Elderly Patients

Wilkinson K. An age-old problem: care of older people undergoing surgery. Br J Hosp Med (Lond). 2011;72(3):126-127. doi:10.12968/hmed.2011.72.3.126

Bottom line: This 2011 BJHM article is a brief synopsis of the findings of full 148-page report  An Age Old Problem by the National Confidential Enquiry into Patient Outcome and Death in the UK. The author's highlight that in reviewing ~800 cases involving patients who were >80 years old and died within 30-days post-op, they found that only 37.5% received "good care" as per peer review.  


The most cited reason for substandard care was preventable delays in the lead up to the OR. Geriatricians were seldom involved in the perioperative period. Complications were common despite adequate senior staff involvement -- for example, perioperative hypotension occurred in half the patients. Finally, 30% of patients received critical care at some point, and 10% of these admissions were unplanned. 

    Chan SP, Ip KY, Irwin MG. Peri-operative optimisation of elderly and frail patients: a narrative review. Anaesthesia. 2019;74 Suppl 1:80-89. doi:10.1111/anae.14512

    Frailty

    Definition: Deterioration of physiological function that affects multiple organs.

     

    A frail patient undergoing surgery is more susceptible to profound change in function.

     

    Can be described in two different models: frailty phenotype and frailty index recognizing that there is a requirement of time and skill for administration of these tools and that is often a barrier to assessment.

     

    Assessment of frailty can be done via tools like the Edmonton Frail Scale or Clinical Frailty Score.

    Clegg A, Young J, Iliffe S, Rikkert MO, Rockwood K. Frailty in elderly people [published correction appears in Lancet. 2013 Oct 19;382(9901):1328]. Lancet. 2013;381(9868):752-762. doi:10.1016/S0140-6736(12)62167-9

    Bottom line: This 2013 review article is a comprehensive review of frailty. It posits a definition of frailty, reviews the pathophysiology behind the condition, discusses the two basic models of frailty (the phenotype model and the cumulative deficit model) and the evidence behind each. The author summarizes the epidemiology of frailty as well the assessments/questionnaires available to identify the condition. Finally, the article summarizes what interventions are available once the condition has been diagnosed and the expected outcomes. 

    Major points:

    1. Frailty is the accumulation of deficits across multiple organ systems which results in a striking and disproportionate response to what would otherwise be a minor stressor (minor surgery, new drug, minor infection) in a non-frail person. Unlike the rest of modern medicine, where the focus is on single-systems, frailty highlights the fact that in the frail elderly people the deficits lie across multiple organ systems. Therefore, treating these patients requires a more holistic approach. 

    2. Clinical judgement should be shifted away from chronological age and towards distinguishing between the frail patient vs non-frail patient. Failure to detect frailty in an elderly patient puts them at risk from an invasive intervention that might do more harm than good given their state. Conversely, without distinguishing between frail vs non-frail, a non-frail patient may be harmed by being denied an otherwise beneficial intervention simply because of their age.


    3. Frailty is important because it focuses clinicians away from the idea of chronological age and towards the idea of frailty - a better gauge of a patient's physiologic reserve and response to potential stressors. Presently, the comprehensive geriatric assessment is the gold standard for diagnosing frailty but is expensive and resource-intensive. Questionnaires such as the Groningen frailty indicator or Tillburg frailty indicator are candidates for cheaper questionairre-based alternatives, but their diagnostic accuracy has not yet been proven. Other physical exam-based assessments exist to identify frailty (timed up-and-go test, hand grip strength, pulmonary function, gait speed or a combination of these as used in the Edmonton Frail Scale) which have showed validity but their diagnostic accuracy is yet to be proven. 

    4. Once frailty is identified complex interventions based on a comprehensive geriatric assessment has been shown to prolong the time a person can live at home. Exercise regimens have been shown to improve outcomes of mobility and functional status. In both cases, the most frail see the least benefit. Nutritional interventions have a lack of evidence to date. Pharmacological interventions including ACEi for improved muscle strength, and Vit D/Calcium for reduction of falls are promising areas of future research for treating frailty. 

      Chan SP, Ip KY, Irwin MG. Peri-operative optimisation of elderly and frail patients: a narrative review. Anaesthesia. 2019;74 Suppl 1:80-89. doi:10.1111/anae.14512

      Bottom line: There are multiple models of care available for managing the elderly in the pre-operative setting --  anesthesiologist-led, geriatrician-led or other innovative models. Whatever the model, various tools exist to identify the frail elderly patient (e.g. Clinical Frailty Scale, Edmonton Frail Scale) - who is at an increased risk for post-operative adverse events (increased LOS, hospitalization, morbidity and mortality).

      Once identified as a frail patient, the process of shared-decision making should begin so that an informed decision can be had about the decision to proceed with surgery. Subsequently, any frailty-related pre-operative interventions (such as exercise or nutrition supplementation) can be applied and finally, the risk factors for post-operative cognitive disorders can be identified so that appropriate interventions can be made. 

      Major points: 

      1. Multiple models exist for peri-operative care of the elderly patient. Geriatrician-led teams such as Older People Undergoing Surgery Service. Anesthesiologist-led teams such as Torbay Pre-operative Preparation Clinic. Other innovative models such as Michigan Surgical Home and Optimisation Program. 

      2. The traditional models of identifying frail patients (phenotype model and deficit accumulation model) are too cumbersome and resource-intensive to be used routinely in the pre-operative setting. Adjustments to the Rockwood model by Farhat et al cut the original 70 variables down to 11 and verified the predictive value for 30-day post-operative mortality. The Edmonton Frail Scale is a 17-point scale which can be used by non-geriatricians in 5 minutes. The Clinical Frailty Scale is semi-qualitative tool that can be used in the outpatient setting by any trained staff. 

      3. There is still a lack of evidence as to whether or not frailty can be delayed or reversed. Exercise interventions can improve mobility and functional ability. Nutritional screens can also be used. Sarcopenia can be corrected. There is no evidence available for the optimal intervention for improving post-operative outcomes. 

      4. Malnutrition (e.g. BMI <18.5) is a strong predictor of mortality, morbidity, increased LOS and readmission rates. All-cause mortality increases at BMI < 24 and doubles when BMI < 22 in men and 20 in women. Albumin is an inexpensive and routinely available biomarker that - when decreased - is associated with increased surgical risk and mortality. Unfortunately, it is neither sensitive, nor specific for malnutrition. 

      5. Post-operative delirium is associated with prolonged LOS and higher mortality. CAM, DSI or NuDESC screens can be used. Various pre-operative risk factors (i.e. malnutrition, hypo/hyperNa, pre-existing cognitive impairment etc.) and peri-operative factors (emergency surgery, longer surgery, more bleeding etc.) can identify patients at increased risk. Benzodiazapenes should then be avoided, depth of anesthesia controlled (40-60 via BIS according to some) and pain tightly controlled to minimize the risk. Low-dose haloperidol or atypical neuroleptics can be used for severe cases once delirium has developed. Compared to sevoflurane, TIVA is associated with less post-operative delirium.

      6. Post-operative cognitive dysfunction is an elusive clinical entity associated with impaired memory, concentration, executive function and mental processing speed that arises after a surgical procedure and is associated with increased mortality, inability to work and social dependency. Found in ~26% of >60 y/o patients 1 week post-op and 9.9% 3 months out, compared to ~3% in controls. Numerous pre-operative and operative risk factors have been identified. There are no guidelines for management or preference for any particular anesthetic technique. Regional anesthesia does not decrease risk. Patients at risk should be identified and counselled appropriately. 

      Partridge JS, Harari D, Dhesi JK. Frailty in the older surgical patient: a review. Age Ageing. 2012;41(2):142-147. doi:10.1093/ageing/afr182

      Bottom Line: This 2012 review article highlights that as more elderly patients are undergoing surgical procedures, many of these patients are "frail" - which has been shown to be an independent risk factor for adverse post-operative outcomes.


      Furthermore, as more evidence is emerging that frailty is potentially modifiable, the natural question arises of whether frailty should be regularly screened for in the pre-operative assessment of the elderly patient and whether optimisation of the "frail syndrome" can improve post-operative outcomes. 

      Major points:


      1. The case for assessing frailty pre-operatively is based on frailty being an independent risk factor for post-operative major morbidity, mortality and prolonged LOS. Assessing frailty can serve two purposes: (1) risk stratify patients so that they can make a fully informed decision, (2) highlight areas for pre-operative optimisation should the decision be made to proceed with surgery. 

      2. The difficulty in assessing frailty is primarily because there is no consensus universal definition of frailty. There are multiple tools available to the clinician, each with their own pros and cons. The Edmonton Frail Scale is one such tool which has been validated for use by non-geriatricians and can be completed in less than 5 minutes. 

      3. Because of varying definitions and differences among populations, prevalence of frailty among older surgical patients varies greatly in the literature (anywhere from 4.1%-50%) with post-discharge institutionalization rates as high as 30%. This raises the question as to whether frailty can be modified pre-operatively and whether those modifications can improve post-operative outcomes. The author discusses emerging evidence on the potential the roles of exercise, nutrition and pharmacotherapy (albeit to a lesser extent) in improving long-term outcomes in frail patients. Whether or not these effects exist in surgical patients is not yet known.

      Michel JP, Cruz-Jentoft AJ, Cederholm T. Frailty, Exercise and Nutrition. Clin Geriatr Med. 2015;31(3):375-387. doi:10.1016/j.cger.2015.04.006

      Bottom line: In this 2015 review article, the author posits that the European prevalence of frailty (5.8-27.3%) and pre-frailty (34.6-50.9%) varied across countries and was associated with exponential increases in mortality between the three groups (robust, pre-frail, frail). With time there is a back-and-forth transition between the three states,  but a gradual trend toward the frail state, with death as the eventual consequence. 

      Interventions involving exercise with or without nutritional supplementation and targeted interventions on specific frailty components have been shown to effectively delay or even reverse the frailty process. 

      Factors associated with transition to a more frail state varied between genders. Older age, previous cancer, previous hospitalization for men. Older age, COPD, previous stroke, hospitalization and OA for women. Factors associated with improvements are lower age, higher MMSE score, and absence of stroke for men. Improvement is seen with lower age, no diabetes, no prior hospitalization and higher socioeconomic status in women.

      McIsaac DI, Aucoin SD, van Walraven C. A Bayesian Comparison of Frailty Instruments in Noncardiac Surgery: A Cohort Study. Anesth Analg. 2020 Nov 30. doi: 10.1213/ANE.0000000000005290. Epub ahead of print. PMID: 33264118

      Bottom line: Frailty is a complex syndrome encompassing age, medical comorbidities as well as other dimensions, and is associated with increased risk of adverse post-operative outcomes. Research in this area can be impeded by the heterogeneity of frailty measurement instruments. 

       

      The RAI-A (risk analysis index-administrative) is a multidimensional frailty assessment instrument. Compared to the more comorbidity-focused 5-item modified frailty index (mFI-5), the RAI-A appear superior for predicting outcomes for inpatient noncardiac surgery. It also improves predictive performance when added to the NSQIP calculator, and can be used more consistently in research related to frailty. 

       

      Major points:

      1. Frailty is a multidimensional syndrome and important prognostic factor for post-operative outcomes. It is a complex concept that encompasses age as well as comorbidities. There is considerable heterogeneity in the ways to measure frailty, which can hinder the translation of research in this area. 

      2. Two tools commonly used in research using the NSQIP data are the RAI-A (risk analysis index-administrative) and 5-item modified frailty index (mFI-5).  The mFI-5 has a heavy focus on comorbidities, whereas the RAI-A is more multidimensional and appears more reflective of nature of the frailty syndrome. 

      3. Using a Bayesian approach to model assessment, RAI-A appears superior to mFI-5 as a predictive instrument for post-operative outcomes in patients with frailty, including when added to the NSQIP calculator for noncardiac inpatient surgery. This further enforces the idea that frailty is a multidimensional concept, and that the instruments chosen for consistent use for research in this area should be reflective of this idea. 

      Hall DE, Arya S, Schmid KK, Carlson MA, Lavedan P, Bailey TL, Purviance G, Bockman T, Lynch TG, Johanning JM. Association of a Frailty Screening Initiative With Postoperative Survival at 30, 180, and 365 Days. JAMA Surg. 2017 Mar 1;152(3):233-240. doi: 10.1001/jamasurg.2016.4219. PMID: 27902826; PMCID: PMC7180387.

      Bottom Line

       

      After implementing a quality improvement project called the Frailty Screening Initiative (FSI) in a prospective cohort of 9153 patients who underwent surgery, patient postoperative mortality decreased significantly at 30, 180, and 365 days compared to those who were not screened for frailty and underwent standard cardiopulmonary testing and preoperative anesthetic assessment. The study highlights the feasibility of facility-wide frailty screening in elective surgery with the potential to improve postoperative survival among frail patients through systemic administrative screening, review, and optimization of perioperative plans. The absolute reduction in 180-day mortality of frail patients was more than 19%. This should be noted in context of potential high-risk patients choosing not to proceed with surgery, where decision-making was facilitated by implementation of frailty screening. Despite improved survival, the quality of surviving life was not evaluated in this study.

       

      Major Points

       

      1. Frailty predicts postoperative mortality and morbidity more than just age alone and high-risk patients require a multidisciplinary approach to perioperative management.

      2. The use of a frailty screening tool provides the opportunity to manage patient expectations of surgery and postoperative recovery and clarify patient goals of care for high-risk patients by including palliative care involvement.

      3. In this paper, the Risk Analysis Index (RAI) encompasses multiple domains of frailty (comorbidity, functional status, nutrition and cognition), which provides a more comprehensive frailty assessment than the modified Frailty Index that has been validated in surgical populations.

      4. A patient’s frailty score impacted the choice of procedure and the anesthetic plan, and occasionally changed the decision to operate.

      5. 180-day mortality increased from 1.6% among those with the lowest RAI scores to 29.6% with the highest RAI scores. Overall, 180-day mortality decreased from 23.9% to 7.7% after FSI implementation in the frail population.

      6. Using the RAI to identify frail patients and targeting interventions based on geriatric domains, the FSI effectively reduced longer-term risks associated with frailty itself based on the 180-day mortality marker, suggesting that it takes more than 30 days to detect the effect of these interventions and highlights the limitation of 30-day outcomes noted in other frailty literature.

      Hshieh TT, Yang T, Gartaganis SL, Yue J, Inouye SK. Hospital Elder Life Program: Systematic Review and Meta-analysis of Effectiveness. Am J Geriatr Psychiatry. 2018 Oct;26(10):1015-1033. doi: 10.1016/j.jagp.2018.06.007. Epub 2018 Jun 26. PMID: 30076080; PMCID: PMC6362826.

      Bottom Line

       

      The Hospital Elder Life Program is the original evidence-based model created in 1993 whereby modifiable delirium risk factors are targeted with multicomponent non-pharmacological interventions to prevent delirium. The HELP components are: sleep enhancement, cognitive stimulation, early mobilization, hydration and feeding assistance, vision and hearing optimization. The authors of this paper conducted an updated meta-analysis of 14 studies which confirmed the effectiveness of the HELP model with significant reductions in delirium incidence (odds ratio [OR] 0.47) and falls (OR 0.58) with a trend towards decreased length of stay and institutionalization. Overall, the HELP model is an effective and well-tested model to improve outcomes in older adults admitted to hospital.

      Eamer G, Taheri A, Chen SS, Daviduck Q, Chambers T, Shi X, Khadaroo RG. Comprehensive geriatric assessment for older people admitted to a surgical service. Cochrane Database Syst Rev. 2018 Jan 31;1(1):CD012485. doi: 10.1002/14651858.CD012485.pub2. PMID: 29385235; PMCID: PMC6491328.

      Bottom Line

       

      Comprehensive geriatric assessments are detailed consultations led by geriatricians as part of a multidisciplinary collaboration to evaluate the medical, psychosocial and functional capabilities of an older adult. The authors performed a meta-analysis of 8 randomized controlled trials to compare the effectiveness of CGA versus standard surgical care on post-operative outcomes of older people admitted to hospital. Seven of these trials were in hip fracture patients and one trial was in surgical oncology patients. The authors found that CGA reduces discharge to an increased level of care (RR 0.71) and probably reduces mortality in older adults with hip fracture (RR 0.85) and delirium rates (RR 0.75). There was a slight reduction in length of stay but no difference in re-admission rates. Overall, CGA has been shown to improve outcomes in older adults with hip fractures but more studies are needed in other surgical patients.

      Qin C, Jiang Y, Lin C, Li A, Liu J. Perioperative dexmedetomidine administration to prevent delirium in adults after non-cardiac surgery: A systematic review and meta-analysis. J Clin Anesth. 2021 Oct;73:110308. doi: 10.1016/j.jclinane.2021.110308. Epub 2021 Apr 28. PMID: 33930679.

      Bottom Line

       

      The authors conducted a meta-analysis of 13 randomized controlled trials including 4015 patients to evaluate the effectiveness of dexmedetomidine in preventing post-operative delirium after non-cardiac surgery. The pooled result showed that dexmedetomidine significantly reduced the risk of postoperative delirium (RR 0.60) compared to placebo. In the subgroup analysis, this association remained significant only for those patients over 65. Dexmedetomidine administration was associated with more intraoperative bradycardia (RR 1.39) and hypotension (RR 1.25) but there were no statistical differences in all-cause mortality rate or length of stay. This meta-analysis suggests promising evidence that dexmedetomidine could significantly reduce the incidence of postoperative delirium in older adults after non-cardiac surgery. More research is warranted to assess potential side effects in this population.

      Pun BT, Balas MC, Barnes-Daly MA, Thompson JL, Aldrich JM, Barr J, Byrum D, Carson SS, Devlin JW, Engel HJ, Esbrook CL, Hargett KD, Harmon L, Hielsberg C, Jackson JC, Kelly TL, Kumar V, Millner L, Morse A, Perme CS, Posa PJ, Puntillo KA, Schweickert WD, Stollings JL, Tan A, D'Agostino McGowan L, Ely EW. Caring for Critically Ill Patients with the ABCDEF Bundle: Results of the ICU Liberation Collaborative in Over 15,000 Adults. Crit Care Med. 2019 Jan;47(1):3-14. doi: 10.1097/CCM.0000000000003482. PMID: 30339549; PMCID: PMC6298815.

      Bottom Line

       

      Historically, common practice in critically ill patients included deep sedation, immobilization and limited family access. The ABCDEF bundle is a multicomponent ICU intervention that focuses on making patients more awake, cognitively engaged and physically active. Its components include: Assess, prevent and manage pain; Both spontaneous awakening and breathing trials; Choice of analgesia and sedation; Delirium assessment, prevention and management; Early mobility and exercise; Family engagement/empowerment. The authors performed a prospective multicenter cohort study involving 68 ICUs and over 15000 patients. They found that complete ABCDEF performance had significantly lower hospital death within 7 days (adjusted HR 0.32), next-day mechanical ventilation (adjusted OR 0.28), delirium (adjusted OR 0.60), coma (adjusted OR 0.35), physical restraint use (adjusted OR 0.37), and discharge to a facility other than home (adjusted OR 0.64). In summary, applying a multicomponent intervention in the ICU is a simple way to improve several outcomes associated with a critical care admission.

      Burry L, Mehta S, Perreault MM, Luxenberg JS, Siddiqi N, Hutton B, Fergusson DA, Bell C, Rose L. Antipsychotics for treatment of delirium in hospitalised non-ICU patients. Cochrane Database Syst Rev. 2018 Jun 18;6(6):CD005594. doi: 10.1002/14651858.CD005594.pub3. PMID: 29920656; PMCID: PMC6513380.

      Bottom Line

       

      Antipsychotics are frequently used in the treatment of delirium in hospitalized patients with the assumption that it will shorten the duration of delirium or resolve symptoms. The authors of this Cochrane systematic review and meta-analysis included 9 randomized controlled trials of 727 non-ICU patients admitted to hospital. Antipsychotics did not reduce mortality, delirium severity or resolve delirium symptoms compared to non-antipsychotic drugs or placebo. No trials reported on duration of delirium, hospital length of stay or discharge disposition. Overall, the evidence does not support the use of antipsychotics to improve outcomes in hospitalized patients with delirium.

      Leung JM, Sands LP, Chen N, Ames C, Berven S, Bozic K, Burch S, Chou D, Covinsky K, Deviren V, Kinjo S, Kramer JH, Ries M, Tay B, Vail T, Weinstein P, Chang S, Meckler G, Newman S, Tsai T, Voss V, Youngblom E; Perioperative Medicine Research Group. Perioperative Gabapentin Does Not Reduce Postoperative Delirium in Older Surgical Patients: A Randomized Clinical Trial. Anesthesiology. 2017 Oct;127(4):633-644. doi: 10.1097/ALN.0000000000001804. PMID: 28727581; PMCID: PMC5605447.

      Bottom Line

       

      Despite sound principles of decreasing delirium with decreased opioid consumption and effective multimodal analgesia, perioperative administration of gabapentin did not reduce delirium or length of stay in elderly patients. Opioid consumption on post operative day one was lower in the gabapentin group. While statistically significant, one could argue that opioid consumption differences were not clinically significant differences given the same median consumption was achieved between groups and the 75th quartile between groups only saw 4.8mg less morphine equivalents administered to the gabapentin group on post operative day one. Ultimately, delirium remains a complex multifactorial disease state that is not easily prevented nor treated pharmacologically.

      Major Points

       

      1. 750 patients of 65 years of age and greater undergoing spine, hip replacement, or knee replacement surgeries were randomized to placebo or gabapentin in addition to their analgesia regiment of a femoral nerve block for knee surgeries, lumbar plexus block for hip surgeries, or on-demand patient controlled analgesia (PCA) for spine surgery. Breakthrough pain for hip and knee surgery patients received IV hydromorphone via PCA and oral opioids. The protocol was sound in randomization and blinding to anesthesiologists.

      2. Gabapentin 300mg orally three times per day was the dose administered to the intervention group. This value was derived from a previous study that achieved analgesia for 50% of older patients with trigeminal neuralgia. The patients were previously gabapentin naïve as the exclusion criteria included previous gabapentin/pregabalin treatment. With a common side effect of gabapentin being sedation, these dosing regiments in naïve patients may have contributed to sedation which may have precipitated or worsened delirium. To this comment, however, oversedation scores (classified as RASS -4 to -5) were not significantly different between groups.

      3. The anesthetic technique included general anesthesia, general anesthesia and regional anesthesia combination, and regional anesthesia alone. No differences between placebo and gabapentin groups were discovered on covariate analysis. Limitations opioid sparing effect of gabapentin were potentially nullified by effective regional anesthesia in this study.

      4. Neither delirium, length of stay, nor pain scores were statistically different between the placebo vs. gabapentin groups.

      5. There were higher delirium rates in the patient groups with higher pain scores, regardless of placebo or gabapentin group. This supports known association with perception of pain and delirium.

      6. Studies such as this one provides good context as to why negative and neutral studies are important and underrepresented in the literature. Despite being rooted in good logic and a reassuring pilot study, it shows that “more” analgesia adjuncts may not be superior. Accordingly, clinical decision making should be based on risk benefit analysis.