Comprehensive Geriatric Assessment of Older and Oldest-Old Patients in the Perioperative Period. Russian Gerontology Research and Clinical Centre Experience

With the aging population, the significance of preoperative diagnostics and optimizing the treatment of surgical patients with frailty syndrome is gaining momentum. For such patients a comprehensive geriatric assessment (CGA) is carried out to clarify the severity of frailty and the individual characteristics of the geriatric status [1]. The results of this assessment are used to stratify the risk in the postoperative period and to determine targeted interventions for the correction of geriatric syndromes [2]. The introduction of new geriatric technologies during hip and knee replacement in weakened older patients needs scientific justification and confirmation of effectiveness.

Objective: to test the method of complex geriatric management of older and oldest-old patients before and after surgical interventions in the provision of planned inpatient orthopedic care (knee and hip arthroplasty).

Materials and methods: the study involved two groups of older and oldest-old patients with frailty: 50 patients, average age 69.2 ± 6.0 years [60 to 87 years] with gonarthrosis and 50 patients, average age 67.6 ± 5.5 years [60 to 81 years] with coxarthrosis. At the prehospital stage, patients were diagnosed with frailty, in accordance with the clinical recommendations of «Senile asthenia» [3]. Upon admission to surgical treatment, a CGA was performed, including indicators of basic (Barthel Activities of daily living Index, Barthel scale [4]) and instrumental activity (The Instrumental Activities of Daily Living Scale, IADL scale [5]), nutrition assessment (Mini Nutritional assessment, MNA scale [6]), cognitive functions (The Montreal Cognitive Assessment, MOCA test [7]), depression (Geriatric Depression Scale, GDS-15 scale [8]), as well as quality of life (A Visual Analogue Scale, EQ-VAS scale [9]), multimorbidity and polypragmasia. An  individual plan of  perioperative management was drawn up.

Results. A  comparative analysis demonstrated statistically significant improvements in  functional status (based on  the Barthel scale), cognitive status (based on the MOCA test), nutritional status (based on the MNA scale) and quality of life (based on the EQ-VAS scale) 12 months after surgical intervention in groups of patients after knee and hip replacement. In the group of patients after hip replacement, there was also an improvement in the quality of life of patients 12 months after surgery. The assessment and dynamics of indicators in functional and cognitive status within the control group were not carried out, which makes it difficult to compare the results. However, there was a reduction in hospital stay for patients using geriatric approaches compared with previously used surgical care in the control group.

Conclusion: the management of  patients with frailty in  the perioperative period with the use of  CGA allows for preventive measures aimed at  maintaining functional, psycho-emotional status. Individual characteristics of  the state of psychoemotional and functional status in older and oldest-old patients may not be considered during the traditional preoperative risk stratification and increase the risks of adverse outcomes of surgical treatment, duration of hospital staying and repeated hospitalizations.

1. Amini S., Crowley S., Hizel L., Arias F., Libon D.J., Tighe P., Giordano C., Garvan C.W., Enneking F.K., Price C.C. Feasibility and Rationale for Incorporating Frailty and Cognitive Screening Protocols in a Preoperative Anesthesia Clinic. Anesth Analg. 2019 Sep;129(3):830–838. DOI: 10.1213/ANE.0000000000004190. PMID: 31425227; PMCID: PMC6927245

2. Lee H., Lee E., Jang I.Y. Frailty and comprehensive geriatric assessment. J Korean Med Sci 2020; 35:e16

3. Ткачева О.Н., Котовская Ю.В., Рунихина Н.К., Фролова Е.В., Наумов А.В., Воробьева Н.М., Остапенко В.С., Мхитарян Э.А., Шарашкина Н.В., Тюхменев Е.А., Переверзев А.П., Дудинская Е.Н. Клинические рекомендации «Старческая астения». Российский журнал гериатрической медицины. 2020;(1):11-46. https://doi.org/10.37586/2686-8636-1-2020-11-46

4. Mahoney, F. Functional evaluation: the Barthel Index / F. Mahoney & D. Barthel // Maryland State Medical Journal. — 1965. — Vol.14. — P. 61–65.

5. Lawton, M.P. Assessment of older people: Self-maintaining and instrumental activities of daily living / M. P. Lawton & E.M. Brody // Gerontologist. — 1969. — Vol. 9, no. 3. — P. 179–186.

6. Guigoz, Y. Mini Nutritional Assessment: a practical assessment tool for grading the nutritional state of elderly patients / Y. Guigoz, B.J. Vellas & P.J. Garry // Facts and Research in Gerontology. — 1994. — Vol. 2. — P. 15–59.

7. Источник: www.mocatest.org

8. Sheikh, J.I. Geriatric Depression Scale (GDS): Recent evidence and development of a shorter version / J.I. Sheikh, J.A. Yesavage // Clinical Gerontologist. — 1986. — Vol. 5, no. 1. — P. 165–173. — DOI: 10.1300/j018v05n0109.

9. Cheng L.J., Tan R.L., Luo N. Measurement Properties of the EQ VAS Around the Globe: A Systematic Review and MetaRegression Analysis. Value Health. 2021 Aug;24(8):1223–1233. DOI:10.1016/j.jval.2021.02.003. Epub 2021 Apr 23. PMID: 34372988.

10. Adeleke, Ibukunoluwa; Blitz, Jeanna. Perioperative frailty: lessons learned and future directions. Current Opinion in Anaesthesiology 34(3):p 373-380, June 2021. DOI: 10.1097/ ACO.0000000000001006

11. McIsaac D.I., Taljaard M., Bryson G.L., et al. Frailty as a predictor of death or new disability after surgery: a Prospective Cohort Study. Ann Surg. 2018 July 24 McIsaac DI, Beaulé P.E., Bryson G.L., Van Walraven C. The impact of frailty on outcomes and healthcare resource usage after total joint arthroplasty: a populationbased cohort study. Bone Joint J. 2016;98-B:799–805

12. Robinson T.N., Wu D.S., Stiegmann G.V., Moss M. Frailty predicts increased hospital and six-month healthcare cost following colorectal surgery in older adults. Am J Surg. 2011;202:511–514.

13. Norris, Christina M. MBBS*, Close, Jacqueline C.T. MD*. Prehabilitation for the Frailty Syndrome: Improving Outcomes for Our Most Vulnerable Patients. Anesthesia & Analgesia 130(6):p 1524–1533, June 2020. | DOI: 10.1213/ANE.0000000000004785

14. Partridge J.S.L. et al. Randomized clinical trial of comprehensive geriatric assessment and optimization in vascular surgery //Journal of British Surgery. — 2017. — Т. 104. — №. 6. — С. 679–687.

15. Ernst K.F. et al. Surgical palliative care consultations over time in relationship to systemwide frailty screening //JAMA surgery. — 2014. — Т. 149. — №. 11. — С. 1121–1126

16. Maria Loreto Alvarez-Nebreda, Nathalie Bentov, Richard D. Urman, Sabeena Setia, Joe Chin-Sun Huang, Kurt Pfeifer, Katherine Bennett, Thuan D.Ong, Deborah Richman, Divya Gollapudi, G.Alec Rooke, Houman Javedan. Recommendations for Preoperative Management of Frailty from the Society for Perioperative Assessment and Quality Improvement (SPAQI). Journal of Clinical Anesthesia, Volume 47, 2018, 33–42, ISSN 0952-8180, https://doi.org/10.1016/j.jclinane.2018.02.011