Perioperative medicine for older people undergoing surgery (POPS) services are gaining traction, in acknowledgment of the poorer outcomes experienced by older surgical patients. In response to the NHS' growing focus on scaling innovation, a logic model of the POPS service at Guy's and St Thomas' NHS Foundation Trust was developed to articulate a founding centre's experience. The logic model was applied as a means of service evaluation and to guide implementation of a new POPS service at a district general trust. This is a novel study within the fi eld of perioperative medicine for older people, interlinking implementation science theory to achieve meaningful clinical results and describe the lessons learnt during the process. Future work will include validation of this logic model to facilitate national POPS scale-up.

Gynae-oncology patients are increasingly older and living with frailty and multimorbidity, resulting in higher rates of perioperative or treatment-associated adverse outcomes. Collaborative shared decision making (SDM), where healthcare professionals and patients work in partnership to reach a treatment decision, can be used to engage patients in treatment decisions. Comprehensive geriatric assessment (CGA), a multidimensional, interdisciplinary process assessing medical, psychological and functional capabilities, can inform individualised management and SDM in older gynae-oncology patients with complex conditions. Evidence is emerging for the use of CGA to inform individualised management and underpin integrated care pathways and SDM for older people. This methodology is advocated in NHS England's Cancer Strategy through integrated pathways for older cancer patients with geriatrician involvement. Using clinical case studies, this review contextualises the application of SDM through CGA in older patients with gynaecological malignancy. Learning objectivesKnow that SDM takes proposed risks and benefits into account, together with projected disease progression with and without treatment and patient preferences. Understand that limitations to SDM in older people include the effects of multimorbidity, cognitive impairment and frailty, limited data on long-term clinician and patient-reported outcomes and frequent exclusion of older people from research trials.

Central sleep apnea (CSA) is characterized by repeated episodes of reduced or absent respiratory airflow during sleep due to reduced ventilatory effort. It can occur in either hyper or hypo-ventilatory states and is primarily due to instability of ventilatory control mechanisms. CSA can be primary (idiopathic), or associated with Cheyne-Stokes breathing (seen in heart failure [HF] and some neurologic disorders), high altitude, central nervous system suppressants such as opioids and following initiation of continuous positive airways pressure (CPAP) therapy (treatment-emergent CSA [TECSA]) (American Academy of Sleep Medicine, 2014). The community prevalence of CSA is estimated at 0.9% (Donovan & Kapur, 2016) and among patients with HF, CSA is common and is associated with a poor prognosis. Treatment options for CSA include positive pressure ventilation, pharmacological therapy and novel modalities such as phrenic nerve stimulation (Fox et al., 2019). Adaptive servo ventilation (ASV) is a treatment option in CSA patients without HF with reduced ejection fraction (HFrEF) (left ventricular ejection fraction [LVEF] ≤45%). It is a form of positive airway pressure therapy that provides expiratory positive airway pressure (EPAP), servo-controlled adaptive pressure support that is inversely related to the patient's peak flows or minute ventilation depending on the device algorithm (Philips Respironics vs. ResMed, respectively), and a backup rate for apneas (Sharma et al., 2012; Teschler, Dohring, Wang, & Berthon-Jones, 2001). Because it provides EPAP and adaptive pressure support, it can alleviate both obstructive and central apneas and hypopneas. In patients with HF and CSA, ASV controls CSA and improves sleep quality more efficaciously than CPAP therapy (Hetzenecker et al., 2016). ASV may improve diastolic dysfunction in patients with HF and co-existing sleep-disordered breathing (SDB) (Daubert et al., 2018) and may also reduce atrial fibrillation (AF) burden (Piccini et al., 2019). In a recent non-randomized observational study of patients with HFrEF and moderate-severe CSA,

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