New horizons in the perioperative care of older adults.

Older adults undergoing surgery have high perioperative morbidity and mortality. Age-related physiological changes and prevalence of geriatric syndromes such as frailty increase the risk of adverse postoperative outcomes. Geriatricians utilise comprehensive geriatric assessment (CGA) and management to identify and manage geriatric syndromes, and deliver patient-centred perioperative care. Perioperative models of CGA are established for older patients undergoing hip fracture surgery. Recent trials support the benefits of perioperative models of CGA for non-orthopaedic surgery, and have influenced current care recommendations for older surgical patients. Areas for further action include addressing the implementation gap between recommended evidence-based perioperative care and routine perioperative care, evaluating the clinical and cost-effectiveness of perioperative models of CGA for patients living with frailty, and embedding routine use of patient-reported outcome measures to inform quality improvement.

Characteristics of patients referred for assessment of decision-making capacity in the acute medical setting of an outer-metropolitan hospital-A retrospective case series.

OBJECTIVE: To identify characteristics of older people referred for assessment of decision-making capacity in the acute hospital setting. METHODS: A retrospective chart audit was undertaken for 98 consecutive medical inpatients referred for capacity assessments between February 2015 and August 2017 in an outer-metropolitan hospital. The data were analysed using descriptive and univariate analysis. RESULTS: In this case series, 56% of patients had a diagnosis of dementia. Social isolation was common; 70% were not presently married, and 63% had no community services. For 90% of patients, the referral was to determine the person's capacity to make their own accommodation decisions-usually to return home on discharge. Of those with impaired capacity, 54% were discharged to residential aged care, whilst most who retained capacity were discharged home (73%). Those with impaired capacity were more likely to have a diagnosis of dementia and a prolonged length of stay (both P < 0.001).

Establishing a successful perioperative geriatric service in an Australian acute surgical unit.

BACKGROUND: The purpose of this study was to assess the impact of a perioperative geriatric service (PGS) in an acute surgical unit (ASU) on patient and organizational outcomes. METHODS: Single centre retrospective cohort study. Inclusion criteria were patients over the age of 65 admitted to the ASU between January and June 2014 (pre-PGS) and 2015 (post-PGS). Chart reviews were performed to identify outcomes of interest including in-hospital morbidity and mortality, length of stay (LOS), 30-day representation and mortality. RESULTS: Geriatric admissions increased by 32% over the two study periods (154 pre-PGS and 203 post-PGS). Surgical intervention increased by 11% (P = 0.01). Significantly more medical complications (14% versus 33%, P < 0.001) were identified after the implementation of the PGS. Recognition of delirium in the over 80s also increased by 57%. Rate of surgical complications was unchanged over the study (28% pre-PGS and 34% post-PGS, P = 0.6). In-hospital (<1%, P = 0.5) and 30-day mortality (<1%, P = 0.6) remained low, as did 30-day representation (10% versus 8%, P = 0.5). A trend towards decreased LOS of 1 day was identified after the implementation of the PGS (P = 0.07). CONCLUSION: This study demonstrated successful implementation of a PGS into an ASU. This multi-disciplinary approach has been effective in maintaining low numbers of surgical complications, in-hospital mortality, LOS and patient representations despite an increased number of medical complications. This likely reflects more timely recognition and intervention of medically unwell patients with the PGS.

Frailty and adverse outcomes: impact of multiple bed moves for older inpatients.

BACKGROUND: A consequence of pressure on hospitals to accommodate care needs of older patients is "boarding" or out-lying from their home ward. This may have greater adverse effects on older inpatients who are frail. METHODS: A retrospective matched cohort study was conducted in an outer metropolitan general hospital. Randomly selected patients hospitalized between July 2012 and June 2013 under the care of an Older Person Evaluation Review and Assessment (OPERA) team (n = 300) were age and sex matched with patients under the care of general physicians (n = 300). Frequency of boarding and number of bed moves were recorded for all patients. For patients who had three or more moves, adverse outcomes were compared between the two groups. RESULTS: A higher proportion of OPERA patients (n = 143; 47.7%) were out-lied from medical wards compared with 94 (31.3%) General Medicine patients (p < 0.001). Three or more bed moves were recorded for 67 (22.3%) OPERA and 24 (8%) General Medicine patients (p < 0.001). Of those with multiple moves, OPERA patients were more likely to have pre-morbid cognitive impairment (p = 0.005), to be moderately to severely frail (p = 0.016) and to suffer acute delirium and falls during admission (p = 0.03), compared with General Medicine patients. OPERA patients were also more at risk of adverse outcomes such as increased dependence, discharge to residential care or death (p = 0.023). CONCLUSION: Compared with age- and sex-matched General Medicine patients, OPERA patients were more likely to undergo multiple bed moves and out-lying, which may have contributed to negative outcomes for these patients.

Rehabilitation of the older vascular amputee: a review of the literature.

The aim was to review the literature on factors affecting prosthetic rehabilitation of older vascular lower extremity amputees. A search of the literature was carried out using the MEDLINE, EMBASE and CINAHL databases up to September 2010. Only original English language articles were accepted. Relevant studies were reviewed and selected based on prespecified inclusion criteria namely: age more than 65 years; vascular cause for the amputation; amputation level of below knee, through-the-knee or above knee; and discussed factors affecting rehabilitation. Age alone is not an absolute contraindication to prosthetic limb prescription; however, it does influence the potential success of gait retraining. Other factors influencing prosthetic fitting and use include comorbidities, premorbid function, level of amputation, status of the remaining limb and patient motivation. Prosthetic gait retraining is not possible in every older dysvascular amputee; however, almost all amputees will benefit from a rehabilitation program to increase independence in transfers and learn wheelchair skills. The MESH key words were: "aged" "diabetes complications" "peripheral vascular diseases" "amputees" "amputation" "rehabilitation" and "artificial limbs".