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Skip to 0 minutes and 15 seconds Why are older patients at a higher risk of perioperative morbidity and mortality? I think there are probably three different reasons as to why they’re at particularly high risk. The first is, of course, ageing is associated with declining physiological function and status. So a fit eighty-year-old is still not as fit as a fit 20-year-old. The second reason is that ageing is associated with increasing multi-morbidity. So if you take the average 75-year-old in the UK, they’re likely to have at least three co-existing medical conditions additional to whatever they’ve presented to surgery with. So they’re likely to have multi-morbidity.

Skip to 0 minutes and 56 seconds And the third thing is that ageing is associated with geriatric syndromes such as frailty and cognitive impairment both of which have also been associated with a worse postoperative outcome. So it’s probably that interplay of all three of those things that physiological status, the multi-morbidity, and the geriatric syndromes that particularly make this into a high risk population.

Skip to 1 minute and 22 seconds Why did you feel there was a need for POPS? There’s probably a few different reasons. I think firstly, it was our clinical experience as geriatricians being called to surgical wards seeing patients who’d come in sometimes for elective surgery sometimes for emergency having had a number of medical complications, functional deterioration, cognitive problems having been on the ward being seen by lots of different medical teams but nobody really taking that overview of what was happening with the patient. And then geriatricians being called in fairly late to try to come and solve some of the issues that had occurred. So it’s partly that clinical experience.

Skip to 2 minutes and 2 seconds It was also the fact that at a time with the National Service framework for older people, there were a number of policy drivers saying that we needed to have much more specialist input for older patients in different surgical settings. And also at the time, we were starting to see literature coming out, both in the anaesthetic and the surgical field really very clearly demonstrating that older people were having worse outcomes in comparison to younger patients. So again, that combination of service, of policy drivers, of our clinical experience, and the data that really pushed us towards thinking that this was needed. How did other groups react to the introduction of POPS? So it varied very much certainly patients wanted it.

Skip to 2 minutes and 49 seconds So when we explained to patients what we were trying to do, they were very much up for it and felt that they needed one person looking after them throughout their surgical pathway and recognised the need for this to not be the surgeon because the issues that they had were beyond the immediate surgical problem that they were presenting with. In terms of the surgeons, there was a very mixed kind of response, really, to having geriatricians involved in their patient group. Though some of the surgeons absolutely recognised the need for collaborative working whereas for others, it was a big behavioural, cultural change.

Skip to 3 minutes and 27 seconds That took a little bit of time for them to start to recognise the added value of these kinds of very collaborative teams that they can bring to the clinical setting.

Skip to 3 minutes and 40 seconds Does POPS work? So over the years, we’ve been kind of working our way through the MRC framework for complex interventions and trying to evaluate the approach that we’ve embedded into routine clinical care. And so we started off with a pre and post study in orthopaedic elective surgery and demonstrated reductions in medical complications, multidisciplinary complications, and a very significant reduction in length of stay. Of course, that was a very small pre and post study with all the limitations that come with that. We’ve then gone on to do a randomised controlled study within vascular elective patients and again shown reductions in medical complications, discharge related issues, and again a 40% reduction in length of stay.

Skip to 4 minutes and 27 seconds Moving on from that, we now need to look at how we can start to implement these types of services and how we can demonstrate evidence of effectiveness on a larger scale by probably using quality improvement methodology, which we started to do in urology but now starting to look more wider afield at other hospital settings as well. What is the future for perioperative care of the older patient? I think there are lots of exciting avenues for research in this field and particularly within older patients. There are issues which are very relevant to specific diseases. So how do we manage anaemia in older patients? What do we do for that preoperatively, postoperatively?

Skip to 5 minutes and 12 seconds There are other things which are really very much looking at the syndromes which older people present with such as frailty and cognitive issues. And again. How do we assess, manage, optimise, and improve outcomes? And which outcomes should we be looking at? And then there’s the health services research angle as well to see whether these kinds of collaborative models of care are effective both in terms of clinical outcomes, but also in terms of cost as well– financial cost. And seeing how we approach that for the future.

POPS - the Proactive care of Older people having Surgery service

Dr Jugdeep Dhesi is a consultant in the department of health and ageing at Guy’s and St Thomas’. She is also the founder and clinical lead for the POPS (Proactive care for the Older Person undergoing Surgery) service.

In the video Dr Dhesi talks about the need for a dedicated service for older people having surgery and the evidence base that supports the service.

Dr Dhesi was also involved in producing a consensus document established by the Association of Anaesthetists of Great Britain and Ireland (AAGBI) which aimed to give guidelines on the peri-operative care of the elderly. It was put together by experts from the College of Emergency Medicine, the British Geriatrics society, Age Anaesthesia Association, the Intensive Care Society and the Royal College of Surgeons.

The full document can be accessed here, the main summary points are included below:

  • Increasing numbers of elderly patients are undergoing an increasing variety of surgical procedures.
  • There is an age-related decline in physiological reserve which may be complicated by illness, cognitive decline, frailty and polypharmacy.
  • The elderly are at a relatively higher risk of morbidity and mortality following elective surgery and even more so with emergency surgery.
  • Multidisciplinary care improves outcomes for elderly surgical patients. Protocol-driven pathways must be individualised to suit each patient. It is advocated that a senior geriatrician should coordinate perioperative care for the elderly with input from senior anaesthetists, surgeons and other specialists.
  • The aims of care should be to treat elderly patients in a timely, dignified manner, to optimise rehabilitation and avoid postoperative complications. This should increase the likelihood of patients returning to their pre-morbid place of residence and maintain the continuity of care.
  • Postoperative delirium is common and underdiagnosed – it delays rehabilitation. A multimodal strategy should be used to prevent postoperative delirium.
  • Postoperative pain is underappreciated in the elderly patient, particularly those with cognitive disorders. Anaesthetists should administer opioid sparing analgesia where possible.
  • Elderly patients should be assumed to have capacity to make their own decisions – good communication is essential to this. If that capacity is lacked, proxy information should be sought to decide on the patients best interests
  • Anaesthetists should not ration surgical or critical care based on age alone but they must be involved in decisions about utility of surgery and resuscitation.
  • Specialists are encouraged to become involved in national audit projects and research specifically involving elderly surgical patients as the evidence base remains poor.

The final statement Dr Dhesi made in her video looked to the future of perioperative medicine and cost effective treatments. The next few steps will expand on this to look at the changing demographic and the implications of cost in perioperative medicine.

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Perioperative Medicine in Action

UCL (University College London)