Perioperative medicine for Older People undergoing Surgery (POPS): Comprehensive Geriatric Assessment (CGA) and optimization in the perioperative setting.

Abstract

In the developed world, the majority of surgery is now undertaken on older patients. This is not surprising given the association between aging and pathologies that require surgery, including degenerative disease (eg, osteoarthritis), neoplastic disease (eg, solid organ tumors), and vascular disease (eg, coronary or peripheral arterial disease). Older people have much to gain from surgery undertaken in terms of increasing longevity and/or symptom control. However, this older population presents to surgical services, not only with the index surgical pathology, but also with age-associated decline in physiological status, and often with other coexisting health issues including multimorbidity and geriatric syndromes such as frailty and/or cognitive impairment. There is now evidence across surgical subspecialties that these factors, poor physiological reserve, multimorbidity, frailty and cognitive impairment, are important, independent predictors of adverse postoperative outcomes. This is true across clinician-reported (morbidity, mortality), patientreported (experience, satisfaction), and process-related (late cancellations of surgery, length of hospital stay, readmissions) outcomes. Furthermore, these same factors are also associated with high financial costs to health and social care systems. With the observed changes in the age and pathophysiological profile of the surgical population, the need for geriatric medicine services to support surgical and anesthetic teams in delivering perioperative care for older people has been recognized. This need was first addressed as orthogeriatric services for patients with hip fractures were developed. Over the past 20 years geriatric medicine delivered perioperative services has expanded with innovative models of care now in existence for those presenting for planned and unplanned surgery across surgical subspecialties. These new perioperative services for older people are usually delivered using Comprehensive Geriatric Assessment (CGA) and optimization methodology. The first service to utilize and describe this CGA-based approach was established at Guy’s and St Thomas’ NHS Foundation Trust in the United Kingdom and has informed the development of other models of care nationally and internationally. In this article, we describe the Guy’s and St Thomas’ Perioperative medicine for Older People undergoing Surgery (POPS) service and discuss the workforce required to deliver it. The evidence supporting such an approach will be summarized and the translation of the service across hospitals in the United Kingdom and internationally will be described.