Tom Robinson MDGrand Rounds – Dec. 12th, 2011
Surgical Care of the Geriatric Patient –
What Every Surgeon Should Know
University of Colorado
Aging and SurgeryResearch Center
Is geriatric surgery a specialty?
General Surgery
Cardiothoracic Surgery
Orthopedic Surgery
Transplant Surgery
Surgical Oncology Neurosurgery
Plastic Surgery Urology Vascular Surgery
Pre-Operative Operation Hospital Course After Discharge Care
Proposed Competencies in Geriatric Patient Care
Pre-Operative Operation Hospital Course After Discharge Care
Proposed Competencies in Geriatric Patient Care
Atypical presentationsAssess risk - frailtyMedication managementComplex/chronic illnessCognitive disordersInformed consent
Pre-Operative Operation Hospital Course After Discharge Care
Proposed Competencies in Geriatric Patient Care for Use in Assessment for Initial and Continued Board Certification of Surgical Specialists
Atypical presentationsAssess risk - frailtyMedication managementComplex/chronic illnessCognitive disordersInformed consent
Medication managementAdvance directivesComplex chronic illness
Pre-Operative Operation Hospital Course After Discharge Care
Proposed Competencies in Geriatric Patient Care
Atypical presentationsAssess risk - frailtyMedication managementComplex/chronic illnessCognitive disordersInformed consent
Medication managementAdvance directivesComplex chronic illness
Medication managementDelirium managementTreat chronic illnessPatient safetyPalliative care / end-of-lifeTransitions of care
Bell RH et al. JACS 2011 213(5): 683.
Pre-Operative Operation Hospital Course After Discharge Care
Proposed Competencies in Geriatric Patient Care for Use in Assessment for Initial and Continued Board Certification of Surgical Specialists
Atypical presentationsAssess risk - frailtyMedication managementComplex/chronic illnessCognitive disordersInformed consent
Medication managementAdvance directivesComplex chronic illness
Medication managementDelirium managementTreat chronic illnessPatient safetyPalliative care / end-of-lifeTransitions of care
Geriatric Surgery – Matrix Management Structure
Head of the Hospital
Chief of Surgery
Head of Surgical SpecialtiesGen Surg Urology Ortho Etc.
Diagram courtesy of Dr. Ben Eiseman MD.
Geriatric Surgery – Matrix Management Structure
Head Geriatric Surgery
Geriatrician
StaffFellow
Essentials in Geriatric
Surgery
Nursing-SNF
Pharmacy
Health Econ
Research
Head of the Hospital
Chief of Surgery
Head of Surgical SpecialtiesGen Surg Urology Ortho Etc.
Diagram courtesy of Dr. Ben Eiseman MD.
Complementary Courses
Advanced Trauma Care for Nurses (ATCN) for Registered Nurses
Pre-Hospital Trauma Life Support (PHTLS) for Pre-hospital Care Providers
Trauma Evaluation and Management (TEAM) for Medical Students
A Model of Multi-Disciplinary Surgical Care
Geriatric Surgery – Matrix Management Structure
Head Geriatric Surgery
Geriatrician
StaffFellow
Essentials in Geriatric
Surgery
Nursing-SNF
Pharmacy
Health Econ
Research
Head of the Hospital
Chief of Surgery
Head of Surgical SpecialtiesGen Surg Urology Ortho Etc.
Diagram courtesy of Dr. Ben Eiseman MD.
Co-Managed Geriatric Hip Fracture Center
• Clinical outcomes– Decreased length of stay– Decreased readmission rate– Decreased complications– Decreased mortality
Kates S et al. J Ortho Trauma (2011) 25:233
Co-Managed Geriatric Hip Fracture Center
• Clinical outcomes– Decreased length of stay– Decreased readmission rate– Decreased complications– Decreased mortality
• Cost of caring for hip fractures was 66.7% of expected cost.
Kates S et al. J Ortho Trauma (2011) 25:233
Age Demographic by Surgical Specialty
National Hospital Discharge Survey 2004
Surgical Specialty Age > 65 years
Cardiovascular 51%
Thoracic 48%
Urologic 45%
Gastrointestinal 43%
Orthopedic 39%
Ophthalmologic 34%
All 35%
U.S. Population Aged 65 and Over
0
20
40
60
80
1900 1930 1960 1980 2002 2030
Population(Millions)
0
5
10
15
20
25
Percent Total
Population
Calendar Year
Geriatric Surgery – Matrix Management Structure
Head Geriatric Surgery
Geriatrician
StaffFellow
Essentials in Geriatric
Surgery
Nursing-SNF
Pharmacy
Health Econ
Research
Head of the Hospital
Chief of Surgery
Head of Surgical SpecialtiesGen Surg Urology Ortho Etc.
Diagram courtesy of Dr. Ben Eiseman MD.
Bell RH et al. JACS 2011 213(5): 683.
Pre-Operative Operation Hospital Course After Discharge Care
Proposed Competencies in Geriatric Patient Care for Use in Assessment for Initial and Continued Board Certification of Surgical Specialists
Atypical presentationsAssess risk - frailtyMedication managementComplex/chronic illnessCognitive disordersInformed consent
Medication managementAdvance directivesComplex chronic illness
Medication managementDelirium managementTreat chronic illnessPatient safetyPalliative care / end-of-lifeTransitions of care
Bell RH et al. JACS 2011 213(5): 683.
Pre-Operative Operation Hospital Course After Discharge Care
Proposed Competencies in Geriatric Patient Care for Use in Assessment for Initial and Continued Board Certification of Surgical Specialists
Atypical presentationsAssess risk - frailtyMedication managementComplex/chronic illnessCognitive disordersInformed consent
Medication managementAdvance directivesComplex chronic illness
Medication managementDelirium managementTreat chronic illnessPatient safetyPalliative care / end-of-lifeTransitions of care
Traditional pre-operative risk assessment strategy does not distinguish risk in these two individuals.
GeriatricAssessment
WalkingSpeed
FunctionalImpairment
GeriatricSyndromes
ImpairedCognition
Nutrition
ChronicDiseaseBurden
GeriatricAssessment
WalkingSpeed
FunctionalImpairment
GeriatricSyndromes
ImpairedCognition
Nutrition
ChronicDiseaseBurden
Geriatric Assessment - Function
Activities of Daily Living (ADLs)• Bathing• Dressing• Transferring• Toileting• Grooming• Feeding
Geriatric Assessment - Function
Instrumental Activities of Daily Living (IADLs)• Using the telephone• Shopping• Food preparation• Housekeeping• Doing laundry• Utilization of transportation• Ability to medicate• Ability to handle finances
GeriatricAssessment
WalkingSpeed
FunctionalImpairment
GeriatricSyndromes
ImpairedCognition
Nutrition
ChronicDiseaseBurden
Geriatric Assessment - Cognition
Mini-Cog• Three item recall - apple, table, penny
• Clock Draw - draw clock face, hands at 11:10
JAGS (2003) 51:1451.
GeriatricAssessment
WalkingSpeed
FunctionalImpairment
GeriatricSyndromes
ImpairedCognition
Nutrition
ChronicDiseaseBurden
Geriatric Assessment – Chronic Disease Burden
• Charlson Index
• Cumulative Illness Rating Scale
• Polypharmacy
• ASA Score
• Anemia of chronic disease (< 35%)
J Chron Dis (1987) 40:373.JAGS (2008) 56:1926.
GeriatricAssessment
WalkingSpeed
FunctionalImpairment
GeriatricSyndromes
ImpairedCognition
Nutrition
ChronicDiseaseBurden
GeriatricAssessment
WalkingSpeed
FunctionalImpairment
GeriatricSyndromes
ImpairedCognition
Nutrition
ChronicDiseaseBurden
Geriatric Assessment – Nutrition
• 10 lbs. weight loss in past year
• 10% weight loss in past year
• Albumin level
• Mini-Nutritional Assessment
GeriatricAssessment
WalkingSpeed
FunctionalImpairment
GeriatricSyndromes
ImpairedCognition
Nutrition
ChronicDiseaseBurden
Geriatric Assessment – Walking Speed
Timed ambulation over 15 feet
Timed ambulation over 6 meters
Timed Up-and-Go
10 feet
GeriatricAssessment
WalkingSpeed
FunctionalImpairment
GeriatricSyndromes
ImpairedCognition
Nutrition
ChronicDiseaseBurden
Geriatric Assessment – Geriatric Syndromes
A geriatric syndrome represents accumulated impairments in multiple organ systems that results in a clinical event.
• Falls
• Continence
Inouye SK et al. JAGS (2007) 55:780.
GeriatricAssessment
WalkingSpeed
FunctionalImpairment
GeriatricSyndromes
ImpairedCognition
Nutrition
ChronicDiseaseBurden
WalkingSpeed
FunctionalImpairment
GeriatricSyndromes
ImpairedCognition
Nutrition
ChronicDiseaseBurden
RiskScale
Accumulation of Geriatric “Deficits”
AVERAGE OUTCOMES
POOROUTCOMES
FunctionalImpairment
NormalGait Speed
RiskScale
Accumulation of Geriatric “Deficits”
AVERAGE OUTCOMES
POOROUTCOMES
FunctionalImpairment
NormalGait Speed
ImpairedCognition
No GeriatricSyndromes
WalkingSpeed
FunctionalImpairment
GeriatricSyndromes
ImpairedCognition
Nutrition
ChronicDiseaseBurden
Pre-OpEvaluation Operation Hospital
Course30-Day
Outcomes6-Month
Outcomes
Group Abnormal Domains
Non-Frail 0 or 1
Pre-Frail 2 or 3
Frail 4 or more
Post-Operative Complications
Pre-OpEvaluation Operation Hospital
Course30-Day
Outcomes6-Month
Outcomes
0
10
20
30
40
50
60
70
1 2 30
10
20
30
40
50
60
70
One or MoreComplications
(%)
Non-Frail Pre-Frail Frail0
10
20
30
40
50
60
70
Robinson TN, et al. Ann Surg (2009) 250:449.Robinson TN, et al. J Am Coll Surg (2011) 213:37.Robinson TN, et al. Am J Surg (2011) epub Sept 2.
Hospital Length of Stay
Pre-OpEvaluation Operation Hospital
Course30-Day
Outcomes6-Month
Outcomes
Hospital Length of Stay(days)
Robinson TN, et al. Ann Surg (2009) 250:449.Robinson TN, et al. J Am Coll Surg (2011) 213:37.Robinson TN, et al. Am J Surg (2011) epub Sept 2.
0
2
4
6
8
10
12
14
16
1 2 30
4
8
12
16
2
6
10
14
Non-Frail Pre-Frail Frail0
Thirty-Day Readmission Rate
Pre-OpEvaluation Operation Hospital
Course30-Day
Outcomes6-Month
Outcomes
30-DayReadmission
(%)
Robinson TN, et al. Ann Surg (2009) 250:449.Robinson TN, et al. J Am Coll Surg (2011) 213:37.Robinson TN, et al. Am J Surg (2011) epub Sept 2.
0
5
10
15
20
25
30
1 2 3Non-Frail Pre-Frail Frail
5
20
30
10
15
25
0
Discharge to an Institutional Care Facility
Pre-OpEvaluation Operation Hospital
Course30-Day
Outcomes6-Month
Outcomes
Dischargeto Institution
(%)
Robinson TN, et al. Ann Surg (2009) 250:449.Robinson TN, et al. J Am Coll Surg (2011) 213:37.Robinson TN, et al. Am J Surg (2011) epub Sept 2.
0
10
20
30
40
50
60
70
1 2 3Non-Frail Pre-Frail Frail
0
10
20
30
40
50
60
70
Cost of Hospitalization
Pre-OpEvaluation Operation Hospital
Course30-Day
Outcomes6-Month
Outcomes
HospitalCost
($10K)
Robinson TN, et al. Ann Surg (2009) 250:449.Robinson TN, et al. J Am Coll Surg (2011) 213:37.Robinson TN, et al. Am J Surg (2011) epub Sept 2.
0
10
20
30
40
50
60
70
80
1 2 3Non-Frail Pre-Frail Frail
20
30
40
50
60
70
10
0
80
Post-Discharge to Six-Month Healthcare Costs
Pre-OpEvaluation Operation Hospital
Course30-Day
Outcomes6-Month
Outcomes
Post-Hospital6-Month
Costs ($10K)
Robinson TN, et al. Ann Surg (2009) 250:449.Robinson TN, et al. J Am Coll Surg (2011) 213:37.Robinson TN, et al. Am J Surg (2011) epub Sept 2.
0
5
10
15
20
25
30
35
40
1 2 3Non-Frail Pre-Frail Frail
10
15
20
25
30
35
5
0
40
GeriatricAssessment
WalkingSpeed
FunctionalImpairment
GeriatricSyndromes
ImpairedCognition
Nutrition
ChronicDiseaseBurden
GeriatricAssessment
WalkingSpeed
FunctionalImpairment
GeriatricSyndromes
ImpairedCognition
Nutrition
ChronicDiseaseBurden
MoodExtrinsic MarkersExhaustionLow activity
Geriatric Assessment and Post-Op Outcomes
Function Cognition DiseaseBurden Nutrition Walking
SpeedGeriatricSyndrome
Dasgupta et al (2009)
Robinson et al (2009, ‘11)
Kristjannssonet al (2010)
Makary et al(2010)
Lee et al(2010)
Saxton et al(2011)
Geriatric Assessment and Post-Op Outcomes
Function Cognition DiseaseBurden Nutrition Walking
SpeedGeriatricSyndrome
Dasgupta et al (2009)
Robinson et al (2009, ‘11)
Kristjannssonet al (2010)
Makary et al(2010)
Lee et al(2010)
Saxton et al(2011)
Geriatric Assessment and Post-Op Outcomes
Function Cognition DiseaseBurden Nutrition Walking
SpeedGeriatricSyndrome
Dasgupta et al (2009)
Robinson et al (2009, ‘11)
Kristjannssonet al (2010)
Makary et al(2010)
Lee et al(2010)
Saxton et al(2011)
Geriatric Assessment and Post-Op Outcomes
Function Cognition DiseaseBurden Nutrition Walking
SpeedGeriatricSyndrome
Dasgupta et al (2009)
Robinson et al (2009, ‘11)
Kristjannssonet al (2010)
Makary et al(2010)
Lee et al(2010)
Saxton et al(2011)
Geriatric Assessment and Post-Op Outcomes
Function Cognition DiseaseBurden Nutrition Walking
SpeedGeriatricSyndrome
Dasgupta et al (2009)
Robinson et al (2009, ‘11)
Kristjannssonet al (2010)
Makary et al(2010)
Lee et al(2010)
Saxton et al(2011)
Geriatric Assessment and Post-Op Outcomes
Function Cognition DiseaseBurden Nutrition Walking
SpeedGeriatricSyndrome
Dasgupta et al (2009)
Robinson et al (2009, ‘11)
Kristjannssonet al (2010)
Makary et al(2010)
Lee et al(2010)
Saxton et al(2011)
Geriatric Assessment and Post-Op Outcomes
Function Cognition DiseaseBurden Nutrition Walking
SpeedGeriatricSyndrome
Dasgupta et al (2009)
Robinson et al (2009, ‘11)
Kristjannssonet al (2010)
Makary et al(2010)
Lee et al(2010)
Saxton et al(2011)
WalkingSpeed
FunctionalImpairment
GeriatricSyndromes
ImpairedCognition
Nutrition
ChronicDiseaseBurden
Bell RH et al. JACS 2011 213(5): 683.
Pre-Operative Operation Hospital Course After Discharge Care
Proposed Competencies in Geriatric Patient Care for Use in Assessment for Initial and Continued Board Certification of Surgical Specialists
Atypical presentationsAssess risk - frailtyMedication managementComplex/chronic illnessCognitive disordersInformed consent
Medication managementAdvance directivesComplex chronic illness
Medication managementDelirium managementTreat chronic illnessPatient safetyPalliative care / end-of-lifeTransitions of care
Why is delirium important?
DELIRIUM
Most common post-operative complication in the elderly.
Closely related to adverse outcomes.
Potentially preventable, and there is room to improve treatment.
What is Delirium?
Pandharipande et al. Curr Opin Crit Care (2005) 11:360.
Delirium is an acute, fluctuating change in mental status, with inattention and altered levels of consciousness.
Diagnostic Criteria for Delirium
1. Coexisting Physiologic Disturbance
2. Acute Onset
3. Disturbance of Consciousness
4. Change in Cognition
Diagnostic and Statistical Manual of MentalDisorders DSM IV - Fourth Edition (1994)
Cataract Surgery5 < 5%
Medical Ward1 15%
Vascular Operation4 36%
Hip Fracture3 40%
DVAMC SICU6 44%
DHMC Trauma ICU7 59%
Medical ICU2 72%
Incidence of Delirium
1NEJM (1999) 340(9):669.2JAGS (2006) 54:479.3JAGS (2002) 50:850
4Gen Hosp Psych (2002) 24:28.5Int Psych (2002) 14:301.6Ann Surg (2009) 249:173.
7Am J Surg (2008) 196:864.
Age and Post-Operative Delirium
0
20
40
60
80
100
50 - 59 60 - 69 70 - 79 80 - 89
Age by Decade(years)
Incidence of Delirium
(%)
Robinson TN et al. Ann Surg (2009) 249:173.
Pre-Operative Risk Factors
Impaired cognition
Functional impairment
High chronic disease burden
Older age
Low albumin
Robinson, TN et al. Ann Surg (2009) 249:173.
Multifactorial Model of Delirium
JAMA (1996) 275:852.
Predisposing Factors/Vulnerability
Precipitating Factors/Insults
Multifactorial Model of Delirium
JAMA (1996) 275:852.
High Risk
Low Risk
DELIRIUM
Predisposing Factors/Vulnerability
Precipitating Factors/Insults
Multifactorial Model of Delirium
JAMA (1996) 275:852.
High Vulnerability
Low Vulnerability
Noxious Insult
Less Noxious Insult
High Risk
Low Risk
DELIRIUM
Predisposing Factors/Vulnerability
Precipitating Factors/Insults
Multifactorial Model of Delirium
JAMA (1996) 275:852.
High Vulnerability
Low Vulnerability
Noxious Insult
Less Noxious Insult
High Risk
Low Risk
DELIRIUM
Predisposing Factors/Vulnerability
Precipitating Factors/Insults
POST-OPDELIRIUMOPERATION
Risk Factors:Older ageDementiaFunctional Impairment
Co-MorbiditiesMalnutrition
Evaluation for an Identifiable Cause:
POST-OPDELIRIUMOPERATION
Risk Factors:Older ageDementiaFunctional Impairment
Co-MorbiditiesMalnutrition
Sepsis
Hypoxemia
Hypoglycemia
Electrolyte Abnormality
Dehydration
Stroke
Medications
Treat Identifiable Cause
H&P Evaluation Mental Status Neuro Exam Substance Abuse Medications Vital Signs
Laboratory Tests CBC Glucose Electrolytes BUN / Cr UA O2 Saturation
Medical Evaluation of Delirium
Potter et al. Clin Med (2006) 6(3):303.
Evaluation for an Identifiable Cause:Electrolyte imbalanceHypoglycemiaHypoxemiaSepsisSubstance WithdrawalReview Medications
POST-OPDELIRIUMOPERATION
Risk Factors:Older ageDementiaFunctional Impairment
Co-MorbiditiesMalnutrition
Identifiable Cause:Treat Appropriately
Evaluation for an Identifiable Cause:Electrolyte imbalanceHypoglycemiaHypoxemiaSepsisSubstance WithdrawalReview Medications
POST-OPDELIRIUMOPERATION
Risk Factors:Older ageDementiaFunctional Impairment
Co-MorbiditiesMalnutrition
Evaluation for an Identifiable Cause:Electrolyte imbalanceHypoglycemiaHypoxemiaSepsisSubstance WithdrawalReview Medications
Multi-Component Treatment Plan
POST-OPDELIRIUMOPERATION
Risk Factors:Older ageDementiaFunctional Impairment
Co-MorbiditiesMalnutrition
Identifiable Cause:Treat Appropriately
Evaluation for an Identifiable Cause:Electrolyte imbalanceHypoglycemiaHypoxemiaSepsisSubstance WithdrawalReview Medications
Multi-Component Treatment Plan
Supportive Measures:
POST-OPDELIRIUMOPERATION
Risk Factors:Older ageDementiaFunctional Impairment
Co-MorbiditiesMalnutrition
Identifiable Cause:Treat Appropriately
Preventing Delirium in the Hospitalized Elderly
• HypothesisReducing the number of risk factors for delirium will prevent delirium in hospitalized elderly patients.
• Methods- 852 hospitalized medical patients
- Older than 70 years
- Compare effectiveness of reducing the riskfactors for delirium to standard of care
Inouye et al. NEJM (1999) 340(9):669.
Multi-Component Interventions To Prevent Delirium
Risk Factors Intervention
Cognitive Impairment Orientation protocol
Sleep Deprivation Sleep enhancement
Immobility Early mobilization
Visual Impairment Early vision correction
Hearing Impairment Hearing protocol
Dehydration Change BUN/Cr ratio
Inouye et al. NEJM (1999) 340(9):669.
Preventing Delirium in the Hospitalized Elderly
Inouye et al. NEJM (1999) 340(9):669.
STUDY GROUP
Intervention Usual Care p value
Incidence Delirium 9.9% 15.0% p=0.02
Total Days Delirium 105 161 p=0.02
Episodes of Delirium 62 90 p=0.03
Evaluation for an Identifiable Cause:Electrolyte imbalanceHypoglycemiaHypoxemiaSepsisSubstance WithdrawalReview Medications
Multi-Component Treatment Plan
Supportive Measures:Re-OrientationSleep EnhancementVision/Hearing ProtocolRemove Foley Medication Choices
POST-OPDELIRIUMOPERATION
Risk Factors:Older ageDementiaFunctional Impairment
Co-MorbiditiesMalnutrition
Identifiable Cause:Treat Appropriately
Screen High Risk Patients in Pre-Operative Clinic
Evaluation for an Identifiable Cause:Electrolyte imbalanceHypoglycemiaHypoxemiaSepsisSubstance WithdrawalReview Medications
Multi-Component Treatment Plan
Supportive Measures:Re-OrientationSleep EnhancementVision/Hearing ProtocolRemove Foley Medication Choices
POST-OPDELIRIUMOPERATION
Risk Factors:Older ageDementiaFunctional Impairment
Co-MorbiditiesMalnutrition
Identifiable Cause:Treat Appropriately
Screen High Risk Patients in Pre-Operative Clinic
Evaluation for an Identifiable Cause:Electrolyte imbalanceHypoglycemiaHypoxemiaSepsisSubstance WithdrawalReview Medications
Pharmacologic Treatment:
Multi-Component Treatment Plan
Supportive Measures:Re-OrientationSleep EnhancementVision/Hearing ProtocolRemove Foley Medication Choices
POST-OPDELIRIUMOPERATION
Risk Factors:Older ageDementiaFunctional Impairment
Co-MorbiditiesMalnutrition
Identifiable Cause:Treat Appropriately
Haldoperidol 2 mg q20 min(while agitation persists)
OR
Degree of Agitation
Initial Dose HaldoperidolPO, IM or IV
Mild 0.25-2mg
Moderate 2-4mg
Severe 4-8mg
Pharmacologic Treatment - ICU
Jacobi et al. Crit Care Med (2002) 30(1):119.
Pharmacologic Treatment - ICU
Maintenance Dose: 50% of total loading dose is the
maintenance dose divided every 6-8 hours daily
Continue maintenance dose for 24-48 hours before tapering
Taper: Taper maintenance dose by 20-30%
daily until off.
Pharmacologic Treatment - ICU
Haldoperidol Administration
Control Moderate Agitation2:00AM – 2mg IV2:30AM – 2mg IV3:00AM – 2mg IV3:30AM – Agitation controlled
Maintain Order 1mg TID IV or PO x 24 hrs.Keep daily dose for 24 – 48 hrs.
Taper 0.5mg PO BID for 24 hrs. then DC
General Recommendation:Haldoperidol 1-2 mg q2-4 hrs PRNMay be administered PO/IM/IV
For Elderly Patients:Haldoperidol 0.25-0.5mg q4hrs PRN
Pharmacologic Treatment - Ward
Practice Guideline for Treatment of Patients with Delirium (1999) American Psychiatric Association
Screen High Risk Patients in Pre-Operative Clinic
Evaluation for an Identifiable Cause:Electrolyte imbalanceHypoglycemiaHypoxemiaSepsisSubstance WithdrawalReview Medications
Pharmacologic Treatment:1. ICUHaldoperidol 1-2mg IVRepeat every 20 min untilresolution of agitation
Taper over several days2. Surgical WardHaldoperidol 1mg PO/IM/IVMaintenance dose 0.25-0.5mgQ4hrsTaper over several days
Multi-Component Treatment Plan
Supportive Measures:Re-OrientationSleep EnhancementVision/Hearing ProtocolRemove Foley Medication Choices
POST-OPDELIRIUMOPERATION
Risk Factors:Older ageDementiaFunctional Impairment
Co-MorbiditiesMalnutrition
Identifiable Cause:Treat Appropriately