Dr Jugdeep Dhesi is Chair of the BGS Peri-operative Care of Older People Ungergoing Surgery SIG (POPS) and is consultant physician and clinical lead for the POPS service at Guy’s and St Thomas’ Hospitals.
The number of frail older people undergoing elective surgical procedures is rapidly increasing. In fact the number of older people undergoing operations, as a proportion of all those having surgery, is increasing more rapidly than is the proportion of frail older people across the population as a whole.
There are a number of reasons for this. Advances in surgical technique and improvements in anaesthetic management have made it possible to operate safely on patients who would have been considered too frail for surgery in the past. At the same time patients and doctors now expect that they will be able to receive operations much later in life.
Despite surgical and anaesthetic advances, older surgical patients remain at increased risk of adverse postoperative outcomes when compared with younger patients. They are more likely to die, more likely to suffer post-operative complications and less likely to be functionally independent following their operation.
Our understanding of the predictors of poor postoperative outcome is improving. Age-related reductions in physiological reserve, multi-morbidity and the frailty syndrome all increase the likelihood of problems. In response to this a number of recent reports suggest that clinicians with experience in assessment and management of these issues (i.e. geriatricians) should play a central role in the surgical pathway for older patients.
Although an important role has been recognised geriatricians and their multidisciplinary teams are not a routine part of care for either emergency or elective surgical patients in the UK.
An example, perhaps, of what could be achieved comes from older patients who present with hip fracture and subsequently have emergency surgery. Geriatricians are now routinely involved in the care of these patients. Orthogeriatrics, as such practice has become known, has seen geriatricians, orthopaedic surgeons, anaesthetists and allied health professional working closely together to develop a service which meets the needs of frail older patients. This has allowed the development of a clinical evidence base, national audit and financial incentives to promote best practice. The BGS Good Practice Guide on Orthogeriatrics Models of care can be found at http://bit.ly/VNqC61
A group of us within the BGS would like to be able to repeat the improvements seen through orthogeriatrics for patients undergoing other types of surgery. There is much to be done. We are just starting to understand how to design and deliver such services. A robust evidence-base is, at present, a noble aspiration.
The Pro-active Care of Older People in Elective Surgery (POPS) service in London, has generated some understanding – and a lot of enthusiasm. An excellent starting point. As a next step, a group of us have established the BGS POPS Specialist Interest Group, published a best practice guideline and worked to ensure the inclusion of pre and perioperative management of the older surgical patient in the specialist registrar curriculum for geriatric medicine.
We need more enthusiasts, though, if we’re to take this forward. If you are interested in this exciting new field of geriatric medicine, join the POPS SIG via the BGS website and let’s work together towards establishing a clinical and research network of geriatricians interested in perioperative medicine.
British Geriatrics Society 