As a large population of older adults undergoes surgical procedures, studies have shown that the biggest risk for complications comes from comorbid conditions and geriatric syndromes.
To address the needs of this population, Dr. Paula E. Lester and her colleagues from New York University developed an assessment and intervention protocol involving several disciplines to provide perioperative care for surgical patients aged 75 and older.
“Common physiologic changes in older adults often raise the risk for surgical complications and lead to increased morbidity and mortality,” Dr. Lester said. “Compared to younger patients admitted to an acute care surgery service, individuals 80 years of age and older have a higher risk of complications, are more likely to require [intensive care unit] admission, and have a longer hospital length of stay. Furthermore, increasing life expectancies paired with age-related comorbidities have resulted in the rise of older adults undergoing surgery.”
The researchers wanted to investigate whether they could develop standardized protocols for these patients, especially considering they had different requirements from younger patients, added coauthor Linnea A. Drew, a certified physician assistant.
The protocol consists of three phases.
Pre-hospital. Pre-admission testing assessed patients for cognitive deficits, mobility, age, nutrition, and delirium, flagging high-risk individuals. A Geriatric Surgery Quality Committee met weekly to review the completed screening tools of high-risk patients and make recommendations for these patients.
Hospital. A geriatric nurse champion received a list of patients to arrive and the results of their pre-admission testing. The nursing staff during each shift assessed mobility, requested physical therapy when warranted, and assessed for delirium. A geriatric pharmacist reviewed the patients’ medications preoperatively and upon admission. Case managers made rounds among high-risk patients at least once a week to discuss nutrition, mobility, and cognition, and to revise goals.
Post-discharge. Discharge planning began preoperatively; home care visits were set up before discharge, and a one-time visit was performed.
The researchers compared 242 individuals who underwent the study’s preintervention protocol with 250 individuals from a year before the intervention was developed. They found that 6.6% of individuals who received the preintervention protocol had postoperative delirium compared with 11.9% of patients who did not. Also, mortality decreased from 2.4% to 0.4%, and readmission decreased from 6% to 4.1%. These results were not statistically significant.
“Even though our effect wasn’t significant, you could see from our study there were improvements in many of our metrics due to the initiatives and protocols we implemented,” Ms. Drew said. “If we were able to continue the pilot and also expand to a larger patient population, we predict it would have shown significant effects.”
“The protocol we implemented was designed through a rigorous process through the ACS Geriatric Surgery Quality Program with input from many stakeholders and experts,” Dr. Lester added. “Our results actually show improvement in reducing post-op pressure ulcer, post-op delirium, 30-day readmission, and 30-day mortality. However, the data did not reach statistical significance, likely because the sample size was too small. Implementation of this protocol in a larger hospital, or multiple settings, or in a hospital with poor-performance measures, or in a high-performing hospital but over a longer period of time might lead to finding statistical differences.”
Given that these various assessments are time-consuming and not sufficiently reimbursed, “I would encourage health care systems to implement as much of the protocol as they can into their current workflow,” Dr. Lester added.
Source: Lester PE, et al. Interdisciplinary Protocol for Surgery in Older Persons: Development and Implementation. J Am Med Dir Assoc. [Manuscript number: JAMDA-D-21-01205R1].
Surgical Hospitalizations and Cognitive Trajectories
Healthy older adults are unlikely to experience long-term cognitive changes after surgery and anaesthesia, Australian researchers found in a secondary analysis of data from a population-based, longitudinal cohort study.
Led by Lucia Chinnappa-Quinn, PhD, of the University of South Wales, researchers used four biennial waves of prospective neuropsychological data to assess cognition among 1,026 individuals aged 70 to 90 years who participated in the Sydney Memory and Ageing Study. Of 3,352 hospitalizations, 1,625 (48.5%) were surgical, and 1,727 (51.5%) were medical.
The researchers found that overnight surgical hospitalizations were not associated with lower baseline global cognition or rate of change in global cognition in the medium to long term. By contrast, medical hospitalizations were associated with a steeper cognitive decline.
Source: Chinnappa-Quinn L, et al. Surgical Hospitalization Is Not Associated With Cognitive Trajectory Over Six Years in Healthy Older Australians. J Am Med Dir Assoc. [Manuscript number: JAMDA-D-21-01264R1].
Jeffrey S. Eisenberg, a freelance writer in the Philadelphia area, compiled this report.
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