Cochrane in CORR®: Comprehensive Geriatric Assessment For Older People Admitted To A Surgical Service

Importance of the Topic The world’s fastest-growing population is that of adults older than 85 years of age [6]. By 2050, one estimate suggests that one in four persons living in North America will be 65 years of age or older [27], while people older than 80 years of age will represent nearly 6% of the American population [31, 32]. Surgery is most commonly performed on those older than the age of 65 [22], and this represents a substantial portion of healthcare spending [24]. Aging is a risk factor for functional decline and chronic conditions including cancer, cardiovascular, neurological, frailty, and musculoskeletal diseases [18, 19]. As a consequence, older adults (65 years of age or older) are at a higher risk of postoperative complications, prolonged hospitalization, and increased dependency or institutionalization [11, 15]. Surgical complications have been shown to increase both hospital and third-party payer costs per admission [4, 7, 34]. Given the complexities of older patients undergoing orthopaedic procedures, coordinated care (composed of teams of specialists along with other healthcare professionals) may be beneficial, particularly for those requiring emergency surgery (due to hip fracture, for example). Coordinated care models seek to identify possible risk factors and take measures to correct or prevent postoperative complications, while also providing greater safety for this high-risk population [12, 13, 21]. Comprehensive geriatric assessment is a care model composed of multidisciplinary assessment of older patients in order to develop an overall plan for treatment and long-term follow-up [25, 26]. This collaborative intervention can be applied to older patients undergoing orthopaedic procedures with the aim of improving postoperative complications and mortality. This Cochrane review from 2018 assessed the effects of comprehensive geriatric assessment compared to standard care on postoperative outcomes of older people undergoing surgical procedures [3]. Upon Closer Inspection This systematic review and meta-analysis included eight randomized trials (1843 participants); but of those, only one trial was at low risk of bias in all the Cochrane risk of bias domains [17]. The included studies with high or unclear risk of bias will decrease the certainty of evidence of this systematic review. Of the included trials [2, 9, 10, 14, 16, 23, 28, 33], seven examined the effect of pre or postoperative comprehensive geriatric assessment in people with hip fracture and one trial recruited frail older adults undergoing elective surgery for a solid tumor [8]. In the oncology trial included in this review, the comprehensive geriatric assessment did not improve any of the outcomes (hospital readmission, major complication, or delirium) [8]. Therefore, the findings of this review are not generalizable to other surgical populations such as spine or joint replacement surgery. In people with hip fracture, pre or postoperative comprehensive geriatric assessment also substantially reduced discharge to an increased level of care (relative risk 0.71, [95% CI 0.55-0.92]; five trials, 941 participants) [3]. There was no difference between comprehensive geriatric assessment and the standard-care group in mortality in older people with hip fracture (RR 0.85, [95% CI 0.68-1.05]; five trials, 1316 participants) [3]. The authors did not to conduct a subgroup analysis comparing the effect of pre versus postoperative comprehensive geriatric assessment, which is an important analysis to guide surgical care for older adults with hip fracture. Only one study in this Cochrane review reported on the cost effectiveness of comprehensive geriatric assessment, and it found only a negligible reduction in costs of care associated with the intervention one year later (EUR 54,332 versus EUR 59,486) [23]. The effect of comprehensive geriatric assessment on the surgical population may have been underestimated in this Cochrane review, since some of the source studies excluded a number of patients who might most benefit from this intervention, including patients who previously resided in a long-term care facility [16, 23], had fewer than 6 months expected lifespan [10, 14, 16, 23, 28, 33], or were unable to ambulate before hip fracture [16, 23, 28, 33]. This would result in a healthier population being included in the studies than those typically presenting for surgical intervention. The evaluated comprehensive geriatric assessment models in this review were defined by coordinated multidisciplinary assessments, identification of medical, physical, social, and psychological problems, and the formation of an appropriate plan of care [30]. The interventions of the included studies implemented all the key components of comprehensive geriatric assessment but varied in the type of physician who led the comprehensive geriatric assessment (surgeons in three studies [8, 14, 16], geriatricians in three studies [23, 28, 33], a general practitioner in one [10] and was unclear for another study [9]). The delivery model also varied: One study developed a preoperative geriatric treatment plan that was monitored by a geriatric nurse postoperatively [8], three studies performed geriatric rounds as a consultation service, two conducted rounds on a daily basis [14, 16] and one conducted rounds twice a week [10]). The heterogeneity of comprehensive geriatric assessment models may hinder its implementation in clinical settings since there is insufficient evidence to define the most effective comprehensive geriatric assessment model, core team, and care organization for older orthopaedic patients [20]. Take-home Messages This review showed that comprehensive geriatric assessment reduced discharge to an increased level of care compared to standard care in patients with hip fracture. There was no compelling evidence that comprehensive geriatric assessment decreases mortality, length of stay, hospital readmission, costs of care, or major postoperative complications. Comprehensive geriatric assessment is an important clinical tool that aims to decrease mortality and postoperative complications of frail older adults. As the global population ages, more rigorous randomized controlled trials are needed to: (1) compare different comprehensive geriatric assessment models and determine the most effective one in the context of the orthopaedic surgery, and (2) examine the comprehensive geriatric assessment effect on older adults undergoing other elective and emergency surgery (besides hip fractures). For example, the FitJoints trial—led by researchers at McMaster University and one of the authors of this column (AN)—is an ongoing preoperative multimodal intervention that aims to reduce frailty and postoperative complications and improve physical function of frail older adults who are undergoing elective joint replacement. The FitJoints intervention includes physiotherapy-led tailored exercise, medication review, and protein and vitamin D supplementations [17]. In the nonsurgical population, comprehensive geriatric assessment was proven to be effective in improving cognition, lowering mortality risk, reducing functional decline, and admissions to nursing homes when compared to usual care [1, 5, 29]. However, there was no discernible difference in mortality and postoperative complication between comprehensive geriatric assessment and usual care in the surgical population included in this review. To increase the effectiveness of comprehensive geriatric assessment in the surgical population, we may need to select frail older adults who will benefit from the intervention and increase the duration of the intervention. The current review did not examine the effect of the intervention on critical patient-reported outcomes such as quality of life, pain, physical function, and performance. Future studies should examine the effect of comprehensive geriatric assessment on these patient important outcomes using validated tools. This review concluded that comprehensive geriatric assessment reduced hip fracture patients discharge to an increased level of care. However, further studies are needed to determine the most effective comprehensive geriatric assessment model and its impact on other patient important outcomes.

Récupéré en direct depuis OpenAlex et désinversé. Les résumés ne sont pas conservés dans cette base de données : les index inversés représentent 8,6 Go des 9,3 Go de texte de la base, et le serveur dispose de 13 Go libres.