In line with enhanced recovery, the ISOG report (2005) stressed the requirement to implement new standards of care that incorporate improved pre-operative assessment, preparation and triage, intra-operative care and improved use of post-operative resources . Since elderly patients are a highly heterogeneous group, static assessment methods are not adequate. Rather, a dynamic approach should be employed so that treatment can be individualised along the whole care pathway. Here, we give some examples of dynamic tests that can be used in elderly patients.
The Department of Health emphasises that an essential feature for enhanced recovery is the need for patients to be in the best possible condition for surgery . Identification and treatment of pre-existing conditions should ideally be dealt with by the GP prior to referral or, at the latest, at the pre-operative assessment . However, risk assessment may be particularly difficult in the elderly surgical population. Senior clinicians in surgery, anaesthesia and medicine need to be involved in the decision to operate on elderly patients [3, 8].
Pre-operative testing example: cardiopulmonary exercise (CPX) testing
Dynamic tests, such as CPX testing, are essential for the identification of at-risk patients undergoing surgery. Wilson et al. (2010) showed that routine measurement of the anaerobic threshold and elevated ventilatory equivalent for carbon dioxide (VE/VCO2) using CPX testing accurately identified the majority of high-risk patients undergoing non-vascular intra-abdominal surgery . They found that the predictive benefit of CPX testing is just as apparent in those patients with no history of ischaemic heart disease or any other cardiac risk factors. Use of clinical risk factors alone only identified a relatively small proportion of at-risk patients, implying that clinical history cannot safely be used as a screening measure for selecting patients for CPX testing.
CPX testing has been advocated in the NCEPOD 2010 report. Most of the patients in the study underwent urgent or emergency surgery; therefore, CPX testing would not usually have been applicable. However, in those patients who had attended a pre-assessment clinic, very few had received formal assessment of cardiopulmonary reserve. The report concluded that CPX would have provided a more specific method of providing targeted management to those patients undergoing major surgery .
Pre-operative testing example: frailty testing
Geriatric frailty is found in 20–30% of the elderly population over 75 years of age and increases with advancing age . Frailty poses a unique clinical challenge, owing to its multifactorial nature . It has been linked to increased risk of death, falls and institutionalisation [3, 21]. The NCEPOD 2010 report identified that whereas frailty is recognised in the surgical setting of the elderly, it may not have been sufficiently factored into risk assessments and subsequent optimal planning of care.
The NCEPOD 2010 report noted that frailty is variously defined, but gives an operational definition, as per the Canadian Veterans Heart Study Definition of frailty, which states that frailty exists when the patient displays any three of the following [3, 23]:
The NCEPOD study showed that the most common method of assessing frailty was by history and examination, and specific scoring systems were not cited. Indeed, there are no specific, validated, pre-operative tests for frailty. The ideal tests would be specific, simple, dynamic and quick to perform. Four examples of tests that could be included in an assessment of frailty are:
Once frailty has been identified in a patient its assessment and management require multidisciplinary input from surgeons, anaesthetists, nursing, rehabilitation, nutritionists and early involvement of Medicine for the Care of Older People [3, 22].
Cognitive dysfunction: the need for a simple, dynamic test
Testing for cognitive dysfunction in elderly patients poses particular difficulties owing to comorbidities and disabilities, such as the patient being blind or deaf. Although there are many general tests of cognitive dysfunction available, such as the Abbreviated Mental Test (AMT) and the Mini-Mental State Examination (MMSE), none are completely satisfactory for elderly surgical patients. Whilst we think testing of cognitive dysfunction is essential, we cannot advocate use of any particular test. However, the ideal test would be dynamic, quick and easy to perform.
Minimally invasive monitors that can be easily utilised intra-operatively include LIDCOplus™, LIDCOrapid™ and the CardioQ™ oesophageal Doppler monitor. Use of oesophageal Doppler monitors to optimise flow-related haemodynamic variables improves short-term outcomes in patients undergoing major abdominal surgery . Currently, there is no targeted research on these techniques in the elderly.
Post-operative testing – Delirium testing and management
The majority of elderly patients presenting for major surgery are at risk from delirium. Early identification of delirium post-surgery, i.e. in the recovery room, allows for more effective targeting for referral and treatment of patients than pre-operative identification. Identification of delirium should trigger the implementation of a management plan to optimise patient care. This should involve liaison with a geriatrician, psychiatrist, community psychiatric nurse, occupational therapist, GP or social services for further assessment, follow-up and/or social support.
Outcomes of delirium
The prevalence of post-operative delirium in elderly patients ranges from 0% to 73%, depending on the study and type of surgery . Post-operative delirium is a medical emergency, which can occur within hours of surgery and has the potential to last up to 7 days . At least a quarter of elderly patients who develop delirium post-operatively may continue to have symptoms for up to 6 months after hospital discharge .
It is important to be aware that delirium also occurs where sedation is used in regional anaesthesia .
Recent guidelines from the National Institute for Health and Clinical Excellence (NICE) emphasise the serious consequences of delirium, including increased risk of dementia, death, increased length of stay in hospital and increased risk of new admission to long-term care . Delirium may also be a marker for development of early post-operative cognitive dysfunction (POCD). The relationship between POCD and delirium has yet to be fully elucidated.
The recovery room as a place for delirium testing
Delirium is often seen in the recovery room and is a good predictor of post-operative delirium on the ward [31, 32]. Routine testing in the recovery room is an effective way of selectively identifying patients to receive post-operative care.
Any test for delirium in the recovery room should be quick and easy to perform by a range of healthcare professionals, including doctors and nurses. Rapid, early recovery of patients in the recovery room will aid the assessment process. The following have been used for delirium testing:
The Confusion Assessment Method (CAM) [33, 34]
The CAM for the intensive care unit (CAM-ICU) [30, 35]
The Nursing Delirium Screening Scale (Nu-DESC) [31, 36]
Owing to the potential for significant events identified post-operatively to cause long-term complications, GPs should be notified if patients develop acute delirium and/or cognitive dysfunction during the post-operative course and informed of the resulting MDT pathway.
Post-operative assessment and management
Elderly patients suffer as much, if not more, pain after surgery than younger patients as they are likely to have to contend with the pain of stiff, arthritic joints and a greater incidence of chronic pain syndromes, as well as incisional/surgical handling pain.
Pain assessment protocols for younger patients do not readily reflect the severity of pain in the elderly. Differences in language, special senses (vision and hearing) and attitudes to pain make interpretation of the scoring more challenging. Attitudes of healthcare providers may limit the provision of effective analgesia, despite a pain score indicating inadequate pain control.
There is no single test/scoring scheme for elderly patients that can be recommended at the moment, but dynamic pain testing is essential in this age group, and specific scoring should be used in patients with identified cognitive dysfunction.
The development of pathways that assess and effectively manage acute pain throughout the peri-operative period is essential .