Danielle Harari

Frailty in the older surgical patient: a review

The rate of surgical procedures in the older population is rising. Despite surgical, anaesthetic and medical advances, older surgical patients continue to suffer from adverse postoperative outcomes. Comorbidities and reduction in physiological reserve are consistently identified as major predictors of poor postoperative outcome in this population. Frailty can be defined as a lack of physiological reserve seen across multiple organ systems and is an independent predictor of mortality, morbidity and institutionalisation after surgery. Despite this identification of frailty as a significant predictor of adverse postoperative outcome, there is not yet a consensus on the definition of frailty or how best to assess and diagnose it. This review describes our current definitions of frailty and discusses the available methods of assessing frailty, the impact on the older surgical population and the emerging potential for modification of this important syndrome.

The impact of pre-operative comprehensive geriatric assessment on postoperative outcomes in older patients undergoing scheduled surgery: a systematic review.

Comprehensive geriatric assessment is an established clinical approach. It reduces mortality and improves the physical wellbeing of older people in the community or hospitalised for medical reasons. Pre‐operative comprehensive geriatric assessment seems a plausible method for reducing adverse postoperative outcomes. The objectives of this systematic review and narrative synthesis are to describe how pre‐operative comprehensive geriatric assessment has been used in surgical patients and to examine the impact of comprehensive geriatric assessment on postoperative outcomes in older patients undergoing scheduled surgery. We searched MEDLINE, EMBASE and Web of Science from 1980 to 2013 (week 26). We included five studies: two randomised controlled trials and three before‐and‐after intervention quasi‐experimental studies. Patient populations, interventions and outcome measures varied between studies. Both the randomised trials showed benefit on postoperative outcomes, including medical complications. Two of the before‐and‐after studies reported a positive impact on postoperative length of stay and other outcomes. The heterogeneity of study methods, populations, interventions and outcomes precluded meta‐analysis. Based on this narrative synthesis, pre‐operative comprehensive geriatric assessment is likely to have a positive impact on postoperative outcomes in older patients undergoing elective surgery, but further definitive research is required. Clinical services providing pre‐operative comprehensive geriatric assessment for older surgical patients should be considered.

Treatment of Constipation and Fecal Incontinence in Stroke Patients Randomized Controlled Trial

Background and Purpose— Despite its high prevalence in stroke survivors, there is little clinical research on bowel dysfunction in this population. This is the first randomized controlled trial to evaluate treatment of constipation and fecal incontinence in stroke survivors. Methods— Stroke patients with constipation or fecal incontinence were identified by screening questionnaire (122 community, 24 stroke rehabilitation inpatients) and randomized to intervention or routine care (73 per group). The intervention consisted of a 1-off structured nurse assessment (history and rectal examination), leading to targeted patient/carer education with booklet and provision of diagnostic summary and treatment recommendations (after consultation with geriatrician) to patient’s general practitioner (GP)±ward physician. Results— Percentage of bowel movements (BMs) per week graded as “normal” by participants in a prospective 1-week stool diary was significantly higher in intervention versus control patients at 6 months (72% versus 55%; P=0.027), as was mean number of BMs per week (5.2 versus 3.6; P=0.005). There was no significant reduction in fecal incontinence, although numbers were small. At 12 months, intervention patients were more likely to be modifying their diets (odds ratio [OR], 3.1 [1.2 to 8.0]) and fluid intake (OR, 4.2 [1.4 to 12.2]) to control their bowels and to have visited their GP for their bowel problem (OR, 5.0 [1.4 to 17.5]). GP prescribing of laxatives and suppositories was significantly influenced at 12 months. Conclusions— A single clinical/educational nurse intervention in stroke patients effectively improved symptoms of bowel dysfunction up to 6 months later, changed bowel-modifying lifestyle behaviors up to 12 months later, and influenced patient–GP interaction and physician prescribing patterns.

Management of Fecal Incontinence in Adults

This article summarises the findings from the conservative management of faecal incontinence in adults committee of the International Consultation on Incontinence. We conducted comprehensive literature searches using the following keywords combined with the relevant intervention: “anal, anorectal, bowel, faecal, fecal, rectal, stool” and “continent

The delirium experience: what is the effect on patients, relatives and staff and what can be done to modify this?

or incontinent

Constipation: Assessment and Management in an Institutionalized Elderly Population

,” Prevalence etimates for faecal or anal incontinence vary widely, from 2.2% to 2.5%. Expert opinion supports the use of general health education, patient teaching about bowel function and advice on lifestyle modification, but the evidence base is small. Unlike urinary incontinence, few “lifestyle” associations have been identified with FI and little is known about whether interventions designed to reduce potential risk factors might improve FI. The article summarises the evidence and recommendations from the committee for clinical practice and future research. Neurourol. Urodynam. 29: 199–206, 2010.

The impact of comprehensive geriatric assessment interventions on tolerance to chemotherapy in older people

Delirium is a common clinical syndrome with significant associated mortality, morbidity and financial cost. Less is understood about the experience of delirium for the patient, their family and staff involved in their care.

Constipation-related symptoms and bowel program concerning individuals with spinal cord injury

OBJECTIVES: To examine prescribing and utilization patterns of laxatives, stool softeners, and enemas in a large, long‐term care facility, to compare self‐reports of constipation with specific, bowel‐related symptoms in residents of this facility, and to examine concordance between bowel symptoms reported by residents and the assessments of the nursing staff.

New-Onset Fecal Incontinence After Stroke. Prevalence, Natural History, Risk Factors, and Impact

Background:Although comorbidities are identified in routine oncology practice, intervention plans for the coexisting needs of older people receiving chemotherapy are rarely made. This study evaluates the impact of geriatrician-delivered comprehensive geriatric assessment (CGA) interventions on chemotherapy toxicity and tolerance for older people with cancer.Methods:Comparative study of two cohorts of older patients (aged 70+ years) undergoing chemotherapy in a London Hospital. The observational control group (N=70, October 2010–July 2012) received standard oncology care. The intervention group (N=65, September 2011–February 2013) underwent risk stratification using a patient-completed screening questionnaire and high-risk patients received CGA. Impact of CGA interventions on chemotherapy tolerance outcomes and grade 3+ toxicity rate were evaluated. Outcomes were adjusted for age, comorbidity, metastatic disease and initial dose reductions.Results:Intervention participants undergoing CGA received mean of 6.2±2.6 (range 0–15) CGA intervention plans each. They were more likely to complete cancer treatment as planned (odds ratio (OR) 4.14 (95% CI: 1.50–11.42), P=0.006) and fewer required treatment modifications (OR 0.34 (95% CI: 0.16–0.73), P=0.006). Overall grade 3+ toxicity rate was 43.8% in the intervention group and 52.9% in the control (P=0.292).Conclusions:Geriatrician-led CGA interventions were associated with improved chemotherapy tolerance. Standard oncology care should shift towards modifying coexisting conditions to optimise chemotherapy outcomes for older people.

The Management of Empyema Thoracis by Thoracoscopy and Irrigation

Purpose. To determine the prevalence of constipation-related symptoms in individuals with chronic spinal cord injury (SCI), to describe the bowel program as reported by patients and including use of bowel medications and evacuation techniques, and to examine the clinical, functional and pharmacological risks of difficulty with evacuation. Patients and Methods. This is a cross-sectional study of all in-patients at least 3 months beyond acute injury, on the West Roxbury/Brockton VAMC SCI Service, during a 10 month period (n=197). Clinical, functional, and medication data were abstracted from medical and nursing records. Individual interviews were conducted with all available participants (n=161, 82%) regarding bowel-related symptoms and treatment over the previous 1 month period. The study definition of difficulty with evacuation was spending more than 1 h per episode of bowel evacuation. Results. Forty-one percent of the 161 interview responders spent more than 1 h on bowel evacuation, 50% reported abdominal distension and 38% reported abdominal pain, 27% reported headaches or sweats relieved by having a bowel movement, and 33% reported fecal incontinence at least once a month. The bisacodyl suppository was the most commonly used laxative agent, while docusate was the most popular oral agent. Subjects with difficulty with evacuation (n=66) were compared with those who spent less than 1 h on evacuation (n=95). Factors associated with difficulty with evacuation were tetraplegia, Frankel grade A/B, laxative use, polypharmacy, previous urinary outlet surgery, and symptoms of abdominal pain and distension. Conclusion. Constipation-related symptoms are highly prevalent in individuals with spinal cord injury, despite considerable laxative use. Our findings suggest that difficulty with evacuation can be predicted on the basis of a patients clinical profile.