Interventions to Improve Clinical Outcomes in Older Adults Admitted to a Surgical Service: A Systematic Review and Meta-analysis

Janani Thillainadesan; Minna F Yumol; Sarah Hilmer; Sarah J Aitken; Vasi Naganathan

doi:10.1016/j.jamda.2020.03.023

Interventions to Improve Clinical Outcomes in Older Adults Admitted to a Surgical Service: A Systematic Review and Meta-analysis

J Am Med Dir Assoc. 2020 Dec;21(12):1833-1843.e20. doi: 10.1016/j.jamda.2020.03.023. Epub 2020 May 14.

Authors

Janani Thillainadesan¹, Minna F Yumol², Sarah Hilmer³, Sarah J Aitken⁴, Vasi Naganathan⁵

Affiliations

¹ Department of Geriatric Medicine, Concord Hospital, Sydney, New South Wales, Australia; Concord Clinical School, Faculty of Medicine and Health, University of Sydney, Sydney, New South Wales, Australia; Centre for Education and Research on Ageing, Sydney, New South Wales, Australia; Ageing and Alzheimer's Institute, Sydney, New South Wales, Australia. Electronic address: Janani.Thillainadesan@health.nsw.gov.au.
² Department of Geriatric Medicine, Concord Hospital, Sydney, New South Wales, Australia.
³ Kolling Institute of Medical Research, Sydney Medical School, University of Sydney, Sydney, New South Wales, Australia; Royal North Shore Hospital, Sydney, New South Wales, Australia.
⁴ Concord Clinical School, Faculty of Medicine and Health, University of Sydney, Sydney, New South Wales, Australia; Centre for Education and Research on Ageing, Sydney, New South Wales, Australia; Ageing and Alzheimer's Institute, Sydney, New South Wales, Australia; Concord Institute of Academic Surgery, Vascular Surgery Department, Concord Hospital, Sydney, New South Wales, Australia.
⁵ Department of Geriatric Medicine, Concord Hospital, Sydney, New South Wales, Australia; Concord Clinical School, Faculty of Medicine and Health, University of Sydney, Sydney, New South Wales, Australia; Centre for Education and Research on Ageing, Sydney, New South Wales, Australia; Ageing and Alzheimer's Institute, Sydney, New South Wales, Australia.

PMID: 32417101
DOI: 10.1016/j.jamda.2020.03.023

Abstract

Objectives: Managing older patients with surgical conditions is a major challenge for hospitals. There is therefore a growing interest in providing geriatric perioperative services. The aim of this systematic review and meta-analysis was to characterize and assess the impact of targeted perioperative geriatric interventions on clinical outcomes of older adults admitted to nonorthopedic surgical teams.

Design, setting and participants: A systematic review and meta-analysis of studies of perioperative geriatric interventions in older adults hospitalized under nonorthopedic surgical teams.

Methods: Ovid MEDLINE, EMBASE, PsycINFO, Scopus, Cochrane Central Register of Controlled Trials, CINAHL, and trial registry databases were searched. Primary outcomes were change in functional status and length of stay (LOS).

Results: Fifteen randomized controlled trials (RCTs) and 9 prospective before-and-after studies met the inclusion criteria (n = 3026 participants). Perioperative geriatric interventions included preoperative comprehensive geriatric assessment and management (CGA) (5 studies), multicomponent inpatient geriatric programs (8 studies), cognitive training (1 study), exercise (5 studies), and prehabilitation (5 studies). Exercise therapy [mean difference (MD) -1.90, 95% confidence interval (CI) -3.01, -0.80], multicomponent inpatient geriatric programs (MD -1.98, 95% CI -3.09, -0.88), and prehabilitation (MD -1.32, 95% CI -2.75, 0.11) reduced LOS. Functional decline was highly heterogeneous, with 4 of 8 studies reporting significantly less functional decline. Geriatric perioperative interventions reduced complications [exercise therapy risk ratio (RR) 0.74, 95% CI 0.48, 1.15; prehabilitation RR 0.61, 95% CI 0.47, 0.80] and delirium (multicomponent inpatient geriatric programs RR 0.49, 95% CI 0.27, 0.90; preoperative CGA RR 0.54, 95% CI 0.33, 0.89). There was no significant impact on mortality or readmissions.

Conclusions and implications: Perioperative geriatric interventions targeted at older nonorthopedic surgical patients improve some clinically relevant outcomes. There is a need for these interventions to be further evaluated in high-quality studies, and future research should explore how to effectively implement these interventions within complex health care systems.

Keywords: Aging; comprehensive geriatric assessment; delirium; functional status; outcomes; surgery.

Publication types

Meta-Analysis
Research Support, Non-U.S. Gov't
Review
Systematic Review

MeSH terms

Aged
Exercise Therapy*
Hospitalization*
Humans
Length of Stay