Background
Methods
Search strategy
Review procedure
Inclusion criteria
Results
Author, year | Study design | Surgical Population | Urgency | Age, years | Articles, N | Patients, N | Tool | Outcome |
---|---|---|---|---|---|---|---|---|
Abdullahi 2017 [12] | SR | Cardiac | Majority elective | Mean > 65 | 6 | 4819 | Gait speed, Katz IADL, Mini-Cog, CCI, Anemia, Geriatric syndrome of falls, CAF, FORECAST, TUGT, gait speed, Nagi scale | Mortality (inpatient, 30-day and 1 year), postoperative complications, length of stay |
Buignes 2015 [13] | SR | Mixed major | Majority elective | Majority mean ≥ 60 | 32 | NA | mFI, Fried criteria, gait speed, CHS, MSSA4, CAF, Katz IADL, EFS, CGA | Postoperative mortality, postoperative complications, Length of stay |
Fagard 2016 [14] | SR | Colorectal cancer | Majority elective | Mean > 65 | 5 | 486 | Fried, GFI, CGA (Barthel index, NEADL, CIRS, polypharmacy, MNA, MMSE, GDS), Katz, TUGT, CCI, Anemia, Mini-Cog, Albumin, falls | Mortality (30-day, 1 year, 5 year), postoperative complications, length of stay, 30-day readmission |
Hewitt 2018 [15] | MA & SR | Gastro-intestinal | Majorityelective | Mean age ≥ 60 | 9 | 2281 | Physical Frailty Phenotype, DAI, GFI, 7-point clinical frailty score | 30-day mortality, postoperative complications, length of stay |
Huisman 2017 [16] | SR | Oncology | Elective | Mean ≥ 60 | 9 | NA | CGA domains: function (ADL impairment, ADL, IADL, Barthel, functional limitations, NEADL, falls, TUGT), nutrition (MNA, weight loss, MMC), cognition (MMSE, mini-cog), social support (MOS-SSS), mood (GDS, HADS, MHI), comorbidity (CIRS, SIC, CCI), polypharmacy (> 5), frailty (CGA-based, GFI, frailty phenotype) | Mortality (short-term, long-term, disease-free survival), postoperative complications |
Lin 2016 [17] | SR | Mixed major | Majority elective | Mean > 75 | 23 | 17,117 | Fried, modified CHS, MSSA4, gait speed, Katz, SHERPA-risk, MMSE, MNA, TUGT, BADL, IADL, Comprehensive assessment of frailty, CAF, FORECAST, Balducci, frailty criteria, John Hopkins, CFS, Vulnerable elderly survey, MFS, Addenbrooke’s vascular frailty score, EFS, FI, mFI, KCCQ-OS QoL time | Mortality (in-hospital, 30 day and long term), postoperative complications, length of stay, discharge to institutional care, functional decline, QoL |
Oldroyd 2017 [18] | MA & SR | Vascular | Majority Elective | > 65 | 16 | 3617 | Risk factors including ASA > 2 | Postoperative delirium |
Panayi 2018 [19] | MA & SR | Mixed major | Majority elective | ≥ 60 | 16 | 683,487 | mFI | 30-day mortality, postoperative complications, readmission, discharged to facility |
Partridge 2014 [20] | SR | Mixed major | Elective | Majority > 60 | 5 | 1364 | CGA tools: MMSE, Barthel, ADL, IADL, TUGT, MNA, clock, GDS, social support scale | Postoperative complications, length of stay, change in QoL |
Sandini 2017 [21] | MA & SR | Mixed major | Elective | Mean age ≥ 65 | 35 | 1,153,684 | Frailty tools: tools not published in paper. Domains listed: activity, sarcopenia, comorbidities, nutrition, cognition, depression, walking incl | Mortality (90-day, 1 year), 30 day major morbidity |
Scholz 2016 [22] | MA & SR | Gastro-intestinal | Elective, mixed | > 65 | 11 | 1427 | Risk factors including ASA > / = 3, CCI | Postoperative delirium |
Sepehri 2014 [23] | SR | Cardiac | Majority elective | > 60 | 6 | 4756 | Fried, Katz IADL, CAF, mFI, CHS, MSSA4, gait speed, MMGA, MGBE (MMSE, MNA, TUGT, BADL) frailty tools | Mortality (in-hospital, all-cause, 1 year), MACCE, discharge to institution, functional decline |
Visser 2015 [24] | SR | Mixed major | Majority elective | Majority mean ≥ 60 | 30 | UNK | Risk factors including ASA grade | Postoperative mortality, postoperative complications |
Warnell 2015 [25] | SR | Oesophagectomy | Elective | Majority mean > 60 | 20 | 13,887 | ASA, POSSUM, P-POSSUM, O-POSSUM, CCI, Karnofsky index | Mortality (in-hospital or 30 day) |
Zhu 2017 [26] | MA | Head and neck cancer | Elective | Majority mean > 60 | 8 | 1940 (incl controls) | Risk factors including ASA ≥ 3 | Postoperative delirium |
Tool | Mortality | Morbidity and length of stay |
---|---|---|
ASA | AUROC 0.64 [25] OR 1.54–11.6 [24] | Postop complications: OR 1.77–7.1 [24] ASA > 2: OR 3.44 (2.02–5.87) [18] ASA-3: Clavien-Dindo 4 OR 6.8 [13] ASA ≥ 3: pooled OR 2.71 (1.64–4.48) [22] Delirium: ASA ≥ 3: OR 5.65 (1.57–20.36) [26] Cardiac arrest: ASA-3: OR 1.2, ASA-4: OR 3.5, ASA-5: OR 7.5 [13] Perioperative MI: ASA-3: OR 3, ASA-4: 6.9, ASA-5: 14.9 [13] |
CAF | ≤ 11 30d mortality OR 1.1 (1.06–1.2) [12] | |
CCI | AUROC 0.57 [25] All-cause mortality HR 1.03 (0.9–1.17) [16] | Postop complications: OR 0.93 (− 1.68–3.54) [22] |
CGA assessment of frailty | 2 frailty markers: 6 mo mortality HR 3.86 (0.41–36.02)–8.88 (1.09–72.29) [16] ≥ 3 markers: 6 mo mortality HR 4.51 (0.49–41.25)–8.5 (1.1–65.87) [16] | Postop complications: RR 1.59 (1.25–2.01)–1.75 (1.28–2.41) [16] Length of stay LOS > 2 days OR 4.2 [13] |
Fried | 30d mortality OR 2.67 (p = 0.029) [17] | Postop complications: OR 2.54 (1.12–5.77) [13] Major Cx OR 3.13 (1.65–5.92)—4.1 [13] ≥ Clavien 2 Cx OR 4.08 (p = 0.006) [17] Mortality or procedural Cx OR 2.2 (p = 0.04) [17] QoL Mortality or poor QoL at 6 mo OR 2.21 (p = 0.03) [17] Length of stay LOS intermediately frail OR 1.49 (1.24–1.8) [13] |
GFI | GFI ≥ 5 30d mortality ES 0.08 (0.02–0.21) [15] | Postop complications: GFI ≥ 5 Postop Cx ES 0.15 (0.06–0.31) [15] GFI ≥ 3 ≥ Clavien 3a OR 3.62 [13] Length of stay GFI ≥ 5 ES 7.17 (6.02–8.54) [15] GFI ≥ 3 ES 15.8 (12.79–19.51) [15] |
Katz IADL | Dependence in ≥ 1 ADL inpatient mortality OR 1.8 (1.1–3) [23] | |
mFI | OR 11–11.7 [13] RR 4.19 (2.96–5.92) [19] | Postop complications: OR 11[13] Clavien 4 and 5 postop Cx OR 14.4 [13] mFI > 0.27: Clavien 4 Cx OR 4.8 [13] mFI > 0.12: postop Cx OR 2.71 [13] mFI > 0: postop Cx pooled RR 1.48 (1.35–1.61), major postop Cx pooled RR 1.48 (1.35–1.61) [19] Discharge to care facility: RR 2.15 (1.92–2.4) [19] |
Slow gait speed 5 m ≥ 6 s | OR 2.63 [13] | Mortality or major morbidity OR 2.63 (1.17–5.9)–3.17 (1.7–2.59) [12] |
American Society of Anesthesiologists Physical Status (ASA-PS)
Frailty
Function
Comprehensive geriatric assessment (CGA)
Current guidelines on perioperative management of older patients
Society | Guideline title | Year | Domain assessed | Evidence | |||||||
---|---|---|---|---|---|---|---|---|---|---|---|
Cognition | Function | Frailty | Mood | Nutrition | Medication | Comorbidity | Other/comments | ||||
ACS NSQIP/ American Geriatrics Society [28] | Optimal Perioperative Management of the Geriatric Patient | 2016 | – | – | – | – | – | + NSQIP 2012 | – | References NSQIP 2012 for assessment of individual domains, covers advance directives, preoperative fasting, antibiotic use and venous thromboembolism prevention | Expert opinion |
ACS NSQIP/American Geriatrics society [29] | Optimal Preoperative Assessment of the Geriatric Surgical Patient | 2012 | + Mini-COG | + TUGT | + | + PHQ-2 | + | + AGS Beers Criteria | + RCRI | Recommends preoperative diagnostic tests including Hb, renal function, serum albumin ± WCC, platelet count, coagulation profile, serum glucose, CXR, ECG, RFT, noninvasive stress testing, BMI and unintentional weight loss | Level 1 + Expert opinion |
Association of Anaesthetists Great Britain and Ireland [30] | Perioperative care of the elderly | 2014 | + NSQIP 2012 | + | + | – | – | + NSQIP 2012 | – | Recommends risk scores such as NSQIP preoperative assessment and Nottingham Hip Fracture Score Recommends multidisciplinary care | Level 1 + Expert opinion |
British Geriatric Society [31] | Perioperative Care for Older Patients Undergoing Surgery | 2013 | + | + | + | – | – | – | + | Social domain assessed | Expert opinion |
New South Wales Government Health [32] | The Perioperative toolkit | 2018 | + | + | + | – | – | + | + | Social domain assessed, involves families in decision-making, multidisciplinary team, patient care pathways, shared decision-making | Expert opinion |
Society for Perioperative Assessment and Quality Improvement (SPAQI) [33] | Recommendations for Preoperative Management of Frailty from the SPAQI | 2018 | + Mini-COG | + | + Frailty/Edmonton score | + | – | – | + | Recommends multidisciplinary care and shared decision-making, prehabilitation principles (eg nutritional intervention), requires further studies prior to inclusion in standard recommendations | Level 1 + Expert opinion |