Acute Care of Older Surgical Patients Dr Shane O Hanlon Consultant Geriatrician St Vincent s University Hospital IHFM 8 th Nov 2017
NCEPOD 2010 overall care % 50 45 40 35 30 25 20 15 10 5 0 Good practice Room for improvement Poor
Access all ages (RCS 2012) Too much variation in procedures by age Increase in emergency procedures in older pts
Surgery and older people Decisions based on age alone Lack of shared decision making Pre-op assessment on day of surgery cancellations, people sent home Poor outcomes post-op with preventable adverse events AKI, poor glycaemic control, VTE
Need for a new approach?
Need for a new approach? Collaborative approach RCOA Perioperative Medicine document Comprehensive pre-op Ax Enhanced multidisciplinary working & shared decision making No age cut-offs (law) Routine geriatrician input for surgical pts
My NHS role 2014-17 Surgical Liaison 75% Joining surgeons on their post-take ward rounds and in clinic Seeing patients with them Helping trainee doctors Available on the ward during the daytime Clinic for comprehensive geriatric assessment (CGA)
Why do geriatricians exist? Single organ focus no longer useful for most pts Only 16% of pts with COPD *only* have COPD Majority of work in healthcare now is looking after frail older people Does this apply to surgery?
Example case: Margaret 87 year old lady with dementia, presenting with iron deficiency anaemia Colonoscopy showed caecal mass Histology - adenocarcinoma CT - no spread Niece doesn t want her to know about cancer What should we do?
Cognitive status Social supports Functional status Environment review CGA = comprehensive geriatric assessment Comorbidity Medication review Nutritional status Mood
Cognitive status Social supports Functional status Environment review CGA = comprehensive geriatric assessment Comorbidity Medication review Nutritional status Mood
Margaret: needs assessment Dementia: moderate. Poor short term memory but living alone independently without any carers. Goes out twice a week to community centre Niece visits regularly Unable to consent (lacks capacity) Medical: bronchiectasis, stable since 1980s No regular medications Examination: normal except chronic lung crackles
Margaret: outcome Best interests meeting Surgeon, anaesthetist, geriatrician, niece, patient, cancer CNS all in same room! Detailed consideration of risks and benefits Admitted next week, lap right hemicolectomy 5 day stay in hospital (brief delirium CNS input) Discharged successfully (OT home visit prior) Telephone 3+12 months later - asymptomatic
Prognosis based on frailty Walter LC, Covinsky KE. Cancer screening in elderly patients: a framework for individualized decision making. JAMA 2001
Geriatrician input recommended for >70 years Achieved for 19%
Developing Evidence Base Integrated orthogeriatric care better than liaison service improved quality & lower 30 day mortality Kristensen et al, Age & Ageing 2015 Older people have most to gain from orthopaedic enhanced recovery Starks et al, Age & Ageing 2014 and from laparoscopic colorectal surgery Moug et al, Annals Med Surg 2015 Frailty assoc with longer LOS and post-op complications Partridge et al, Intl Jrn Surgery 2015
Frailty Evidence Base Frailty better than ASA (!) for predicting postop mortality, complics, d/c to home Kim et al, JAMA Surgery 2014 Assessment of pre-op frailty assoc w reduced 1 yr mortality for frail pts (34%-> 11%) Hall et al, JAMA Surgery 2017 Association btw volume of frail patients and higher survival rates for them McIsaac et al, Anesthesiology 2017
Recommendations Provide geriatrician input for frail patients being considered for surgery Integrated care model works best (my opinion) Need a lot more collaboration between surgeons/anaesthetists/geriatricians NELA is a good way to start Frailty should be top of the agenda