Frailty as a Growing Challenge for Anesthesiologists

Results of a Dutch National Survey

A. Bouwhuis; C. E. van den Brom; S. A. Loer; C. S. E. Bulte

Disclosures

BMC Anesthesiol. 2021;21(307) 

In This Article

Discussion

The results from this survey demonstrate that anesthesiologists and residents in the Netherlands are familiar with the frailty syndrome, and agree that frailty influences perioperative anesthetic management. The increasing number of frail elderly patients is perceived as important and relevant for anesthesiologists, however, also as a challenge. Unfortunately, there is low familiarity with the current Dutch frailty screenings among the respondents, and frailty is infrequently documented during preassessment visits. The presence of dedicated geriatric care pathways, participation of anesthesiologists in multidisciplinary geriatric teams and collaboration with geriatric specialists is limited and generally not perceived as well implemented, especially in academic hospitals. Altogether, the challenge lies in improving the organization and effectuation of perioperative care for elderly patients.

The present study shows that the increasing number of frail elderly patients is important and relevant for anesthesiologists, however, that the participation of anesthesiologists in perioperative care for these patients in the Netherlands is currently limited. This is in line with a previous study concluding that involvement of anesthesiologists varies dependent on how important and involved people feel towards multidisciplinary anesthetic geriatric perioperative care for frail elderly.[14] Also, a recent edition of Anesthesia & Analgesia on frailty called anesthesiologists for action to better appreciate how perioperative outcomes are impacted by frailty by increasing awareness, education, geriatric collaboration, dedicated care pathways, and incorporation of the perioperative setting into frailty research.[15] Similarly, the guideline from the AAGBI states there is an expanding role for anesthesiologists into multidisciplinary perioperative care for the elderly.[16] This is confirmed by the present study by the unanimous opinion of the respondents stating that anesthesiologists should not only be aware of the presence of frailty, but also feel that the presence of frailty influences anesthetic management. The more active role for anesthesiologists appears rational as perioperative derailment of physiology and development of delirium is greatly influenced by various aspects of anesthetic practice. Elements that impair postoperative recovery include altered consciousness, immobility, pain, fluid disturbances, hypothermia, altered appetite and the substantial number of medications.[17] Several optimization strategies could be applied by the anesthesiologist. The preoperative evaluation should preferably occur at least 1 to 3 weeks prior to surgery via face-to-face visits in the presence of a relative or care-giver to gather important information about functional status. Timely evaluation creates the possibility for medication review including substance abuse, geriatric consultation, or the initiation of prehabilitation regimens aiming at correction of anemia, nutritional status, exercise capacity, cognitive or social support. Furthermore, logistics regarding the procedure (e.g., procedure in day care setting or hospitalization, postoperative ICU admission) and choice for anesthetic technique and monitoring should be tailored to the identified most profound vulnerabilities. Thorough preoperative evaluation clarifies benefits and risks, which should not be limited to the procedure and anesthesia alone, but also incorporate the expected influence on postoperative functional status. Preoperative knowledge of the presence of frailty will enable patients, their families, anesthesiologists, intensivists and surgeons to make informed decisions regarding treatments and surgical options. Taken together, these findings suggest a role for anesthesiologists in perioperative management of frail elderly patients.

Another finding of the present survey is that frailty is perceived as a responsibility of all clinicians, including anesthesiologists, but more education is desirable to gain confidence in frailty assessment. Deficiencies in training and resources as a barrier to identification of frailty in hospitalized patients were already reported in the United Kingdom.[18] A survey amongst health care professionals in Canada also stated that the lack of knowledge about frailty was a prominent barrier to the use of frailty assessments in practice, despite clinicians' understanding that frailty affects their patients' outcomes.[19] We can therefore conclude that more education will improve timely recognition of the frailty syndrome in elderly patients.

Besides education on the assessment of the frailty syndrome, collaboration with geriatric specialists is of importance. In the current study unsatisfactory collaboration with geriatric specialists was identified as well as lack of knowledge on the presence of dedicated geriatric care pathways. Dutch guidelines recommend implementation of dedicated care pathways for frail elderly undergoing surgery in which multidisciplinary evaluation, monitoring and treatment by professionals with both surgical and geriatric expertise are essential to achieve favorable recovery.[20] The guideline suggests that frailty screenings by anesthesiologists would be sensible, followed by more elaborate assessment performed by geriatricians. Geriatric evaluation should occur early in the perioperative track.[21] and should include physical, cognitive and social domains. Besides medical history, functional status, cognitive and sensorial impairments, mood, living situation, social support and financial constraints influence the patients' health status and resilience after surgery. It should also be reviewed what defines the patients' quality of life in the current state and the near future. Currently, Dutch guidelines do not specify who should provide the perioperative geriatric evaluation; in the Netherlands geriatric consultation is most frequently performed by geriatric physician assistants or geriatric specialists. Global European guidelines on perioperative frail elderly patients are lacking. However, the guideline focusing on postoperative delirium, with frailty as a substantial risk factor, also encourages education and implementation of multidisciplinary team-based approaches.[22] Co-management by geriatric specialists has been proven to improve patient outcome in patients with hip fractures as well as other procedures.[23] Taken together, more consistent participation of anesthesiologists in multidisciplinary geriatric teams and collaboration with geriatric specialists are opportunities for optimization of perioperative care of frail elderly.

This study has several limitations. First, there was a low response rate and although respondents were from hospitals throughout the Netherlands and included academic as well as non-academic centers significant response bias arises. Respondents that already have interest in geriatric care may have been more likely to respond to the survey. Secondly, the comparison between subgroups could have been affected by the small sample size and the relatively large number of residents. Residents naturally have fewer years of perioperative experience, therefore these results need to be interpreted with caution.

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