The very first requirement in a hospital is that it should do the sick no harm.
In response to the needs and demands of an aging population, geriatric medicine has grown rapidly during the past three decades and developed new models of care from new concepts like multimorbidity, frailty and geriatric syndromes.
Multimorbidity (Tinetti et al. 2012) is common in the older adult population, affects more than half of the elderly population and almost all hospitalized geriatric patients. Two terms, “comorbidity” and “multi-morbidity” have been mostly used. The term comorbidity refers to a combination of additional diseases beyond an index disorder. In contrast, multimorbidity (see Chapter 3) is defined as any co-occurrence of diseases in the same person indicating a shift of interest from a given index condition to individuals who suffer from multiple diseases (Marengoni et al. 2011). It has been reported than 65% of Medicare beneficiaries have two or more chronic diseases and 43% have three or more (Lee et al. 2009). Multimorbidity/comorbidity is an important determinant of health outcomes in older adults, responsible for a high treatment burden and for an increased risk of hospitalization and death (AGS 2012, Vetrano et al. 2016).
In parallel, the concept of frailty has been developed (Rockwood 2005, Fried et al. 2001). Frailty is considered to be highly prevalent with increasing age and to confer risk for adverse health outcomes, including mortality, institutionalization and hospitalization (Widagdo et al. 2015, Fried et al. 2001). Frailty has been considered synonymous with disability and comorbidity, but Fried et al. (2001) provides evidence that frailty is not synonymous, whereas comorbidity is an etiologic risk factor for and disability is an outcome of frailty.
In 2009, Collerton et al. (2009) speculated that disability, rather than disease, is the better predictor of mortality at these older ages, and that people who cope better with their disease(s), perhaps via enhanced functional reserve or adaptive capacity, are the survivors. This reflects the concept of geriatric syndromes (GSs), described since the 1980s. In most studies, GSs included the following main concepts: urinary incontinence, pressure ulcers, falls, delirium and functional decline (Inouye et al. 2007, Lee et al. 2009, Lakhan et al. 2011, Senn and Monod 2015). But, depending on the study, pain, dizziness, sleep disorders, malnutrition, hearing and visual impairment have also been cited (Kane et al. 2012, Koroukian et al. 2016; Vetrano et al. 2016).
Although different from the concept of multimorbidity or frailty, all these notions are associated and entangled. In this chapter we will firstly try to define GSs, and then we will detail their implications in the postoperative period. Understanding these concepts is pivotal in preventing their occurrence after surgery and in supporting the elderly surgical patient in the best way.
GSs refer to “multifactorial health conditions that occur when the accumulated effects of impairments in multiple systems render [an older] person vulnerable to situational challenges” (Tinetti et al. 1995, Inouye et al. 2007). While heterogeneous, GSs share many common features. They occur in older, particularly frail persons, intermittently rather than either continuously or as single episodes. They are precipitated by one or more acute triggers, and are often linked to subsequent functional decline (Inouye et al. 2007). They have been shown to be as prevalent as chronic diseases, but despite their prevalence and outcomes (poor survival, poor quality of life), they may not be recognized and managed adequately (Oliver 2008).
Inouye et al. (2007) defined, or redefined, the concept of GSs (Figure 42.1). They proposed a unifying conceptual model, demonstrating that common risk factors may lead to these syndromes, which may in turn lead to frailty, with feedback mechanisms enhancing the presence of shared risk factors and GSs. Such self-sustaining pathways may result in poor outcomes involving disability-dependence, nursing home placement and ultimately death. In their study, four shared risk factors were identified across all the GSs: older age, cognitive impairment, functional impairment and impaired mobility.
Figure 42.1 Conceptual model for geriatric syndromes.
Conceptual Model for Geriatric Syndromes (Bouchon 1984)
Jean-Pierre Bouchon (1984) defined – without naming it – GSs by the so-called “1+2+3” model (Figure 42.2). The “1” represents the physiological aging of an organ, the “2,” the pathological aging of an organ and the “3,” a triggering factor. Only the “2” can lead to organ failure, which may be nevertheless accelerated by the “3.” This concept and diagram reflect the complexity of geriatric medicine with the presence of multiple risk factors for one GS. For example, treating a pressure ulcer without considering malnutrition, arterial insufficiency and immobility, will not allow complete healing. Worse, it may lead to a new pressure ulcer at the same time.
Figure 42.2 Conceptual model for geriatric syndromes.
Delirium is a common clinical syndrome characterized by inattention and acute cognitive dysfunction (Fong et al. 2009, Inouye et al. 2014). Postoperative delirium (POD, see Chapters 14 and 38) occurs in 15–53% of surgical patients over the age of 65 years. Its clinical presentation is variable, but can be broadly classified into three sub-types – hypoactive, hyperactive and mixed – on the basis of psychomotor behavior. The diagnosis of delirium is made on the basis of clinical history, behavioral observation and cognitive assessment. According to its prognosis, prevention of delirium is a challenging, major issue.
A fall is defined as an unintentional change in position from lying, sitting or standing to a lower level or resting on the ground (Mancini et al. 2016). Thirty percent of community-dwelling adults over 65 years of age fall at least once a year, and 12% fall at least twice. Both the incidence and the severity of complications following a fall increase after the age of 60. In this population, falls are reported even after minor surgery (Eto and Miyauchi 2017).
The International Continence Society Standardization Committee defined urinary incontinence (UI) as “a condition in which involuntary loss of urine is a social or hygienic problem and is objectively demonstrable” (Kargar Jahromi et al. 2014, Jerez-Roig et al. 2014). Urinary incontinence affects an estimated 15 to 35% of the adult ambulatory population aged 60 and older that live in the community with prevalence rates for women being twice that of men. It leads to a massive reduction in quality of life and causes an enormous socio-economic burden. Despite the impact of UI, this is an underdiagnosed and undertreated health problem, due to patient embarrassment and the misconception that incontinence is a natural part of the aging process, and also due to the lack of motivation of health professionals to investigate this condition. In general, UI can be triggered by numerous precipitating factors, including medications and urinary catheters, and prevention is a major goal in the perioperative period.
Pressure ulcers (PU) are frequent in older patients, and the healing process is usually challenging. Prevention should be the first strategic line in PU management (see Chapter 35). Diabetes, congestive heart failure, renal dysfunction, chronic obstructive pulmonary disease, progressive neurological disorder, malnutrition and aging skin are considered to be medical comorbidities associated with PU (Bredesen et al. 2015, Chou et al. 2015, Raju et al. 2015).
The National Pressure Ulcer Advisory Panel have proposed a classification system to grade pressure ulcers from stage I to IV according to the integrity of the epidermis and the depth of the wound.
There is growing interest in the functional prognosis of older patients, particularly for quality of life issues and associated costs. To summarize functional decline as a GS can appear a simplistic view, since functional preservation or optimization represents the major goal of older patients. But it highlights the continuous fight it represents to remain independent. Activities of daily living (ADL) and instrumental activities of daily living (IADL) scales are an essential part of patient assessment for functional status. Functional decline can lead to (permanent) disability and may lead to a prolonged hospital stay, institutionalization and even death (Buurman et al. 2011, Zisberg et al. 2015).
Surgery may have life-altering effects beyond those related to the condition that required surgery. Particularly in the elderly, both physical and psychological postsurgical stress can lead to an imbalance in autonomic, endocrine and immune functions that lowers the homeostatic threshold and increases their risk of postoperative adverse events, so hampering their return to independence after surgery. Some patients heal from the condition that required the operation, but become incontinent, or have an increased risk of fall or functional decline; the recovery trajectory varies depending on the patient’s preoperative physiologic reserve, associated conditions and clinical course. Evidence-based predictors are not available; however, advanced age, frailty and major surgery seem to be related to increased risk.
GSs after surgery often impact negatively on their lives and are also risk factors for negative outcomes (Stenhagen et al. 2013, Yang et al. 2015). For example, urinary incontinence, disability and falls have been associated with reduced perceived quality of life in the elderly, and weight loss and pressure ulcers with mortality and other negative events (Vetrano et al. 2016). Stenhagen et al. (2013) and Yang et al. (2015) found that an increased number of GSs were associated with a perceived lower quality of life.
Delirium is one of the most common adverse outcomes in hospitalized elderly patients. It is characterized by inattention and acute cognitive dysfunction and is a serious, under-recognized and often fatal condition (Inouye et al. 2014).
Postoperative delirium is common after hip fracture surgery, and its frequency has been reported to range from 35% to 65% of cases (Marcantonio et al. 2001). It is frequently associated with pre-existing cognitive impairment and is highly predictive of functional decline, need for institutionalization and increased mortality (Marcantonio et al. 2001, Liang et al. 2014, ESA 2017). Bellelli et al. (2014) provided new evidence for the importance of persistent delirium as a risk factor for mortality in elderly adults with hip fracture. In particular, each day of delirium increased the risk of death within six months by 17%. Previous studies reported that post-operative delirium was partially avoidable, with a 30% risk reduction when using a specialized geriatric intervention (Marcantonio et al. 2001, Deschodt et al. 2012). In 2016, The European Society of Anaesthesiology issued a guideline on postoperative delirium prevention and treatment (see Chapters 13 and 39).
One or more postoperative falls occur in 1.6% of surgical inpatients and can lead to significant morbidity. Recognition of fall risk factors is required for postoperative fall prevention programs, by identifying patients at highest risk for postoperative falls (Church et al. 2011). Oliver et al. (2004) pooled data from 13 studies evaluating falls in hospitalized patients. Significant risk factors identified for hospitalized falls included gait instability, lower limb weakness, urinary incontinence, history of previous falls, delirium, and the prescription of drugs like sedatives and hypnotics. Moreover, the number of falls and the time elapsed to the first fall can be reduced during inhospital rehabilitation after a femoral neck fracture (Stenvall et al. 2007). The successful reduction in number of falls in this study could be a result of the active prevention, detection and treatment of postoperative complications after surgery, including other GSs, especially delirium.
UI is a risk factor for falls and hip fractures (Oliver et al. 2004, Foley et al. 2011). A urinary indwelling catheter (UIC) should be removed within 24 hours after surgery, with the aim of reducing its occurrence. Patients with prolonged UI are more prone to develop delirium and urinary tract infection (Sørbye and Grue 2012).
Patients with preoperative PU are at higher risk for postoperative adverse outcomes, including septicemia, pneumonia, stroke, urinary tract infection and acute renal failure. Surgical patients with PU were found to have approximately a 1.83-fold risk of 30-day postoperative mortality, compared with a control group (Chou et al. 2015).
A significant proportion of older patients undergoing major surgery experience functional decline at one month (45.3%), three months (30.1%) and one year (28.3%) (Kwon et al. 2012). A case series study of nonagenarians reported a 27% loss in the ability to ambulate independently after all major surgery. A more recently published retrospective cohort study found that 16% of all adults were unable to return directly home after non-cardiac surgery, increasing to 39% in adults aged 80 years and older.
As GSs negatively impact quality of life and increase healthcare-related and social costs, their prevention is a major issue. It has been observed that the literature on interventions to reduce 30-day rehospitalization (a measure that is strictly – even though not exclusively – related to the frequency with which GSs occur after surgery), has significant limitations due to heterogeneity, susceptibility to bias and lack of reporting on important contextual factors (Dharmarajan and Krumholz 2014).
Different from what was reported in studies examining hospital-acquired conditions and infections, one or more dominant risk factors (for instance, prolonged bed rest or overuse of a medical device such as a UIC or endotracheal tube) have not been identified.
Nevertheless, important insights can be found in the number of papers that examine harmful routine events occurring during hospitalization to which only limited attention is often paid. This is especially evident with regard to the aged patient.
Malnutrition resulting in impaired wound healing, increased risk of infection and pressure ulcers was extensively reported by many authors. Krumholz (2013) reported reduced nutrient intake of less than 50% of their calculated maintenance energy requirements and prolonged fasting periods in a population of older hospitalized subjects. Friedmann et al. (1997) reported weight loss and decreased blood albumin levels after discharge to be strong predictors of readmission within 30 days in elderly patients.
The effects of decreasing hospital length of stay on change in functioning from prehospital admission to posthospital discharge in older patients have been recently investigated in a nationwide cohort study (van Villet et al. 2017). Results suggest that the decrease in hospital length of stay is associated with better functional outcomes and lower mortality.
On the cognitive front, older hospitalized patients often experience a variety of stressors, such as information overload, uncertainty about outcome, sleep deprivation and depression that can cause delirium, which is associated with increased risk of adverse events before and after discharge.
Pain and other discomforts are often inadequately addressed. They can lead to sleep disorders, mood disturbances and impaired cognitive functioning, and are known to influence immune and metabolic function. Moreover, medications to treat symptoms can negatively affect the early recovery period. Finally, hospitalized patients commonly become deconditioned, have impaired coordination and are consequently at increased risk of falling.
Whereas no specific studies have been conducted to investigate the relationships between these factors and the occurrence of GSs after surgery, studies on models of care for elderly hospitalized patients demonstrated their effectiveness in reducing delirium, pressure sores, falls and functional decline after discharge (see Chapter 45). Geriatric nursing protocols were also shown to be quintessential in preventing falls, functional decline and cognitive impairment in older hospitalized patients (Capezuti et al. 2008).
In the absence of defined, evidence-based preventive criteria, mitigating stressors during the hospital stay through the implementation of dedicated clinical pathways – such as Acute Care of the Elderly (ACE) Units or Proactive Care for Older Patients Undergoing Surgery (POPS) – and substantially meeting the patient’s explicit and implicit needs (that is the essence of quality) is the way to prevent the occurrence of GSs after a surgical operation in geriatric patients.
Usually, GSs are defined as urinary incontinence, pressure ulcers, falls, delirium and functional decline, with four major shared risk factors (with the possible addition of poor quality of care):
GSs occur intermittently and are often linked to subsequent functional decline. All geriatric syndromes are partly inter-related and they are also related to the concept of multimorbidity and frailty. Koroukian et al. (2016) found that, rather than chronic conditions, the combination of functional limitations and/or GSs were the most prominent conditions in predicting health outcomes.