New guidelines for the perioperative care of people living with frailty undergoing elective and emergency surgery—a commentary

Abstract

Frailty is common in the older population and is a predictor of adverse outcomes following emergency and elective surgery. Identification of frailty is key to enable targeted intervention throughout the perioperative pathway from contemplation of surgery to recovery. Despite evidence on how to identify and modify frailty, such interventions are not yet routine perioperative care. To address this implementation gap, a guideline was published in 2021 by the Centre for Perioperative Care and the British Geriatrics Society, working with patient representatives and all stakeholders involved in the perioperative care of patients with frailty undergoing surgery. The guideline covers all aspects of perioperative care relevant to adults living with frailty undergoing elective and emergency surgery. It is written for healthcare professionals, as well as for patients and their carers, managers and commissioners. Implementation of the guideline will require collaboration between all stakeholders, underpinned by an implementation strategy, workforce development with supporting education and training resources, and evaluation through national audit and research. The guideline is an important step in improving perioperative outcomes for people living with frailty and quality of healthcare services. This commentary provides a summary and discussion of the evidence informing the standards and recommendations in the published guideline.

POSTOPED: improving surveillance of postoperative delirium in a Scottish tertiary hospital

“…This is despite British Geriatrics Society (BGS) guidance that recommends daily 4ATs for surgical inpatients over the age of 65. 7 …”

“…This behaviour is reactive in nature, rather than the proactive approach that professional guidelines recommend. 7 This approach risks missing many patients with delirium, and some literature estimates that 60%–66% of delirium diagnoses are missed, 8 9 due partly to hypoactive forms of the syndrome. We wished to change the reactive process that seemed to be happening on the wards, with a proactive one.…”

“…This is despite British Geriatrics Society (BGS) guidance that recommends daily 4ATs for surgical inpatients over the age of 65. 7 Preintervention snapshot data showed that 74.1% of elderly inpatients underwent 4AT assessments on arrival to the acute surgical admission unit; of these 15% were identified as delirious (4AT score ≥4). Only 14.8% of all WHAT IS ALREADY KNOWN ON THIS TOPIC ⇒ Delirium is the most common postoperative complication in over 65 s yet it is underdiagnosed in part due to its hypoactive forms.…”

Fried Frailty Phenotype Questionnaire scores and postoperative patient‐reported outcomes of patients undergoing major abdominal cancer surgery: A secondary analysis

“…Previous studies have investigated the association between increasing age and postoperative outcomes; however, in recent years, the focus has shifted to patient-specific reserve capacity, such as physical and nutritional status. [1][2][3][4][5] Frailty is a condition characterized by decreased reserves and reduced resistance to stressors, such as surgery, resulting in an increased risk of adverse outcomes, including postoperative functional disability and mortality. [6][7][8] Two conceptual frameworks have been used to assess frailty: the phenotype and accumulating deficit models.…”

“…The number of older adults undergoing surgery is increasing worldwide, and this trend is likely to continue in the future. Previous studies have investigated the association between increasing age and postoperative outcomes; however, in recent years, the focus has shifted to patient‐specific reserve capacity, such as physical and nutritional status 1–5 …”