Interventions to Improve Clinical Outcomes in Older Adults Admitted to a Surgical Service: A Systematic Review and Meta-analysis

Thillainadesan, Janani; Yumol, Minna F.; Hilmer, Sarah N.; Aitken, Sarah; Naganathan, Vasi

doi:10.1016/j.jamda.2020.03.023

Cited by 20 publications

(26 citation statements)

References 42 publications

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“…Determining accurate methods for early identification of patients at risk of developing geriatric syndromes is also important for targeting and evaluating interventions. In our systematic review and meta‐analysis of 24 controlled trials of perioperative geriatric interventions in older non‐orthopedic surgical patients, multicomponent inpatient geriatric programs (usually based on the Hospital Elder Life Program) and preoperative comprehensive geriatric assessment were found to reduce delirium 44 . Only 5 of the 24 included studies were in frail surgical patients.…”

Section: Discussionmentioning

confidence: 99%

The Prognostic Performance of Frailty for Delirium and Functional Decline in Vascular Surgery Patients

Thillainadesan

Mudge

Aitken

et al. 2020

J American Geriatrics Society

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Background Frailty in older vascular surgery patients is associated with increased mortality, hospital stay, and morbidity. The association of frailty with hospital‐acquired geriatric syndromes such as delirium and functional decline has not been well studied. Objectives To investigate the association between frailty and hospital‐acquired geriatric syndromes in older hospitalized vascular surgery patients, and to evaluate the prognostic performance of the frailty index (FI) and the Clinical Frailty Scale (CFS) for delirium and functional decline. Design Prospective cohort study. Setting Acute care academic hospital. Participants Patients aged 65 years or more admitted to a tertiary vascular surgery unit (N=150). Measurements Frailty was assessed using the FI and CFS. The adjusted association of frailty status with delirium and functional decline was assessed using logistic regression analysis. The prognostic performance of FI and CFS was determined by assessing C‐statistic and positive and negative predictive values (PPV and NPV). Results Of 150 participants, FI identified 34 (23%) and CFS identified 45 (30%) as frail. Frailty was an independent predictor of delirium (FI adjusted odds ratio, odds ratio (OR) = 5.66, 95% confidence interval (CI) = 1.53–21.03; CFS adjusted OR = 4.07, 95% CI = 1.14–14.50), but not functional decline. FI and CFS showed acceptable prognostic performance for delirium (C‐statistic 0.74), but not functional decline (C‐statistic 0.63–0.64). For both outcomes, the FI and CFS had high NPV (86–96%), and low PPV (22–29%). Conclusion Frail older vascular surgery patients are more likely to develop hospital‐acquired geriatric syndromes. The FI and CFS have acceptable prognostic performance for predicting delirium but not all individuals who are identified as frail develop delirium. Ongoing research is needed to identify interventions that improve outcomes in patients who screen positive for frailty.

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Section: Discussionmentioning

confidence: 99%

The Prognostic Performance of Frailty for Delirium and Functional Decline in Vascular Surgery Patients

Thillainadesan

Mudge

Aitken

et al. 2020

J American Geriatrics Society

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“…diabetes), the growing recognition of the complex care needs of older adults undergoing surgery has seen recent international perioperative care guidelines recommend proactive management of geriatric syndromes such as delirium, frailty and functional impairment [7,8]. Accordingly, new perioperative interventions and models of care are being developed that embed multidisciplinary teams and target geriatric syndromes [9,10].…”

Section: Introductionmentioning

confidence: 99%

“…Referrals to other specialties occur as required and often 'reactively', that is, after medical complications including geriatrics syndromes have developed. Evidence for geriatrics surgical collaborative models of care beyond orthogeriatrics is emerging [9,10,16]. In these models of care a dedicated geriatric medicine team proactively undertakes comprehensive geriatric assessment and management (CGA) on all patients whom fulfil a pre-determined criteria such as older age, multiple comorbidities or frailty.…”

Section: Introductionmentioning

confidence: 99%

“…In the UK there has been an increase in the number of geriatric medicine services for older surgical patients from 38 (29.2%) in 2013 to 81 (53.3%) in 2018 [13,14]. With recent national and international emphasis on collaborative perioperative models of care [7,8], and emerging evidence for these models [9,10,16], this study was planned to explore the challenges and opportunities to develop and deliver geriatrics perioperative medicine services from the geriatrician's perspective. Surveys of geriatricians have been undertaken to examine the state of perioperative medicine services using quantitative methods [13][14][15].…”

Section: Introductionmentioning

confidence: 99%

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Geriatrician perspectives on perioperative care: a qualitative study

Thillainadesan

Jansen

et al. 2021

BMC Geriatr

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Background Perioperative medicine services for older surgical patients are being developed across several countries. This qualitative study aims to explore geriatricians’ perspectives on challenges and opportunities for developing and delivering integrated geriatrics perioperative medicine services. Methods A qualitative phenomenological semi-structured interview design. All geriatric medicine departments in acute public hospitals across Australia and New Zealand (n = 81) were approached. Interviews were conducted with 38 geriatricians. Data were analysed thematically using a framework approach. Results Geriatricians identified several system level barriers to developing geriatrics perioperative medicine services. These included lack of funding for staffing, encroaching on existing consultative services, and competing clinical priorities. The key barrier at the healthcare professional level was the current lack of clarity of roles within the perioperative care team. Key facilitators were perceived unmet patient needs, existing support for geriatrician involvement from surgical and anaesthetic colleagues, and the unique skills geriatricians can bring to perioperative care. Despite reporting barriers, geriatricians are contemplating and implementing integrated proactive perioperative medicine services. Geriatricians identified a need to support other specialties gain clinical experience in geriatric medicine and called for pragmatic research to inform service development. Conclusions Geriatricians perceive several challenges at the system and healthcare professional levels that are impacting current development of geriatrics perioperative medicine services. Yet their strong belief that patient needs can be met with their specialty skills and their high regard for team-based care, has created opportunities to implement innovative multidisciplinary models of care for older surgical patients. The barriers and evidence gaps highlighted in this study may be addressed by qualitative and implementation science research. Future work in this area may include application of patient-reported measures and qualitative research with patients to inform patient-centred perioperative care.

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“…Multidisciplinary models of care, such as collaborative care involving geriatricians or comprehensive geriatric assessment, can reduce hospital-acquired complication rates, especially for the older patients with multiple clinical conditions who are readmitted more frequently than younger patients. 6,7 Peri-operative interventions, such as prehabilitation or allied health support, may also avert complications and reduce hospital length of stay, but less is known about how they influence readmission rates. 7 Woelk and colleagues 4 and investigators in other countries 5,8 have reported that PAD severity and operative interventions are major predictors of unplanned readmission.…”

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confidence: 99%

Reducing the number of unplanned returns to hospital after treatment for peripheral artery disease

Stavert

Aitken

2021

Medical Journal of Australia

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Interventions to Improve Clinical Outcomes in Older Adults Admitted to a Surgical Service: A Systematic Review and Meta-analysis

Cited by 20 publications

References 42 publications

The Prognostic Performance of Frailty for Delirium and Functional Decline in Vascular Surgery Patients

The Prognostic Performance of Frailty for Delirium and Functional Decline in Vascular Surgery Patients

Geriatrician perspectives on perioperative care: a qualitative study

Reducing the number of unplanned returns to hospital after treatment for peripheral artery disease

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