Delaying Elective Surgery in Geriatric Patients: An Opportunity for Preoperative Optimization.

Deciding whether to pursue elective surgery is a complex process for older adults. Comprehensive geriatric assessment (CGA) can help refine estimates of benefits and risks, at times leading to a delay of surgery to optimize surgical readiness. We describe a cohort of geriatric patients who were evaluated in anticipation of elective abdominal surgery and whose procedures were delayed for any reason. Themes behind the reasons for delay are described, and a holistic framework to guide preoperative discussion is suggested.

Bach to the Basics: Implementation and Impact of a Postoperative, Inpatient Personalized Music Program for Older Adults.

PURPOSE: Music as an intervention to mitigate pain and anxiety has been well studied in the perioperative period. We present a quality improvement (QI) report describing implementation and evaluation of a postoperative, inpatient personalized music program for older adults undergoing elective surgeries. DESIGN: We embedded this program in an existing interdisciplinary perioperative care program, with an outpatient and an inpatient component, at an academic institution. METHODS: We describe our initial QI steps, highlight critical lessons learned from this behavioral intervention, and discuss high yield areas to focus on future implementation efforts. FINDINGS: Rapid cycle improvement was an effective method to monitor QI measures. Participants in our program perceived improved mood and pain control, were satisfied with their experience, and had lower rates of incident delirium. CONCLUSIONS: This program offers perioperative teams, especially frontline nursing staff, an inexpensive, patient-centered tool to optimize postoperative pain and anxiety. We believe that it can be easily replicated at a variety of hospital systems.

Association of Integrated Care Coordination With Postsurgical Outcomes in High-Risk Older Adults: The Perioperative Optimization of Senior Health (POSH) Initiative.

Importance: Older adults undergoing elective surgery experience higher rates of preventable postoperative complications than younger patients. Objective: To assess clinical outcomes for older adults undergoing elective abdominal surgery via a collaborative intervention by surgery, geriatrics, and anesthesia focused on perioperative health optimization. Design, Setting, and Participants: Perioperative Optimization of Senior Health (POSH) is a quality improvement initiative with prospective data collection. Participants in an existing geriatrics-based clinic within a single-site academic health center were included if they were at high risk for complications (ie, older than 85 years or older than 65 years with cognitive impairment, recent weight loss, multimorbidity, or polypharmacy) undergoing elective abdominal surgery. Outcomes were compared with a control group of patients older than 65 years who underwent similar surgeries by the same group of general surgeons immediately before implementation of POSH. Main Outcomes and Measures: Primary outcomes included length of stay, 7- and 30-day readmissions, and level of care at discharge. Secondary outcomes were delirium and other major postoperative complications. Outcomes data were derived from institutional databases linked with electronic health records and billing data sets. Results: One hundred eighty-three POSH patients were compared with 143 patients in the control group. On average, patients in the POSH group were older compared with those in the control group (75.6 vs 71.9 years; P < .001; 95% CI, 2.27 to 5.19) and had more chronic conditions (10.6 vs 8.5; P = .001; 95% CI, 0.86 to 3.35). Median length of stay was shorter among POSH patients (4 days vs 6 days; P < .001; 95% CI, -1.06 to -4.21). Patients in the POSH group had lower readmission rates at 7 days (5 of 180 [2.8%] vs 14 of 142 [9.9%]; P = .007; 95% CI, 0.09 to 0.74) and 30 days (14 of 180 [7.8%] vs 26 of 142 [18.3%]; P = .004; 95% CI, 0.19 to 0.75) and were more likely to be discharged home with self-care (114 of 183 [62.3%] vs 73 of 143 [51.1%]; P = .04; 95% CI, 1.02 to 2.47). Patients in the POSH group experienced fewer mean number of complications (0.9 vs 1.4; P < .001; 95% CI, -0.13 to -0.89) despite higher rates of documented delirium (52 of 183 [28.4%] vs 8 of 143 [5.6%]; P < .001; 95% CI, 3.06 to 14.65). A greater proportion of POSH patients underwent laparoscopic procedures (92 of 183 [50%] vs 55 of 143 [38.5%]; P = .001; 95% CI, 1.04 to 2.52). Tests for interactions between POSH patients and procedure type were insignificant for all outcomes. Conclusions and Relevance: Despite higher mean age and morbidity burden, older adults who participated in an interdisciplinary perioperative care intervention had fewer complications, shorter hospitalizations, more frequent discharge to home, and fewer readmissions than a comparison group.

Efficacy of selected complementary and alternative medicine interventions for chronic pain.

Complementary and alternative medicine (CAM) is a group of diverse medical and healthcare systems, therapies, and products that are not presently considered part of conventional medicine. This article provides an up-to-date review of the efficacy of selected CAM modalities in the management of chronic pain. Findings are presented according to the classification system developed by the National Institutes of Health National Center for Complementary and Alternative Medicine (formerly Office of Alternative Medicine) and are grouped into four domains: biologically based medicine, energy medicine, manipulative and body-based medicine, and mind-body medicine. Homeopathy and acupuncture are discussed separately as "whole or professionalized CAM practices." Based on the guidelines of the Clinical Psychology Division of the American Psychological Association, findings indicate that some CAM modalities have a solid track record of efficacy, whereas others are promising but require additional research. The article concludes with recommendations to pain practitioners.

Concurrent administration of coenzyme Q10 and alpha-tocopherol improves learning in aged mice.

The main purpose of this study was to determine whether supplemental intake of coenzyme Q10 (CoQ) (ubiquinone-10) or alpha-tocopherol, either alone or together, could improve brain function of aged mice, as reflected in their cognitive or psychomotor performance. Separate groups of aged mice (24 months) were administered either CoQ (123 mg/kg/day), or alpha-tocopherol acetate (200 mg/kg/day), or both, or the vehicle (soybean oil) via gavage for a period of 14 weeks. Three weeks following the initiation of these treatments, mice were given a battery of age-sensitive behavioral tests for the assessment of learning, recent memory, and psychomotor function. In a test that required the mice to rapidly identify and remember the correct arm of a T-maze, and to respond preemptively in order to avoid an electric shock, the intake of alpha-tocopherol plus CoQ resulted in more rapid learning compared to the control group. Learning was not significantly improved in the mice receiving CoQ or alpha-tocopherol alone. None of the treatments resulted in a significant improvement of psychomotor performance in the old mice. In a separate study, treatment with higher doses of CoQ alone (250 or 500 mg/kg/day) for 14 weeks failed to produce effects comparable to those of the combination of alpha-tocopherol and CoQ. The apparent interaction of CoQ and alpha-tocopherol treatments is consistent with the previous suggestion, based on biochemical studies, that coenzyme Q and alpha-tocopherol act in concert. Overall, the findings suggest that concurrent supplementation of alpha-tocopherol with CoQ is more likely to be effective as a potential treatment for age-related learning deficits than supplementation with CoQ or alpha-tocopherol alone.

Lifelong vitamin E intake retards age-associated decline of spatial learning ability in apoE-deficient mice.

The potential for lifelong vitamin E supplementation to delay age-associated cognitive decline was tested in apoE-deficient and wild-type C57BL/6 mice. Beginning at eight weeks of age, the mice were maintained on a control diet or diets supplemented with dl-α-tocopheryl acetate yielding approximate daily intakes of either 20 or 200 mg/kg body weight. When 6 or 18 months of age, cognitive functioning of the mice was assessed using swim maze and discriminated avoidance testing procedures. For the mice maintained on control diets, the age-related declines in swim maze performance were relatively larger in apoE-deficient mice when compared with wild-type. On the other hand, age-associated declines in learning and working memory for discriminated avoidance were similar in the two genotypes. The 200-mg/kg dose of vitamin E prevented the accelerated decline in spatial learning apparent in 18-month-old apoE-deficient mice, but had no equivalent effect on performance declines attributable to normal aging in the wild-type mice. Vitamin E supplementation failed to prevent age-related impairments in learning and memory for discriminated avoidance observed in both the wild-type and apoE-deficient mice. The current findings are consistent with the hypothesis that apoE deficiency confers an accelerated, though probably selective, loss of brain function with age. This loss of function would appear to involve pathogenic oxidative mechanisms that can be prevented or offset by antioxidant supplementation.