Geriatric syndromes may have multiple precipitating or causative factors and require management with multifaceted interventions.
A structured systematic geriatric assessment targeted toward medically complex or frail older persons is an effective tool for addressing unrecognized risks and health issues that can influence perioperative outcomes.
Geriatric care is best delivered by interdisciplinary teams.
According to the United Nation’s 2017 World Population Aging report, the number of adults aged 60 and older more than doubled from 1980 to 2017. The current number of 962 million adults in this age group is expected to grow to 2.1 billion in 2050. By 2050 there will be more older adults than those aged 10 to 24. These demographic changes are most pronounced in Europe and North America but are now also being observed in the rest of the world. 1 An aging population has many socioeconomic, political and health care implications. For example, as people get older, the number of patients with degenerative musculoskeletal disorders increases, including degenerative spine disease. 2 , 3 , 4 , 5 Additionally, the prevalence of persons 65 and older with injurious falls, osteoporosis, and resulting fractures rises. 6 , 7 It is important to note that with increased longevity, a person’s expectations on quality of life can change. In Europe and North America, adults may focus more on “aging well” rather than “aging as long as possible.” An integral part of the quality of life of older adults is to be pain free, mobile, and able to live independently. 8 Consequently, it is anticipated that older persons seeking care for spine diseases to maintain or improve their quality of life will significantly increase. As such, the knowledge of how to assess, counsel, and treat geriatric patients will become vital to health care providers treating spine disorders.
Geriatric patients are more than “old” adults. There is a great variation in biological and physical function among older adults. Therefore, chronological age cannot be used to estimate how well older individuals function from a biological, physical, or psychosocial perspective. A 75-year-old individual might still run marathons, work 60 hours a week or play in an orchestra. On the other hand, he or she might live in a nursing home and require help with relatively simple tasks such as using the phone, cooking meals or even cleaning themselves. Additionally, variations in organ system function within the same individual often exist. For example, an older adult might develop heart failure, diabetes mellitus, and depression but not suffer from osteoarthritis or dementia, while another might have renal insufficiency, skin cancer, and dementia.
Accepting this marked increase in the number and heterogeneity of older individuals seeking care for their spinal disease, it is vital for health care providers to take into account the overall health (biological, physical, cognitive, and psychological), support network, and goals of care of each particular aging individual when developing a treatment plan. This chapter aims to: a) summarize current aging epidemiology and knowledge of physiologic changes of aging, b) describe critical geriatric syndromes that might be particularly important for caring for patients with spine disease, and c) introduce the concept of the structured geriatric assessment.
1.2 Changes of Aging
A foundational understanding of the biology and physiology of aging is necessary to assess, counsel and adequately treat aging patients with spine disease. This chapter highlights a few important concepts regarding the physiology of aging. Foremost, it is critical to recognize that not all individuals age in the same manner. This leads to a diversity of biologic, physical, and cognitive function across older persons. These aging factors may lead to the loss of physiological buffer or homeostatic reserve that can in turn lead to earlier presentations of disease or more rapid deterioration in health status or function when stressors emerge. In an outstanding review of the hallmarks of aging, Lopez-Otin and colleagues 9 proposed a framework that groups nine aging factors into three categories. These three categories are: causes of damage (e.g., genomic instability), response to damage (e.g., mitochondrial dysfunction), and the integration of these two processes (e.g., altered intracellular communication). Clinically, this is observed as a phenotype (presentation) that is the result of a complex and variable combination of causes and responses to damage that manifests differently in various cell systems, tissues, and organs. This aging phenotype can be grouped into four different categories: body composition, energetics, homeostatic regulation and neurodegeneration. These domains of the aging phenotype are helpful because they can be assessed and quantified clinically (Fig. 1‑1 , Table 1‑1). 10
In sum, the pattern of biological changes described through the hallmarks of aging and the resultant aging phenotype in a particular individual lead to a susceptibility for certain common age-related conditions, termed geriatric syndromes. This entire picture ultimately explains why there is so much variability in biological, physical, and cognitive function in older adults and why chronological age cannot be used to quantify the overall health of a geriatric patient. Instead, the comprehensive geriatric assessment was developed to systematically assess the domains of the aging phenotype, presence of geriatric syndromes, and level of frailty.
1.3 Geriatric Syndromes and Problems
When familiarizing oneself with geriatric health issues, it is important to understand the concept of geriatric syndromes. Although the term is somewhat vague, there are key aspects on which experts agree. In contrast to diseases that are common in geriatric patients (for example, cancer, diabetes mellitus, or heart disease), geriatric syndromes are not pathophysiologically linked to one organ or organ system. Rather, they have multifactorial etiologies. 11 Often in frail individuals, an insult to one organ system (for example, an orthopedic surgery of the hip), leads to multiple intermediate changes in other domains (e.g., increased adrenergic tone, fluid shifts, pain, and new medications) that leads to a deficit in an altogether different organ system (e.g., the development of delirium). As such, the clinically presenting symptom (in our example of delirium it could be confusion, agitation or apathy) is not as easily traced back to one inciting event that caused the symptom to develop. It is difficult to solve this puzzle by applying a “one cause and one outcome” mindset because of the multifactorial character of geriatric syndromes. The health provider has to look for interactions of multiple factors. Our surgical patient might have had a prior trauma, received psychotropic medication such as opioids, and/or have comorbidities such as dementia that all contribute to or even cause delirium independently.
1.4 Fundamental Geriatric Syndromes
Fundamental geriatric syndromes are grouped into “The Body” (frailty, sarcopenia, cachexia, falls), “The Mind” (cognitive impairment, delirium, depression) and “Others” (polypharmacy, support network) in order to aid conceptualization of this multifactorial framework.
1.4.1 The Body
Frailty– Its Components and Outcomes
Frailty is one of the most global and ubiquitous, yet difficult to characterize, geriatric syndromes. Frailty is defined as multiple incremental factors that lead to loss of functional reserve to respond to internal and external stressors that results in difficulty regaining homeostasis after a physiological or medical challenge. Frailty is associated with an increased risk for adverse health outcomes such as disability, falls, delirium, morbidity, and mortality. 12 , 13 , 14 , 15 A common external stressor is a surgical intervention. 13 It is important to identify frail older adults prior to surgery to reduce the risk of postoperative complications such as delirium, delayed wound healing, and loss of ability to perform activities of daily living or live independently. 14 , 16 , 17 , 18 Optimizing the health of such an individual prior to surgery can reduce the risk of postoperative complications, and being aware of nonmodifiable risk factors will help to risk-stratify the surgery and put measures in place to recognize and treat complications as early as possible. 14
Frailty is often considered the most important geriatric syndrome, as it underlies and contributes to many other geriatric syndromes such as delirium, falls, and incontinence. There are two common approaches to classify and diagnose frailty: a phenotype model which hypothesizes that frailty is based on distinct features (the phenotype) and a cumulative deficit model which proposes that frailty is based on the accumulation of a number of abnormal health conditions. There is no consensus as to which approach should be used, particularly clinically. 15 Regardless of the ongoing scientific debate, many clinicians have incorporated the assessment of frailty using the phenotype definition, often because it is easier to do in a busy practice. Text box 1 shows this frailty definition proposed by Linda Fried. 19
Reviewing these five criteria one can easily see that body composition (weight loss) and muscle function (weakness and walking speed) are key components of frailty according to this definition. As such, cachexia and sarcopenia often coexist and contribute to frailty but can also exist on their own. (Fig. 1‑2)
Fried Index (or Cardiovascular Health Study Index).
Positive for frailty with ≥ 3 positive
Weight loss (≥ 5% of body weight in the last year)
Exhaustion (positive response to questions regarding effort required for activity)
Weakness (decreased grip strength)
Slow walking speed (> 6 to 7 s to walk 15 feet)
Decreased physical activity (Kcals/week: males expending < 383 Kcals and females < 270 Kcal)
Sarcopenia and Cachexia
Sarcopenia is the age-related loss of muscle mass. Most definitions include a measure of muscle mass (appendicular lean mass) and a measure of physical function (gait speed), muscle function (grip strength) or both. 20 Cachexia is defined as the inflammation-associated weight loss seen in many chronic illnesses such as malignancy, chronic kidney disease, congestive heart failure, COPD or rheumatoid arthritis. Some authors also suggest an idiopathic, senile form of cachexia. Usually the loss of muscle mass is larger than the loss of fat mass. Due to the overlap in definitions, it should be no surprise that sarcopenia and cachexia are also associated with the adverse health outcomes of frailty. 21 , 22 It should be noted, however, that physical function and muscle function tests by themselves predict health outcomes such as falls, fractures, and mortality. As a matter of fact, studies have suggested that muscle function is a better predictor of health outcomes than appendicular lean mass. 23 , 24 , 25 , 26
Falls and fractures in older adults often lead to injuries of the spine and skeletal system, so they are of particular relevance to spine providers. Approximately one-third of adults above 65 years of age fall once a year or more. This number significantly increases in older age groups, with the percentage increasing to over 50% in adults older than 90 years. Sixty to 70% of older adults who fall will fall again in the next 12 months. Ten to 20% of falls lead to an injury, with approximately 5% of these being a fracture. But even falls without significant injuries can lead to decrease in quality of life and loss of independence, with 70% of fallers developing a fear of falling that can result in a decrease in mobility and increased social isolation. 24 , 27 As seen in Table 1‑2, the risk factors with the highest relative risk are linked to the musculoskeletal system. Additional risk factors involve vision, cognition, and the cardiovascular system. The table also reinforces that falls fit the paradigm of a geriatric syndrome, given their multifactorial nature. 24 This is important because the management of falls requires a multidisciplinary approach that can be best coordinated by a health provider with geriatric experience. (Table 1‑2)
1.4.2 The Mind
Depression is common in the general population and increases further in older adults. Prevalence for current depression in many studies ranges between 5 and 15%, with prevalence of lifetime depression being significantly higher. A subclinical depression, whereby only some but not all of the criterion for major depression are met, is two to three times more frequent in older adults. It is important to note that the rate of suicidality is higher in older age groups compared to younger age groups and higher in men compared to females. 28 , 29 , 30 Geriatric patients may also present with a different constellation of symptoms, with more somatic and less psychological features than other populations. Specifically, there may be more complaints of pain, neurocognitive difficulties, or sleep disturbance and less endorsement of guilt, worthlessness and hopelessness. 29 A commonly used tool to assess depression in older adults is the Geriatric Depression Scale (GDS), which consists of 15 questions. A score of five or above suggests mild or moderate depression, whereas a score of 10 or higher suggests a major depression. It is important to recognize depression in older adults, not only because of the significant rate of suicide but also because it is associated with poorer surgical results, postoperative complications, and decreased ability to participate in rehabilitation. 31 , 32
Delirium is one of the most common postsurgical complications, especially in individuals with coexisting dementia, depression, or polypharmacy. It has a substantial financial and individual cost, with longer hospitalizations, more hospital acquired complications, greater institutionalization rates postdischarge, and higher 30-day mortality rates. 31 It is characterized by problems with attention and typically one or more additional neurocognitive difficulties (such as memory, orientation, sensory perception, or language) which waxes and wanes. 33 , 34 , 35 Most providers taking care of older adults have encountered agitated, disoriented patients with delirium, but there are equal numbers of individuals with hypoactive delirium that may go unrecognized yet have equally negative outcomes. Where a hyperactive delirious patient will be recognized quickly, patients with hypoactive delirium might suffer significantly longer before it is diagnosed. 34 A tool to diagnose delirium is the Confusion Assessment Method (CAM). 34 , 35 This screening instrument is also available for patients who are unable to communicate verbally, for example because they are ventilated in the Intensive Care Unit (CAM-ICU). 35 As with falls (or any other geriatric syndrome), finding the underlying causes of delirium and developing a treatment plan requires a multidisciplinary approach often lead by a provider with geriatric experience. 36
Dementia is another cognitive disorder that influences an older adult’s ability to function in their environment and interact with others. As the U.S. population is aging and safer surgical and anesthetic approaches are developed, older and more debilitated patients are now undergoing spine surgery, including those with dementia. Management of perioperative status and comorbid conditions is more challenging in the presence of dementia, due to the often-limited capability of the patient to communicate or adhere to treatment recommendations. There are established associations between a preoperative diagnosis of dementia and increased rate of discharge to a facility as well as length of stay, though not with case fatality. 37 Dementia is defined as a cognitive impairment that persists, involves at least two cognitive domains (decline in memory being a prominent one), and is a decline from previous cognitive abilities. The cognitive impairment must be severe enough to result in difficulties or inabilities to manage one’s daily activities independently. If the cognitive impairment is present but does not limit daily function the individual is classified as mild cognitive impairment (MCI). 38 , 39 , 40 , 41 Before the diagnosis of dementia can be made, other causes which can lead to similar symptoms need to be excluded, important examples of which are depression and delirium. Several types of dementia exist which have different pathophysiological causes and present with different clinical features (i.e., different cognitive domains being affected) and different time lines. Alzheimer’s dementia is the most common type of dementia, with vascular, frontotemporal, and Lewy body dementia being other common types. 38 , 39 , 40 , 41 Several screening tools for dementia exist. They vary in length of time to complete and sensitivity/specificity; also, not all are freely available. Two commonly used, free and validated tools are the St. Louis University Mental Status (SLUMS) and the Mini-Cog. 42 , 43 Ultimately, the provider assessing for dementia should use the tool she/he is most comfortable with and is broadly used in the health system the provider is working. Identifying individuals with dementia has the same importance as other geriatric syndromes such as frailty or depression, because dementia also increases the risk for postoperative delirium and falls and can result in more frequent rehospitalization and longer hospital stays. 44 , 45 As outlined above, it is fairly straightforward to screen an individual for dementia, but it is a lot more time intensive and requires experience to make the diagnosis of dementia. As such, a positive dementia screen should lead to a referral to a provider who has this experience.
The presence of multiple concurrent health issues, termed multimorbidity, leads to polypharmacy. Older patients with many geriatric syndromes and other diseases often take more than five prescription medications, which is often the number suggested to be classified as polypharmacy. To some, this might be a surprisingly low number, considering that many patients take more than 10 or even 20 medications. Polypharmacy is associated with health problems such as gastrointestinal bleeding, hypotension, and liver and renal disease, but also several geriatric syndromes such as falls and delirium. 46 , 47 This can quickly turn into a vicious cycle in which the treatment of certain diseases and syndromes results in creation of new ones or worsening of already existing ones through side effects of medication. This increased morbidity causes decreased quality of life, more frequent and longer hospitalizations, hospital readmissions, and an increase in mortality. Certain medication groups such as anticholinergic drugs and psychotropic medications cause a particularly high risk for adverse events. 46 , 48
Managing polypharmacy requires both the discontinuation of certain potentially inappropriate medications (PIMS), termed deprescribing, and ensuring that age-relevant medications are used. Several tools and approaches exist to address polypharmacy, including the American Geriatric Society’s Beers criteria or the START/STOPP tool. 49 , 50 , 51 , 52 Again, the decision to remove PIMS is best accomplished by engaging a multidisciplinary geriatric team (particularly a pharmacist).
Even after addressing and optimizing the many aforementioned health factors, the older adult may still have residual physical and psychological deficits. In such cases, the patient’s social support network, access to home resources and care management serves as key determinants for the success or failure of that individual to safely return home and live independently. As such, it is essential for the spine provider to know how much help the cared-for patient has available. 53 , 54 , 55 The postdischarge care plan (e.g., medication administration, wound care, physical therapy) and care coordination (attending clinic appointments, etc.) will only be successful if the geriatric patient has the necessary support to follow these recommendations. However, many older adults are socially isolated and do not have a primary social support network anymore. 56 In such cases, the support cannot be provided through the patient’s own social network. Evaluating and optimizing the social support network is often accomplished through comprehensive discharge planning and transitions of care programs, or as part of a comprehensive geriatric assessment during inpatient or outpatient visits. 57 , 58 , 59 , 60 , 61 , 62 , 63 , 64 , 65 , 66 , 67 , 68
1.5 Structured Geriatric Assessment
A geriatric patient will present with his or her own aging phenotype and resulting geriatric diseases, syndromes, and concurrent psychosocial and psychological complexity. It is easy to miss important issues if a systematic approach is not employed in the patient’s evaluation. The comprehensive geriatric assessment (CGA) was developed as a structured method with adequate time dedicated by an interdisciplinary team to properly define and examine the presence and severity of these health issues. Special emphasis is placed on addressing common age-associated illnesses, function, and patient care preferences. A number of controlled trials demonstrate the value of preoperative comprehensive geriatric assessment in reducing complications and improving postoperative outcomes in older patients undergoing elective surgery. 60 However, it is unrealistic to expect that a comprehensive geriatric assessment can be performed in a busy spine clinic. Rather, it will be important to build a network within one’s own health system that engages geriatric specialists and other health care disciplines such as social work, nursing, pharmacy, and rehabilitation therapists to accomplish this task. This information ideally should be easily available in a structured format in the electronic health record.
It might not, however, be possible to create such a system quickly or to easily access a geriatrics care team, so the spine provider and team should understand the core elements of such an assessment. Ultimately, the spine provider should get a general idea of the patient’s functional status, mobility, and level of independence. A basic screen for cognitive impairment and depression and the quality of the patient’s social support network can predict the capacity for the patient to adhere to the postoperative care plan. 60 , 61 Having this information will make it much easier to be able to estimate whether a certain intervention has the potential to improve the particular patient’s mobility, independence, and quality of life, whether the patient can understand the risks and benefits of such an intervention and consent to it themselves, how high the risk of potential complications are, and how well and quickly the patient will recover from the intervention.
There are many publications and guidelines on how to perform a geriatric assessment and which factors should be included. 59 , 61 , 62 , 63 , 64 , 65 , 66 , 67 , 68 In practice, it is helpful to focus on a few very common and clinically important geriatric problems. To start, determine the patient’s degree of independence. There are several validated tools to assess Activities of Daily Living (ADLs) and Instrumental Activities of Daily Living (IADLs). Some examples of ADLs and IADLs are listed in Table 1‑3. This information gives a broad overview of how a patient is functioning and how much assistance he or she needs. Several factors, including geriatric syndromes and diseases will impact ADLs and IADLs.
As mentioned above, there are many algorithms describing how to perform a comprehensive geriatric assessment and systematically assess the presence and severity of geriatric syndromes. Several common approaches warrant brief description. The first one, the MAGIC (M anageable Geriatric Assessment) approach, has been developed for primary care providers. It includes nine factors that were chosen out of a larger set. 66 , 67 A German guideline committee added five additional points that also are relevant to health providers taking care of older adults with spine problems. 69 All 14 are listed in Table 1‑3 The table also lists reasons why addressing this problem might improve care during a spine health encounter.
Even addressing these 14 points will take some time, likely 10 to 30 minutes depending on the patient. As such, a provider might choose only to address a few in the encounter or have the patient go through these with the clinical team prior to the encounter. Ideally, this information is already available in the medical record, and the presence of geriatric syndromes is flagged and easily accessed by every provider. To structure and speed up the assessment, John Morley and colleagues developed the Saint Louis University Rapid Geriatric Assessment that focuses on frailty, sarcopenia, anorexia, cognition, constipation, incontinence, and advanced directives. Their approach provides simple screening tools and helpful mnemonics to identify older individuals at risk and potential causes of anorexia and cognitive impairment. 62 Regardless of how the information becomes available to the provider, it should then be used to tailor intervention to the particular patient in a patient-centered care fashion. This means identifying syndromes that may require preoperative intervention, such as nutrition or preoperative physical therapy. Or it could mean identifying problems that need to be organized postoperatively, such as a skilled nursing facility, home health, or planned assistance of family members for recovery. This could include asking the patient to bring glasses and hearing aids to clinic visits and/or potential hospital stays, and asking family members to be present at important appointments to help with understanding and decision-making. Furthermore, it may emphasize strategies to ensure good nutritional intake and appropriate rehabilitation interventions or to flag the patient as a high fall risk during a hospital stay or ensure regular checks for pressure ulcers if the patient is incontinent. A geriatric or internal medicine consult service could be engaged at the onset of the admission to minimize the risk of delirium, change potentially harmful medication, and help manage problems such as depression and pain. These targeted interventions can lead to better outcomes, less complications, shorter hospital stays, and better patient satisfaction, with many reviews and guidelines providing guidance regarding how to best implement them. 36 , 60 , 61 , 68 , 70