An age old problem

In the previous step we discussed ideal perioperative care for the elderly and the barriers to providing this. Here we will summarise a 2010 report from the National Confidential Enquiry into Patient Outcome and Death (NCEPOD) titled “An Age Old Problem: A review of the care received by elderly patients undergoing surgery”. [1]

Setting the scene

The UK has a rapidly expanding population of elderly people, currently 1 in 5 people (12 million) are pensioners. This group is predicted to double in the next 25 years and treble in the next 35. [2] The main reasons for surgical admission in this group are fractured hip (around 50%), laparotomy (13%) and amputation. [3] Care of the patient with the fractured hip is covered more extensively in week 3.

Laparotomy and bowel resection is one of the most commonly performed operations in both the elective and emergency setting. These patients may have inadequate oral intake relative to fluid loss resulting in acute electrolyte abnormalities superimposed on reduced renal reserve which may be complicated further by sepsis and third space fluid losses. These patients require skilled resuscitation and careful perioperative management of cardiovascular parameters and fluid balance.

In this study NCEPOD reviewed a sample of deaths following emergency and elective surgery in the elderly population in order to establish shortcomings in their care and provide further recommendations for perioperative care of the elderly. Information was collected on each individual case by a review of case note extracts as well as questionnaires from surgeons, anaesthetists and an organisational questionnaire.

The sample aimed to identify key learning points based on:

  • Fluid management
  • The seniority of clinicians involved in intra-operative care
  • Delays in surgery
  • Anaesthetic management including pre-operative assessment
  • Acute pain management
  • Post-operative cognitive dysfunction
  • Use of critical care facilities
  • Nutrition
  • Comorbidities
  • Medications including thromboembolism prophylaxis
  • Consent
  • Prevention of peri-operative hypothermia

Key findings

A general assessment of the standards of care achieved is shown below.

View the graphic on page 21 of the PDF.

The key finding are covered over several chapters in the full document but are summarised here in the points below:

Hospital facilities and multidisciplinary care of the eldery

  • There was a relative paucity of input from a Medicine for the Care of Older People (MCOP) physician at all stages of care
  • Mechanisms for assessment of nutrition and mental capacity were absent from a number of sites. Documentation of nutritional assessment and evidence of appropriate management was extremely poor

Patient comorbidities

  • Comorbidity was extremely common in the elderly surgical populations with frailty being clearly identified. Acute kidney injury at the time of admission was an additional important cause of comorbidity
Comorbidity n* %
Ischaemic Heart Disease 814 81.3
Hypertension 478 47.8
Respiratory disease 280 28.0
Renal disease 217 21.7
Previous Transient Ischaemic Attack (TIA) & Stroke 197 19.7
Dementia 185 18.5
Memory impairment 144 14.4
Diabetes 136 13.6
Osteoporosis or previous bone fracture 132 13.2
Parkinson's disease 24 2.4
Delirium 23 2.3
Not answered 27
  • Disabilities (including hearing and visual loss) were common and not well documented which could have led to difficulties in caring for these patients
  • Acute illness was complicated by pre-existing memory loss and dementia
  • Documentation of mental capacity was poor, though when patients were unable to consent the correct procedures were followed in the majority of cases
  • Some patients were receiving a large variety of medications with a serious risk of drug interactions

Pre-operative care

  • Risk assessment is particularly difficult in the elderly and should include input from senior surgeons, anaesthetists and MCOP clinicians
  • A clinically significant delay occurred between admission and operation in over 1 in 5 patients
  • Pain was poorly assessed and documented

Intra-operative care

  • Consultant involvement in care was high in this group of patients but there was a lack of documentation of temperature monitoring. Perioperative hypotension was a very common event.

View the graphic on page 70 of the PDF.

View the graphic on page 74 of the PDF.

  • Post-operative acute kidney injury was related to poor intra-operative management of fluids and cardiovascular status and complicated further by poor post-operative fluid management

Post-operative care

  • Epidurals and PCAs were used sparingly in this population
  • Level 2 and 3 care was utilised more than 10 years ago, however, it was still planned less often than would be expected

Remediable factors

Out of 1098 cases included in the peer review, 302 cases were identified where specific remediable factors were identified in the process of care.

Recurring themes n*
Seniority 67
Team structure 70
MCOP input 29
Decision making 84
Delay 54
Pre-operative preparation 105
Failure to optimise patient 30
Post operative care 53
Aggressive surgery without after care 17
Poor fluid resuscitation 21
Poor communication 39
Consent 15
Poor documentation 71
Poor analgesia 7

Key recommendations

  • Routine daily input from Medicine for the Care of Older People should be available to elderly patients undergoing surgery
  • Comorbidity, disability and frailty need to be clearly recognised as independent markers of risk in the elderly
  • Delays in surgery for the elderly are associated with poor outcome. This should be audited alongside agreed standards
  • All elderly surgical admissions should have a formal nutritional assessment during their admission
  • Temperature monitoring and management of hypothermia should be recorded in the anaesthetic record
  • There should be clear strategies for the management of intra-operative low blood pressure in the elderly to avoid cardiac and renal complications
  • There is an ongoing need for level 2 and 3 (ITU/HDU) care to support major surgery in the elderly
  • For less major surgery extended recovery and high observation facilities in existing wards should be considered
  • Post-operative acute kidney injury is avoidable and should not occur. There is a need for education amongst physicians, surgeons and anaesthetists around assessment of risk factors.
  • Clear and specific guidance on recognition and treatment o pain in the elderly should be widely available
  • Greater vigilance is required when elderly patients with non-specific abdominal symptoms present to exclude significant surgical pathology

Before moving on take a moment to think about the findings and recommendations laid out in this paper. How closely do they mirror your own reflections on perioperative care for the elderly that you discussed in the previous step? Were there any findings that surprised you?


References

  1. NCEPOD report. An Age Old Problem
  2. Office of National Statistics
  3. NCEPOD Report. Extremes of Age

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This article is from the free online course:

Perioperative Medicine in Action

UCL (University College London)