Where are we in perioperative medicine for older surgical patients? A UK survey of geriatric medicine delivered services in surgery

Perioperative geriatrics: A bibliometric analysis of the top 100 cited articles in an emerging specialty

BACKGROUND

The success of modern medicine has led to surgery being performed on an increasingly older, frailer and more comorbid population. As a result, perioperative geriatrics has emerged as an important specialty, relevant to both medical and surgical disciplines. Only a small number of papers have been published on the topic. A bibliometric analysis is used to identify themes and trends in current research and practice.

OBJECTIVES

To identify and describe research topics relating to perioperative geriatrics; to find themes and gaps in the current literature.

METHODS

Thompson Reuters Web of Science indexing database was searched for all manuscripts relating to perioperative geriatrics. Of these, the top 100 were subcategorised into manuscript type, age, theme, specialty, journal and citation rate.

RESULTS

The highest cited article was by Bhandari et al with 294 citations. The highest citation rate was achieved by Partridge et al, with 23.75 citations/year. Across the series, the mean number of citations was 50.41 (range 294-12). The highest number of manuscripts were published between 2010 and 2019 (n = 55), with 70% of manuscripts published in journals with impact factor <5. The specialty with the highest number of publications was orthopaedics (n = 36). Most articles focussed on surgical management of geriatrics patients, followed by anaesthetic management.

CONCLUSION

This is the first bibliometric analysis of the top 100 most cited papers in perioperative geriatrics. Only 395 papers were returned, indicating that this needs to be further researched as a topic. Key themes identified were surgical management of hip fractures and anaesthetic preoperative assessment. Emerging themes from this study highlight the need for perioperative publications in the fields of geriatric vascular, general, plastic and gynaecology.

Assessing and managing frailty in emergency laparotomy: a WSES position paper

Many countries are facing an aging population. As people live longer, surgeons face the prospect of operating on increasingly older patients. Traditional teaching is that with older age, these patients face an increased risk of mortality and morbidity, even to a level deemed too prohibitive for surgery. However, this is not always true. An active 90-year-old patient can be much fitter than an overweight, sedentary 65-year-old patient with comorbidities. Recent literature shows that frailty-an age-related cumulative decline in multiple physiological systems, is therefore a better predictor of mortality and morbidity than chronological age alone. Despite recognition of frailty as an important tool in identifying vulnerable surgical patients, many surgeons still shun objective tools. The aim of this position paper was to perform a review of the existing literature and to provide recommendations on emergency laparotomy and in frail patients. This position paper was reviewed by an international expert panel composed of 37 experts who were asked to critically revise the manuscript and position statements. The position paper was conducted according to the WSES methodology. We shall present the derived statements upon which a consensus was reached, specifying the quality of the supporting evidence and suggesting future research directions.

Geriatric care for surgical patients: results and reflections from a cross-sectional survey in acute Belgian hospitals

PURPOSE

To explore geriatric care for surgical patients in Belgian hospitals and geriatricians' reflections on current practice.

METHODS

A web-based survey was developed based on literature review and local expertise, and was pretested with 4 participants. In June 2021, the 27-question survey was sent to 91 heads of geriatrics departments. Descriptive statistics and thematic analysis were performed.

RESULTS

Fifty-four surveys were completed, corresponding to a response rate of 59%. Preoperative geriatric risk screening is performed in 25 hospitals and systematically followed by geriatric assessment in 17 hospitals. During the perioperative hospitalisation, 91% of geriatric teams provide non-medical and 82% provide medical advice. To a lesser extent, they provide geriatric protocols, geriatric education and training, and attend multidisciplinary team meetings. Overall, time allocation of geriatric teams goes mainly to postoperative evaluations and interventions, rather than to preoperative assessment and care planning. Most surgical patients are hospitalised on surgical wards, with reactive (73%) or proactive (46%) geriatric consultation. In 36 hospitals, surgical patients are also admitted on geriatric wards, predominantly orthopaedic/trauma, abdominal and vascular surgery. Ninety-eight per cent of geriatricians feel that more geriatric input for surgical patients is needed. The most common reported barriers to further implement geriatric-surgical services are shortage of geriatricians and geriatric nurses, and unadjusted legislation and financing.

CONCLUSION

Geriatric care for surgical patients in Belgian hospitals is mainly reactive, although geriatricians favour more proactive services. The main opportunities and challenges for improvement are to resolve staff shortages in the geriatric work field and to update legislation and financing.

Perceptions and practices surrounding the perioperative management of frail emergency surgery patients: a WSES-endorsed cross-sectional qualitative survey

BACKGROUND

Frailty is associated with poor post-operative outcomes in emergency surgical patients. Shared multidisciplinary models have been developed to provide a holistic, reactive model of care to improve outcomes for older people living with frailty. We aimed to describe current perioperative practices, and surgeons' awareness and perception of perioperative frailty management, and barriers to its implementation.

METHODS

A qualitative cross-sectional survey was sent via the World Society of Emergency Surgery e-letter to their members. Responses were analysed using descriptive statistics and reported by themes: risk scoring systems, frailty awareness and assessment and barriers to implementation.

RESULT

Of 168/1000 respondents, 38% were aware of the terms "Perioperative medicine for older people undergoing surgery" (POPS) and Comprehensive Geriatric Assessment (CGA). 66.6% of respondents assessed perioperative risk, with 45.2% using the American Society of Anaesthesiologists Physical Status Classification System (ASA-PS). 77.8% of respondents mostly agreed or agreed with the statement that they routinely conducted medical comorbidity management, and pain and falls risk assessment during emergency surgical admissions. Although 98.2% of respondents agreed that frailty was important, only 2.4% performed CGA and 1.2% used a specific frailty screening tool. Clinical frailty score was the most commonly used tool by those who did. Screening was usually conducted by surgical trainees. Key barriers included a lack of knowledge about frailty assessment, a lack of clarity on who should be responsible for frailty screening, and a lack of trained staff.

CONCLUSIONS

Our study highlights the ubiquitous lack of awareness regarding frailty assessment and the POPS model of care. More training and clear guidelines on frailty scoring, alongside support by multidisciplinary teams, may reduce the burden on surgical trainees, potentially improving rates of appropriate frailty assessment and management of the frailty syndrome in emergency surgical patients.

Change in healthcare utilisation after surgical treatment: observational study of routinely collected patient data from primary and secondary care

BACKGROUND

Most patients fully recover after surgery. However, high-risk patients may experience an increased burden of medical disease.

METHODS

We performed a prospectively planned analysis of linked routine primary and secondary care data describing adult patients undergoing non-obstetric surgery at four hospitals in East London between January 2012 and January 2017. We categorised patients by 90-day mortality risk using logistic regression modelling. We calculated healthcare contact days per patient year during the 2 yr before and after surgery, and express change using rate ratios (RaR) with 95% confidence intervals.

RESULTS

We included 70 021 patients, aged (mean [standard deviation, sd]) 49.8 (19) yr, with 1238 deaths within 2 yr after surgery (1.8%). Most procedures were elective (51 693, 74.0%), and 20 441 patients (29.1%) were in the most deprived national quintile for social deprivation. Elective patients had 12.7 healthcare contact days per patient year before surgery, increasing to 15.5 days in the 2 yr after surgery (RaR, 1.22 [1.21-1.22]), and those at high-risk of 90-day mortality (11% of population accounting for 80% of all deaths) had the largest increase (37.0 days per patient year before vs 60.8 days after surgery; RaR, 1.64 [1.63-1.65]). Emergency patients had greater increases in healthcare burden (13.8 days per patient year before vs 24.8 days after surgery; RaR, 1.8 [1.8-1.8]), particularly in high-risk patients (28% of patients accounting for 80% of all deaths by day 90), with 21.6 days per patient year before vs 49.2 days after surgery; RaR, 2.28 [2.26-2.29].

DISCUSSION

High-risk patients who survive the immediate perioperative period experience large and persistent increases in healthcare utilisation in the years after surgery. The full implications of this require further study.

New horizons in the perioperative care of older adults

Older adults undergoing surgery have high perioperative morbidity and mortality. Age-related physiological changes and prevalence of geriatric syndromes such as frailty increase the risk of adverse postoperative outcomes. Geriatricians utilise comprehensive geriatric assessment (CGA) and management to identify and manage geriatric syndromes, and deliver patient-centred perioperative care. Perioperative models of CGA are established for older patients undergoing hip fracture surgery. Recent trials support the benefits of perioperative models of CGA for non-orthopaedic surgery, and have influenced current care recommendations for older surgical patients. Areas for further action include addressing the implementation gap between recommended evidence-based perioperative care and routine perioperative care, evaluating the clinical and cost-effectiveness of perioperative models of CGA for patients living with frailty, and embedding routine use of patient-reported outcome measures to inform quality improvement.

Utility and reliability of the Clinical Frailty Scale in patients scheduled for major vascular surgery: a prospective, observational, multicentre observer-blinded study

Background

Frailty is a distinctive health state associated with a loss of physiological reserve that results in higher rates of perioperative complications and impaired return to pre-morbid functional status. It is prevalent in the vascular population; however routine assessment is not common despite national guidance to the contrary. We aimed to evaluate the reliability of the Clinical Frailty Scale in assessing frailty in the surgical vascular population.

Methods

In this prospective, observational, observer-blinded study, we compared assessment of frailty in patients scheduled for major vascular surgery attending the pre-operative assessment clinic using the Clinical Frailty Scale against the Edmonton Frailty Scale.

The study investigator completed the Edmonton Frailty Scale assessment; this was compared to the Clinical Frailty Scale assessments performed by the pre-assessment consultant and pre-assessment nurse, who were blinded to the Edmonton Frailty Scale score. The inter-rater reliability of the Clinical Frailty Scale between the pre-assessment consultant and pre-assessment nurse was determined by comparing their frailty scores for each patient.

Results

Ninety-seven patients were included in the analysis (median age 72 years, 84% male and 16% female). There was a moderate level of agreement between the Edmonton and Clinical Frailty Scale score for both consultants (87.6% agreement) and pre-assessment nurses (87.6% agreement). There was a substantial level of agreement between consultants and pre-assessment nurses for the Clinical Frailty Scale (89.7% agreement)

Conclusions

The Clinical Frailty Scale is a useful tool to assess frailty in the vascular surgical population. It is more practical than the Edmonton Frailty Scale: quick to complete, requires minimal training and can be used when physical disability is present.

Trial registration

The study was approved by the Wales Health and Care Research Ethics Service (REC reference 17/WA/0160, IRAS 201173). Trial registration: NCT03403673. Registered 19 January 2018, https://clinicaltrials.gov/ct2/show/NCT03403673

Frailty and emergency abdominal surgery: A systematic review and meta-analysis

INTRODUCTION

Patients aged ≥65 years currently account for approximately 55% of all emergent operations. However, these patients account for 75% of post-operative mortality. Older age has long been associated with adverse outcomes from emergency surgery. However, old age is a heterogenous state. Recent studies have indicated that frailty may more accurately reflect true biological age and perioperative risk than chronological age alone in patients undergoing elective surgery. Few studies have evaluated the impact of frailty on post-operative outcomes in this setting.

METHODS

A systematic, electronic search for relevant publications was performed in November 2019 using Pubmed and Embase from 2009 to 2019. The latest search for articles was performed on February 16th, 2020. Articles were excluded if frailty was not measured using a frailty tool, or if patients did not undergo emergency general surgery (EGS).

RESULTS

The prevalence of frailty amongst patients undergoing emergency abdominal surgery was 30.8%. The all-cause mortality rate was 15.68%. The mortality rate amongst the frail undergoing EGS was 24.7%. Frailty was associated with an increased mortality rate compared with the non-frail (odds ratio (OR) 4.3, 95% CI 2.25-8.19%, p < 0.05, I² = 80%).

CONCLUSIONS

There is strong evidence to suggest that frailty in the older population predicts post-operative mortality, complications, prolonged length of stay and the loss of independence. Collaborative working with medicine for the elderly physicians to target modifiable aspects of the frailty syndrome in the perioperative pathway may improve outcomes. Frailty scoring should be integrated into acute surgical assessment practice to aid decision-making and development of novel postoperative strategies.

Establishing a perioperative medicine for older people undergoing surgery service for general surgical patients at a district general hospital

INTRODUCTION

There is growing recognition of the need for perioperative medicine services for older surgical patients. Comprehensive geriatric assessment and optimisation methodology has been successfully used to improve perioperative outcomes at tertiary centres. This paper describes translation of an established model of geriatrician-led perioperative care to a district general hospital (DGH) setting.

METHODS

A mixed methods quality improvement programme was used and included stakeholder co-design, identification of core components, definition of mechanisms for change, and measurement of impact through qualitative and quantitative approaches.

RESULTS

Within 18 months, a substantive perioperative service for older people was established at a DGH, funded by the surgical directorate. Key outcomes included reduction in length of stay and 30-day readmission and positive staff and patient experience.

DISCUSSION

This study is in keeping with improvement science literature demonstrating the importance of a mixed-methods approach in translating an evidenced-based intervention into another setting, maintaining fidelity and replicating results.

Sustainability and Well-being in Geriatrics: proposing a performance-based approach for the implementation of geriatric care activities

The evaluation and measurement of Sustainable Development and Well-being represent a widespread emerging theme in healthcare, especially concerning, among others, the concepts of social equity and universality of health from an intergenerational perspective. To achieve such goals, Geriatrics would play a prominent role, especially considering the growing portion of the senior population in developed countries. This work intends to explore the possibility to connect Sustainable Development Goals and dimensions of Well-being to a set of performance indicators which are representative of geriatric activities in different settings of care. To this purpose, a pattern of indicators from Emilia- Romagna Region (RER) in Italy is considered. Furthermore, a range of Transitional Care interventions is discussed and proposed in order to ameliorate (or keep stable) the performance.

Geriatrician perspectives on perioperative care: a qualitative study

Background

Perioperative medicine services for older surgical patients are being developed across several countries. This qualitative study aims to explore geriatricians’ perspectives on challenges and opportunities for developing and delivering integrated geriatrics perioperative medicine services.

Methods

A qualitative phenomenological semi-structured interview design. All geriatric medicine departments in acute public hospitals across Australia and New Zealand (n = 81) were approached. Interviews were conducted with 38 geriatricians. Data were analysed thematically using a framework approach.

Results

Geriatricians identified several system level barriers to developing geriatrics perioperative medicine services. These included lack of funding for staffing, encroaching on existing consultative services, and competing clinical priorities. The key barrier at the healthcare professional level was the current lack of clarity of roles within the perioperative care team. Key facilitators were perceived unmet patient needs, existing support for geriatrician involvement from surgical and anaesthetic colleagues, and the unique skills geriatricians can bring to perioperative care. Despite reporting barriers, geriatricians are contemplating and implementing integrated proactive perioperative medicine services. Geriatricians identified a need to support other specialties gain clinical experience in geriatric medicine and called for pragmatic research to inform service development.

Conclusions

Geriatricians perceive several challenges at the system and healthcare professional levels that are impacting current development of geriatrics perioperative medicine services. Yet their strong belief that patient needs can be met with their specialty skills and their high regard for team-based care, has created opportunities to implement innovative multidisciplinary models of care for older surgical patients. The barriers and evidence gaps highlighted in this study may be addressed by qualitative and implementation science research. Future work in this area may include application of patient-reported measures and qualitative research with patients to inform patient-centred perioperative care.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12877-021-02019-x.

Protocol for evaluation of perioperative risk in patients aged over 75 years: Aged Patient Perioperative Longitudinal Evaluation-Multidisciplinary Trial (APPLE-MDT study)

Background

With the extended life expectancy of the Chinese population and improvements in surgery and anesthesia techniques, the number of aged patients undergoing surgery has been increasing annually. However, safety, effectiveness, and quality of life of aged patients undergoing surgery are facing major challenges. In order to standardize the perioperative assessment and procedures, we have developed a perioperative evaluation and auxiliary decision-making system named “Aged Patient Perioperative Longitudinal Evaluation–Multidisciplinary Trial (APPLE-MDT)”.

Methods

We will conduct a perioperative risk evaluation and targeted intervention, with follow-ups at 1, 3, and 6 months after surgery. The primary objective of the study is to evaluate the effectiveness of the “Aged Patient Perioperative Longitudinal Evaluation-Multiple Disciplinary Trial Path” (hereinafter referred to as the APPLE-MDT path) in surgical decision-making for aged patients (≥75 years) undergoing elective surgery under non-local anesthesia in the operating room. The secondary objectives of the study are to evaluate the postoperative outcome and health economics of the APPLE-MDT path applied to the surgical decision-making of aged patients (≥75 years) undergoing elective surgery under non-local anesthesia and to optimize intervention strategies for aged patients undergoing surgery to reduce the occurrence of postoperative complications and improve the quality of life after surgery.

Discussion

It is necessary to formulate a reliable, effective, and concise evaluation tool, which can effectively predict the perioperative complications and mortality of aged patients, support targeted intervention strategies, and allow for a more comprehensive risk and benefit analysis, thereby forming an effective senile perioperative surgery management path. It is expected that the implementation of this protocol can reduce the occurrence of postoperative complications, improve the postoperative quality of life, shorten hospital stay, reduce hospitalization expenses, reduce social burden, and allow the elderly to have a good quality of life after surgery.

Trial registration

ChiCTR, ChiCTR1800020363, Registered 15 December 2018.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12877-020-01956-3.

A key role for comprehensive geriatric assessment in aortic valve replacement

As our population ages, the demand for surgical services in older people is increasing exponentially. Shown to be indispensable in the care of medical patients, use of the comprehensive geriatric assessment (CGA) is also growing in the perioperative setting. We present the case of a previously independent 82-year-old man who underwent a standard preoperative assessment and surgical aortic valve replacement. In the 7 months that followed, prior to his death, he suffered a rapid functional decline contributed to by slow postoperative recovery, delirium and recurrent falls. Post-mortem revealed cardiac amyloid deposition and extensive small vessel disease in the brain. This case highlights the importance of the CGA in the perioperative management of older patients, especially in identification and optimisation of geriatric syndromes and consideration of less-invasive alternative treatments. We review the existing literature on CGA use in cardiothoracic and vascular surgical settings, drawing on experiences learnt from the above case.

The Efficacy of Opioid-Free General Anesthesia in the Management of Hip Surgeries in Elderly Patients

Introduction

Perioperative management of elderly patients differ from young patients due to physiologic and pharmacologic differences related to aging. Moreover, assessment for perioperative parameters and risks between age-matched elderly patients should be discerned while planning for the anaesthesia regimen. The latter could consist of opioid-free general anaesthesia (OFA) or non-opioid-free general anaesthesia (NOFA). Among the parameters for assessing the regimen’s efficacy, time to extubate and pain control should be included. However, it is not yet established whether OFA could replace NOFA as a standard regimen for management of hip fracture. Therefore, the aim of this study is to evaluate the efficacy of OFA for hip surgeries in elderly patients.

Methods

This is a retrospective study consisting of patients undergoing hip surgeries under opioid-free or opioid-induced general anaesthesia. Two groups were defined: Group 1 consisting of treated patients using OFA and Group 2 consisting of treated patients using NOFA. Patient demographics (age, sex, and weight), mean time to extubate and mean dose of morphine after recovery were computed. Postoperative morphine use was assessed for up to 24 hours. Comparison of the computed data was conducted between both groups. Mean postoperative morphine use was compared using the Mann-Whitney U-test. The remainder of the means were compared using independent t-test. Qualitative data were compared using Fisher’s exact test. Level of significance was set at p<0.05.

Results

A total of 73 patients were included. Group 1 consisted of 37 patients (12 were males with mean age 77±14 years) who underwent hip fracture procedure whereas Group 2 consisted of 36 patients (18 were males with mean age 73±17). There were significant differences when comparing sex, weight, and time to extubate (6.8±3 and 10±5 minutes in Groups 1 and 2, respectively; p<0.05). There were six patients in Group 1 and 17 patients in Group 2 that required postoperative morphine administration. Mann-Whitney U comparison of postoperative morphine use yielded significant differences (4.8±3 and 14.65±13 mg in Groups 1 and 2, respectively; p=0.001).

Discussion

This is the first study that assessed the efficacy of OFA compared to NOFA in the management of hip fractures. Non-significant differences in age might suggest that both groups are age matched. In addition, significant differences in time to extubate might help in reducing impact on ventilation, maintaining safe anaesthesia while minimizing intraoperative work overflow. Patients in Group 1 required less morphine in the postoperative setting than in Group 2. This might be explained by the sensation of paraesthesia which might have been confused with pain.

Conclusions

OFA could be considered in hip management in elderly patients; femoral and lateral cutaneous block seemed to act as morphine sparing in operative and postoperative settings by providing significantly less time to extubate with less postoperative morphine requirement.

Older patients undergoing emergency laparotomy: observations from the National Emergency Laparotomy Audit (NELA) years 1-4

BACKGROUND

older patients aged ≥65 years constitute the majority of the National Emergency Laparotomy Audit (NELA) population. To better understand this group and inform future service changes, this paper aims to describe patient characteristics, outcomes and process measures across age cohorts and temporally in the 4-year period (2014-2017) since NELA was established.

METHODS

patient-level data were populated from the NELA data set years 1-4 and linked with Office of National Statistics mortality data. Descriptive data were compared between groups delineated by age, NELA year and geriatrician review. Primary outcomes were 30- and 90-day mortality, length of stay (LOS) and discharge to care-home accommodation.

RESULTS

in total, 93,415 NELA patients were included in the analysis. The median age was 67 years. Patients aged ≥65 years had higher 30-day (15.3 versus 4.9%, P < 0.001) and 90-day mortality (20.4 versus 7.2%, P < 0.001) rates, longer LOS (median 15.2 versus 11.3 days, P < 0.001) and greater likelihood of discharge to care-home accommodation compared with younger patients (6.7 versus 1.9%, P < 0.001). Mortality rate reduction over time was greater in older compared with younger patients. The proportion of older NELA patients seen by a geriatrician post-operatively increased over years 1-4 (8.5 to 16.5%, P < 0.001). Post-operative geriatrician review was associated with reduced mortality (30-day odds ratio [OR] 0.38, confidence interval [CI] 0.35-0.42, P < 0.001; 90-day OR 0.6, CI 0.56-0.65, P < 0.001).

CONCLUSIONS

older NELA patients have poorer post-operative outcomes. The greatest reduction in mortality rates over time were observed in the oldest cohorts. This may be due to several interventions including increased perioperative geriatrician input.

Perioperative care of older persons: where are we?

not available.

A two-step surgery and a multidisciplinary approach in a centenarian patient with an acute presentation of right colon cancer

Background

As surgery remains the cornerstone of colorectal cancer (CRC) treatment, the number of older patients presented for colorectal resection is rapidly increasing. Nevertheless, the choice to operate an oldest-old patient still remain challenging and requires a careful assessment of risk to benefit ratio in order to guarantee appropriate surgical strategies and perioperative management.

Case presentation

A centenarian patient, acutely admitted to the emergency department, was diagnosed with an ileus caused by stenosing ascending colon cancer with abnormal distension of the right colon at high risk of perforation. Facing with this complex clinical scenario, a lateral decompressive cecostomy as alternative surgical procedure, was performed in local anesthesia in order to avoid the stressful event of an emergency surgery. Thereafter, the patient was admitted to the surgical ward and followed by a geriatrician who performed a comprehensive geriatric assessment (CGA) and daily clinical evaluations. This integrated plan of care was mainly focused on rehabilitation, nutritional interventions and therapeutic reconciliation, maximizing patient’s clinical conditions and performance status. Then, the second surgical step, the radical colon surgery with curative intent and bowel continuity reestablishment was performed, demonstrating to be feasible and safety also in a very advanced age patient in term of prolonged survival and preservation of an adequate quality of life.

Conclusions

This is the first case-report that illustrates a successful two step surgery for CRC in a centenarian patient thanks to a multidisciplinary based approach, overwhelming the mere concept of chronological age.

[Cross-speciality geriatrics: A health-care challenge for the 21st century]

Increasing numbers of older persons are being treated by specialties other than Geriatric Medicine. Specialists turn to Geriatric Teams when they need to accurately stratify their patients' risk and prognosis, predict the potential impact of their, often, invasive interventions, optimise their clinical status, and contribute to discharge planning. Oncology and Haematology, Cardiology, General Surgery, and other surgical departments are examples where such collaborative working is already established, to a varying extent. The use of the term "Cross-speciality Geriatrics" is suggested when geriatric care is provided in clinical areas traditionally outside the reach of Geriatric Teams. The core principles of Geriatric Medicine (comprehensive geriatric assessment, patient-centred multidisciplinary targeted interventions, and input at point-of-care) are adapted to the specifics of each specialty and applied to frail older patients in order to deliver a holistic assessment/treatment, better patient/carer experience, and improved clinical outcomes. Using Comprehensive Geriatric Assessment methodology and Frailty scoring in such patients provides invaluable prognostic information, helps in decision making, and enables personalised treatment strategies. There is evidence that such an approach improves the efficiency of health care systems and patient outcomes. This article includes a review of these concepts, describes existing models of care, presents the most commonly used clinical tools, and offers examples of excellence in this new era of geriatric care. In an ever ageing population it is likely that teams will be asked to provide Cross-specialty Geriatrics across different Health Care systems. The fundamentals for its implementation are in place, but further evidence is required to guide future development and consolidation, making it one of the most important challenges for Geriatrics in the coming years.

A review of surgical and peri-operative factors to consider in emergency laparotomy care

Patients undergoing emergency laparotomy are a heterogeneous group with regard to comorbidity, pre-operative physiological state and surgical pathology. There are many factors to consider in the peri-operative period for these patients. Surgical duration should be as short as possible for adequate completion of the procedure. This is of particular importance in the elderly and comorbid population. To date, there are limited data addressing the role of damage control surgery in emergency general surgery. Dual consultant-led care in all stages of emergency laparotomy care is increasing, with increased presence out of hours and also for high-risk patients. The role of the stoma care team should be actively encouraged in all patients who may require a stoma. Due to the emergent and unpredictable nature of surgical emergencies, healthcare teams may need to employ novel strategies to ensure early input from the stoma care team. It is important for all members of the medical teams to ensure that patients have given consent for both anaesthesia and surgery before emergency laparotomy. Small studies suggest that patients and their families are not aware of the high risk of morbidity and mortality following emergency laparotomy before operative intervention. Elderly patients should have early involvement from geriatric specialists and careful attention paid to assessment of frailty due to its association with mortality and morbidity. Additionally, the use of enhanced recovery programmes in emergency general surgery has been shown to have some impact in reducing length of stay in emergency surgical patients. However, the emergent nature of this surgery has been shown to be a detrimental factor in full implementation of enhanced recovery programmes. The use of a national database to collect data on patients undergoing emergency laparotomy and their processes of care has led to reduced mortality and length of stay in the UK. However, internationally, fewer data are available to draw conclusions.

Perioperative multidisciplinary implementation enhancing recovery after hip arthroplasty in geriatrics with preoperative chronic hypoxaemia

We investigated risk factors for postoperative serious adverse events (SAEs) in elderly patients with preoperative chronic hypoxaemia undergone total hip arthroplasty (THA) or hemiarthroplasty and performed an implementation to modify and improve clinical outcome. A retrospective medical record review was performed to identify geriatric patients who receiving THA or hemiarthroplasty at a single university teaching hospital, Kunming, Yunnan, China between January 2009 and August 2017. Total of 450 elderly patients were included in the study. Data were collected on baseline characteristics, detailed treatments, and adverse events. Univariate and multivariate logistic regression analysis were used to identify risk factors for SAEs. In multivariate regression analysis, a higher occurrence of general anaesthesia and multiple episodes of hypotension were associated with higher risk of SAEs (general anesthesia: odds ratio [OR] 5.09, 95% confidence interval [CI] 1.96–13.24, P = 0.001; hypotension time: OR 4.29, 95% CI 1.66–11.10, P = 0.003). After the multidisciplinary implementation, the postoperative length of stay was decreased from 15 days to 10 days (P < 0.0001); incidence of SAEs was decreased from 21.1% to 7.0% (P = 0.002), and the all-cause mortality rate within 30 days decreased from 4.6% to 1.0% (P = 0.040). Our observational study demonstrated that an increasing application of general anaesthesia and longer time of hypotension were associated with an increased risk of postoperative SAEs in patients after THA or hemiarthroplasty. Additionally, optimizing stable haemodynamics under higher application of combined-spinal epidural anaesthesia was associated with improved outcome up to 30 days after THA or hemiarthroplasty.

Transitions of care in the perioperative period - a review

The perioperative period extends from the moment of contemplation of surgery through to recovery at home. Patients on a surgical pathway will experience multiple transition points in their care. As we move to more collaborative working and caring for increasingly medically complex patients, we must establish robust processes to mitigate against the potential for patient harm posed by these multiple transition points. This article reviews best practice and guidance on handover of care throughout the perioperative period. We will look at models of transition of care beyond the hospital environment and how better use of community resources can smooth the transition of care out of hospital for ongoing rehabilitation.

Perioperative Medicine for Older People

Global demographic changes have resulted in an older, frailer surgical population with significant multimorbidity causing higher frequency of adverse postoperative outcomes. The need for restructuring of perioperative care pathways to address this issue has been recognised. Comprehensive geriatric assessment (CGA) and optimisation are emerging as innovative perioperative pathways. This paper describes one centre’s approach in applying CGA in the surgical setting and presents the evidence in support of this. Similar models are being established in Singapore in hip fracture, colorectal and vascular populations. The challenges in the widespread adoption of such models of care are similar across settings. The global nature of translation is also discussed in this paper. Key words: Comprehensive geriatric assessment, Geriatrician-led multidisciplinary team, Optimisation

Comprehensive Geriatric Assessment in the perioperative setting; where next?

Comprehensive Geriatric Assessment (CGA) is being employed in the perioperative setting to improve outcomes for older surgical patients. Traditionally CGA is delivered by a geriatrician led multidisciplinary team but with the acknowledged workforce challenges in geriatric medicine, it has been suggested that non-geriatricians may be able to deliver CGA. HOW-CGA developed a toolkit to facilitate the delivery of CGA by non-geriatricians in the perioperative setting. Across two hospital sites uptake and implementation of this toolkit was limited by a potential lack of face validity, behavioural and cultural barriers and an acknowledgement that geriatric medicine expertise is key to CGA and optimisation. In-keeping with this finding there has been an observed expansion in geriatrician led CGA services for older surgical patients in the UK. In order to demonstrate the effectiveness of perioperative CGA services, implementation science should be combined with health services research methodology and the use of big data through linked national audit.

Implementation of a Surgical Liaison Service for Elderly Patients: A Single Unit Experience

Older people over the age of 65 years are recognized as higher risk surgical candidates and it is therefore recommended that their care should be coordinated through a multidisciplinary team (MDT) approach involving senior geriatricians, anaesthetists and surgeons. As one of only a handful of hospitals to implement a liaison service for elderly surgical patients we have seen both quantitative and qualitative improvements in the care delivered. Both co-ordination and continuity of care has improved and overall staff feel that the service forms an integral part of caring for the older surgical patient. Currently only 1% of UK hospitals are meeting targets for implementation of liaison services for their elderly surgical patients. Our surgical liaison service offers consultant led care for older people and is valued amongst users. We would like to share our experiences in the service setup, provision and its subsequent impact on patient care.

Age of patients undergoing surgery

Background

Advancing age is independently associated with poor postoperative outcomes. The ageing of the general population is a major concern for healthcare providers. Trends in age were studied among patients undergoing surgery in the National Health Service in England.

Methods

Time trend ecological analysis was undertaken of Hospital Episode Statistics and Office for National Statistics data for England from 1999 to 2015. The proportion of patients undergoing surgery in different age groupings, their pooled mean age, and change in age profile over time were calculated. Growth in the surgical population was estimated, with associated costs, to the year 2030 by use of linear regression modelling.

Results

Some 68 205 695 surgical patient episodes (31 220 341 men, 45·8 per cent) were identified. The mean duration of hospital stay was 5·3 days. The surgical population was older than the general population of England; this gap increased over time (1999: 47·5 versus 38·3 years; 2015: 54·2 versus 39·7 years). The number of people aged 75 years or more undergoing surgery increased from 544 998 (14·9 per cent of that age group) in 1999 to 1 012 517 (22·9 per cent) in 2015. By 2030, it is estimated that one-fifth of the 75 years and older age category will undergo surgery each year (1·49 (95 per cent c.i. 1·43 to 1·55) million people), at a cost of €3·2 (3·1 to 3·5) billion.

Conclusion

The population having surgery in England is ageing at a faster rate than the general population. Healthcare policies must adapt to ensure that provision of surgical treatments remains safe and sustainable.

Perioperative comprehensive geriatric assessment: what do we need to know?

As a consequence of an ageing population greater numbers of elderly patients are presenting for both elective and emergency surgery. These older patients typically present with an increased burden of age-related problems and multimorbidity, which is associated with an increased risk of adverse postoperative outcomes. Traditional preoperative assessment models are adept at discerning patients' suitability for anaesthesia and surgery, but there is minimal focus on improving postoperative outcomes.

Comprehensive geriatric assessment is a multidisciplinary approach used both to assess existing ‘known’ pathology and to screen for previously undiagnosed issues across medical, functional, social and/or psychological domains. This diagnostic phase then leads to the development and implementation of an individualized ‘optimization’ strategy across these domains. There is emerging evidence that comprehensive geriatric assessment and optimization in the surgical setting leads to improved outcomes, and it is reasonable to conclude that it would benefit the patient's long-term health.

Where are we now in perioperative medicine? Results from a repeated UK survey of geriatric medicine delivered services for older people

INTRODUCTION

national reports highlight deficiencies in the care of older patients undergoing surgery. A 2013 survey showed less than a third of NHS trusts had geriatrician-led perioperative medicine services for older surgical patients. Barriers to establishing services included funding, workforce and limited interspecialty collaboration. Since then, national initiatives have supported the expansion of geriatrician-led services for older surgical patients.This repeat survey describes geriatrician-led perioperative medicine services in comparison with 2013, exploring remaining barriers to developing perioperative medicine services for older patients.

METHODS

an electronic survey was sent to clinical leads for geriatric medicine at 152 acute NHS healthcare trusts in the UK. Reminders were sent on four occasions over an 8-week period. The survey examined the nature of the services provided, extent of collaborative working and barriers to service development. Responses were analysed descriptively.

RESULTS

eighty-one (53.3%) respondents provide geriatric medicine services for older surgical patients, compared to 38 (29.2%) in 2013. Services exist across surgical specialties, especially in orthopaedics and general surgery. Fourteen geriatrician-led preoperative clinics now exist. Perceived barriers to service development remain workforce issues and funding. Interspecialty collaboration has increased, evidenced by joint audit meetings (33% from 20.8%) and collaborative guideline development (31% from 17%).

CONCLUSION

since 2013, an increase in whole-pathway geriatric medicine involvement is observed across surgical specialties. However, considerable variation persists across the UK with scope for wider adoption of services facilitated through a national network.

Are we on the same page? Exploring the role of the geriatrician in the care of the older surgical patient from the perspective of surgeons and geriatricians

There is increasing recognition that the ageing population represents a challenge to existing surgical services. National reports recommend that geriatricians proactively review older surgical patients to improve care and outcomes. However, this approach has not been widely translated into practice. A qualitative study was conducted using 12 semi-structured interviews of surgeons and geriatricians to explore the role of the geriatrician in the care of older surgical patients. Participants agreed that the current system did not meet the needs of older surgical patients. Geriatricians valued their holistic way of working but these generalist skills can overlap with other specialties, seen by some as wasting resources. Three models of care were proposed, with the ownership and location of the patient as well as the role of education being the key variables. The main obstacle preventing integrated working was the concern of de-skilling the surgeons, narrowing their role to that of a 'technician'. Other barriers included loss of autonomy; lack of evidence; and a lack of recognition of the need for a geriatrician. There is acceptance that closer working practices are necessary to meet the needs of this complex patient group but a lack of evidence, together with significant human factors, are challenges that must be addressed to realise this aim.

Establishing a proactive geriatrician led comprehensive geriatric assessment in older emergency surgery patients: Outcomes of a pilot study

INTRODUCTION

Increasing numbers of older adults are presenting with acute surgical disease to the unselected general surgical take. General surgeons have little training to manage these patients. We developed a pilot service of proactive geriatrician input into older emergency general surgical patients in a single institution. We wanted to demonstrate if geriatricians improve the management of these patients.

METHODS

Patients aged 70 years or older admitted acutely under the general surgeons were assessed proactively by a geriatrician using comprehensive geriatric assessment (CGA). Data were collected prospectively using a data collection form of any new issues detected and interventions made by the geriatricians in addition to the surgical plan. This information was entered into an excel database and analysed.

RESULTS

We obtained data for 447 patients between November 2016 and July 2017. CGA led to additional diagnoses or interventions in 83% of patients. The most common problems identified included a new medical diagnosis (35.2%), polypharmacy (30%), recent falls (19.7%), weight loss (17.2%) and uncontrolled pain (16.7%). Abbreviated mental tests were performed in 87.5% patients, with 22% being detected with cognitive impairment. Frailty screening was performed in 97% of patients resulting in 38% being identified as frail. New interventions included stopping medications (40%), starting medications (28%) and referral to multidisciplinary teams (70.1%). Length of stay was reduced by 0.55 days.

CONCLUSION

Proactive geriatrician input identifies medical diagnoses and geriatric syndromes missed by the surgical teams. Managing these issues has contributed to a reduced length of stay in these patients.

Geriatricians and the older emergency general surgical patient: proactive assessment and patient centred interventions. Salford-POP-GS

Increasing numbers of older patients require Emergency admission under General Surgery (EGS). This is a group of heterogeneous and often complex individuals with varying degrees of multimorbidity, polypharmacy, functional, mobility and cognitive impairment. Our article describes the benefits of comprehensive assessment coupled with patient-centred multiprofessional interventions and timely discharge planning. We discuss diverse service models and describe our experience in the planning, development and consolidation of a perioperative service for older EGS patients.

Proactive care of older people undergoing surgery

The number of older patients undergoing surgery is increasing due to changing demographics, surgical and anaesthetic advances and shifts in patient expectations of healthcare. The benefits of surgery in older people are well documented and include symptom control and increased life expectancy. However, older surgical patients present not only with the index pathology requiring surgery but with concurrent age related physiological decline, multimorbidity and geriatric syndromes. These additional issues increase the risk of adverse postoperative outcome, in particular of postoperative medical and functional complications. In recent years, there has been recognition of the need for collaborative surgical and geriatric medicine working to address the health care needs of the increasingly complex older surgical population. Guidelines have been published to support clinicians looking after older surgical patients, however, there has been little published on the establishment of such services. In this paper, we describe the evolution of the proactive care of older patients undergoing surgery (POPS) service and how through the use of comprehensive geriatric assessment methodology and intervention throughout the surgical pathway, outcomes for complex older surgical patients can be improved.

Is current preoperative frailty assessment adequate?

SUMMARY

Preoperative frailty predicts adverse postoperative outcomes. Recommendations for preoperative assessment of elderly patients include performing a frailty assessment. Despite the advantages of incorporating frailty assessment into surgical settings, there is limited research on surgical health care professionals' perception and use of frailty assessment for perioperative care. We surveyed local health care employees to assess their attitudes toward and practices for frail patients. Nurses and allied health professionals were more likely than surgeons to agree frailty should play a role in planning a patient's care. Lack of knowledge about frailty issues was a prominent barrier to the use of frailty assessments in practice, despite clinicians understanding that frailty affects their patients' outcomes. Results of this survey suggest further training in frailty issues and the use of frailty assessment instruments is necessary and could improve the uptake of such tools for perioperative care planning.

Facilitators and barriers of change toward an elder-friendly surgical environment: perspectives of clinician stakeholder groups

BACKGROUND

Current acute care surgical practices do not focus on the unique needs of older adults. Adverse outcomes in older patients result from a complex interrelationship between baseline vulnerability and insults experienced during hospitalization. The purpose of this study is to assess the organizational readiness and the barriers and facilitators for the implementation of elder-friendly interventions in the acute care of unplanned abdominal surgery patients.

METHODS

This cross-sectional mixed methods study included a convenience sample of clinician stakeholder groups. Eight focus groups were conducted with 33 surgical team members including: 10 health care aides, 6 licensed practical nurses, 6 registered nurses, 4 nurse managers and 7 surgeons, to identify barriers and facilitators to the implementation of an elder-friendly surgical unit. Audio recordings of the focus groups were transcribed verbatim and analysed using interpretive description techniques. Transcripts were coded along with explanatory memos to generate a detailed description of participant experiences. Themes were identified followed by refining the codes. Participants also completed the Organizational Readiness for Implementing Change questionnaire. Differences in organizational readiness scores across clinician stakeholder groups were assessed using Kruskal-Wallice tests. Mann-Whitney tests (Bonferroni's corrections for multiple comparisons) were conducted to assess pair-wise relationships.

RESULTS

The focus group data were conceptualized to represent facilitators and barriers to change at two levels of care delivery. Readiness to change at the organizational level was evident in five categories that reflected the barriers and facilitators to implementing an elder-friendly surgical unit. These included education, environment, staffing, policies and other research projects. At the individual level barriers and facilitators were apparent in staff members' acceptance of new roles and duties with other staff, family and patients. Examples of these included communication, teamwork and leadership. The mean change commitment and change efficacy scores on the Organizational Readiness for Implementing Change Questionnaire were 3.7 (0.8) and 3.5 (0.9) respectively. No statistically significant differences were detected between the stakeholder groups.

CONCLUSIONS

Staff are interested in contributing to improved care for elderly surgical patients; however, opportunities were identified to enhance facilitators and reduce barriers in advance of implementing the elder-friendly surgical unit intervention.

Surgical frailty assessment: a missed opportunity

Background

Preoperative frailty predicts adverse postoperative outcomes. Despite the advantages of incorporating frailty assessment into surgical settings, there is limited research on surgical healthcare professionals’ use of frailty assessment for perioperative care.

Methods

Healthcare professionals caring for patients enrolled at a Canadian teaching hospital were surveyed to assess their perceptions of frailty, as well as attitudes towards and practices for frail patients. The survey contained open-ended and 5-point Likert scale questions. Responses were compared across professions using independent sample t-tests and correlations between survey items were analyzed.

Results

Nurses and allied health professionals were more likely than surgeons to think frailty should play a role in planning a patient’s care (nurses vs. surgeons p = 0.008, allied health vs. surgeons p = 0.014). Very few respondents (17.5%) reported that they ‘always used’ a frailty assessment tool. Results from qualitative data analysis identified four main barriers to frailty assessment: institutional, healthcare system, professional knowledge, and patient/family barriers.

Conclusion

Across all disciplines, the lack of knowledge about frailty issues was a prominent barrier to the use of frailty assessments in practice, despite clinicians’ understanding that frailty affects their patients’ outcomes. Confidence in frailty assessment tool use through education and addressing barriers to implementation may increase use and improve patient care. Healthcare professionals agree that frailty assessments should play a role in perioperative care. However, few perform them in practice. Lack of knowledge about frailty is a key barrier in the use of frailty assessments and the majority of respondents agreed that they would benefit from further training.

Electronic supplementary material

The online version of this article (doi:10.1186/s12871-017-0390-7) contains supplementary material, which is available to authorized users.

The physician's role in perioperative management of older patients undergoing surgery

Life-sustaining and life-improving surgical interventions are increasingly available to older, frailer patients, many of whom have multimorbidity. Physicians can help support perioperative multidisciplinary teams with assessment and preoperative optimisation of physiological reserve, comorbidities and associated geriatric syndromes. Similar structured support can be useful in the postoperative period where older patients are at increased risk of delirium, medical complications, increased functional dependency and where discharge planning can prove more difficult than in younger cohorts. Comprehensive geriatric assessment has been shown to improve outcomes and is now embedded in most UK-based services for traumatic hip fracture. Perioperative comprehensive geriatric assessment has been explored in other surgical disciplines and procedures and, where evaluated, has been associated with improved outcomes. The need to support older patients with frailty undergoing surgery exceeds the capacity of specialist geriatricians. Other groups of healthcare professionals need to nurture the core competencies to support this group perioperatively.

Effects of preoperative chronic hypoxemia on geriatrics outcomes after hip arthroplasty: A hospital-based retrospective analysis study

The partial pressure of oxygen decreases as altitude increases, the preoperative chronic hypoxemia (CH) may have a plausible clinical impact. Risk factors for postoperative serious adverse events (pSAEs) in patients living in high altitudes during primary hip arthroplasty (HA) are not clear.This is an observational study embracing patients from January 1, 2011 to December 31, 2015 at Yan'an Hospital of Kunming City, a 1338-bed municipal teaching hospital of Kunming Medical University. Univariate analysis revealed that significant differences between patients with and without preoperative CH occurred in intraoperative hypotension (77 [33%] vs 34 [47%], P = .040) and that significant differences between patients with and without pSAEs occurred in following variables: preoperative CH (32 [57%] vs 199 [80%], P < .001), intraoperative hypotension (37 [66%] vs 74 [30%], P < .001), highest noradrenaline support (.09 [.01-.21] vs .03 [.01-.05] μg/kg/min, P < .001), higher application of general anesthesia (15 [27%] vs 29 [12%], P = .004), and lower of combined-spinal epidural anesthesia (CSEA) (21 [37%] vs 165 [66%], P < .001). The general anesthesia and intraoperative hypotension remained the independent risk factors for pSAEs (P < .05), while the preoperative CH presented by decreasing its risk (P < .05).This study suggests that various intraoperative events including general anesthesia, hypotension were risk factors for the development of pSAEs. Preoperative CH, presenting with decreased incidence of intensive care unit (ICU) admission and pSAEs, may mimic hypoxic preconditioning in organic protection, for which further study is needed to uncover the underlying mechanisms.

The role of diagnosis in delirium

Delirium is common and is commonly misdiagnosed, chiefly in being missed (Bhat and Rockwood, 2007). The consequences of misdiagnosis are often severe and wide ranging, affecting patients, caregivers, health professionals, and hospitals (Inouye et al., 2014). Many an older hospitalized person with delirium is trapped in the interface between psychiatry and the rest of medicine, and can too easily be caught in the tendentious battles between treating teams. Both researchers and policymakers have sought to improve this unacceptable state of affairs (Young et al., 2010; Tieges et al., 2015).