Perioperative Management of Elderly patients (PriME): recommendations from an Italian intersociety consensus

Abstract

Background Surgical outcomes in geriatric patients may be complicated by factors such as multiple comorbidities, low functional performance, frailty, reduced homeostatic capacity, and cognitive impairment. An integrated multidisciplinary approach to management is, therefore, essential in this population, but at present, the use of such an approach is uncommon. The Perioperative Management of Elderly patients (PriME) project has been established to address this issue. Aims To develop evidence-based recommendations for the integrated care of geriatric surgical patients. Methods A 14-member Expert Task Force of surgeons, anesthetists, and geriatricians was established to develop evidence-based recommendations for the pre-, intra-, and postoperative care of hospitalized older patients (≥ 65 years) undergoing elective surgery. A modified Delphi approach was used to achieve consensus, and the strength of recommendations and quality of evidence was rated using the U.S. Preventative Services Task Force criteria. Results A total of 81 recommendations were proposed, covering preoperative evaluation and care (30 items), intraoperative management (19 items), and postoperative care and discharge (32 items). Conclusions These recommendations should facilitate the multidisciplinary management of older surgical patients, integrating the expertise of the surgeon, the anesthetist, the geriatrician, and other specialists and health care professionals (where available) as needed. These roles may vary according to the phase and setting of care and the patient’s conditions.

Predicting Length of Stay and Discharge Destination for Surgical Patients: A Cohort Study

“…Our study again confirms the role of patients’ ages as a factor involved in determining a longer LOS, as shown as well by Lin et al, and the need for additional care after discharge, as per the recent review of Kobewka et al This correlation has also been acknowledged by several Italian scientific societies of anesthesiology, gerontology, geriatrics, and surgery that, in a recent consensus paper, recommended taking into consideration age as a key factor in perioperative management [ 17 , 18 ]. The role of age may also hinder, under his umbrella, several issues such as clinical problems (e.g., frailty [ 19 ] and cognitive decline) and social issues (e.g., weak social networks and the absence of caregivers), which are both tied to the LOS, as shown by Morgan and Beech [ 5 ].…”

“…The role of age may also hinder, under his umbrella, several issues such as clinical problems (e.g., frailty [ 19 ] and cognitive decline) and social issues (e.g., weak social networks and the absence of caregivers), which are both tied to the LOS, as shown by Morgan and Beech [ 5 ]. For this reason, it is recommended to plan in advance a discharge plan with different healthcare professionals [ 17 ]. Regarding the social issues, although other work, such as the review by Lin et al, emphasizes the role of the presence of a caregiver [ 18 ], our study does not highlight, in Period 2, their role in the LOS and the need for additional care after discharge.…”

Implementation of frailty preoperative assessment to predict outcome in patients undergoing urological surgery: a systematic review and meta‐analysis

“…In case of abnormal results, other than frailty assessment, a specialist consult for mild cognitive impairment should be requested [40]. The Comprehensive Geriatric Assessment (CGA) has been recommended in frail patients undergoing surgery in addition to the standard preoperative anaesthesiological assessment [11]. The CGA is a multidimensional evaluation of the geriatric patient based on the evaluation of different fields (cognitive-behavioural, biological and socioeconomic).…”

“…the fact that complications in the frail elderly patient can be fatal [9]. The identification of the frail patient allows clinicians to evaluate the combined effect of ageing and comorbidities on the patient's functional reserve [10,11].…”

Management of Frailty and its Challenges in Geriatric Patients on General Abdominal Anesthesia.

“…in postoperative period we need to used general strategies for optimizing postoperative recovery [24]. eRAs protocols aimed at reducing postoperative morbidity cover the whole perioperative period [25] Optimal postoperative pain control and use of nonopioid analgesia, absence of a nasogastric tube and prevent PONv (post-operative nausea and vomiting); early mobilization, oral nutrition, and removal of the urinary catheter, early resumption of feeding, early mobilization and walking or using physiotherapy [24,25]. importantly, reduction in surgical stress through eRAs appears to be particularly effective in reducing complications and supporting recovery in older and frail patients and especially post-operator delirium [24].…”