Randomized Clinical Trial of Comprehensive Geriatric Assessment and Optimization in Vascular Surgery

Reviewed by Dr. Jasmine Singh
Partridge JS, et al. Br J Surg. 2017 May; 104(6): 679-687

SUMMARY
As the population ages, more geriatric patients are undergoing surgical procedures.1 Elderly patients have unique postoperative complications, and many studies have shown that a comprehensive preoperative assessment provides better outcomes compared with traditional preoperative evaluation.2-5

Patients 65 years or older scheduled for either elective aneurysm repair or lower limb arterial surgery were randomized to either standard preoperative assessment or preoperative comprehensive geriatric assessment. The geriatric assessment was delivered by a multidisciplinary team (geriatrician, nurse specialist, social worker, occupational therapist) who assessed patients using peer-reviewed protocols based on current evidence, national and hospital guidelines, and expert opinion. Examples of such protocols include cognition and frailty assessments. The study included 176 patients from an inner city teaching hospital (control=91, intervention=85). Mean length of hospital stay, the primary outcome, was 5.53 days in the control group and 3.32 days in the intervention group (ratio of geometric means 0.60, 95% CI 0.46-0.79; P <0.001). There was also a statistically significant lower incidence of delirium, cardiac complications, and bladder/bowel incontinence in the intervention group compared with control (secondary outcomes). Furthermore, patients in the intervention group were less likely to require higher level of dependency at discharge (4 of 85 versus 12 of 91; P = 0.051).

COMMENTARY
Older adults undergoing major elective vascular surgery had reduced length of hospital stay and perioperative complications and were less likely to decline in functional dependency when a comprehensive geriatric preoperative assessment was performed. Such patients often were diagnosed with previously unrecognized pathology and risk factors that were subsequently intervened upon and led to better outcomes.

This study emphasizes the benefit of comprehensive geriatric assessment prior to elective vascular surgery. Larger scale studies, as well as those across multiple hospital centers, would help further validate these findings. Furthermore, preoperative comprehensive geriatric assessment should be studied with other procedures to understand if such beneficial outcomes are reproducible across surgical disciplines. Positive results would lead to substantial clinical implications for internists performing preoperative risk assessment in the elderly population.

REFERENCES
1. Etzioni DA,Liu JH,Maggard MA,Ko CY. The aging population and its impact on the surgery workforce. Ann Surg 2003; 238: 170–177.
2. Partridge JS,Dhesi JK,Cross JD,Lo JW,Taylor PR,Bell R et al. The prevalence and impact of undiagnosed cognitive impairment in older vascular surgical patients. J Vasc Surg 2014; 60: 1002–1011.
3. Partridge JS,Fuller M,Harari D,Taylor PR,Martin FC, Dhesi JK. Frailty and poor functional status are common in arterial vascular surgical patients and affect postoperative outcomes. Int J Surg 2015; 18: 57–63
4. Wilkinson K.An Age Old Problem: a Review of the Care Received by Elderly Patients Undergoing Surgery: a Report by the National Confidential Enquiry into Patient Outcome and Death (2010). National Confidential Enquiry into Patient Outcome and Death: London, 2010.
5. Partridge JS,Harari D, Martin FC, Dhesi JK. The impact of pre-operative comprehensive geriatric assessment on postoperative outcomes in older patients undergoing scheduled surgery: a systematic review. Anaesthesia 2014; 69 (Suppl 1): 8–16.

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