Judith Partridge

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

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.

Frailty and poor functional status are common in arterial vascular surgical patients and affect postoperative outcomes

OBJECTIVES Increasing numbers of older people are undergoing emergency and elective arterial vascular procedures. Many older patients are frail which is a recognised predictor of adverse postoperative outcomes in other surgical specialties. This study in older patients undergoing arterial vascular surgery examined; the prevalence of preoperative frailty; the clinical feasibility of preoperatively measuring frailty and functional status; the association between these characteristics and adverse postoperative outcome. METHODS Prospective observational study in patients aged over 60 years undergoing elective and emergency arterial vascular surgery. Baseline measures of frailty (Edmonton Frail Scale), functional status (gait velocity, timed up and go, hand grip strength) and cognitive function (Montreal Cognitive Assessment) were obtained preoperatively. The primary outcome measure Length of Stay (LOS) and secondary outcome measures of postoperative morbidity (medical and surgical complications), functional status and postoperative in-hospital mortality were recorded. RESULTS 125 patients were recruited. Frailty was common in this older surgical population (52% EFS score of ≥ 6.5) with high frailty scores observed (mean EFS 6.6, SD 3.05) and poor functional status (60% had TUG > 15 s, 45% had gait velocity of < 0.6 m/s). Higher preoperative EFS (> 6.5) was univariately associated with longer LOS (≥ 12 days), composite measures of postoperative infections, postoperative medical complications and adverse functional outcomes. EFS ≥ 6.5 was predictive of LOS ≥ 12 days, adjusted for age (AUC 0.660, CI 0.541-0.779, p = 0.010). This association between EFS ≥ 6.5 and LOS ≥ 12 days was strengthened with the addition of MoCA < 24 (AUC 0.695, CI 0.584-0.806, p = 0.002). CONCLUSIONS Patients aged over 60 years admitted for arterial vascular surgery were frail, had impaired functional status and were cognitively impaired. This combination of preoperative characteristics was predictive of longer hospital length of stay and associated with adverse postoperative outcome.

Randomized clinical trial of comprehensive geriatric assessment and optimization in vascular surgery

Increasing numbers of older patients are undergoing vascular surgery. Inadequate preoperative assessment and optimization may contribute to increased postoperative morbidity and mortality.

Anaemia in the older surgical patient: a review of prevalence, causes, implications and management

This review provides the clinician with a summary of the causes, implications and potential treatments for the management of anaemia in the older surgical patient. The prevalence of anaemia increases with age and is frequently identified in older surgical patients. Anaemia is associated with increased postoperative morbidity and mortality. Allogenic blood transfusion is commonly used to treat anaemia but involves inherent risks and may worsen outcomes. Various strategies for the correction of pre- and postoperative anaemia have evolved. These include correction of nutritional deficiencies and the use of intravenous iron and erythropoesis stimulating therapy. Clear differences exist between the elective and emergency surgical populations and the translation of research findings into these individual clinical settings requires more work. This should lead to a standardized approach to the management of this frequently encountered clinical scenario.

Do surgical trainees believe they are adequately trained to manage the ageing population? A UK survey of knowledge and beliefs in surgical trainees.

OBJECTIVE Increasing numbers of older patients are undergoing surgery. Older surgical patients are at a higher risk of perioperative complications and mortality. Multimorbidity, frailty, and physiological changes of ageing contribute to adverse outcomes. These complications are predominantly medical, rather than directly surgical. Guidelines recommend preoperative assessment of comorbidity, disability, and frailty in older patients undergoing surgery and closer perioperative collaboration between surgeons and geriatricians. We conducted a survey to assess knowledge and beliefs of surgical trainees toward common perioperative problems encountered in older surgical patients. DESIGN Paper-based survey. SETTING Unselected UK surgical training-grade physicians (CT1-ST8) attending the 2013 Congress of The Association of Surgeons of Great Britain and Ireland, Glasgow, UK, May 1-3, 2013. PARTICIPANTS A total of 160 eligible UK surgical trainees attending the conference were invited to participate in the survey. Of them, 157 participated. RESULTS Of the trainees, 68% (n = 107) reported inadequate training and 89.2% (n = 140) supported the inclusion of geriatric medicine issues in surgical curricula. Of the respondents, 77.2% (n = 122) were unable to correctly identify the key features required to demonstrate mental capacity, and only 3 of 157 respondents were familiar with the diagnostic criteria for delirium. Support from geriatric medicine was deemed necessary (84.7%, n = 133) but often inadequate (68.2%, n = 107). Surgical trainees support closer collaboration with geriatric medicine and shared care of complex, older patients (93.6%, n = 147). CONCLUSIONS UK surgical trainees believe that they receive inadequate training in the perioperative management of complex, older surgical patients and are inadequately supported by geriatric medicine physicians. In this survey sample, trainee knowledge of geriatric issues such as delirium and mental capacity was poor. Surgical trainees support the concept of closer liaison and shared care of complex, older patients with geriatric medicine physicians. Changes to surgical training and service development are needed.

Indications for and use of inferior vena cava filters in the preoperative phase

A 66 year old man presented for preoperative assessment and optimisation before a left thoracoabdominal oesophagectomy for oesophageal adenocarcinoma (T3N2). He had undergone three cycles of chemotherapy and developed a deep vein thrombosis in the right popliteal vein. He was started on low molecular weight heparin. His medical history included deep vein thrombosis of the right leg and pulmonary embolism four years ago, myocardial infarction, hypertension, and hypercholesterolaemia. His history of venous thromboembolism and high ongoing thrombotic risk meant that lifelong anticoagulation was indicated. The need for surgery made it necessary to interrupt therapeutic anticoagulation within two months of his venous thromboembolism. Repeat Doppler scans of the right leg undertaken as part of the preoperative assessment and optimisation process showed residual thrombosis. ### 1 How should patients with previous venous thromboembolism be managed preoperatively? #### Short answer Preoperative management depends on the history of venous thromboembolism, the patient’s risk profile, the type of surgery that is planned, and the patient’s renal function. All patients at risk of venous thromboembolism should be prescribed antiembolic stockings and pharmacological thromboprophylaxis unless contraindicated. #### Long answer The importance of thromboprophylaxis in preventing deep vein thrombosis was established more than three decades ago.1 Because deep vein thrombosis can lead to fatal pulmonary embolism—the most common preventable risk factor for inpatient mortality2—perioperative thromboprophylaxis has become the norm in at risk patients. Current National Institute for Health and Care Excellence (NICE) guidelines suggest that any patient at risk of venous thromboembolism (for example, previous venous thromboembolism, cancer surgery, age over 60 years, or serious …

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.