Lyndsay Pearce

Prevalence of multimorbidity and its association with outcomes in older emergency general surgical patients: an observational study.

Objectives Multimorbidity is the presence of 2 or more medical conditions. This increasingly used assessment has not been assessed in a surgical population. The objectives of this study were to assess the prevalence of multimorbidity and its association with common outcome measures. Design A cross-sectional observational study. Setting A UK-based multicentre study, included participants between July and October 2014. Participants Consecutive emergency (non-elective) general surgical patients admitted to hospital, aged over 65 years. Outcome measures The outcome measures were (1) the prevalence of multimorbidity and (2) the association between multimorbidity and frailty; the rate and severity of surgery; length of hospital stay; readmission to hospital within 30 days of discharge; and death at 30 and 90 days. Results Data were collected on 413 participants aged 65–98 years (median 77 years, (IQR (70–84)). 51.6% (212/413) participants were women. Multimorbidity was present in 74% (95% CI 69.7% to 78.2%) of the population and increased with age (p<0.0001). Multimorbidity was associated with increasing frailty (p for trend <0.0001). People with multimorbidity underwent surgery as often as those without multimorbidity, including major surgery (p=0.03). When comparing multimorbid people with those without multimorbidity, we found no association between length of hospital stay (median 5 days, IQR (1–54), vs 6 days (1–47), (p=0.66)), readmission to hospital (64 (21.1%) vs 18 (16.8%) (p=0.35)), death at 30 days (14 (4.6%) vs 6 (5.6%) (p=0.68)) or 90-day mortality (28 (9.2%) vs 8 (7.6%) (p=0.60)). Conclusions and implications Multimorbidity is common. Nearly three-quarters of this older emergency general surgical population had 2 or more chronic medical conditions. It was strongly associated with age and frailty, and was not a barrier to surgical intervention. Multimorbidity showed no associations across a range of outcome measures, as it is currently defined. Multimorbidity should not be relied on as a useful clinical tool in guidelines or policies for older emergency surgical patients.

The prevalence of hyperglycaemia and its relationship with mortality, readmissions and length of stay in an older acute surgical population: a multicentre study

Background The purpose of the study is to examine the prevalence of hyperglycaemia in an older acute surgical population and its effect on clinically relevant outcomes in this setting. Methods Using Older Persons Surgical Outcomes Collaboration (OPSOC) multicentre audit data 2014, we examined the prevalence of admission hyperglycaemia, and its effect on 30-day and 90-day mortality, readmission within 30 days and length of acute hospital stay using logistic regression models in consecutive patients, ≥65 years, admitted to five acute surgical units in the UK hospitals in England, Scotland and Wales. Patients were categorised in three groups based on their admission random blood glucose: <7.1, between 7.1 and 11.1 and ≥11.1 mmol/L. Results A total of 411 patients (77.25±8.14 years) admitted during May and June 2014 were studied. Only 293 patients (71.3%) had glucose levels recorded on admission. The number (%) of patients with a blood glucose <7.1, 7.1–11.1 and ≥11.1 mmol/L were 171 (58.4), 99 (33.8) and 23 (7.8), respectively. On univariate analysis, admission hyperglycaemia was not predictive of any of the outcomes investigated. Although the characteristics of those with no glucose level were not different from the included sample, 30-day mortality was significantly higher in those who had not had their admission glucose level checked (10.2% vs 2.7%), suggesting a potential type II error. Conclusion Despite current guidelines, nearly a third of older people with surgical diagnoses did not have their glucose checked on admission highlighting the challenges in prognostication and evaluation research to improve care of older frail surgical patients.

Rectourethral fistula secondary to a bowel management system

A 67-year-old Caucasian male was admitted under the vascular team with critical lower limb ischaemia. Bypass surgery was performed and he was admitted to the intensive care unit post-operatively. The patient experienced a turbulent post-operative recovery complicated by pneumonia, poor respiratory wean and faecal incontinence. A bowel management system was inserted but after 18 days it was reported faecal matter was bypassing his catheter. A CT scan demonstrated an area of necrosis where the bowel management system had been sited which formed a rectourethral fistula. Bowel management systems are frequently used in intensive care unit settings where a high proportion of patients suffer from faecal incontinence. If used correctly they can reduce skin contamination, infection and maintain patient hygiene. However, appropriate assessment and investigations should be addressed before inserting such devices. This case report highlights serious adverse effects of these devices and describes the first documented case of these devices causing a rectourethral fistula.

Cognitive impairment in older patients undergoing colorectal surgery

Background With increasing numbers of older people being referred for elective colorectal surgery, cognitive impairment is likely to be present and affect many aspects of the surgical pathway. This study is aimed to determine the prevalence of cognitive impairment and assess it against surgical outcomes. Methods The Montreal Cognitive Assessment (MoCA) was carried out in patients aged more than 65 years. We recorded demographic information. Data were collected on length of hospital stay, complications and 30-day mortality. Results There were 101 patients assessed, median age was 74 years (interquartile range = 68–80), 54 (53.5%) were women. In total, 58 people (57.4%) ‘failed’ the Montreal Cognitive Assessment test (score ≤ 25). There were two deaths (3.4%) within 30 days of surgery in the abnormal Montreal Cognitive Assessment group and none in the normal group. Twenty-nine (28.7%) people experienced a complication. The percentage of patients with complications was higher in the group with normal Montreal Cognitive Assessment (41.9%) than abnormal Montreal Cognitive Assessment (19.9%) (p = 0.01) and the severity of those complications were greater (chi-squared for trend p = 0.01). The length of stay was longer in people with an abnormal Montreal Cognitive Assessment (mean 8.1 days vs. 5.8 days, p = 0.03). Conclusion Cognitive impairment was common, which has implications for informed consent. Cognitive impairment was associated with less postoperative complications but a longer length of hospital stay.

Is anaemia associated with cognitive impairment and delirium among older acute surgical patients

The determinants of cognitive impairment and delirium during acute illness are poorly understood, despite being common among older people. Anemia is common in older people, and there is ongoing debate regarding the association between anemia, cognitive impairment and delirium, primarily in non‐surgical patients.

Influence of frailty in older patients undergoing emergency laparotomy: a UK-based observational study

Introduction The National Emergency Laparotomy Audit (NELA) has reported that older patients (≥65 years) form a large percentage of emergency high-risk cases with increased postoperative morbidity and mortality. With the population continuing to age rapidly, it is clear that a greater understanding of the factors affecting surgical outcomes in older patients is required. Frailty is a relatively new concept taking into account a variety of factors that increase an individual’s vulnerability to increased dependency and death. Research has suggested that high frailty scores increase postoperative complications, length of stay and mortality but the majority of these studies have been carried out on elective patients. Knowledge of how frailty affects patients in an emergency setting would aid clinicians’ and patients’ decision-making process. Methods and analysis This multicentre study will include consecutive adult patients aged 65 years and over undergoing emergency laparotomies over a 3-month period at 52 National Health Service hospitals across the UK. The primary outcome will be 90-day mortality. Secondary outcomes will include length of hospital stay, 30-day complications, change in level of independence and 30-day readmission. This study has been powered to detect a 10% change in mortality associated with frailty (n=500 patients). Ethics and dissemination This study has been approved by the National Health Service Research Ethics Committee. It has been registered centrally with HRA for English sites, NRSPCC for Scottish sites and Health and Care Research Permissions Service for sites in Wales.Dissemination will be via international and national surgical and geriatric conferences. In addition, manuscripts will be prepared following the close of the project. Trial registration number This study is also registered online at www.clinicaltrials.gov (registration number NCT02952430).

36COGNITIVE IMPAIRMENT AND OUTCOMES IN OLDER UNSELECTED ACUTE SURGICAL ADMISSIONS: A MULTICENTRE STUDY

Introduction: The prevalence of cognitive impairment is set to rise. One valid method of measuring cognitive function is through using the Montreal Cognitive Assessment (MoCA). Consequently, we were interested in investigating the outcome of older surgical patients with poor cognition who are admitted to the acute surgical setting. Methods: We identified older surgical patients who had lowest 25% of cognition using consecutive acute surgical admission data from Older Persons Surgical Outcomes Collaboration (www.OPSOC.eu) (2013 and 2014). The effect of having a low MoCA score on relevant outcomes of receipt of surgical intervention, 30and 90-day mortality, readmission within 30-days and hospital length of stay were examined using multivariate logistic regression models, adjusting for age, sex, polypharmacy, haemoglobin, albumin and having diabetes for the first outcome and additionally controlling for surgical intervention for other outcomes. Results: A total of 660 older patients admitted to five surgical units (mean age (SD) = 77(8.1) years) were included. 148 (22.4%) had a MoCA score in the lowest 25% (≤17). The emergency operation rate was 12.0% (N = 79) in this cohort. Characteristic comparisons with the rest of the group showed increasing age, length of hospital stay, polypharmacy and low haemoglobin levels were all significantly associated with having a low MoCA score. A low MoCA score was not associated with sex, low albumin, diabetes or receiving surgical intervention. Multivariate analyses showed low MoCA group had increased 30-day mortality (adjusted odds ratio = 2.84 (95% CI:1.29-6.23; P = 0.009) compared to the remaining cohort. No significant association was found between having a low MoCA score and the other outcomes including receipt of surgical intervention. Conclusion: Whilst low MoCA doesn’t appear to preclude the receipt of emergency surgical intervention among older people, our findings highlight the poor prognosis associated with cognitive impairment in older surgical patients.