Among the 25 (out of 27) Scottish centres that responded to the survey, 64% stated that the majority of their workload involved the perioperative care of older patients. This is consistent with the findings of a similar survey by the American Society of Anesthesiologists (ASA), where 60% of their members reported that at least half of their cases were elderly adults (Deiner et al. 2020). This is unsurprising as our population is ageing, and it is well-established that although adults over 75 accounted for less than 10% of the population, they represented nearly 25% of all operations performed (Association of Anaesthetists of Great Britain and Ireland 2014). Despite this, and the AAGBI’s 2014 recommendation, only one department had an appointed lead clinician for geriatric anaesthesia. Furthermore, this centre with the lead clinician had both a specialist pre-assessment service and access to a geriatrician for advice on perioperative medicine.
There is a large body of evidence which suggests that multidisciplinary care improves both perioperative morbidity and mortality in elderly patients (Association of Anaesthetists of Great Britain and Ireland 2014). Paramount to this is the inclusion of a senior geriatrician in the co-ordination of perioperative care, a recommendation that is echoed in guidelines across specialities, from the Royal College of Emergency Medicine to the British Geriatrics Society (BGS) (Conroy 2012; Dhesi 2018). Only 20% of departments had access to this, a finding that highlights a fundamental barrier to delivering good multidisciplinary care. It must be acknowledged, however, that the design of our survey relied on a nominated individual replying on behalf of their department. In many cases, this individual had no formal responsibility for geriatric anaesthesia, and a few had no special interest in geriatrics but declared interest in pre-assessment. This leaves the data vulnerable to individual knowledge (or lack thereof) with potential to miss less formal multidisciplinary team (MDT) relationships that would lead to under-reporting of the available specialist input. In addition to this, the survey will not identify any formal collaboration between surgeons and geriatricians, a model that is increasingly seen in areas such as ortho-geriatrics and enhanced recovery after surgery (ERAS) programmes. It is, however, still useful in indicating that the formal clinical collaboration between anaesthetics and geriatricians, recommended by both the AAGBI and BGS, is clearly not yet established and still in its infancy (Association of Anaesthetists of Great Britain and Ireland 2014; Conroy 2012).
It is difficult to explain why there appear to be so few formal anaesthetic-geriatric care pathways, and this may simply reflect more informal surgical-geriatric clinical collaboration. However, it is important that anaesthetists, in their role as perioperative physicians, are formally included in multidisciplinary team models, particularly with regard to preoperative assessment and optimisation. The reported lack of specialist pre-assessment services in 80% of departments was another finding which requires improvement. This is particularly important as increased access to these services including geriatric input would increase both clinical frailty scoring and cognition screening, two areas where the survey found high variability.
The BGS good practice guideline sets out a number of models for multidisciplinary care in the pre-assessment of older adults. Their guideline distinguishes between geriatrician-led and anaesthetist-led preoperative services (Conroy 2012). We did not make this distinction as we felt that either service would represent adherence to the AAGBI guidelines. It was interesting to note that all but one of the centres that had specialist pre-assessment services were group 3 centres (commonly known as large district general hospitals). A total of 24% (6/25) of our survey respondents were from hospitals that are classified as rural general hospitals; only one of these centres had more than 100 staffed beds (The Scottish Government 2008). It is likely that in these hospitals, given their size and geographical location, that implementation of such services was simply not feasible with the resources available. However, it is unclear why the vast majority of the larger, tertiary care hospitals in Scotland were not providing specialist pre-assessment services. One explanation may be that these hospitals had access to other perioperative resources such as enhanced recovery specialist nurses, and ortho-geriatricians, therefore reducing the need for specialist geriatric pre-assessment.
There are several limitations to the findings of the present survey. We were unable to obtain any information from the largest department in Scotland and one of the largest in the UK.
This represented a significant gap in our dataset. A further limitation is that we began this project during the COVID-19 pandemic. Although it was conducted between ‘waves’, and we were careful to frame all questions as enquiring about ‘normal’ pre-pandemic services, this may well have had an influence. It is likely that centres will have been forced to change practices surrounding their elective work and may have changed service pathways such as those relating to elective and urgent elderly care. This may have contributed to the number of ‘unsure’ responses received. However, an ‘unsure’ response still has some value in that it suggests at the very least a lack of information or communication regarding elderly perioperative care. Therefore, we decided to group these responses with ‘no’, unless the respondent provided free text to suggest otherwise.