Assessment and Management of Ischaemic Heart Disease in Non-Cardiac Surgery.

In the setting of non-cardiac surgery, cardiac complications contribute to over a third of perioperative deaths. With over 230 million major surgeries performed annually, and an increasing prevalence of cardiovascular risk factors and ischaemic heart disease, the incidence of perioperative myocardial infarction is also rising. The recent European Society of Cardiology guidelines on cardiovascular risk in noncardiac surgery elevated practices aiming to identify those at most risk, including biomarker monitoring and stress testing.

Implementing a perioperative care of older people undergoing surgery (POPS) service: findings from a multi-site qualitative implementation study.

Background: The Perioperative care for Older People undergoing Surgery (POPS) service model is increasingly being implemented across care providers in the English and Welsh National Health Services.

Objective: The study aimed to produce evidence regarding clinical leaders' activities to implement POPS across different service contexts and to produce generalisable recommendations for future implementation.

Methods: A qualitative interview study was undertaken across six National Health Services hospitals with established POPS services.

Preoperative assessment and optimisation prior to planned aortic aneurysm repair: a UK survey examining current practice and attitudes of vascular surgeons and vascular anaesthetists.

Background: The majority of those diagnosed with aortic aneurysm in the UK are older, multi-morbid patients. Decision-making as to who may benefit from intervention (open or endovascular aneurysm repair) is highly variable across the NHS (as is the mode of intervention), in part because there are no detailed guidelines or consensus on preoperative assessment. Thus, there is likely to be significant variation in the pre-operative assessment and optimisation of these patients.

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

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.

A Description of Interventions Prompted by Preoperative Comprehensive Geriatric Assessment and Optimization in Older Elective Noncardiac Surgical Patients.

Objectives: Comprehensive Geriatric Assessment (CGA), a multicomponent, complex intervention, can be used to improve perioperative outcomes. This study aimed to describe the actions and interventions prompted by preoperative CGA and optimization in elective noncardiac, older, surgical patients.

Design: Retrospective observational study.

Perioperative care for older people.

Increasing numbers of older people are undergoing surgery with benefits including symptom relief and extended longevity. Despite these benefits, older people are more likely than younger patients to experience postoperative complications, which are predominantly medical as opposed to surgical. Comprehensive Geriatric Assessment and optimisation offers a systematic approach to risk assessment and risk modification in the perioperative period.

Preoperative comprehensive geriatric assessment and optimisation prior to elective arterial vascular surgery: a health economic analysis.

Background: increasing numbers of older people are undergoing vascular surgery. Preoperative comprehensive geriatric assessment and optimisation (CGA) reduces postoperative complications and length of hospital stay. Establishing CGA-based perioperative services requires health economic evaluation prior to implementation.

Using implementation science to develop and implement a guideline to reduce unnecessary preoperative testing for asymptomatic bacteriuria prior to elective arthroplasty.

: Guidelines and consensus statements do not support routine preoperative testing for asymptomatic bacteriuria (ASB) prior to elective arthroplasty. Despite this, urine testing remains commonplace in orthopaedic practice. This mixed methods stepwise quality improvement project aimed to develop and implement a guideline to reduce unnecessary preoperative testing for asymptomatic bacteriuria prior to elective arthroplasty within a single centre.

Functional recovery in older women undergoing surgery for gynaecological malignancies: A systematic review and narrative synthesis.

Objectives: Older women are increasingly undergoing surgery for gynaecological malignancies. Although survival data is available other outcomes such as functional recovery are less well described. This systematic review and narrative synthesis describes functional recovery after gynaeoncology surgery with respect to baseline characteristics.

Older patients undergoing emergency laparotomy: observations from the National Emergency Laparotomy Audit (NELA) years 1-4.

Background: older patients aged ≥65 years constitute the majority of the National Emergency Laparotomy Audit (NELA) population. To better understand this group and inform future service changes, this paper aims to describe patient characteristics, outcomes and process measures across age cohorts and temporally in the 4-year period (2014-2017) since NELA was established.

Methods: patient-level data were populated from the NELA data set years 1-4 and linked with Office of National Statistics mortality data.

Distress in delirium: causes, assessment and management.

Purpose: Delirium is a common clinical syndrome associated with increased physical and psychological morbidity, mortality, inpatient stay and healthcare costs. There is growing interest in understanding the delirium experience and its psychological impact, including distress, for patients and their relatives, carers and healthcare providers.

Methods: This narrative review focuses on distress in delirium (DID) with an emphasis on its effect on older patients.

Measuring the distress related to delirium in older surgical patients and their relatives.

Objectives: Delirium is a common postoperative complication with implications on morbidity and mortality. Less is known about the psychological impact of delirium in patients and relatives. This study aimed to quantitatively describe distress related to postoperative delirium in older surgical patients and their relatives using the distress thermometer, examine the association between degree of distress and features of delirium on the Delirium Rating Scale (DRS), and examine the association between recall of delirium and features of delirium on the DRS.

Where are we now in perioperative medicine? Results from a repeated UK survey of geriatric medicine delivered services for older people.

Introduction: national reports highlight deficiencies in the care of older patients undergoing surgery. A 2013 survey showed less than a third of NHS trusts had geriatrician-led perioperative medicine services for older surgical patients. Barriers to establishing services included funding, workforce and limited interspecialty collaboration.

Preoperative discussion with patients about delirium risk: are we doing enough?

Postoperative delirium is a common complication in the older surgical population, occurring in 10-50 % of cases. It is thought to be more common if an individual is identified as frail. Postoperative delirium is associated with poor outcome including higher mortality rates, prolonged length of hospital stay, increased care needs on discharge and longer term post-traumatic stress disorder.

Frailty and poor functional status are common in arterial vascular surgical patients and affect postoperative outcomes.

Objectives: Increasing numbers of older people are undergoing emergency and elective arterial vascular procedures. Many older patients are frail which is a recognised predictor of adverse postoperative outcomes in other surgical specialties. This study in older patients undergoing arterial vascular surgery examined; the prevalence of preoperative frailty; the clinical feasibility of preoperatively measuring frailty and functional status; the association between these characteristics and adverse postoperative outcome.

Where are we in perioperative medicine for older surgical patients? A UK survey of geriatric medicine delivered services in surgery.

Introduction: national reports have highlighted deficiencies in care provided to older surgical patients and suggested a role for innovative, collaborative, inter-specialty models of care. The extent of geriatrician-led perioperative services in the UK (excluding orthogeriatric services) has not previously been described. This survey describes current services and explores barriers to further development.

The prevalence and impact of undiagnosed cognitive impairment in older vascular surgical patients.

Objective: The objectives of this observational cohort study were to investigate the prevalence of undiagnosed cognitive impairment in older patients presenting for vascular surgery, to examine its association with adverse postoperative outcomes, and to test the feasibility of a preoperative cognitive assessment tool.

Methods: Patients aged 60 years or older were recruited by consent on admission to the vascular surgical ward of an inner-city teaching hospital with a large tertiary referral practice for proposed elective or emergency aortic or lower limb arterial intervention. Cognition was assessed preoperatively by the Montreal Cognitive Assessment (MoCA), and a score below 24/30 indicated cognitive impairment or dementia.

The delirium experience: what is the effect on patients, relatives and staff and what can be done to modify this?

Background: Delirium is a common clinical syndrome with significant associated mortality, morbidity and financial cost. Less is understood about the experience of delirium for the patient, their family and staff involved in their care.

Objective: This synthesis draws on qualitative and quantitative literature examining different populations (patients, relatives and staff) in different clinical settings (intensive care units, surgery and hospice care) to provide a clinical summary of the delirium experience from the perspective of patients, relatives and staff.

Frailty in the older surgical patient: a review.

The rate of surgical procedures in the older population is rising. Despite surgical, anaesthetic and medical advances, older surgical patients continue to suffer from adverse postoperative outcomes. Comorbidities and reduction in physiological reserve are consistently identified as major predictors of poor postoperative outcome in this population.