Surgical Guidelines for Perioperative Management of Older Adults: What Geriatricians Need to Know

Jessica L. Colburn, MD; Sanjay Mohanty, MD, MS; John R. Burton, MD

Disclosures

J Am Geriatr Soc. 2017;65(6):1339-1346. 

In This Article

Abstract and Introduction

Abstract

A multidisciplinary panel of experts representing surgery, anesthesia, and geriatrics recently published guidelines for surgeons on the optimal perioperative management of older adults, including recommendations on postoperative recovery and posthospital transitions of care. Geriatricians have an important role in the care for older adults in the preoperative period as older adults consider surgical options and prepare for surgical procedures, during the perioperative period as inpatient consultants, and in the postoperative period as older adults transition to rehabilitation facilities or to home. This article outlines the perioperative surgical guidelines and describes how they apply to the role of the geriatrician in the care of older adults during the perioperative period.

Introduction

A panel of experts representing the American College of Surgeons (ACS), American Society of Anesthesiologists, American Geriatrics Society (AGS), ACS Geriatric Surgery Task Force, and AGS Geriatrics for Specialists Initiative recently published guidelines for surgeons focused on perioperative management of older adults.[1] The first set of guidelines, published in 2012, addressed optimal preoperative assessment of older adults undergoing surgery, including risk assessment and evaluation. The new set of guidelines, discussed herein, focuses on additional aspects of the immediate preoperative period and extends recommendations through the perioperative period, including discharge and transition to home. As experts in the care of older adults with multiple comorbidities and in managing systems and transitions of care, geriatricians are well positioned to work collaboratively with surgeons to provide optimal care for older adults in the perioperative period. This article identifies the areas of the surgical guidelines that apply to geriatricians. Although geriatricians are focused on, the roles described are applicable to other clinicians who collaborate in the care of people in the perioperative period.

In addition to discussing the geriatrician's role in the care of highly complex older adults undergoing surgery, it is important to address the prominent role of geriatricians as health system leaders and innovators. Hospitals and health systems seek innovations to improve care provided to older adults, who, as a group, are especially vulnerable and experience a higher rate of complications, less-favorable outcomes, and more-frequent readmissions.[2] A geriatric–surgical co-management service is one example of a highly successful care innovation model. Co-management innovations began with hip fracture co-management by orthopedic surgeons and geriatricians and successfully demonstrated shorter intensive care unit admissions, shorter hospital stays, lower costs per person, and lower mortality.[3,4] Surgical co-management programs have since expanded to other surgical specialties, and geriatricians are emerging as natural leaders in developing co-management programs with surgeons to improve quality of care of older adult. Co-Management of Older Operative Patients En Route Across Treatment Environments, a new care model at the Veterans Affairs Health Care Connecticut, in preliminary studies has shown that co-management care of a broad variety of individuals undergoing surgery leads to a higher rate of return to the community as opposed to an institution if geriatricians are involved in the preoperative evaluation.[5]

For individuals, geriatricians serve an important role in maintaining continuity for vulnerable older adults: referring to a surgeon for consultation after considering a person's goals and function, communication with a surgeon regarding surgical risk, assistance with transitions of care, and resuming care of the individual in the postoperative period. This complex care includes medication management, coordination of home care services, continuing guidance and support of the individual and caregiver, and reassessment of a person's goals in anticipation of potential functional decline or surgical complications. This complex continuity of care that geriatricians provide is discussed below using the template of the surgical guidelines.

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