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Risk prediction instruments to guide perioperative care in elderly patients with advanced disease: A basic necessity

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Abstract

High-income countries are faced with increasingly ageing populations because of rising life expectancy and decreasing fertility rates.1 This relates to a growing number of elderly patients (commonly defined for research purposes as those older than 60 or 65 years of age) being treated in acute care hospitals.2
These elderly patients, many of whom are frail, can have considerable comorbidities, reduced physical activity and cognitive impairment. Pre-existing comorbidities are related to postinterventional complications. Therefore, even minor surgical interventions or nonsurgical procedures may have considerable postinterventional complications, including death.3,4
Most of these elderly patients can be treated successfully with an adequate strategy, including early identification of patients at risk, interdisciplinary management, adequate preparation, well established clinical pathways, adapted minimally invasive interventions, preventive perioperative procedures and monitored structures with sufficient numbers of well trained nurses. These supplementary care processes and interventions during the perioperative period, increasingly referred to as ‘perioperative medicine’, may change perioperative outcomes, reducing the high complication rate and hospital stay in this population.5 These ‘geriatric, peri-interventional pathways’ can include a peri-interventional stay in an intermediate care or high-dependency unit for physiological stabilisation6,7 and/or specialised geriatric consultations during the perioperative period,8 measures which have been identified as effective. Potentially, even long-term survival could be improved, as mortality remains elevated for years in patients who develop early postinterventional complications.9,10
It is ethically inappropriate to manage the elderly with poorer care quality than that provided to younger patients. On the contrary, if we manage the most vulnerable elderly patient with the highest standards and success, we will probably also treat less vulnerable patients more successfully. However, there are limits to perioperative care in elderly patients with advanced disease. To exceed physiological and cognitive limitations is associated with an excessive postinterventional mortality.4,11–13 Therefore, considerations regarding personal perioperative goals, advance directives (including resuscitation status and limitations on invasive and intensive treatment) and potential end-of-life care must be part of the peri-interventional care of the elderly.
Surgical or nonsurgical indications for an intervention in elderly patients should include an estimation of the risk of major complications or death based on the assessment of frailty, and on physical and cognitive capacities. Importantly, care should be taken to avoid over-optimistic prognosis and inappropriate indications for burdensome interventions in the last months of life, which happens too often, as suggested by a recent investigation in which 18% of patients in a cohort of elderly Medicare beneficiaries had surgery in the last month of life.14 High-risk interventions often performed at the end of life are emergency laparotomy, hip fracture repair or minimally invasive valve repair in patients with advanced dementia, and drainages in advanced and metastatic tumours often combined with a history of recent sepsis.15 Similar risks have been described in patients with end-stage liver cirrhosis16,17 or advanced neurological diseases.18 It is not unusual to witness disagreement between interventional physicians estimating the potential benefits of an intervention (e.g. cure of disease or improved mobility) and physicians responsible for preventing and treating major complications, such as anaesthesiologists and intensive care physicians.
Reliable, quantitative risk assessment of comorbidities, cognition and frailty for realistic prognosis could nuance the complex preinterventional decision-making process in these elderly patients with advanced disease, contributing to a broader consensus of all healthcare personnel involved in the perioperative period for the best care of their patients. Realistic estimates of outcomes and postinterventional complications with avoidance of therapeutic illusions could optimise patient selection, personalised diagnostic and therapeutic preparation, and timing of intervention in these high-risk patients.
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