Prudence Joan McRae B.Phty, Grad Dip Manip Therapy373252/s3170067... · 2019. 10. 9. · frailty),...

Understanding the occurrence of geriatric syndromes in older surgical patients

Prudence Joan McRae

B.Phty, Grad Dip Manip Therapy

A thesis submitted for the degree of Master of Philosophy at

The University of Queensland in 2015

School of Medicine

I

Abstract

The population is ageing and surgery is becoming more common as the treatment of choice for

many diseases and conditions in older people. Although mortality rates are low for many

operations, older patients are at increased risk of complications and may have poor outcomes

including longer hospital stays and discharge to sub-acute care or aged care facilities.

The aim of this thesis was to describe the occurrence of non-disease specific complications, known

as geriatric syndromes, in older patients admitted to surgical wards, and to explore the association

of ‘frailty’ and other key risk factors with geriatric syndromes and discharge outcomes in order to

identify high risk groups who might benefit from interventions designed to prevent these

complications and improve discharge outcomes.

The specific aims were to:

1. Describe the occurrence of geriatric syndromes in older surgical ward patients (with the

exception of hip fracture or cardiothoracic patients)

2. Investigate the association between key risk factors for geriatric syndromes and discharge

outcomes (acute length of stay and discharge destination) in older surgical ward patients.

A literature review of the occurrence of geriatric syndromes in the broader surgical population

cared for in usual care wards is presented in Chapter 2(1).

The occurrence of geriatric syndromes in older patients admitted under two surgical subspecialty

units is presented in Chapter 3 (2). In this retrospective cohort study of 112 patients aged 65,

admitted under the urology or vascular surgical units of Royal Brisbane and Women’s Hospital for

three days or more, we found that geriatric syndromes occurred in 32 % of patients. We examined

the association of pre-existing impairment in activities of daily living (a unidimensional marker of

frailty), mode of admission (elective versus non-elective), extent of surgery (non-operative, minor,

major) and surgical sub-specialty unit with ≥1 geriatric syndromes. In multivariable analysis, non-

elective admission, major surgery and pre-existing impairment in activities of daily living increased

the likelihood of geriatric syndromes. No significant association was seen in the adjusted model

with surgical unit, age or comorbidity score.

In Chapter 4, we describe the prevalence of frailty and the occurrence of geriatric syndromes in

older vascular surgical ward patients and more precisely examine the association of pre-existing

II

patient factors (frailty and comorbidities), illness severity, surgical severity and mode of admission

with ≥1 geriatric syndromes, acute length of stay and discharge destination from the vascular

surgical unit. In a prospective cohort study of 110 patients admitted to the vascular surgical unit of

Royal Brisbane and Women’s Hospital for three days or more, we found that 39% of participants

were frail and 36% developed ≥1 geriatric syndromes. In multivariable analysis, this study found

multiple risk factors for geriatric syndromes; frailty and non-elective admission were important

predictors for both geriatric syndromes and discharge destination; diabetes with end organ damage

was an important predictor of longer length of stay and discharge destination.

In conclusion, these studies add to the evidence that geriatric syndromes are common complications

in older surgical ward patients. They contribute to the design of future studies by identifying that

frail and non-elective patients are at increased risk and should be the target for interventions to

prevent geriatric syndromes and therefore improve outcomes; and identify multiple risk factors for

geriatric syndromes and discharge outcomes to be considered when designing or evaluating

interventions. Finally, these studies have informed the design of a before-and-after study of an

enhanced interdisciplinary model to prevent geriatric syndromes and improve outcomes of vascular

surgical elders at Royal Brisbane and Women’s Hospital.

References

1. McRae P, Mudge A, Peel NM, Walker P. Geriatric Syndromes in Older Surgical Patients -

A Literature Review. J Frailty Aging. 2013;2(4):205-10.

2. McRae PJ, Peel NM, Walker PJ, de Looze JW, Mudge AM. Geriatric Syndromes in

Individuals Admitted to Vascular and Urology Surgical Units. J Am Geriatr Soc. 2014;62 (6):1105-

9.

III

Declaration by author

This thesis is composed of my original work, and contains no material previously published or

written by another person except where due reference has been made in the text. I have clearly

stated the contribution by others to jointly authored works that I have included in my thesis.

I have clearly stated the contribution of others to my thesis as a whole, including statistical

assistance, survey design, data analysis, significant technical procedures, professional editorial

advice, and any other original research work used or reported in my thesis. The content of my thesis

is the result of work I have carried out since the commencement of my research higher degree

candidature and does not include a substantial part of work that has been submitted to qualify for

the award of any other degree or diploma in any university or other tertiary institution. I have

clearly stated which parts of my thesis, if any, have been submitted to qualify for another award.

I acknowledge that an electronic copy of my thesis must be lodged with the University Library and,

subject to the policy and procedures of The University of Queensland, the thesis be made available

for research and study in accordance with the Copyright Act 1968 unless a period of embargo has

been approved by the Dean of the Graduate School.

I acknowledge that copyright of all material contained in my thesis resides with the copyright

holder(s) of that material. Where appropriate I have obtained copyright permission from the

copyright holder to reproduce material in this thesis.

IV

Publications during candidature

Peer-reviewed papers

McRae P, Mudge A, Walker P, Peel N, Geriatric Syndromes in Older Surgical Patients – A

Literature Review, J Frailty Aging.2013;2(4):205-210

McRae PJ, Peel NM, Walker PJ, de Looze JW, Mudge AM. Geriatric Syndromes in Individuals

Admitted to Vascular and Urology Surgical Units, J Am Geriatr Soc.2014;62(6):1105-9

Chari S, McRae P, Varghese P, Ferrar K, Haines TP. Predictors of fracture from falls reported in

hospital and residential care facilities: a cross-sectional study. BMJ Open. 2013;3(8) pii: e002948.

doi:10.1136/bmjopen-2013-002948.

Mudge A, McRae P, Cruickshank M, Eat Walk Engage: An interdisciplinary collaborative model

to improve care of hospitalized elders, Am J Med Qual. 2015;30(1):5-13

McRae P, Walker PJ, Peel NM, Hobson D, Parsonson F, Donovan P, Reade M, Marquart L,

Mudge AM, Frailty and Geriatric Syndromes in Vascular Surgical Patients. Submitted to Annals of

Vascular Surgery but not yet accepted

Conference abstracts

McRae P, Mudge A, Walker P, Peel N, Understanding the interdisciplinary care needs of older

surgical patients POSTER ABSTRACT. Australas J Ageing.2012;31:67–83.

McRae P, Mudge A, Cruickshank M. Eat Walk Engage – impact of an integrated approach to

inpatient care, ORAL ABSTRACT. Australas J Ageing.2012;31:1–66.

Publications included in this thesis

1. McRae P, Mudge A, Walker P, Peel N, Geriatric Syndromes in Older Surgical Patients – A

Literature Review, J Frailty Aging.2013;2(4):205-210

(Chapter 2)

V

Contributor Statement of contribution

Prue McRae Identified search terms (80%), undertook systematic review (100%),

prepared manuscript drafts and final manuscript (70%)

Dr Alison Mudge Provided advice on undertaking a systematic review, identified search

terms (10%) and comments on manuscript drafts and final manuscript

(10%)

Dr Nancye Peel Provided detailed advice on undertaking a systematic review, identified

search terms (10%) and comments on manuscript drafts and final

manuscript (10%)

Professor Philip

Walker

Provided comments on manuscript drafts and final manuscript (10%)

2. McRae PJ, Peel NM, Walker PJ, de Looze JW, Mudge AM. Geriatric Syndromes in Individuals

Admitted to Vascular and Urology Surgical Units. J Am Geriatr Soc.2014;62(6):1105-9

(Chapter 3)


Prue McRae Study concept (50%), study design (40%), data collection (60%),

analysis and interpretation (80%), prepared manuscript drafts and final

manuscript (60%)

Dr Alison Mudge Study concept (50%), study design (40%), data analysis and

interpretation (20%), comments on manuscript draft and final

manuscript (10%)

VI

Dr Nancye Peel Contributed to study design (10%), comments on manuscript draft and

final manuscript (10%)

Professor Philip Walker Contributed to study design (10%), comments on manuscript draft and


Dr Julian de Looze Contributed to data collection (20%), comments on manuscript draft

and final manuscript (10%)

3. Publication submitted to Annals of Vascular Surgery and currently under review:

McRae P, Walker PJ, Peel NM, Hobson D, Parsonson F, Donovan P, Reade M, Marquart L, Mudge

AM, Frailty and Geriatric Syndromes in Vascular Surgical Patients. (Chapter 4)


Prue McRae Study concept (35%), study design (30%), data analysis and

interpretation (80%), prepared manuscript drafts and final manuscript

(80%)

Dr Alison Mudge Study concept (35%), study design (30%), data analysis and

interpretation (10%), prepared manuscript drafts and final manuscript

(20%)

Dr Nancye Peel Contributed to study design (10%), comments on manuscript draft and


Professor Philip Walker Study concept (30%), study design (10%), comments on manuscript

drafts (10%)

VII

Dr Denise Hobson Contributed to data collection (35%), comments on manuscript draft and


Dr Fiona Parsonson Contributed to data collection (25%), comments on manuscript draft and


Dr Peter Donovan Contributed to study design (10%), data collection (10%), comments on

manuscript draft and final manuscript (5%)

Dr Michael Reade Contributed to study design (10%), data collection (5%), comments on


Ms Louise Marquart Contributed to statistical analysis and interpretation (10%), comments on


Contributions by others to the thesis

Ms Louise Marquart provided advice regarding statistical analysis for Chapters 3 and 4.

Dr Alison Mudge provided very regular input into the ideas, analyses, manuscripts and thesis

preparation through regular meetings and email contact.

Dr Nancye Peel and Prof. Philip Walker provided input into the ideas, manuscripts and thesis

preparation via meetings and email contact.

Statement of parts of the thesis submitted to qualify for the award of another

degree

“None”.

VIII

Acknowledgements

I am very grateful to my supervisors for all the support and encouragement they have given me over

the past four years. They have patiently steered me and helped me develop my research skills. It is

with great sadness that I acknowledge the passing of Professor Philip Walker.

Dr Alison Mudge has been an incredibly patient, encouraging and supportive Principal supervisor,

mentor and friend. Dr Nancye Peel has gently guided me to undertake a systematic and disciplined

approach. Professor Philip Walker provided quiet encouragement and support, and offered balanced

and considered advice. Despite being unwell in 2014, Phil continued to supervise me and remain

positive.

I am grateful to the Safety and Quality Unit, the Department of Internal Medicine and Aged Care,

the Departments of Urological Surgery and Vascular Surgery and the patients and staff of 7BS and

7BW at Royal Brisbane and Women’s Hospital who supported this work.

I would like to thank Louise Marquart who helped me with statistical advice; and Dr Julian de

Looze, Dr Fiona Parsonson, Dr Kim Ullett and Dr Denise Hobson and Mrs Karen Kasper for their

assistance with data collection.

I am very appreciative of the support provided by the following grants, awards and funds:

• Royal Brisbane Women’s Hospital Research grant: Identifying Interdisciplinary care needs in

older surgical patients

• The Australian Centre for Health Services Innovation research grant: Improving care and

outcomes in older surgical patients

• Professor William Burnett Research Fellowship, University of Qld, School of Medicine 2013-

2015

• 2013 Allied Health Thesis Assistance Scheme Scholarship, Queensland Health

• Professor Philip Walker Consultancy Fund, University of Qld, School of Medicine: for travel

support to the Australian and New Zealand Vascular Surgical Society Conference, Canberra

2014

IX

My thanks go to my children for their patience and understanding, and my sister and close friends

for their encouragement and support over the past four years. Finally I would like to acknowledge

the influence of my parents, Neville and Lois Davis, who approached life with an open and

enquiring mind; and my father, who taught me the value of conducting research to inform clinical

practice and improve patient outcomes.

Keywords

Geriatric syndromes, geriatric surgery, frailty, predictor, risk factor

Australian and New Zealand Standard Research Classifications (ANZSRC)

110323 Surgery 50%

110308 Geriatrics and Gerontology 50%

Fields of Research (FoR) Classification

Group 1103 Clinical Sciences 100%

X

Table of Contents

Abstract ........................................................................................................................................................... I

Declaration by author ............................................................................................................................. III

Publications during candidature ........................................................................................................ IV

Publications included in this thesis ................................................................................................... IV

Contributions by others to the thesis ............................................................................................... VII

Statement of parts of the thesis submitted to qualify for the award of another degree VII

Acknowledgements ............................................................................................................................... VIII

Keywords ..................................................................................................................................................... IX

Australian and New Zealand Standard Research Classifications (ANZSRC) ........................ IX

Fields of Research (FoR) Classification ............................................................................................. IX

Table of Contents ........................................................................................................................................ X

List of Tables............................................................................................................................................... XI

List of Figures ............................................................................................................................................ XII

List of Abbreviations used in the thesis ......................................................................................... XIII

Chapter 1. Introduction and Context ................................................................................................. 1

Chapter 2. Geriatric Syndromes In Older Surgical Patients - A Literature Review .......... 10

Chapter 3. Geriatric Syndromes In Patients Admitted To Vascular And Urology Surgical

Units ............................................................................................................................................................. 41

Chapter 4. Frailty and Geriatric Syndromes in Older Vascular Patients ............................. 61

Chapter 5. Conclusion ........................................................................................................................... 88

Appendices ................................................................................................................................................. 93

XI

List of Tables

Chapter 2:

Table 1. Summary of the main characteristics and findings of included studies ………………….23

Table 2. Summary of the main characteristics and findings of included additional studies……….36

Chapter 3:

Table 1. Participant characteristics (n=112) according to Elective Status………………………….53

Table 2. Participant characteristics according to severity of surgery……………………………….55

Table 3.Particpant characteristics according to surgical sub-specialty unit………………………. .57

Table 4. Multivariate Analysis of predictors of any geriatric syndromes…………………………..59

Chapter 4:

Table I. Description of patient and surgical characteristics (n=110)……………………………….78

Table II. Description of patient and surgical characteristics (n=110), frail versus non-frail……….80

Table III. Univariate associations of frailty and other explanatory variables with outcomes………81

Table IV. Multivariate logistic regression analyses of outcomes…………………………………...83

XII

List of Figures

Chapter 1:

Figure 1.1 The proportion of the population aged over 65…………………………………………..2

Figure 1.2 Overnight Acute Occupied Bed Days RBWH………………………………………… ..5

Chapter 2:

Figure 1. Schematic of the study selection process………………………………………………..22

Chapter 4:

Figure 1. Study recruitment flow chart……………………………………………………………..77

XIII

List of Abbreviations used in the thesis

ADL Activities of daily living

BDI Beck Depression Inventory

CAM Confusion Assessment Method

CCI Charlson Comorbidity Index

CI Confidence Interval

DOS Delirium Observation Scale

DSM-III Diagnostic and Statistical Manual of Mental Disorders Third Edition

DSM-IV Diagnostic and Statistical Manual of Mental Disorders Fourth Edition

GDS Geriatric Depression Scale

IADL Instrumental activities of daily living

IQR Interquartile range

MNA Mini-Nutritional Assessment

OR Odds ratio

POD Postoperative delirium

POSSUM The Physiologic and Operative Severity Score for the enUmeraton of

XIV

Mortality and Morbidity

RBWH Royal Brisbane and Women’s Hospital

SD Standard deviation

SGDS-K Short Form of the Korean Geriatric Depression Scale

SNAQ Short Nutritional Assessment Questionnaire

V-POSSUM Vascular Physiologic and Operative Severity Score for the enUmeration of Mortality

and Morbidity

1

Chapter 1. Introduction and Context

2

Introduction

Developed countries are experiencing an ageing of the population. In Australia, the proportion of

people aged 65 and older is predicted to increase over the next 40 years from 15% to 23% of the

total population, with the greatest increase occurring in those aged over 85 years, from 2% to 5 %

as seen in Figure 1.1 (1). The ageing of the population has important implications for the delivery of

hospital care because older people account for 35% of admissions and 48% of hospital bed days

while comprising 13% of the total population (2).

Figure 1.1 The proportion of the population aged over 65 (1)

Older people are at increased risk of adverse outcomes of hospitalization compared to younger

patients, regardless of the reason for admission (3). Age specific comorbidities and comorbid

chronic diseases accumulate with ageing, accompanied by an accumulation of functional, cognitive

and nutritional impairments. In addition, physiological changes occur resulting in decreased

physiological reserves. As multiple physiological systems become affected and the ability to

maintain homeostasis is reduced, an increased state of vulnerability to acute stressors (such as acute

illness or surgery) develops, known as frailty (4). Although complications can occur related to the

reason for admission, non-disease specific complications may occur due to an interaction between

frailty, pre-existing impairments, comorbidities, acute illness or surgery and hospitalisation itself.

These complications are known as geriatric syndromes and include falls, delirium, increased

dependency in activities of daily living and instrumental activities of daily living (functional

decline), nutritional decline and malnutrition, pressure ulcers and incontinence. Geriatric syndromes

3

are highly prevalent in older hospitalized patients, are multi-factorial, have shared risk factors and

may interact contributing to increasing dependency, frailty and ultimately death (5, 6). They may be

present at hospital admission or develop / worsen during hospitalization (7). Hospital processes may

impact negatively on their course (8-11). Geriatric syndromes have been identified as strong

predictors of poor outcomes of hospitalisation including longer length of stay (LOS), increased

dependency, transfer to sub-acute facilities or admission to residential aged care facilities and

recovery may take months (12-16). Systematic reviews have identified that pro-active identification

of risk, and management to prevent new or worsening syndromes, requires a coordinated

multidisciplinary approach (17-19). However, most of these studies have been conducted in older

medical and hip fracture patients.

Yet an increasing proportion of older vulnerable patients are cared for in surgical wards. Conditions

such as cancer and vascular disease are very common in the elderly (people aged over 65 years),

and particularly in those aged over 80 years. Currently approximately half of all operations are

performed in the elderly (20) and this is likely to increase due to a number of factors: the ageing of

the population; increased life expectancy; advances in surgical and anaesthetic techniques; and low

mortality rates for many surgical procedures (21). In addition, surgical wards care for a substantial

proportion of non-operative cases (22) who may require investigation and surgical decision making

but not operative care.

Surgical studies have found that older age, non-elective admission, comorbid illness and pre-

existing frailty are more important predictors of post-operative mortality and complications than

operative factors (23). Recent studies have reported a high prevalence of frailty in older surgical

patients and identified that pre-operative frailty is an important predictor of poor discharge

outcomes including longer hospital stays and the need for higher levels of care (24, 25). However,

there is limited evidence supporting interventions to improve discharge outcomes (26-29). There is

a clear need to understand the risk of geriatric syndromes and the relationship between frailty,

geriatric syndromes and outcomes in both elective and non-elective older surgical ward patients in

order to design intervention studies to improve these outcomes. Furthermore, functional

independence and quality of life are important considerations for the elderly, especially the frail

elderly, and improved understanding of the risk of geriatric syndromes, likely hospital length of

stay and discharge destination could assist patients and surgeons in decision-making regarding

surgery and appropriate care.

4

In summary, surgical services are faced with caring for a higher proportion of elderly patients.

Outcomes for older surgical patients are poorer than younger patients, mediated in part by frailty,

but there is little evidence supporting interventions to improve outcomes in this vulnerable group.

The papers comprising this thesis aim to contribute to the understanding of the occurrence of

geriatric syndromes in the broader surgical population; and the association of frailty and other key

risk factors with geriatric syndromes and discharge outcomes (acute length of stay and discharge

destination) in order to identify high risk groups. This offers the potential to inform targeted

interventions to improve outcomes for vulnerable older surgical ward patients in future studies.

The setting

This work was conducted at Royal Brisbane and Women’s Hospital (RBWH) between 2011-2015

while I was working in a role to improve the safety, quality of care and outcomes for older

inpatients. In 2008-9, administrative data demonstrated that 4000 patients aged 65 years and older

were admitted to surgical services at RBWH and over half of these admissions were non-elective.

Elderly patients in surgical wards accounted for more occupied bed days than in general medical

wards (Figure 1.2).

The mean length of stay for older surgical ward patients was 11 days compared to 5.5 days in

younger patients. Incident data and audits of admission risk, performed in my clinical role, showed

similar levels of risk of falls and pressure ulcers in older medical and surgical ward patients. Pilot

studies at RBWH to reduce geriatric syndromes and improve outcomes in acute medical patients

had shown promising results (30-33). A better understanding of the occurrence of geriatric

syndromes in older surgical ward patients would inform the potential for broader applicability of

these interventions with vulnerable older surgical groups.

5

Overnight Acute OBDs 2008-2009

0

2000

4000

6000

8000

10000

12000

14000

General Medicine Specialty Medicine Surgery Oncology

85+

65-85

<65

Figure 1.2 Overnight Acute Occupied Bed Days RBWH

(Clinical Costings Unit, RBWH)

Research questions and thesis outline

The intention of this thesis was to describe the occurrence of geriatric syndromes in older surgical

ward patients and explore the association of frailty and other key risk factors with geriatric

syndromes and discharge outcomes (LOS and discharge destination) in order to identify high risk

groups. The design and research question for each chapter are summarised below.

Chapter 2 (literature review):

What is the occurrence of geriatric syndromes in the broader surgical population cared for in usual

care wards?

Chapter 3 (retrospective cohort study):

What is the occurrence of geriatric syndromes in two surgical sub-specialty units?

Does admission type (elective versus non-elective), operative severity (non-operative,

minor/moderate, major) or surgical sub-specialty (urology versus vascular) increase the risk of

geriatric syndromes?

Chapter 4 (prospective cohort study):

6

What is the prevalence of frailty and occurrence of geriatric syndromes (delirium, functional

decline, falls and pressure ulcers) in older patients admitted to a vascular surgical ward?

What is the association between frailty, non-elective admission, operative severity and

physiological severity with any geriatric syndromes and discharge outcomes (length of stay and

discharge destination)?

General approach to this thesis

This thesis has formed part of a larger action research project for which the candidate is an associate

investigator. Chapters 2 (literature review) and 3 (a retrospective cohort study) have provided

evidence and preliminary data to inform a trial to improve care and outcomes of older patients

admitted to the vascular surgical ward (An Interdisciplinary Model to Enhance Care of Surgical

Elders; ACTRN12612001201864). Chapter 4 (a prospective cohort study) has described the pre-

intervention (usual care) cohort of this trial.

The thesis is based on two published papers (Chapter 2 and 3) and a paper submitted for publication

(Chapter 4). The specific aims, methods, results, discussion, conclusion and references of each

study are described in the individual papers. The papers are linked by joining sections.

Chapter 5 (Conclusion) reiterates the key findings of this thesis and discusses their significance;

describes research I am currently involved in as a result of this work; and suggests areas for future

research.

7

References

1. The Department of the Treasury. Intergenerational Report: Australia in 2055. Canberra: The

Department of the Treasury; 2015.

2. Australian Institute of Health andWelfare. Older Australia at a glance:4th edition. Canberra:

AIHW; 2007.

3. Karmel R, Hayes C, LLoyd J. Older Australians in hospital. AIHW Bulletin 53. Canberra;

2007.

4. Fried LP, Tangen CM, Walston J, et al. Frailty in older adults: evidence for a phenotype. J

Gerontol A Biol Sci Med Sci. 2001;56(3):M146-56.

5. Inouye SK, Studenski S, Tinetti ME, et al. Geriatric syndromes: clinical, research, and

policy implications of a core geriatric concept. J Am Geriatr Soc. 2007;55(5):780-91.

6. Chen CC, Dai YT, Yen CJ, et al. Shared risk factors for distinct geriatric syndromes in older

Taiwanese inpatients. Nurs Res. 2010;59(5):340-7.

7. Lakhan P, Jones M , Wilson A et al. A prospective cohort study of geraitric syndromes

among older medical patients admitted to acute care hospitals. J Am Geriatr Soc.

2011;59(11):2001-8.

8. Palmer RM. Acute hospital care of the elderly: minimizing the risk of functional decline.

Cleve Clin J Med. 1995;62(2):117-28.

9. Creditor MC. Hazards of hospitalization of the elderly. Ann Intern Med. 1993;118(3):219-

23.

10. Covinsky KE, Pierluissi E, Johnston CB. Hospitalization-associated disability: "She was

probably able to ambulate, but I'm not sure". JAMA. 2011;306(16):1782-93.

11. Zisberg A, Shadmi E, Gur-Yaish N, et al. Hospital-associated functional decline: the role of

hospitalization processes beyond individual risk factors. J Am Geriatr Soc. 2015;63(1):55-

62.

12. Anpalahan M, Gibson SJ. Geriatric syndromes as predictors of adverse outcomes of

hospitalization. Intern Med J. 2008;38(1):16-23.

8

13. Rudolph JL, Marcantonio ER. Review articles: postoperative delirium: acute change with

long-term implications. Anesth Analg. 2011;112(5):1202-11.

14. Quinlan N, Rudolph JL. Postoperative delirium and functional decline after noncardiac

surgery. J Am Geriatr Soc. 2011;59 Suppl 2:S301-4.

15. Buurman BM, Hoogerduijn JG, de Haan RJ, et al. Geriatric conditions in acutely

hospitalized older patients: prevalence and one-year survival and functional decline. PLoS

One. 2011;6(11):e26951.

16. Inouye SK, Rushing JT, Foreman MD, et al. Does delirium contribute to poor hospital

outcomes? A three-site epidemiologic study. J Gen Intern Med. 1998;13(4):234-42.

17. Cameron ID, Gillespie LD, Robertson MC, et al. Interventions for preventing falls in older

people in care facilities and hospitals. Cochrane Database Syst Rev. 2012;12:Cd005465.

18. Ellis G, Whitehead MA, O'Neill D, et al. Comprehensive geriatric assessment for older

adults admitted to hospital. Cochrane Database Syst Rev. 2011(7):Cd006211.

19. Baztan JJ, Suarez-Garcia FM, Lopez-Arrieta J, et al. Effectiveness of acute geriatric units on

functional decline, living at home, and case fatality among older patients admitted to

hospital for acute medical disorders: meta-analysis. BMJ. 2009;338:b50.

20. Christmas C, Makary MA, Burton JR. Medical considerations in older surgical patients. J

Am Coll Surg. 2006;203(5):746-51.

21. Etzioni DA, Liu JH, Maggard MA, et al. The aging population and its impact on the surgery

workforce. Ann Surg. 2003;238(2):170-7.

22. Hewitt J, Moug SJ, Middleton M, et al. Prevalence of frailty and its association with

mortality in general surgery. Am J Surg. 2014.

23. Ahmed Ali U, Dunne T, Gurland B, et al. Actual versus estimated length of stay after

colorectal surgery: which factors influence a deviation? Am J Surg. 2014;208(4):663-9.

24. Partridge JS, Harari D, Dhesi JK. Frailty in the older surgical patient: a review. Age Ageing.

2012;41(2):142-7.

9

25. Oresanya LB, Lyons WL, Finlayson E. Preoperative assessment of the older patient: a

narrative review. JAMA. 2014;311(20):2110-20.

26. Harari D, Hopper A, Dhesi J, et al. Proactive care of older people undergoing surgery

('POPS'): designing, embedding, evaluating and funding a comprehensive geriatric

assessment service for older elective surgical patients. Age Ageing. 2007;36(2):190-6.

27. Chen CC, Lin MT, Tien YW, et al. Modified hospital elder life program: effects on

abdominal surgery patients. J Am Coll Surg. 2011;213(2):245-52.

28. Bakker FC, Persoon A, Bredie SJ, et al. The CareWell in Hospital program to improve the

quality of care for frail elderly inpatients: results of a before-after study with particular focus

on surgical patients. Am J Surg. 2014.

29. Tan KY, Tan P, Tan L. A collaborative transdisciplinary "geriatric surgery service" ensures

consistent successful outcomes in elderly colorectal surgery patients. World J Surg.

2011;35(7):1608-14.

30. Mudge AM, Giebel AJ, Cutler AJ. Exercising body and mind: an integrated approach to

functional independence in hospitalized older people. J Am Geriatr Soc. 2008;56(4):630-5.

31. Mudge AM, Maussen C, Duncan J, et al. Improving quality of delirium care in a general

medical service with established interdisciplinary care: a controlled trial. Intern Med J.

2013;43(3):270-7.

32. Mudge AM, McRae P, Cruickshank M. Eat Walk Engage: An Interdisciplinary

Collaborative Model to Improve Care of Hospitalized Elders. Am J Med Qual. 2013.

33. Young AM, Mudge AM, Banks MD, et al. Encouraging, assisting adn time to

EAT:improved nutrtional intake for older medical patients receiving Protected Mealtimes

and/or additional nursing feeding assistance. Clin Nutr. 2013;32(4):543-9.

10

Chapter 2. Geriatric Syndromes In Older Surgical Patients - A Literature

Review

McRae P, Mudge A, Peel NM, Walker P.

Geriatric Syndromes in Older Surgical Patients - A Literature Review.

J Frailty Aging. 2013;2(4):205-10.

Reproduced with permission

11

Title

Geriatric Syndromes in Older Surgical Patients – A Literature Review

Authors

Prudence Joan McRae1

Alison M Mudge1,2

Nancye May Peel3

Philip J Walker1,4

Affiliations

1 Royal Brisbane and Women’s Hospital

The University of Queensland School of Medicine

3Centre for Research in Geriatric Medicine, The University of Queensland

4The University of Queensland School of Medicine, Discipline of Surgery and Centre for Clinical

Research

Correspondence

Mrs Prue McRae

Safety and Quality Unit

Block 7, Level 7

Royal Brisbane and Women’s Hospital

Herston

Brisbane

Queensland 4029

Australia

Ph: 61 7 36465450

Fax: 61 7 36461406

Email: [email protected]

Running head

Geriatric syndromes in surgical patients

Key words

12

geriatric syndromes, geriatric conditions, geriatric surgery

Word count

Abstract 201; Main text 2195

13

Abstract

With the ageing of the population, surgical wards are caring for an increased proportion of older

patients. Geriatric syndromes are common in older hospitalised medical and hip fracture patients

and are important predictors of poor outcomes in these groups, however the extent of presenting

and hospital acquired geriatric syndromes in other older inpatients is less clear. This systematic

literature review aimed to identify the proportion of patients aged 60 or older, cared for in usual-

care surgical wards, who presented with and/or developed geriatric syndromes. Observational

studies in English were identified through searches in CINAHL and Medline databases from 1985-

2012. Studies of hip fracture patients and those requiring surgical intensive care (eg cardiac

surgery) were excluded. The review included 25 studies. The majority of studies reported on the

incidence of post-operative delirium, which ranged from 2% to 51% and varied with the type of

surgery. The prevalence of depression at pre-admission screening varied from 9% to 29%. No

studies reported on functional decline. Estimates of falls, malnutrition, pressure ulcers and urinary

incontinence were limited by the small number of studies. These findings indicate the need for

further studies to improve the understanding of geriatric syndromes in older surgical patients in

usual-care wards.

14

Introduction

Older hospitalised patients are at increased risk of serious complications including delirium,

functional decline, falls, pressure ulcers, malnutrition, and urinary incontinence. These non-disease

specific conditions are known as geriatric syndromes, and result from an interaction of ‘frailty’,

acute illness and the hospital environment itself (1). They are multi-factorial and mutually

reinforcing, and may be present on admission, or develop or worsen during hospitalisation (2).

Geriatric syndromes are strong predictors of poor outcomes of hospitalisation including longer

length of stay, increased dependency and admission to residential aged care facility (3). Systematic

reviews and meta-analyses of studies conducted mostly in older medical patients have shown that

coordinated, patient-centred care with comprehensive multidisciplinary assessment and a focus on

early rehabilitation and discharge planning can improve outcomes (4-6).

Although numerous studies have documented the prevalence of geriatric conditions in hospitalised

medical and hip fracture patients, there are limited data from the broader range of surgical patients,

cared for in usual-care wards. With the ageing of the population, the proportion of older vulnerable

patients in surgical wards is increasing. Pre-operative frailty (7-9) and composite measures of

geriatric risk factors (10) have been identified as important predictors of poor surgical outcomes,

including mortality, increased length of stay and institutionalisation. However there is little

evidence supporting interventions to manage these risks in older surgical patients in usual-care

wards. Because geriatric syndromes are often an expression of underlying ‘frailty’, understanding

the occurrence of geriatric syndromes in this large sub-group offers the potential for targeted

interventions to improve patient outcomes.

The aim of this literature review was to identify the proportion of older patients cared for in usual-

care surgical wards who presented with or developed geriatric syndromes.

Methods

Inclusion criteria

Types of participants

Older adults (aged 60 and over) admitted to usual-care surgical wards were the focus of this review.

Studies of older patients admitted for surgery for hip fractures were excluded as geriatric conditions

and care models for this population have been well described previously (11). Studies reporting on

surgical patients usually managed in high dependency units (cardiac surgery patients and surgical

15

intensive care units) were also excluded, as the purpose of the review was to understand the

characteristics of patients cared for in usual-care surgical wards.

Type of geriatric syndromes

The geriatric syndromes included in this review were delirium (12), functional decline (13),

depression (14), malnutrition (15), falls (16), pressure ulcers (17), and urinary incontinence (18).

Delirium, functional decline, depression and malnutrition were included if the syndrome was

identified using a validated geriatric screening or assessment tool. Falls were identified by

documentation in the medical record (19), or incident reports (20). The presence of pressure ulcers

was initially to be identified by a staging system (17, 21); however the criteria were widened to

include patient self-report supported by nurse inspection, due to the lack of studies identified during

the review process. Urinary incontinence was based on patient report (18) or documentation in the

medical record (22).

Any of the following time points were included: pre-operative (pre-admission or admission

assessment); post-operative (until discharge); and during hospitalisation (from admission to

discharge).

Type of studies

Original research papers reporting results from observational (retrospective, prospective and cross-

sectional) studies were included. The quality of the studies was assessed against the STROBE

guidelines for observational studies, although this does not offer a quantitative grading system (23).

Search Strategy

Medline and CINAHL databases were systematically searched using combinations of the terms:

(MH "Urinary Incontinence") OR "urinary incontinence" OR (MH "Accidental Falls") OR "falls"

OR (MH "Delirium") OR "delirium" OR "geriatric condition*" OR "geriatric syndrome*" OR

frail* OR "decubitus ulcer" OR (MH "Pressure Ulcer") OR "pressure ulcer" OR bedsore OR (MH

"Depression") OR "depression" OR "functional decline" OR (MH "Activities of Daily Living") OR

"activities of daily living" OR "nutritional decline" OR (MH "Protein-Energy Malnutrition") OR

(MH "Malnutrition") OR "sarcopenia"

AND (MH "Aged") OR "aged" OR (MH "Aged, 80 and Over") OR (MH "Frail Elderly")

AND (MH "Geriatric Assessment") OR "comprehensive geriatric assessment" OR screening

16

AND (MH "Surgery, Operative") OR "operative surgery" OR surg* OR (MH "Surgical Procedures,

Operative").

Only articles in English on humans from January 1985 to December 2012 were sought. Hand

searching involved the checking of all reference lists of included studies, and retrieving potentially

relevant citations to assess for eligibility.

Data extraction

Data were extracted from papers by PM and entered into a purpose designed spreadsheet. The data

extracted included the study design, country, number of centres, surgery type, sample size,

participant characteristics, inclusion and exclusion criteria, assessment measures and prevalence or

incidence of the geriatric syndromes (summarised using proportions). Data were tabulated

according to the geriatric condition described. As the type of surgery may be a determinant of risk,

studies were also grouped into 4 broad categories – abdominal, urological, orthopaedic surgery or

mixed surgical population (including various combinations of vascular, orthopaedic, non-cardiac,

abdominal, genito-urinary).

Results

Eight hundred and thirty-one studies were retrieved. Figure 1 shows the flow chart for the

systematic review.

Description of studies

The review identified 25 studies, which included a total of 8362 patients. A summary of the main

characteristics and findings of the studies is provided in Table 1. Seven studies were from USA; 3

from Canada; 2 each from England, Italy, Japan and Taiwan; 1 each from France, Norway, Sweden,

Korea and Australia; and 2 were international studies. Twenty-two of the studies were single centre

studies; one study reported from 3 centres in Norway (24) and 2 were multi-centre international

studies (25, 26). The study design varied and included twenty-two prospective studies, two

retrospective studies and one cross-sectional study. Five of the included studies were sub-group

analyses of larger studies (27-31). Several studies reported findings for more than one outcome (10,

24, 30, 32, 33).

Almost all studies were conducted in patients undergoing elective surgery. Only one study (34)

specifically reported on patients undergoing emergency and elective surgery. Five studies did not

17

describe the acuity of surgery specifically (27, 29-31, 35) - three of these were ward based studies

of surgical patients and may have included a mixed group of elective and emergency patients.

As illustrated in Table 1, the majority of studies investigated post-operative delirium (POD), while

there were few studies in most of the other syndromes under investigation.

Delirium

Eighteen studies investigated delirium. Of these, 17 studies reported specifically on post-operative

delirium and one study reported on delirium at any time during hospitalisation. Studies used either

the DSM criteria for delirium (by clinician review) or the validated Confusion Assessment Method

based on these criteria (36). Earlier studies used the DSM-III criteria (26, 37) which may be less

sensitive than current criteria (26). In addition to these measurement differences, frequency of

delirium assessment, time to first assessment, follow-up periods, sample sizes and study populations

differed among studies.

There was a wide variation in the incidence of post-operative delirium (POD), with rates ranging

from 2% to 51%. The largest study to investigate POD included 1161 participants from 8 countries

(26) and found that rates of POD varied with different types of surgery: the highest incidence

occurred with vascular surgery (20%) compared to abdominal (10%), orthopaedic (5%),

genitourinary (3%) and thoracic surgery (8%). This variation was supported by the other reported

studies of POD in this review. For example, the highest incidence of delirium occurred in patients

undergoing abdominal surgery (24-51%) (32, 38-40) compared to those undergoing orthopaedic

(10-28%) (37, 41-44) or urological procedures (2-9%) (28,35).

Only one study reported elective versus emergency surgical patients (34) and found that POD

occurred more frequently in emergency (18%) than elective patients (7%) following general

surgical procedures.

One study considered both prevalent and incident delirium, following older patients admitted to

mixed surgical wards daily for the first week, then every second day until discharge (29). They

reported that delirium occurred in 11% of patients. This rate is lower than most other studies of a

comparable mixed surgical sample (33, 34, 45, 46), perhaps because the sample included less-

severely ill patients who did not require operative management (compared to post-operative studies

which only included operative cases) or perhaps reflecting measurement differences between these

studies.

18

Depression

Seven studies screened for depression in elective patients pre-operatively. Most studies (10, 24, 25,

30, 33) used the Geriatric Depression Score, although cut-off scores for depression were

inconsistent between studies. The prevalence of depression ranged from 9 to 29%. In a cross-

sectional survey of 270 patients admitted to mixed surgical wards, 32% of patients were found to be

depressed (30).

Falls

Two studies measured patient falls; however, there were differences in patient population, time

points and the method of identification of falls. A retrospective study investigated postoperative

falls in an orthopaedic ward which predominantly admitted elective patients for hip and knee

arthroplasty and found that 2% of patients fell (27). A higher incidence of falls (6%) was reported

in a prospective study which examined the frequency of falls from admission to discharge in

patients admitted to mixed surgical wards (31).

Malnutrition

Two studies investigated the prevalence of malnutrition pre-operatively (10, 24), using the Mini

Nutritional Assessment (MNA). Malnutrition ranged from 9% in a study of routine admissions for

colorectal cancer surgery (24) to 28% in a mixed population of older surgical patients referred

specifically for comprehensive geriatric assessment (10). Chen reported the prevalence of

malnutrition as 37% in a cross-sectional study of a mixed population of older surgical patients (30).

Pressure ulcers

One study (30) reported on the prevalence of pressure ulcers in a cross-sectional survey of

participants in mixed surgical wards. Patients were asked if they had a pressure ulcer, which was

then verified by the research assistant. They reported a low rate (3% of patients), which might be

partly explained by the use of patient report to identify the presence of pressure ulcers.

Urinary incontinence

Chen’s cross-sectional survey (30) was the only study to investigate urinary incontinence, which

was identified by patient self–report. They reported urinary incontinence in 29% of patients.

Functional decline

19

Although functional outcome is a very important consideration for older patients (47), no studies

were identified which investigated the proportion of patients who developed functional decline

from pre-admission or admission to discharge.

Discussion

In summary, several studies have documented the incidence of POD and the prevalence of

depression pre-operatively in various surgical populations, but there is a lack of studies reporting on

other geriatric syndromes. Very few studies reported on falls, malnutrition, pressure ulcers or

urinary incontinence so it is unclear how representative they are of the older surgical population in

usual-care wards. No studies reported on functional decline.

Few studies included emergency patients and only one study (34) specifically reported on patients

undergoing emergency surgery. With the ageing of the population, the proportion of older patients

undergoing emergency surgery has increased (48, 49). Elective patients are a highly selected group

and unselected emergency patients are more likely to be frail, have multi-morbidities (50) and have

poorer outcomes including delirium (49, 51), mortality (50, 52), and admission to residential aged

care facilities (49).

Furthermore, most studies excluded patients with pre-existing cognitive impairment. Cognitive

impairment is an important risk factor for geriatric syndromes (2, 53), yet only 3 studies included

patients with cognitive impairment, describing this element specifically (10, 41, 45). One study

noted, following testing of baseline cognitive status, that that there were no patients with cognitive

impairment (37). Three studies did not exclude participants with cognitive impairment, but either

did not describe this element specifically (27, 31) or it could not be extracted because the study was

a subgroup analysis of a larger study (28).

In view of the exclusion of emergency patients and those with cognitive impairment from most

studies, the results of the studies included in this review may under-estimate the true risk of

developing geriatric syndromes in older patients in usual-care surgical wards.

The review suggested variation between different surgical sub-populations, although variation in

participant selection and measurement methods make direct comparison between studies difficult.

Identification of surgical procedures or sub-populations associated with higher risk of common

geriatric syndromes, such as POD, offers the potential to target higher risk groups who may be

more likely to benefit from interventions.

20

There are several limitations to the present review. It included observational studies but intervention

studies were excluded. As there are few published intervention studies on geriatric syndromes in

older surgical patients (54-56), it is unlikely that important data were missed. Data were extracted

by a single author (PM), but in consultation with two other authors (AM, NP). Variable study

quality and methodological differences between studies are likely to have contributed to the

heterogeneity of estimates, but in view of the paucity of studies we chose to include all available

reports meeting our criteria.

Conclusion

Although surgical services are treating an increasing proportion of the older patients, the incidence

of geriatric syndromes is not well documented in older surgical patients in usual-care wards, with

the exception of POD. Future studies should include emergency patients and those with cognitive

impairment to improve the generalisability of estimates, and sample a variety of surgical sub-

populations using consistent methods. Understanding the occurrence of geriatric syndromes offers

the potential for targeted interventions to improve patient outcomes in this surgical population.

Funding and acknowledgements

This work was unfunded.

21

Figure 1. Schematic of the study selection process

22

Table 1. Summary of the main characteristics and findings of included studies

Study Country Type of study Sample

Size

Mean

age

Type of surgery Type of

measure

Timing of

measure

Finding

(%)

Delirium

Brouquet 2010(32) France Prospective 118 81 Abdominal CAM Post-op 24

Bryson 2011(40) Canada Prospective 83 71 Abdominal CAM Post-op 36

Morimoto 2009 (38) Japan Prospective 20 70* Abdominal DSM-IV Post-op 25

Shigeta 2001 (57) Japan Prospective 29 † Abdominal CAM Post-op 34

Olin 2005 (39) Sweden Prospective 51 75 Abdominal CAM Post-op 51

Ansoloni 2010 (34) Italy Prospective 351 76 Mixed CAM Post-op 13

Leung 2005 (33) USA Prospective 219 74 Mixed CAM Post-op 46

Leung 2011 (45) USA Prospective 63 72* Mixed CAM Post-op 25

McAlpine 2008 (46) Canada Prospective 103 74 Mixed CAM Post-op 18

Pompei 1995 (29) USA Prospective 196 72* Mixed DSM-III-R During stay 11

23

Rudolph 2007 (26) 8 countries Prospective 1161 69 Mixed DSM-III Post-op 8

Dai 2000 (28) Taiwan Prospective 232 † Urological DSM-IV Post-op 2

Tognoni 2011 (35) Italy Prospective 90 74 Urological CAM Post-op 9

Fisher 1995 (41) Canada Prospective 80 71 Orthopaedic CAM Post-op 18

Lowery 2008 (42) England Prospective 94 77 Orthopaedic CAM Post-op 15

Rogers 1989 (37) England Prospective 46 70 Orthopaedic DSM-III Post-op 28

Jankowski 2011 (43) USA Prospective 418 73* Orthopaedic CAM Post-op 10

Flink 2012 (44) USA Prospective 106 74* Orthopaedic DSM-IV Post-op 25

Depression

Audisio 2008 (25) 5 countries Prospective 460 77 Abdominal GDS Pre-op 27

Brouquet 2010 (32) France Prospective 118 70 Abdominal GDS Pre-op 29

Kristjansson 2010(24) Norway Prospective 178 80 Abdominal GDS Pre-op 10

Bass 2008 (58) USA Prospective 347 70 Mixed BDI Pre-op 15

Leung 2005 (33) USA Prospective 219 74 Mixed GDS Pre-op 12

Kim 2012 (10) Korea Retrospective 141 78 Mixed SGDS-K Pre-op 9

24

Chen 2011 (30) Taiwan Cross-sectional 270 † Mixed GDS During stay 32

Malnutrition

Kristjansson 2010(24) Norway OPC 178 80 Abdominal MNA Pre-op 9

Kim 2012 (10) Korea Retrospective 141 78 Mixed MNA Pre-op 28

Chen 2011 (30) Taiwan Cross-sectional 270 † Mixed MNA During stay 37

Falls

Ackermann 2010 (27) USA Retrospective 3524

† Orthopaedic Reported

falls

Post-op 2

Webster 2008 (31) Australia

Prospective 327 77 Mixed Reported

and / or

documented

falls

During stay 6

Pressure ulcers

25

† mean age was not provided or could not be extracted as surgical patients were a sub-group analysis of a mixed cohort

* calculated mean age

CAM: Confusion Assessment Method. DSM-1V: Diagnostic and Statistical Manual of Mental Disorders Fourth Edition. DSM-111: Diagnostic and

Statistical Manual of Mental Disorders Third Edition. GDS: Geriatric Depression Scale. BDI: Beck Depression Inventory. SGDS-K: Short Form of

the Korean Geriatric Depression Scale. MNA: Mini-Nutritional Assessment.

Chen 2011 (30) Taiwan Cross-sectional 270 † Mixed

Self-report

and

inspection

During stay 3

Urinary Incontinence

Chen 2011 (30) Taiwan Cross-sectional 270 † Mixed

Self-report During stay 29

26

References

1. Creditor MC. Hazards of hospitalization of the elderly. Ann Intern Med. 1993 Feb

1;118(3):219-23.

2. Inouye SK, Studenski S, Tinetti ME, Kuchel GA. Geriatric syndromes: clinical, research,

and policy implications of a core geriatric concept. J Am Geriatr Soc. 2007 May;55(5):780-

91.

3. Buurman BM, Hoogerduijn JG, de Haan RJ, Abu-Hanna A, Lagaay AM, Verhaar HJ, et al.

Geriatric conditions in acutely hospitalized older patients: prevalence and one-year survival

and functional decline. PLoS ONE. 2011;6(11):e26951.

4. Ellis G, Whitehead MA, O'Neill D, Langhorne P, Robinson D. Comprehensive geriatric

assessment for older adults admitted to hospital. Cochrane Database Syst Rev.

2011(7):CD006211.

5. Fox MT, Persaud M, Maimets I, O'Brien K, Brooks D, Tregunno D, et al. Effectiveness of

acute geriatric unit care using acute care for elders components: a systematic review and

meta-analysis. J Am Geriatr Soc. 2012 Dec;60(12):2237-45.

6. Baztan JJ, Suarez-Garcia FM, Lopez-Arrieta J, Rodriguez-Manas L, Rodriguez-Artalejo F.

Effectiveness of acute geriatric units on functional decline, living at home, and case fatality

among older patients admitted to hospital for acute medical disorders: meta-analysis. BMJ.

2009;338:b50.

7. Makary MA, Segev DL, Pronovost PJ, Syin D, Bandeen-Roche K, Patel P, et al. Frailty as a

predictor of surgical outcomes in older patients. J Am Coll Surg. 2010;210(6):901-8.

8. Robinson TN, Wu DS, Stiegmann GV, Moss M. Frailty predicts increased hospital and six-

month healthcare cost following colorectal surgery in older adults. Am J Surg. 2011

Nov;202(5):511-4.

9. Dasgupta M, Rolfson DB, Stolee P, Borrie MJ, Speechley M. Frailty is associated with

postoperative complications in older adults with medical problems. Arch Gerontol Geriatr.

2009 Jan-Feb;48(1):78-83.

10. Kim KI, Park KH, Koo KH, Han HS, Kim CH. Comprehensive geriatric assessment can

predict postoperative morbidity and mortality in elderly patients undergoing elective

surgery. Arch Gerontol Geriatr. 2012 Dec 13.

11. Pioli G, Giusti A, Barone A. Orthogeriatric care for the elderly with hip fractures: where are

we? Aging Clin Exp Res. 2008;20(2):113-22.

27

12. Inouye SK. Delirium in older persons. N Engl J Med. 2006 Mar 16;354(11):1157-65.

13. Sager MA, Franke T, Inouye SK, et al. Functional outcomes of acute medical illness and

hospitalization in older persons. Arch Int Med. 1996;156 (6): 645-652

14. Yesavage JA, Brink TL, Rose TL, Lum O, Huang V, Adey M, et al. Development and

validation of a geriatric depression screening scale: a preliminary report. J Psychiatr Res.

1982;17(1):37-49.

15. National Collaborating Centre for Acute Care. Nutrition support in adults: Oral nutrtion

support, enteral tube feeding and parenteral nutrtition. London: National Collaborating

Centre for Acute Care,; 2006 [cited 2012 August 21]; Available from:

http://www.rcseng.ac.uk.

16. World Health Organization. Who Global Report on Falls Prevention in Older Age. World

Health Organization; 2008 [cited 2012 August 3]; Available from:

http://books.google.com.au/books?id=ms9o2dvfaQkC.

17. The National Pressure Ulcer Advisory Panel. Pressure ulcers prevalence, cost and risk

assessment: consensus development conference statement--The National Pressure Ulcer

Advisory Panel. Decubitus. 1989 May;2(2):24-8.

18. Zisberg A, Gary S, Gur-Yaish N, Admi H, Shadmi E. In-hospital use of continence aids and

new-onset urinary incontinence in adults aged 70 and older. J Am Geriatr Soc. 2011

Jun;59(6):1099-104.

19. Hill AM, Hoffmann T, Hill K, Oliver D, Beer C, McPhail S, et al. Measuring falls events in

acute hospitals-a comparison of three reporting methods to identify missing data in the

hospital reporting system. J Am Geriatr Soc. 2010 Jul;58(7):1347-52.

20. Nyberg L, Gustafson Y, Janson A, Sandman PO, Eriksson S. Incidence of falls in three

different types of geriatric care. A Swedish prospective study. Scand J Soc Med. 1997

Mar;25(1):8-13.

21. European Pressure Ulcer Advisory Panel, National Pressure Ulcer Advisory Panel.

Prevention and treatment of pressure ulcers: quick reference guide. Washington DC:

National Pressure Advisory Panel; 2009 [cited 2012 August 21]; Available from:

http://www.npuap.org/wp-

content/uploads/2012/03/Final_Quick_Prevention_for_web_2010.pdf.

28

22. Palmer MH, Baumgarten M, Langenberg P, Carson JL. Risk factors for hospital-acquired

incontinence in elderly female hip fracture patients. J Gerontol A Biol Sci Med Sci. 2002

Oct;57(10):M672-7.

23. von Elm E, Altman DG, Egger M, Pocock SJ, Gotzsche PC, Vandenbroucke JP. The

Strengthening the Reporting of Observational Studies in Epidemiology (STROBE)

statement: guidelines for reporting observational studies. Lancet. 2007 Oct

20;370(9596):1453-7.

24. Kristjansson SR, Nesbakken A, Jørdhoy MS, Skovlund E, Audisio RA, Johannessen H-O, et

al. Comprehensive geriatric assessment can predict complications in elderly patients after

elective surgery for colorectal cancer: a prospective observational cohort study. Crit Rev

Oncol Hematol. 2010;76(3):208-17.

25. Audisio RA, Pope D, Ramesh HSJ, Gennari R, van Leeuwen BL, West C, et al. Shall we

operate? Preoperative assessment in elderly cancer patients (PACE) can help. A SIOG

surgical task force prospective study. Crit Rev Oncol Hematol. 2008;65(2):156-63.

26. Rudolph JL, Jones RN, Rasmussen LS, Silverstein JH, Inouye SK, Marcantonio ER.

Independent vascular and cognitive risk factors for postoperative delirium. Am J Med.

2007;120(9):807-13.

27. Ackerman DB, Trousdale RT, Bieber P, Henely J, Pagnano MW, Berry DJ. Postoperative

patient falls on an orthopedic inpatient unit. J Arthroplasty. 2010;25(1):10-4.

28. Dai YT, Lou MF, Yip PK, Huang GS. Risk factors and incidence of postoperative delirium

in elderly Chinese patients. Gerontology. 2000;46(1):28-35.

29. Pompei P, Foreman M, Cassel CK, Alessi C, Cox D. Detecting delirium among hospitalized

older patients. Arch Intern Med. 1995;155(3):301-7.

30. Chen CC-H, Yen C-J, Dai Y-T, Wang C, Huang G-H. Prevalence of geriatric conditions: a

hospital-wide survey of 455 geriatric inpatients in a tertiary medical center. Arch Gerontol

Geriatr. 2011;53(1):46-50.

31. Webster J, Courtney M, O'Rourke P, Marsh N, Gale C, Abbott B, et al. Should elderly

patients be screened for their 'falls risk'? Validity of the STRATIFY falls screening tool and

predictors of falls in a large acute hospital. Age Ageing. 2008 Nov;37(6):702-6.

32. Brouquet A, Cudennec T, Benoist Sp, Moulias S, Beauchet A, Penna C, et al. Impaired

mobility, ASA status and administration of tramadol are risk factors for postoperative

29

delirium in patients aged 75 years or more after major abdominal surgery. Ann Surg.

2010;251(4):759-65.

33. Leung JM, Sands LP, Mullen EA, Wang Y, Vaurio L. Are preoperative depressive

symptoms associated with postoperative delirium in geriatric surgical patients? J Gerontol A

Biol Sci Med Sci. 2005;60(12):1563-8.

34. Ansaloni L, Catena F, Chattat R, Fortuna D, Franceschi C, Mascitti P, et al. Risk factors and

incidence of postoperative delirium in elderly patients after elective and emergency surgery.

Br J Surg. 2010 Feb;97(2):273-80.

35. Tognoni P, Simonato A, Robutti N, Pisani M, Cataldi A, Monacelli F, et al. Preoperative

risk factors for postoperative delirium (POD) after urological surgery in the elderly. Arch

Gerontol Geriatr. 2011;52(3):e166-e9.

36. Inouye SK, van Dyck CH, Alessi CA, Balkin S, Siegal AP, Horwitz RI. Clarifying

confusion: the confusion assessment method. A new method for detection of delirium. Ann

Intern Med. 1990 Dec 15;113(12):941-8.

37. Rogers MP, Liang MH, Daltroy LH, Eaton H, Peteet J, Wright E, et al. Delirium after

elective orthopedic surgery: risk factors and natural history. Int J Psychiatry Med.

1989;19(2):109-21.

38. Morimoto Y, Yoshimura M, Utada K, Setoyama K, Matsumoto M, Sakabe T. Prediction of

postoperative delirium after abdominal surgery in the elderly. Journal Of Anesthesia.

2009;23(1):51-6.

39. Olin K, Eriksdotter-Jöhnhagen M, Jansson A, Herrington MK, Kristiansson M, Permert J.

Postoperative delirium in elderly patients after major abdominal surgery. Br J Surg.

2005;92(12):1559-64.

40. Bryson GL, Wyand A, Wozny D, Rees L, Taljaard M, Nathan H. The clock drawing test is a

poor screening tool for postoperative delirium and cognitive dysfunction after aortic repair.

Can J Anaesth. 2011;58(3):267-74.

41. Fisher BW, Flowerdew G. A simple model for predicting postoperative delirium in older

patients undergoing elective orthopedic surgery. J Am Geriatr Soc. 1995;43(2):175-8.

42. Lowery DP, Wesnes K, Brewster N, Ballard C. Quantifying the association between

computerised measures of attention and confusion assessment method defined delirium: a

prospective study of older orthopaedic surgical patients, free of dementia. Int J Geriatr

Psychiatry. 2008;23(12):1253-60.

30

43. Jankowski CJ, Trenerry MR, Cook DJ, Buenvenida SL, Stevens SR, Schroeder DR, et al.

Cognitive and functional predictors and sequelae of postoperative delirium in elderly

patients undergoing elective joint arthroplasty. Anesth Analg. 2011 May;112(5):1186-93.

44. Flink BJ, Rivelli SK, Cox EA, White WD, Falcone G, Vail TP, et al. Obstructive sleep

apnea and incidence of postoperative delirium after elective knee replacement in the

nondemented elderly. Anesthesiology. 2012 Apr;116(4):788-96.

45. Leung JM, Tsai TL, Sands LP. Brief report: preoperative frailty in older surgical patients is

associated with early postoperative delirium. Anesth Analg. 2011;112(5):1199-201.

46. McAlpine JN, Hodgson EJ, Abramowitz S, Richman SM, Su Y, Kelly MG, et al. The

incidence and risk factors associated with postoperative delirium in geriatric patients

undergoing surgery for suspected gynecologic malignancies. Gynecol Oncol.

2008;109(2):296-302.

47. Chee J, Tan KY. Outcome studies on older patients undergoing surgery are missing the

mark. J Am Geriatr Soc. 2010;58(11):2238-40.

48. Etzioni DA, Liu JH, Maggard MA, Ko CY. The aging population and its impact on the

surgery workforce. Ann Surg. 2003 Aug;238(2):170-7.

49. Blansfield JA, Clark SC, Hofmann MT, Morris JB. Alimentary tract surgery in the

nonagenarian: elective vs. emergent operations. J Gastrointest Surg. 2004 Jul-Aug;8(5):539-

42.

50. Story DA. Postoperative mortality and complications. Best Pract Res Clin Anaesthesiol.

2011 Sep;25(3):319-27.

51. Koebrugge B, van Wensen RJA, Bosscha K, Dautzenberg PLJ, Koning OHJ. Delirium after

emergency/elective open and endovascular aortoiliac surgery at a surgical ward with a high-

standard delirium care protocol. Vascular. 2010;18(5):279-87.

52. Khuri SF, Henderson WG, DePalma RG, Mosca C, Healey NA, Kumbhani DJ.

Determinants of long-term survival after major surgery and the adverse effect of

postoperative complications. Ann Surg. 2005 Sep;242(3):326-41.

53. Mecocci P, von Strauss E, Cherubini A, Ercolani S, Mariani E, Senin U, et al. Cognitive

impairment is the major risk factor for development of geriatric syndromes during

hospitalization: results from the GIFA study. Dement Geriatr Cogn Disord. 2005;20(4):262-

9.

31

54. Chen CC, Lin MT, Tien YW, Yen CJ, Huang GH, Inouye SK. Modified hospital elder life

program: effects on abdominal surgery patients. J Am Coll Surg. 2011 Aug;213(2):245-52.

55. Harari D, Hopper A, Dhesi J, Babic-Illman G, Lockwood L, Martin F. Proactive care of

older people undergoing surgery ('POPS'): designing, embedding, evaluating and funding a

comprehensive geriatric assessment service for older elective surgical patients. Age Ageing.

2007;36(2):190-6.


consistent successful outcomes in elderly colorectal surgery patients. World J Surg. 2011

Jul;35(7):1608-14.

57. Shigeta H, Yasui A, Nimura Y, Machida N, Kageyama M, Miura M, et al. Postoperative

delirium and melatonin levels in elderly patients. Am J Surg. 2001;182(5):449-54.

58. Bass DS, Attix DK, Phillips-Bute B, Monk TG. An efficient screening tool for preoperative

depression: the Geriatric Depression Scale-Short Form. Anesth Analg. 2008;106(3):805.

32

Updated literature review and conclusions

An update to the literature review was conducted utilising the same search strategy described in the

previous paper. Articles from January 2013-April 2015 were sought.

Results

Eleven additional studies (1-11) were identified which included a total of 3,016 patients. A

summary of the main findings is provided in Table 1. All of the studies were single centre studies; 4

studies reported on findings for more than one outcome (4-7). Elective and emergency cases were

included in 4 studies (1, 4, 5, 8) and all except 3 studies (1, 7, 9) included patients with cognitive

impairment. Non-operative cases were included in two studies (1, 10).

Delirium

Eight studies reported on postoperative delirium (POD) (2-7, 9, 11) and two studies reported on

delirium at any time during the hospital stay (1, 10). Validated tools to identify delirium varied,

including the Confusion Assessment Method (real time and /or chart-based), the Delirium

Observational Screening Scale, Delirium Assessment Scale and DSM-IV criteria. Screening

occurred at least daily in all studies but duration of screening varied.

The incidence of delirium and POD varied from 5-37%, with higher rates seen in mixed surgery (5-

37%), followed by orthopaedic surgery (9-23%) then gynaecological surgery (7%), which is

broadly consistent with the previous paper.

Two studies compared the incidence of delirium in elective and emergency admissions. De Castro

(1) found that delirium occurred more frequently in emergency (23%) than elective cases (3%) in

patients admitted to a general surgical ward. Similarly, Liang (4) reported a higher rate of POD in

emergency patients (18%) compared to elective patients (8%) undergoing orthopaedic surgery.

One study (1) assessed patients for delirium each shift from hospital admission to discharge and

reported the timing of delirium. Of those who developed delirium (17%), 17% of patients were

identified with delirium within 12 hours of admission and 75% within 72 hours of admission. This

study also reported that the incidence of delirium did not differ between operative (16%) and non-

operative cases (21%).

Depression

33

Four studies screened for depression pre-operatively (4-6). One study used the Hospital Anxiety

and Depression Scale (5) and three studies used the Geriatric Depression Score (4, 6, 7) however

cut-off scores for depression differed between studies. The prevalence of depression ranged from

8% in orthopaedic patients (4) to 52% in patients undergoing surgery for gynaecological cancer (6).

The high rate in the latter group might be explained in part by the lower cut-off score of the

Geriatric Depression Score.

Malnutrition

Three prospective studies (4, 6, 8) reported on the prevalence of malnutrition pre-operatively using

different tools (Mini Nutritional Assessment, Mini Nutritional Assessment Short Form, Short

Nutritional Assessment Questionnaire). Malnutrition ranged from 8% in orthopaedic patients (4) to

48% in women undergoing gynaecological surgery (6).

Falls

One prospective study of vascular surgical patients investigated patient falls postoperatively and

found that 10% of patients experienced a fall (5).

Discussion

In summary, the majority of studies have reported on the incidence of POD, consistent with the

earlier review. A few studies reported on the prevalence of pre-operative depression and

malnutrition. There continues to be a lack of studies reporting on other geriatric syndromes. One

study reported on the incidence of post-operative falls but no studies reported on pressure ulcers,

urinary incontinence or functional decline.

Two studies reported higher rates of delirium or POD in emergency admissions compared to

elective admissions, consistent with a previous study of POD in general surgical patients (12). One

study (1) of surgical ward patients reported a prevalence of delirium of 17%, consistent with studies

of prevalent delirium in older medical patients who are largely acute admissions (13). This study

also reported the incidence of delirium was similar for operative and non-operative cases. To our

knowledge, this is the first study to specifically compare the incidence of delirium in operative and

non-operative cases; the incidence of delirium in non-operative cases is consistent with older

medical patients (13).

In contrast to the previous paper, the majority of studies in this review included participants with

cognitive impairment and four studies included elective and emergency cases. Additionally, two

34

studies (1, 5) reported on more representative patient cohorts than previous studies by including

operative and non-operative cases. Including those with cognitive impairment, emergency

admissions and those undergoing interventional procedures or managed conservatively has

improved the generalisability of their findings.

The variation in rates of POD, prevalence of depression and malnutrition among surgical

populations is consistent with the findings in the previous paper. However differences in study

participants, severity of surgery and measurement methods between studies makes direct

comparison difficult.

Conclusion

Overall the majority of studies have reported on the incidence of POD, followed by the prevalence

of pre-operative depression and malnutrition. There continue to be few estimates of other geriatric

syndromes in older surgical patients. The higher incidence of postoperative delirium in emergency

admissions compared to elective admissions suggests that emergency admissions may be a high risk

group and warrants further investigation.

35

Table 2. Summary of the main characteristics and findings of included additional studies

Study Country Type of study Sample

size

Mean

age

Type of

surgery

Type of

measure

Timing of

measure

Finding

Delirium

de Castro 2014 (1) USA Prospective 209 76 mixed# DOS/ DSM-IV During 17%

Hempenius 2014 (2) The Netherlands Retrospective 251 74 mixed CAM Post-op 18%

Saczynski 2014 (9) USA Prospective 566 77 mixed CAM Post-op 24%

Korc-Grodzicki 2014 (3) USA Retrospective 416 80* mixed CAM Post-op 19%

Partridge 2014 (5) England Prospective 114 76 vascular CAM Post-op 18%

36

Visser 2015 (11) The Netherlands Prospective 463 72* vascular DOS/

DSM-IV

Post-op 5%

Raats 2015 (10) The Netherlands Prospective 87# † vascular

# DOS/DSM-IV During 37%

Liang 2014 (4) Taiwan Prospective 232 75 orthopaedic CAM Post-op 9%

Kosar 2014 (7) USA Prospective 459

orthopaedic CAM Post-op 23%

Suh 2014 (6) Korea Prospective 60 73* gynaecological DAS Post-op 7%

Depression

Partridge 2014 (5) England Prospective 114 76 vascular HADS Admission 17%

Suh 2014 (6) Korea Prospective 60 73 gynaecological GDS Admission 52%

37

Liang 2014 (4) Taiwan Prospective 232 75 orthopaedic GDS Admission 8%

Kosar 2014 (7) USA Prospective 459 76 orthopaedic GDS Admission 25%

Malnutrition

Reisinger 2015 (8) The Netherlands Prospective 159# † abdominal SNAQ Pre-admission

/ admission

11%

Suh 2014 (6) Korea Prospective 60 73 gynaecological MNA Admission 48%

Liang 2014 (4) Taiwan Prospective 232 75 orthopaedic MNA Admission 8%

Falls

Partridge 2014 (5) England Prospective 114 76 vascular Documentation

in chart

Post-op 10%

38

*median age, mean age was not provided; †mean age was not provided or could not be extracted as surgical patients were a subgroup analysis of a

mixed cohort; #included non-operative cases; CAM: Confusion Assessment Method; DOS: Delirium Observation Screening Score; DSM-1V:

Diagnostic and Statistical Manual of Mental Disorders Fourth Edition. DAS: Korean version of Delirium Assessment Scale. HADS: Hospital Anxiety

and Depression Score GDS: Geriatric Depression Scale; SNAQ: Short Nutritional Assessment Questionnaire; MNA: Mini-Nutritional Assessment.

39

References

1. de Castro SM, Unlu C, Tuynman JB, Honig A, van Wagensveld BA, Steller EP, et al.

Incidence and risk factors of delirium in the elderly general surgical patient. Am J Surg.

2014;208(1):26-32.

2. Hempenius L, Slaets JP, van Asselt DZ, Schukking J, de Bock GH, Wiggers T, et al.

Interventions to prevent postoperative delirium in elderly cancer patients should be targeted

at those undergoing nonsuperficial surgery with special attention to the cognitive impaired

patients. Eur J Surg Oncol. 2015; 41(1):28-33

3. Korc-Grodzicki B, Sun SW, Zhou Q, Iasonos A, Lu B, Root JC, et al. Geriatric Assessment

as a Predictor of Delirium and Other Outcomes in Elderly Patients With Cancer. Ann Surg.

2014. May 30 [Epub ahead of print]

4. Liang CK, Chu CL, Chou MY, Lin YT, Lu T, Hsu CJ, et al. Interrelationship of

postoperative delirium and cognitive impairment and their impact on the functional status in

older patients undergoing orthopaedic surgery: a prospective cohort study. PLoS One.

2014;9(11):e110339.

5. Partridge JS, Dhesi JK, Cross JD, Lo JW, Taylor PR, Bell R, et al. The prevalence and

impact of undiagnosed cognitive impairment in older vascular surgical patients. J Vasc

Surg. 2014; 60(4):1002-11.

6. Suh DH, Kim JW, Kim HS, Chung HH, Park NH, Song YS. Pre- and intra-operative

variables associated with surgical complications in elderly patients with gynecologic cancer:

the clinical value of comprehensive geriatric assessment. J Geriatr Oncol. 2014;5(3):315-22.

7. Kosar CM, Tabloski PA, Travison TG, Jones RN, Schmitt EM, Puelle MR, et al. Effect Of

Preoperative Pain And Depressive Symptoms On The Development Of Postoperative

Delirium. Lancet Psychiatry. 2014;1(6):431-6.

8. Reisinger KW, van Vugt JLA, Tegels JJW, Snijders C, Hulsewé KWE, Hoofwijk AGM, et

al. Functional compromise reflected by sarcopenia, frailty, and nutritional depletion predicts

adverse postoperative outcome after colorectal cancer surgery. Annals Of Surgery.

2015;261(2):345-52.

40

9. Saczynski JS, Inouye SK, Kosar C, Tommet D, Marcantonio ER, Fong T, et al. Cognitive

and Brain Reserve and the Risk of Postoperative Delirium in Older Patients. Lancet

Psychiatry. 2014;1(6):437-43.

10. Raats JW, van Hoof-de Lepper CC, Feitsma MT, Meij JJ, Ho GH, Mulder PG, et al. Current

factors of fragility and delirium in vascular surgery. Ann Vasc Surg. 2015.Mar 11 [Epub

ahead of print]

11. Visser L, Prent A, van der Laan MJ, van Leeuwen BL, Izaks GJ, Zeebregts CJ, et al.

Predicting postoperative delirium after vascular surgical procedures. J Vasc Surg. 2015.Mar

6 [Epub ahead of print]

12. Ansaloni L, Catena F, Chattat R, Fortuna D, Franceschi C, Mascitti P, et al. Risk factors and

incidence of postoperative delirium in elderly patients after elective and emergency surgery.

Br J Surg. 2010;97(2):273-80.

13. Inouye SK, Westendorp RG, Saczynski JS. Delirium in elderly people. Lancet.

2014;383(9920):911-22.

41

Chapter 3. Geriatric Syndromes In Patients Admitted To Vascular And

Urology Surgical Units

42

Introduction

The previous chapter highlighted the need for further studies to improve the estimates of geriatric

syndromes in older surgical patients admitted to usual care wards. The majority of studies had

reported on POD, with few studies reporting of the incidence of other geriatric syndromes. We

conducted a retrospective study of patients admitted to 2 surgical sub-specialty units (vascular and

urology). This design was chosen because it was a less resource-intensive method compared to a

prospective design. The retrospective design ensured the inclusion of emergency cases and those

with cognitive impairment because individual patient consent was not required. We explicitly

described elective and non-elective cases. We also included non-operative cases because few

studies had included these groups. The vascular and urology surgical wards were chosen because

they care for a high proportion of patients aged 65 and older.

We collected information on delirium, functional decline, falls and pressure ulcers and also reported

on a combined measure of one or more of these syndromes We selected these geriatric syndromes

for a number of reasons: delirium is prevalent in older surgical ward patients; it is known that

approximately 30% of older hospitalised patients leave hospital with a new disability in activities of

daily living (1) so we hypothesized that functional decline would be a frequent syndrome in our

cohort; falls and pressure ulcers are less frequent events but are commonly reported indicators of

quality of care; and information on all of these syndromes was available from the medical record.

We used the combined measure for several reasons: our sample size was small which would likely

prevent analysis of associations of variables with falls and pressure ulcers because of an anticipated

low event rate; recognizing patients at risk of developing one or more geriatric syndromes might

identify common risk factors and provide a more integrated approach to care, which is increasingly

advocated rather than the current approach in acute hospitals of assessment and management of

single diseases and syndromes in older patient (2); and combined measures have been reported in

previous studies of older medical patients (3, 4), cardiology patients (5, 6) and community dwelling

patients (7).

As discussed in the introduction, this study formed part of a larger action research project and

allowed us to obtain preliminary data on the scope of the problem to inform key stakeholders at

RBWH. A briefer version of this chapter has been published in the Journal of the American

Geriatrics Society (Appendix ).

43

References

1. Covinsky KE, Pierluissi E, Johnston CB. Hospitalization-associated disability: "She was

probably able to ambulate, but I'm not sure". JAMA. 2011;306(16):1782-93.

2. Tinetti ME, Inouye SK, Gill TM, et al. Shared risk factors for falls, incontinence, and

functional dependence. Unifying the approach to geriatric syndromes. JAMA.

1995;273(17):1348-53.

3. Lakhan P, Jones M, Wilson A, et al. A prospective cohort study of geriatric syndromes


2011;59(11):2001-8.



5. Flood KL, Rohlfing A, Le CV, et al. Geriatric syndromes in elderly patients admitted to an

inpatient cardiology ward. J Hosp Med. 2007;2(6):394-400.

6. Sanchez E, Vidan MT, Serra JA, et al. Prevalence of geriatric syndromes and impact on

clinical and functional outcomes in older patients with acute cardiac diseases. Heart.

2011;97(19):1602-6.

7. Wang HH, Sheu JT, Shyu YI, et al. Geriatric conditions as predictors of increased number

of hospital admissions and hospital bed days over one year: findings of a nationwide cohort

of older adults from Taiwan. Arch Gerontol Geriatr. 2014;59(1):169-74.

44

ABSTRACT

Objectives: To document the incidence of geriatric syndromes (delirium, functional decline, falls

and pressure ulcers) in two surgical units and to determine the association between the occurrence

of geriatric syndromes and admission type (elective vs nonelective), severity of surgery (non-

operative vs minor vs major), and surgical subspecialty unit.

Design: Retrospective cohort study.

Setting: One vascular surgical unit and one urology surgical unit in an Australian tertiary teaching

hospital.

Participants: Individuals aged 65 and older admitted to a study unit for 3 days or more (N=112).

Measurements: Delirium was identified using a validated chart extraction tool. Functional decline

from admission to discharge was identified from nursing documentation. Falls were identified

according to documentation in the medical record cross-checked with the hospital incident reporting

system. Pressure ulcers were identified according to documentation in the medical record.

Results: Geriatric syndromes were present in 32% of participants. Delirium was identified in 21%,

functional decline in 14%, falls in 8%, and pressure ulcers in 5%. Individuals admitted directly

from the emergency or outpatient department and interhospital transfers (nonelective) were

significantly more likely to develop any geriatric syndrome than those on an elective surgery list

before admission to the hospital (41% vs 18%, p=.01). Nonelective admission (odds ratio (OR)=3.3,

95% confidence interval (CI)=1.6–4.7, p= .005) and major surgery (OR=3.1, 95% CI=1.7–3.7,

p=.004) increased the likelihood of geriatric syndromes. Preexisting impairment in activities of

daily living (ADLs) was an important independent predictor of geriatric syndromes (OR 2.9, 95%

CI 1.5–3.6, p=.007).

Conclusion: Geriatric syndromes are common in older adults undergoing surgery, and nonelective

admission and major surgery increase the likelihood of geriatric syndromes occurring during

hospitalization. Baseline dependency in ADLs is an important risk factor for the occurrence of these

conditions.

45

Key words: geriatric syndromes, geriatric surgery, predictor

46

Introduction

Older hospitalized adults are at increased risk of complications compared to younger adults.

Common inter-related conditions such as delirium, functional decline, falls and pressure ulcers

(known as geriatric syndromes) can develop or worsen during hospitalization due to an interaction

between acute illness, individual factors (such as age, comorbidity, pre-existing functional

impairments) and the hospital environment itself (1).

Although the incidence of geriatric syndromes has been described in certain surgical populations

such as for hip fracture and cardiac surgery, there are limited studies describing the development of

geriatric syndromes in the broader surgical population cared for in usual-care wards (2). The

majority of studies have been conducted with individuals undergoing major elective surgery. Non-

elective patients may be a high risk group but have often been excluded from studies. Similarly,

non-operative patients have seldom been studied but comprise a considerable proportion of older

surgical ward inpatients, may require considerable surgical expertise and decision-making and may

also be at risk of poor outcomes (3). Some studies have shown variation in geriatric syndromes

between surgical sub-specialties. Therefore the aims of this exploratory study were to describe the

occurrence of geriatric syndromes (delirium, functional decline, falls, and pressure ulcers) in older

adults admitted to two surgical subspecialty units (vascular and urology) and to determine the

association between the occurrence of geriatric syndromes and admission type (elective vs

nonelective), severity of surgery (non-operative vs minor vs major) and surgical subspecialty unit.

Methods

Setting

The study was retrospective cohort study conducted in the vascular and urology surgical units of a

900-bed metropolitan tertiary teaching hospital in Brisbane, Australia. These wards care for a high

proportion of older patients and patients admitted to a vascular surgical unit may be at increased

risk of delirium and pressure ulcers compared to those admitted to a urology unit due to the

presence of vascular risk factors and poor skin perfusion respectively (4, 5).

47

Participants

Individuals consecutively admitted to the vascular surgery and urology units from January to March

2011 were eligible if they were aged 65 and older and hospitalized for at least 72 hours. Individuals

were excluded if they were admitted with a terminal illness or transferred to another unit within 72

hours of admission to the unit. Approval was obtained from the hospital human research ethics

committee.

Outcomes and measurement

Experienced auditors comprising a physiotherapist(PM), a medical registrar (JD), and a an

experienced research nurse, researcher conducted a retrospective medical record review using a

purpose-built chart abstraction tool. Information on participant demographic characteristics,

comorbidity score (6), number of prescribed medications, American Society of Anesthesiologists

(ASA) classification, details of interventional procedures and surgery, length of stay on the surgical

unit, and discharge destination was collected to characterize the population.

The primary outcomes of interest were the occurrence of delirium, functional decline, falls and

pressure ulcers from admission to discharge from the urology/vascular surgical unit and a combined

measure of one or more of these syndromes. Delirium was defined as an acute decline in attention

and cognition (7) and was identified using validated chart extraction methodology (8). Functional

decline was defined as any increase from admission in the number of activities of daily living

(ADL)—dressing, bathing, eating, toileting, transfers, mobility—for which human assistance was

required at discharge, according to nursing documentation in routine standardized nursing

assessments and care plans (9). Because the sample would include individuals who underwent an

above- or below-knee amputation, mobility was defined as ambulation by walking or independent

wheeling in a wheelchair (which defines readiness for discharge). A fall was defined as

inadvertently coming to rest on the ground or other lower level (10) and was identified according to

documentation in the medical record cross-checked with the hospital incident reporting system.

Pressure ulcers were defined as localized injury to the skin or underlying tissue as a result of

pressure, shear, or friction (11) and were identified according to documentation in the medical

record.

48

Elective admissions included individuals booked on an elective surgery list before admission to the

hospital (12). Nonelective admissions included individuals admitted directly from the emergency or

outpatient department and interhospital transfers (12). The Physiologic and Operative Severity

Score for the enUmeration of Mortality and Morbidity for severity of surgery procedures (13) was

used to classify the severity of surgery, dichotomized (minor to moderate vs major or greater) to

avoid small cell sizes for analysis and compared with non-operative cases.

Analysis

Descriptive analysis was undertaken using SPSS version 20.0 (SPSS, Inc., Chicago, IL).

Categorical variables were summarized using proportions, and continuous variables were

summarized using means or medians depending on variable distribution. Primary outcomes were

reported as point estimates with 95% Confidence Intervals (CI). Differences in proportions between

groups were evaluated using chi-square or Fisher exact tests, with statistical significance defined as

P ≤0.05.

Independent associations between elective status, surgery severity, unit and any geriatric syndromes

were determined using multivariable logistic regression adjusting for the following known risk

factors: aged 75 and older, comorbidity score, and premorbid functional status (any ADL

dependency vs independent). Odds ratios (ORs) generated from logistic regression were adjusted as

recommended to approximate risk ratios (14).

As this study was exploratory, and intended to obtain point estimates to inform the design of a

prospective intervention study, no formal sample size calculations were undertaken.

Results

Of 117 individuals consecutively admitted meeting the study criteria, 112 records were available for

review (61 vascular, 51 urological). Mean age was 74 ± 8, 79% were male, and median length of

stay was 8 days (interquartile range 5–13 days). Sixty-six percent of participants underwent surgery,

5% had other interventional procedures (e.g., angiogram with stenting), and 29% were treated

conservatively. The most frequently performed operations were bypass grafts (13%), aortic

aneurysm repairs (13%), cystoscopies (13%), embolectomies (10%), minor lower limb amputations

(9%), major amputations (7%), and transurethral resections (7%). The majority of admissions were

nonelective (61%). Participant characteristics are summarized in Table 1, 2 and 3 according to

49

elective status, severity of surgery and surgical subspecialty unit respectively. Nonelective cases

tended to be older, and have poorer baseline function than elective cases. Similarly, non-operative

cases and those undergoing minor/ moderate surgery tended to be older and have poorer baseline

function compared to those undergoing major surgery. Characteristics of participants by surgical

sub-specialty unit were similar.

Overall, 32% (95% CI 23-41%) of participants developed one or more geriatric syndromes during

hospitalization. There was evidence of delirium in 21% (95% CI 13-28%) of all admitted

participants, falls in 8% (95% CI 3-13%,) and pressure ulcers in 5% (95%CI 1-10%). Nursing

documentation of admission ADLs was available for 106 (95%) participants and discharge ADLs

for 104 (93%); functional decline occurred in 14% (95% CI 8-21%) of participants (15/104). Of

participants who developed one or more geriatric syndromes, 23 (64%) developed one, 10 (28%)

developed two, two (6%) developed three, and one (3%) developed four.

Participants undergoing nonelective surgery were significantly more likely to develop any geriatric

syndrome (41%) than those undergoing elective surgery (18%, p=.01). The occurrence of any

geriatric syndrome tended to be higher with major surgery (37% major, 32% minor or moderate,

26% nonoperative, p=.57) and in vascular inpatients than urological (38% vs 26%, p=.17).

In multivariate analysis (Table 4), participants undergoing nonelective surgery were more than three

times as likely to develop a geriatric syndrome as those undergoing elective surgery. Major surgery

was also significantly associated with greater likelihood of developing a geriatric syndrome. No

significant association was seen in the adjusted model with surgical unit, age, or comorbidity score,

but premorbid impairment in ADLs was a strong independent predictor.

Discussion

Geriatric syndromes occurred in 32% of participants, which suggests that they are more common

than many other post-operative complications (15, 16). Although it was not possible to make direct

comparisons because of methodological differences, these findings are consistent with ranges

reported in previous studies of individual geriatric syndromes in other general surgical, medical,

and mixed samples (2, 7, 17-20). Similarly, the occurrence of multiple syndromes is broadly

consistent with a study of older medical patients (21).

50

Geriatric syndromes were much more common in nonelective admissions, consistent with the

findings of studies investigating the incidence of postoperative delirium that reported higher rates of

postoperative delirium in individuals undergoing emergency surgery than in those undergoing

elective surgery (22, 23). Furthermore, the results of the current study are consistent with findings

in older medical patients, who are predominantly nonelective admissions and known to be at high

risk of developing geriatric syndromes (21).

Although major surgery was associated with geriatric syndromes, they also occurred in

approximately one-quarter of participants not undergoing surgery, consistent with a recent study of

the incidence of delirium in operative and non-operative groups(24). Those undergoing major

surgery tended to be independent in ADLs at baseline and were largely elective admissions in

contrast to the nonoperative group, who tended to have ADL impairment at baseline and were

nonelective admissions; these factors may have contributed to their risk.

Finally, baseline functional dependency was identified as an important independent predictor of any

geriatric syndrome. Although preoperative interventions to improve baseline functional levels in

individuals undergoing major elective surgery have been suggested as a potential strategy to

improve postoperative outcomes (25), identification of baseline function on admission to hospital

and implementation of strategies to prevent the development or worsening of these conditions may

be particularly important for nonelective admissions and an area for investigation to improve care

and outcomes in older adults undergoing surgery in future intervention studies.

This study has several strengths and limitations. Individuals undergoing elective surgery are a

highly selected group, whereas the sample included nonelective and nonoperative cases. Including

these two groups has added to the evidence on geriatric syndromes in individuals undergoing

nonelective surgery and those not undergoing surgery, and a more-representative sample of older

adults undergoing surgery was studied, increasing the generalizability of the study.

This study has several limitations due to the retrospective study design. The collection of

information on geriatric syndromes using chart review is limited and not ideal. Missing data on

nursing-reported functional status at admission or discharge may have affected estimates of

functional decline. Delirium was identified at any point in the admission and may have included

delirium at the time of admission as well as incident cases. It is also likely that hypoactive delirium

was underreported, affecting estimates of the occurrence of delirium (26). Severity of surgery was

51

based on only one indicator of operative severity. Although associations between different variables

were sought, these were not adjusted for potential confounders such as disease severity, serious

complications, and length of stay. The study was conducted at a single metropolitan tertiary

teaching hospital, and approximately 40% of cases were elective admissions, which may not be

typical of all centers. Finally, interrater agreement was not formally assessed, although there was

extensive discussion and agreement about the meaning of the terms in the chart abstraction tool

before the audit, and any queries raised during chart abstraction were resolved by achieving

consensus within the group.

Conclusion

The findings of this study suggest that geriatric syndromes are common in older adults in vascular

and urological surgical subspecialty units. Nonelective admission and major surgery increase the

likelihood of geriatric syndromes occurring, and preexisting impairment in ADLs is an important

independent predictor of these conditions. Larger prospective studies that include validated scores

of operative severity and potential confounders are required to confirm these findings.

52

Table 1. Participant Characteristics (n= 112) According to Elective Status

Characteristic Elective,

n=44

Non-elective,

n=68

Total,

N=112

Age, mean ± standard deviation 71±6 76±8 74±8

Male, n (%) 30 (68) 58 (85) 88 (79)

Living arrangements, n (%)

Community

Residential aged care facility

Other (long-stay hospital)

44 (100)

0

0

62 (91)

5 (7)

1 (1)

106 (95)

5 (4)

1 (1)

Functional status on admission, n (%)a

Independent in ADLs

Dependent in ≥1 ADLs

36 (95)

2 (5)

49 (72)

19 (28)

85 (80)

21 (20)

Documented diagnosis of dementia, n (%) 1 (2) 5 (7) 6 (5)

Surgical subspecialty type, n (%)

Urological

Vascular

24 (56)

20 (45)

27 (40)

41 (60)

51 (46)

61 (54)

Comorbidity score, median (IQR) 1 (1) 2 (2) 2 (1–3)

Number of prescribed medications 6 (4) (4) 7 (4)

53

Extent of surgery

Non operative procedure

Minor surgery

Major surgery

3 (7)

13 (30)

28 (64)

35 (52)

18 (27)

15 (22)

38 (34)

31 (28)

43 (38)

Length of stay in acute ward, days, median (IQR) 7 (4–11) 8 (5–17) 8 (5–13)

Discharge destination, n (%)

Home


Hospital transfer

Died during hospitalization

42 (95)

1 (2)

1 (2)

0 (0)

45 (66)

6 (9)

16 (24)

1 (1)

87 (78)

7 (6)

17 (15)

1 (1)

aAdmission functional status available for 106 participants.

ADLs=activities of daily living; IQR=interquartile range.

54

Table 2. Participant Characteristics (n= 112) According to Severity of Surgery

Characteristic No Surgery

n=38

Minor

Surgery n=31

Major Surgery

n=43

Age, mean ± standard deviation 76±8 75±8 72±6

Male, n (%) 33 (87) 24 (77) 31 (72)


Community



35 (92)

3 (7)

0

28 (90)

2 (6)

1 (3)

43 (100)

0

0

Functional status on admission, n (%)a

Independent in ADLs

Dependent in ≥1 ADLs

27 (71)

11 (29)

23 (77)

7 (23)

35 (92)

3 (8)

Documented diagnosis of dementia, n (%) 3 (8) 1 (3) 2 (5)

Admission type, n (%)

Elective

Non-elective

3 (8)

35 (92)

13 (42)

18 (58)

28 (65)

15 (35)

Comorbidity score, median (IQR) 3 (2) 2 (2) 1 (1)

Number of prescribed medications 7 (5) 7 (4) 6 (3)

55

Surgical subspecialty type, n (%)

Urological

Vascular

23 (61)

15 (39)

16 (52)

15 (48)

12 (28)

31 (72)

ASA score ,mean ±standard deviation - 3 ±1 3 ±1

Length of stay in acute ward, days, median

(IQR)

8 (5–13) 8 (5–13) 8 (5–12)


Home


Hospital transfer


27 (71)

5 (13)

5 (13)

1 (3)

24 (77)

2 (6)

5 (16)

0

36 (84)

0

7 (16)

0

aAdmission functional status available on 106 participants.

ADLs=activities of daily living; IQR=interquartile range.

ASA score= American Society of Anesthesiologists physical status classification score

56

Table 3 Participant Characteristics (n= 112), according to Subspecialty Unit

Characteristic Vascular

N=61

Urology

N=51

Age, mean ± standard deviation 75±8 74±7

Male, n (%) 47 (77) 41 (80)


Community



61 (100)

49 (96)

1 (2)

1 (2)

Functional status on admission, n (%)

Independent in ADLs

Dependent in ≥ 1 ADLs

41 (75)

14 (25)

41 (80)

10 (20)

Documented diagnosis of dementia, n (%) 5 (8) 1 (2)

Admission type, n (%)

Elective

Non-elective

20 (33)

41 (67)

24 (47)

27 (53)

Comorbidity score, median (IQR) 2 (1,3) 2 (0,4)

Number of prescribed medications, mean ± SD 8± 4 6 ±4

Length of stay in acute ward, days, median (IQR) 10 (7,15) 6 (4,11)


Home

46 (75)

45 (88)

57


Hospital transfer


1 (2)

14 (23)

2 (4)

3 (6)

1 (2)

aAdmission functional status available on 106 participants.

58

Table 4. Multivariate Analysis of Predictors of Any Geriatric Syndromes

Predictor Adjusted Odds Ratio (95%

Confidence Interval)

P-Value

Aged ≥75 (reference <75) 1.4 (0.7–2.4) .37

Charlson Comorbidity Index 1.2 (0.92–1.5) .20

Urology unit (reference vascular unit) 1.2 (0.49–2.2) .67

Premorbidly dependent in activities of

daily living (reference independent)

2.9 (1.5–3.6) .007

Nonelective (reference elective) 3.3 (1.6–4.7) .005

Severity of surgery (reference no surgery)

Minor

Major

2.0 (0.9–3.2)

3.1 (1.7–3.7)

.07

.004

59

References

1. Creditor MC. Hazards of hospitalization of the elderly. Ann Intern Med. 1993;118(3):219-

23.

2. McRae P, Mudge A, Peel NM, et al. Geriatric Syndromes in Older Surgical Patients - A

Literature Review. The Journal of Frailty and Aging. 2013;2(4):205-10.

3. Hewitt J, Moug SJ, Middleton M, et al. Prevalence of frailty and its association with

mortality in general surgery. Am J Surg. 2014.

4. Coleman S, Gorecki C, Nelson EA, et al. Patient risk factors for pressure ulcer development:

systematic review. Int J Nurs Stud. 2013;50(7):974-1003.

5. Rudolph JL, Jones RN, Rasmussen LS, et al. Independent vascular and cognitive risk factors

for postoperative delirium. American Journal Of Medicine. 2007;120(9):807-13.

6. Charlson ME, Pompei P, Ales KL, et al. A new method of classifying prognostic

comorbidity in longitudinal studies: development and validation. J Chronic Dis.

1987;40(5):373-83.

7. Inouye SK. Delirium in hospitalized older patients. Clin Geriatr Med. 1998;14(4):745-64.

8. Inouye SK, Leo-Summers L, Zhang Y, et al. A chart-based method for identification of

delirium: validation compared with interviewer ratings using the confusion assessment

method. J Am Geriatr Soc. 2005;53(2):312-8.

9. Mudge AM, O'Rourke P, Denaro CP. Timing and risk factors for functional changes

associated with medical hospitalization in older patients. Journals of Gerontology Series A-

Biological Sciences & Medical Sciences. 2010;65(8):866-72.

10. World Health Organization 2008;Pages. Accessed at World Health Organization at

http://books.google.com.au/books?id=ms9o2dvfaQkC on August 3 2012.

11. European Pressure Ulcer Advisory Panel, Panel. NPUA 2009;Pages. Accessed at National

Pressure Advisory Panel at http://www.npuap.org/wp-

content/uploads/2012/03/Final_Quick_Prevention_for_web_2010.pdf on August 21 2012.

12. Story DA, Leslie K, Myles PS, et al. Complications and mortality in older surgical patients

in Australia and New Zealand (the REASON study): a multicentre, prospective,

observational study. Anaesthesia. 2010;65(10):1022-30.

13. Copeland GP, Jones D, Walters M. POSSUM: a scoring system for surgical audit. The

British journal of surgery. 1991;78(3):355-60.

14. Zhang J, Yu KF. What's the relative risk? A method of correcting the odds ratio in cohort

studies of common outcomes. JAMA. 1998;280(19):1690-1.

http://books.google.com.au/books?id=ms9o2dvfaQkC

http://www.npuap.org/wp-content/uploads/2012/03/Final_Quick_Prevention_for_web_2010.pdf


60

15. Hamel MB, Henderson WG, Khuri SF, et al. Surgical outcomes for patients aged 80 and

older: morbidity and mortality from major noncardiac surgery. J Am Geriatr Soc.

2005;53(3):424-9.

16. Story DA. Postoperative mortality and complications. Best Pract Res Clin Anaesthesiol.

2011;25(3):319-27.

17. Webster J, Courtney M, O'Rourke P, et al. Should elderly patients be screened for their 'falls

risk'? Validity of the STRATIFY falls screening tool and predictors of falls in a large acute

hospital. Age Ageing. 2008;37(6):702-6.

18. Theisen S, Drabik A, Stock S. Pressure ulcers in older hospitalised patients and its impact

on length of stay: a retrospective observational study. J Clin Nurs. 2012;21(3-4):380-7.



20. Covinsky KE, Palmer RM, Fortinsky RH, et al. Loss of independence in activities of daily

living in older adults hospitalized with medical illnesses: increased vulnerability with age. J

Am Geriatr Soc. 2003;51(4):451-8.

21. Lakhan P, Jones M, Wilson A, et al. A prospective cohort study of geriatric syndromes


2011;59(11):2001-8.

22. Koebrugge B, van Wensen RJ, Bosscha K, et al. Delirium after emergency/elective open

and endovascular aortoiliac surgery at a surgical ward with a high-standard delirium care

protocol. Vascular. 2010;18(5):279-87.

23. Ansaloni L, Catena F, Chattat R, et al. Risk factors and incidence of postoperative delirium

in elderly patients after elective and emergency surgery. Br J Surg. 2010;97(2):273-80.

24. de Castro SM, Unlu C, Tuynman JB, et al. Incidence and risk factors of delirium in the

elderly general surgical patient. Am J Surg. 2014;208(1):26-32.


2012;41(2):142-7.

26. Saczynski JS, Kosar CM, Xu G, et al. A tale of two methods: chart and interview methods

for identifying delirium. J Am Geriatr Soc. 2014;62(3):518-24.

61

Chapter 4. Frailty and Geriatric Syndromes in Older Vascular Patients

62

Introduction

In the previous chapter, we found that geriatric syndromes were common in older patients admitted

to a vascular and urology surgical ward, with a combined incidence (delirium, functional decline,

falls and pressure ulcer) of 32% (95% CI 23-41%). Delirium was the most common syndrome

(21%) and we thought that this was likely underestimated by chart review. This chapter (a

prospective cohort study) provided the opportunity to overcome the limitations of identifying

geriatric syndromes through chart review with the collection of real time data on older patients

admitted to the vascular surgical unit at RBWH. We chose to incorporate the same combined

measure of geriatric syndromes as an outcome measure in this study to ensure consistency between

studies.

We had also found that major surgery and non-elective admission increased the likelihood of

geriatric syndromes occurring, and that pre-existing impairment in ADL was an important patient

risk factor for the occurrence of these syndromes. Functional impairment can be a marker of frailty

(1). This highlighted the need to further explore the association of frailty with geriatric syndromes.

Two main models exist to describe frailty (phenotypic and deficit accumulation) but there is no

universally agreed measure for frailty (2). It has been suggested that frailty tools should 1) act as

predictors of poor outcome; and 2) identify potentially modifiable risk factors to improve outcomes

(3, 4). In addition, it has been suggested that some tools may be better suited to screening for frailty

rather than assessing frailty. A range of frailty tools have been reported in the surgical literature,

including single item measures and composite measures (including validated and unvalidated

measures) (4). These approaches have been demonstrated to predict adverse outcomes in elective

and emergency surgical populations (4-6). However most studies have been conducted in research

settings and few studies have investigated how clinicians can measure frailty in the everyday

clinical setting in a simple, valid and reliable way. Physical performance measures may be

impractical in patients admitted to vascular surgical wards, and comprehensive assessments of

deficit accumulation (for which 30-40 items are included) are time consuming (6-8). Therefore we

chose to incorporate a simple multidimensional measure of baseline vulnerability or ‘frailty’. We

conceptualized frailty as functional dependency, cognitive impairment or nutrition risk. These

geriatric markers are common elements of comprehensive frailty indices (9-11); have been

identified as shared risk factors for geriatric syndromes; are strong predictors of inpatient geriatric

63

syndromes and adverse outcomes (5, 12); and were clinically feasible to collect from elective and

non-elective admissions. Furthermore, these risk factors have the potential to be modified prior to

admission and during hospitalisation thus offering useful information on potentially treatable

domains.

We also wanted to examine more precisely the relationship between frailty, non-elective admission,

severity of surgery, geriatric syndromes and discharge outcomes in this cohort so we included a

valid measure of surgical severity and physiological severity. This would overcome some of the

limitations of the analysis in the previous study.

A version of this chapter has been submitted to the Annals of Vascular Surgery and is currently

under review.

64

References

1. Sternberg SA, Wershof Schwartz A, Karunananthan S, et al. The identification of frailty: a

systematic literature review. J Am Geriatr Soc. 2011;59(11):2129-38.

2. Rockwood K. What would make a definition of frailty successful? Age Ageing.

2005;34(5):432-4.

3. Clegg A, Young J, Iliffe S, et al. Frailty in elderly people. Lancet. 2013;381(9868):752-62.


2012;41(2):142-7.



6. Joseph B, Pandit V, Sadoun M, et al. Frailty in surgery. J Trauma Acute Care Surg.

2014;76(4):1151-6.

7. Hubbard RE, Story DA. Patient frailty: the elephant in the operating room. Anaesthesia.

2014;69 Suppl 1:26-34.

8. Partridge JS, Fuller M, Harari D, et al. Frailty and poor functional status are common in

arterial vascular surgical patients and affect postoperative outcomes. Int J Surg. 2015;18:57-

63.

9. Rolfson DB, Majumdar SR, Tsuyuki RT, et al. Validity and reliability of the Edmonton

Frail Scale. Age Ageing. 2006;35(5):526-9.

10. Kim SW, Han HS, Jung HW, et al. Multidimensional frailty score for the prediction of

postoperative mortality risk. JAMA Surg. 2014;149(7):633-40.

11. Rockwood K, Mitnitski A. Frailty in relation to the accumulation of deficits. J Gerontol A

Biol Sci Med Sci. 2007;62(7):722-7.

12. Partridge JS, Dhesi JK, Cross JD, et al. The prevalence and impact of undiagnosed cognitive

impairment in older vascular surgical patients. J Vasc Surg. 2014;60(4):1002-11.

65

ABSTRACT

Introduction: Pre-operative frailty is an important predictor of poor outcomes but the relationship

between frailty and geriatric syndromes is less clear. The aims of this study were to describe the

prevalence of frailty and incidence of geriatric syndromes in a cohort of older vascular surgical

ward patients; and investigate the association of frailty, non-elective admission, physiological

severity and surgical severity with the occurrence of one or more geriatric syndromes (delirium,

functional decline, falls and/or pressure ulcers) and two hospital outcomes (acute length of stay and

discharge destination).

Methods: This prospective cohort study was conducted in a vascular surgical unit in a tertiary

teaching hospital in Brisbane, Australia. Consecutive patients aged ≥ 65 years, admitted for ≥72

hours were eligible for inclusion. Frailty was defined as one or more of functional dependency,

cognitive impairment or nutritional impairment at admission. Delirium was identified using the

Confusion Assessment Method and a validated chart extraction tool. Functional decline from

admission to discharge was identified from daily nursing documentation of activities of daily living.

Falls were identified according to documentation in the medical record cross-checked with the

incident reporting system. Pressure ulcers, acute length of stay and discharge destination were

identified by documentation in the medical record. Risk factors associated with geriatric

syndromes, acute length of stay and discharge destination was assessed using multivariable logistic

regression models.

Results: Of 110 participants, 43 (39%) were frail and geriatric syndromes occurred in 40 (36%).

Functional decline occurred in 25% of participants, followed by delirium (20%), pressure ulcers

(12%) and falls (4%). In multivariable logistic analysis, non-elective admission (OR 7.2, 95% CI =

2.2-25.3, P = 0.002), frailty (OR 6.7, 95% CI = 2.0-22.1, P = 0.002), higher physiological severity

(OR 5.5, 95% CI = 1.1-26.8, P = 0.03) and operative severity (OR 4.6, 95% CI= 1.2-17.7, P = 0.03)

increased the likelihood of any geriatric syndrome. Frailty (OR 2.6, 95% CI = 1.0-6.8, P = 0.06),

(OR 4.2, 95% CI = 1.2-13.8, P = 0.02) was an important predictor of longer length of stay and

discharge destination respectively. Non-elective admission significantly increased the likelihood of

discharge to a higher level of care (OR 5.3, 95%CI 1-3-21.6, P= 0.02).

66

Conclusion: Frailty and geriatric syndromes were common in elderly vascular surgical ward

patients. Frail patients and non-elective admissions were more likely to develop geriatric

syndromes, have a longer length of stay and be discharged to a higher level of care.

67

Introduction

With the ageing of the population in many Western countries, surgical services are caring for an

increasing proportion of elders. Older patients have a higher risk of complications, poorer

functional outcomes and higher mortality than younger patients (1, 2). Frailty - a diminished

capacity to compensate for external stressors, which becomes more common with ageing (3) - has

been identified as an important predictor of poor outcomes including longer length of stay and

discharge destination in older surgical patients (4). Frailty may also be associated with geriatric

syndromes such as delirium, falls, pressure ulcers and functional decline (5). These non-disease

specific complications are poorly recognized by medical and nursing staff (6) but are associated

with increased dependency, longer length of stay, transfer to rehabilitation facilities or admission to

aged care facilities and can take months to improve (7-11).

Pre-operative frailty is of interest to surgeons in establishing perioperative risk, and understanding

the relationship between frailty, geriatric syndromes and clinical outcomes may assist in prognostic

decision making regarding surgical management. Furthermore, it could guide discussions with

patients and family members about potential complications, and identify patients in surgical wards

who might benefit from interventions to prevent and manage geriatric syndromes and improve

clinical outcomes. A recent retrospective study of older vascular and urology surgical ward patients

found that one-third of patients developed one or more geriatric syndromes (delirium, functional

decline, falls or pressure ulcers) during hospitalization (12). Pre-existing functional dependence

(which may be a marker of frailty), non-elective admission and major surgery were identified as

important risk factors for these geriatric syndromes. Other studies have shown that frailty predicts

post-operative delirium (5) and poorer outcomes (4, 13) but the nature of the relationship between

frailty, geriatric syndromes and poor outcomes has not been fully described, and most studies have

focused on selected elective surgical patients who only partly represent hospitalized surgical elders.

The specific aims of this prospective study were to document the incidence of geriatric syndromes

(delirium, functional decline, falls and / or pressure ulcers) and the prevalence of frailty in a

representative cohort of vascular surgical ward patients; to identify the characteristics of this “frail”

cohort; and to explore the relationship between frailty and other key risk factors with the occurrence

68

of geriatric syndromes (delirium, functional decline, falls and pressure ulcers) and two hospital

outcomes (discharge destination and acute length of stay).

Methods

Study design and setting

This was a prospective observational study of patients aged 65 years and older admitted to the

vascular surgical unit of metropolitan, tertiary university hospital in Brisbane, Australia. The unit

admits approximately 600 patients aged 65 and older per year, of whom two-thirds have a length of

stay ≥3 days. The patients formed the pre-intervention (usual care) cohort of a trial of improved

care of surgical elders (An Interdisciplinary Model to Enhance Care of Surgical Elders;

ACTRN12612001201864). The Royal Brisbane and Women’s Hospital Human Research Ethics

Committee approved the study.

Participants

The study recruited participants from August 2012 – February 2013. Consecutive patients aged 65

and older, admitted to the vascular surgical unit for a predicted stay of at least three days, were

eligible for inclusion in the study. Patients were excluded if they were terminally ill or discharged /

transferred to another unit within 72 hours, or had previously been enrolled in the cohort. The

sample size for this study was determined by requirements for the intervention study with a

recruitment aim of 125 participants.

Two senior internal medicine fellows, who did not provide clinical services to the ward,

prospectively screened patients through ward admission lists and medical record review. Screening

of patients occurred 3 times per week (Monday, Wednesday, Friday). Study staff assessed capacity

to consent and if necessary sought consent from a statutory health attorney (usually a family

member), in order to avoid excluding patients with cognitive impairment. Informed consent was

obtained from all participants or their statutory health attorney.

Frailty

Structured interviews were conducted with patients (or their health attorney) by a senior internal

medicine fellow within three days of admission and then three times per week until discharge. Items

collected at the first interview included baseline dependency in activities of daily living (ADL)

69

[defined as patient report of the need for assistance in one or more activities of daily living (bathing,

toileting, transferring, eating, mobilizing, dressing) two weeks prior to admission], cognitive status

using the Abbreviated Mental Test (14) and nutrition risk based on the Malnutrition Screening Tool

(15). Frailty was defined as the presence of one or more of the following: baseline functional

dependency (in 1 or more ADL), cognitive impairment (AMT <7) or nutrition risk (MST ≥ 2).

These markers are the most common elements of frailty indices (16), have been identified as shared

risk factors for inpatient geriatric syndromes and are strong predictors of adverse outcomes (13,

17).

Outcomes

The primary outcomes of interest were any geriatric syndrome (delirium, functional decline, falls

and / or pressure ulcer), acute length of stay under the care of the vascular unit and discharge

destination. Delirium was defined as an acute decline in attention and cognition (7). Delirium was

identified using both the Confusion Assessment Method (CAM) (18) (administered on initial

interview and follow-up interviews) and a validated chart extraction method (19). In order to

maximize sensitivity, delirium was coded as present if either method was positive (20). Functional

decline was defined as any increase (compared to admission) in the total number of ADL for which

human assistance was required at discharge, and was extracted from routine standardized nursing

assessments and care plans in the medical record (21). Because the sample would include patients

who underwent an above- or below- knee amputation, mobilizing was defined as ambulation by

walking or independent wheeling in a wheelchair (which defines readiness for discharge) and

transfers were defined as independent transfers to / from a chair / wheelchair. A fall was defined as

inadvertently coming to rest on the ground or other lower level (22), and identified by

documentation in the medical record cross-checked with the hospital incident reporting system.

Pressure ulcers were defined as localized injury to the skin and / or underlying tissue as a result of

pressure, shear and / or friction (23) , and identified by documentation in the medical record.

Discharge destination from the vascular surgical unit was obtained from the medical record and

dichotomized as home / usual care or a higher level of care (e.g. a rehabilitation unit, other hospital

or aged care facility) than had been required prior to hospital admission. Length of stay under the

vascular surgical unit was obtained from the medical record and dichotomized as < 8days and

≥8days (based on the median length of stay).

Covariates

70

Patient demographics, co-morbidities, number of prescribed medications, details of interventional

procedures and surgery, elective status and items required to calculate the Vascular Physiologic and

Operative Severity Score for the enUmeration of Mortality and Morbidity (V-POSSUM) (24) were

obtained from the medical chart using a purpose-built chart extraction tool. The chart abstractors

were two internal medicine fellows who worked independently of the internal medicine fellows

conducting the patient interviews. Elective admissions were defined as patients booked on an

elective surgery list prior to hospital admission (1). Non-elective admissions were defined as

individuals admitted directly from the emergency or outpatient department and inter-hospital

transfers (1). The V-POSSUM score was calculated using an online tool

(www.riskprediction.org.uk) and used to describe physiological severity for all patients. Those

managed non-invasively /conservatively were classified as non-operative and those managed

surgically in an operating theatre were classified according to the V-POSSUM operative severity

score. Physiological severity scores were categorized into three groups to avoid small cell sizes

( 18 vs 19-24 vs 25); surgical severity scores were categorised into 3 groups (non-operative vs 6

-10 vs 11 ), with higher scores indicative of higher severity. Co-morbidities were explored in

analyses both as individual variables and a weighted score [the Charlson Comorbidity Index (25)].

Statistical analyses

Descriptive analysis was undertaken using SPSS version 20.0 (IBM, Armonk NY). Categorical

variables were summarized using proportions and continuous variables summarized using mean

(standard deviation) or median (interquartile range) depending on distribution. Patient and surgical

characteristics were compared for frail and non-frail patients using chi-square tests for categorical

variables and independent samples t-tests for continuous variables, with statistical significance

defined as P < .05.

The associations of frailty and other explanatory variables with any geriatric syndrome, discharge

destination and acute length of stay were explored by chi-squared tests for categorical variables and

t-test for continuous variables. If bivariate analysis suggested a possible association (P < .10), the

variable was included in multivariable logistic regression models constructed for geriatric

syndromes, length of stay ≥8 days and discharge to a higher level of care. Co-morbid dementia was

not included in the logistic regression models due to small cell size. Surgical severity was retained

http://www.riskprediction.org.uk)/

71

in the model as an explanatory variable. All logistic models were adjusted for the following

confounding variables: age, sex, and comorbidities.

The sample size of this study was determined by requirements for the intervention study, with a

recruitment aim of 125 participants in order to have 80% power to detect a 30% reduction in

delirium or functional decline or a 2 day reduction in mean acute length of stay.

Results

As shown in Figure 1, two hundred and thirty-nine patients aged 65 and older were screened for

inclusion in the study, resulting in a final cohort of 110 participants. The most common reasons for

exclusion were repeat admissions, and hospital length of stay <72 hours.

Participant characteristics are shown in Table 1. Mean age was 75 years (± 7), and three quarters

were male. Sixty-six percent of patients underwent operative surgery, 15% underwent non-

operative interventional procedures only (for diagnostic or therapeutic purposes), and 18% were

treated conservatively. The most frequently performed operations were carotid endarterectomy

(10%), toe amputations (10%), open aortic aneurysm repair (7%), lower limb endarterectomy (7%),

femoral-popliteal bypass graft (7%) and above- or below- knee amputations (5%). Half of

admissions were non-elective.

At baseline, 23% of participants were dependent in one or more activities of daily living, 13% were

cognitively impaired and 18% were at risk of malnutrition (Table 1). Overall, 43 (39%) of

participants were considered to be frail. As shown in Table 2, frail participants were significantly

older than non-frail patients (P = .008), more likely to be female (P = .044) and more likely a non-

elective admission (P = .025). The two groups did not differ in comorbidity burden, type of

comorbidities, number of medications, type of surgical management, physiological severity or

severity of surgery.

Geriatric syndromes occurred in 40 [36% (95% CI 27-45)] of participants. There was evidence of

delirium in 22 [20% (95%CI 12-28%)], functional decline in 27 [25% (95%CI 16-33%)], falls in 4

[4% (95% CI 0-7%)] and pressure ulcers in 13 [12% (95% CI 6-18%)] of participants respectively.

The median acute length of stay was 8 (IQR 5-16) days and 26 (24%) participants were discharged

to a higher level of care.

72

In univariate analysis, frail patients (compared to non-frail patients) were significantly more likely

to develop any geriatric syndrome (P = <.001), have an acute length of stay 8 days (P = .01) and

be discharged to a higher level of care (P = .002) (Table 3). Non-elective admission was the most

significant other predictor of these outcomes (Table 3). Of note, 35/40 (88%) of participants who

developed geriatric syndromes, 41/60 (68%) with long stays and 22/26 (85%) requiring increased

level of care on discharge were non-elective. Physiological severity was a significant predictor of

all outcomes, and operative severity was associated with all except discharge destination. Older age

predicted any geriatric syndrome and discharge destination. The overall burden of co-morbidities

was associated with discharge destination, dementia was associated with geriatric syndromes,

diabetes with end organ damage was associated with length of stay and discharge destination, while

cancer was associated with length of stay.

In multivariable logistic regression (Table 4), non-elective admission, physiological severity, frailty

and surgical severity were the strongest predictors of geriatric syndromes but age and comorbidity

burden were less strongly associated. Frailty and non-elective admission were significant predictors

of discharge to a higher level of care. There was no significant interaction effect between frailty and

non-elective admission. In this model, higher physiological or surgical severity were not associated

with longer length of stay or discharge destination. Amongst comorbidities, diabetes with end organ

damage remained significantly associated with longer length of stay and discharge to a higher level

of care.

Discussion

Our frailty measure identified 39% of patients as frail, and geriatric syndromes occurred in over

one-third of participants, consistent with a previous study of vascular and urological surgical ward

patients (12). Frailty was a strong independent predictor of geriatric syndromes, consistent with a

previous study of the association of frailty and post-operative delirium (5). Frailty was also

independently associated with discharge to higher care, consistent with previous studies of the

association of frailty with discharge destination in vascular (26) and non-vascular surgical patients

(4, 13) respectively. We found that frailty reached marginal statistical significance as a risk factor

for length of stay (P=.06) which may be due to our small sample size, because other prospective

studies of vascular and non-vascular surgical patients have identified frailty as a predictor of length

of stay (26-28). Nonetheless, we found that frailty was a stronger predictor of adverse outcomes

than age alone or co-morbidity burden, consistent with previous studies of older vascular (29, 30)

73

and non-vascular surgical patients (31, 32) which supports recommendations that frailty is an

important factor for prognostic decision-making and should form part of the pre-operative risk

assessment for older surgical ward patients (4, 13, 33).

Adverse outcomes were much more common in non-elective admissions, consistent with findings

of other surgical studies investigating the incidence of delirium (34, 35), geriatric syndromes (12),

longer length of stay (26) and discharge destination(2, 26, 36). These findings highlight the need for

brief practical measures of frailty that can readily be applied to elective and non-elective patients,

and the investigation of interventions to prevent and manage geriatric syndromes in this vulnerable

group where pre-operative optimization is not feasible. Previous promising interventions have

largely focused on elective patients (37-41) but the potential benefits of such strategies may be

greatest in non-elective patients with higher risk of adverse outcomes.

Diabetes with end organ damage was a strong independent predictor of length of stay and discharge

destination which is not surprising considering the complexity of this condition. Our findings are

consistent with a recent study of risk factors for length of stay in patients undergoing lower

extremity bypass surgery (42). However it was interesting to note that this condition was not

associated with geriatric syndromes.

While higher surgical severity increased the likelihood of geriatric syndromes, approximately 30%

of patients who developed geriatric syndromes were non-operative cases, consistent with a recent

study of older patients admitted to a general surgical ward which found a similar incidence of

delirium in the operative and non-operative groups (34). Our findings support the concept that

geriatric syndromes may occur from an interplay between pre-existing factors (frailty,

comorbidities) and acute stressors (measured as physiological severity, surgical severity and

elective status). In view of the interplay of multiple risk factors, a proactive and coordinated

multidisciplinary team approach that includes targeting of geriatric risk factors associated with our

measure of frailty (such as functional, nutritional and cognitive risk factors) and management of

physiological condition and co-morbidities may be required to reduce geriatric syndromes and

improve discharge outcomes in older patients admitted to vascular surgical units. Promising

approaches include co-management (43) and non-pharmacological delirium prevention models (44)

Our study has both strengths and weaknesses. It extends findings from previous research, with a

range of outcomes and valid measurement of physiological and surgical severity as covariates. The

74

inclusion of non-elective and non-operative cases, and patients with cognitive impairment

maximizes generalizability. We used a brief measure of frailty and although the validity of this

measure has not been tested, our multi-dimensional measure identified a similar prevalence of

frailty as more complex measures previously used in vascular (30) and other surgical patients (28)

and was strongly associated with outcomes. Furthermore, our frailty measure may be clinically

feasible to apply compared to more complex frailty measures in vascular surgical ward patients,

particularly for non-elective admissions (45). Future studies could confirm the validity of this

simple and brief measure of frailty in larger samples of patients admitted to vascular surgical wards.

We used any geriatric syndromes as a primary outcome, consistent with a previous study of older

surgical ward patients (12). There is currently no agreed definition of the types of geriatric

syndromes to include in a combined measure which limits comparisons between studies. However,

we were able to identify risk factors for any syndrome versus single syndromes. Future studies are

required to confirm our findings.

The study sample was small which limits the power of multivariable analyses, reflected in wide

confidence intervals. Our analyses were confined to patient and operative characteristics and did not

explore the influence of processes of care or other complications, which will be examined as part of

the larger intervention study. Screening of patients for eligibility occurred on three days /week

which may have missed some patients but the sample is more broadly representative of a surgical

cohort than most previously reported prospective studies of older surgical patients (4, 46).

Functional decline was based on in-hospital decline and did not measure functional trajectory after

discharge from hospital. Nevertheless increased functional dependency at discharge has important

implications for quality of life of patients, carer burden, and costs for the healthcare system. Length

of stay and discharge destination may be affected by local healthcare systems and may not be

directly comparable across facilities. Finally, the study was conducted at a single metropolitan

tertiary university hospital which limits the generalizability of our findings.

Conclusion

In this cohort of elderly vascular surgical ward patients, geriatric syndromes were common. Frailty

and non-elective admission increased the likelihood of all adverse outcomes. The contribution of

multiple risk factors to geriatric syndromes and poor outcomes highlights the need for a coordinated

multidisciplinary approach to reduce geriatric syndromes and improve outcomes.

75

Figure 1. Study Recruitment

76

Table 1 . Description of patient and surgical characteristics (n=110)

Age, mean ± SD 75 ± 7

Male, n (%) 83 (76)


Community

RACF

105 (95)

5 (5)

Functional status at baseline, n (%)

Independent in ADL*

Dependent in ≥ 1 ADL

85 (77)

25 (23)

Documented diagnosis of dementia, n (%) 6 (5)

AMT†

<7, n (%) 14 (13)

At nutrition risk‡, n (%)

§ 19 (18)

Admission source, n (%)

Elective

Inter-hospital transfer

Emergency department

Same day outpatient department

53 (48)

31 (28)

20 (18)

6 (6)

Comorbidity score[], mean ± SD 3 ±1

77

Comorbidity||, n (%)

Myocardial Infarction

Chronic Obstructive Pulmonary Disease

Diabetes with end organ damage

Cerebrovascular disease

Congestive Cardiac Failure

Cancer

Moderate to severe kidney disease

Other

60 (55)

49 (45)

42 (38)

37 (34)

30 (27)

17 (16)

18 (16)

16 (15)

Number of prescribed medications, mean ± SD 9 ± 4

V-POSSUM¶ physiological score, n (%)

≤18

19-24

≥25

32 (29)

44 (40)

34 (31)

V-POSSUM operative severity score, n (%)

Non-operative

6-10

≥11

37 (34)

39 (36)

34 (31)

*Activities of daily living;

†Abbreviated mental Test;

‡ Malnutrition Screening Tool≥2;

§available

for 105 participants; []Charlson Comorbidity Index;

|| according to the classification of the Charlson

Comorbidity Index; ¶ Vascular – POSSUM scoring system

78

Table II. Description of patient and surgical characteristics (n=110), frail versus non-frail

Non-Frail

N= 67

Frail

N= 43

P value

Age, mean ± SD 74 ± 6 78 ± 7 .008

Male, n % 55 (82) 28 (65) 0.04

Admission category, n %

Elective

Non-elective

38 (57)

29 (43)

15 (35)

28 (65)

0.03

Comorbidity score*, mean ± SD 3 ± 1 3 ± 2 0.29

Number of prescribed medications, mean ± SD 8 ± 4 9 ± 5 0.13

V-POSSUM† Physiological score, n (%)

≤18

19-24

≥25

24 (37)

26 (39)

17 (25)

8 (19)

18 (42)

17 (40)

0.11

V-POSSUM Operative Severity Score, n %

Non-operative

6-10

≥11

22 (33)

26 (39)

19 (28)

15 (35)

13 (30)

15 (35)

0.63

* Charlson Comorbidity Index; † Vascular – POSSUM scoring system

79

Table III. Univariate analysis of frailty and other explanatory variables with outcomes. Only variables with a potentially significant

association (P<.10) are shown.

Variable ≥1 geriatric syndrome Acute length of stay Discharge destination

No geriatric

syndromes

N=70

≥1 geriatric

syndromes

N=40

P

value

Acute LOS

<8days

N=50

Acute LOS

>8 days

N=60

P

value

Discharge

home

N= 84

Discharge to

a higher level

of care

N=26

P

value

Frail, n (%) 17 (40) 26(61) <.001 13 (30) 30 (70) .01 26 (61) 17 (40) .002

Age ≥75, n (%) 28 (52) 26 (48) .012 - - 37 (69) 17 (32) .06

Non-elective admission, n

(%)

24 (42) 35 (58) <.001 16 (28) 41 (72) <.001 35 (61) 22 (39) <.001

Comorbidity score* >2 - - - - - - 45 (70) 19 (30) .08

Cancer†, n (%) - - - 12 (67) 6 (33) .05 - - -

Dementia†, n (%) 0 (0) 6 (100) .002 - - - - - -

80

Diabetes with end organ

damage†, n (%)

- - - 13 (31) 29 (69) .02 26 (62) 15 (38) .005

V-POSSUM‡ Physiological

Severity score, n (%)

≤18

19-24

≥25

28 (88)

25 (57)

17 (50)

4 (13)

19 (43)

17 (50)

.003

19 (59)

20(46)

11 (32)

13 (41)

24 (55)

23 (68)

.09

29 (91)

32 (73)

23 (68)

3 (9)

12 (27)

11 (32)

.07

V-POSSUM‡ Operative

Severity score, n (%)

Non-operative

6-10

≥11

26(70)

25 (64)

14 (41)

11 (30)

8 (24)

20 (59)

.004

16 (43)

25 (64)

9 (27)

21 (57)

14 (36)

25 (74)

.005

-

-

-

-

-

-

* Charlson Comorbidity Index; † according to the classification of the Charlson Comorbidity Index;

‡ Vascular – POSSUM scoring system

81

Table IV. Multivariable logistic regression analysis of outcomes. Variables with potentially significant association (P <.10) in univariate

analysis were included. Comorbidity burden, age, sex and V-POSSUM Operative Severity Score were retained in the model.

Variable ≥1 geriatric syndrome

OR 95% CI P value

Acute length of stay

OR 95% CI P value

Discharge destination

OR 95% CI P value

Frail 6.7 2.0-22.1 0.002 2.6 1.0 -6.8 0.06 4.2 1.3-13.8 0.02

Age ≥75 3.12 1.0-10.2 0.06 1.4 0.5-3.7 0.51 2.90 0.9-10.3 0.08

Non-elective admission 7.2 2.1-25.3 0.002 2.4 0.9.0-6.3 0.08 5.3 1.3-21.6 0.02

Comorbidity score* >2 2.2 0.7-6.7 0.18 0.6 0.2-1.6 0.33 1.3 0.4-4.5 0.68

Diabetes with end organ damage† - - - 4.1 1.4-11.8 0.009 5.5 1.5-20.7 0.01

Cancer† - - - 0.5 0.1-1.7 0.24 - - -

V-POSSUM‡ Physiological score, ref≤18

19-24

≥25

-

8.1

5.5

-

1.7-38.6

1.1-26.8

0.03

0.009

0.03

-

1.3

1.6

-

0.4-4.0

0.5-6.1

0.63

0.62

0.33

-

2.2

1.9

-

0.4-10.7

0.4-9.3

0.64

0.35

0.45

82

V-POSSUM‡ Operative Severity Score, ref

non-operative

6-10

≥11

-

.8

4.6

-

0.2-3.2

1.2-17.7

0.04

0.76

0.03

-

0.5

2.1

0.2-1.5

0.7-6.5

0.08

0.23

0.21

-

1.1

2.1

-

0.3-5.1

0.6-7.9

0.52

0.85

0.27

Sex (reference male) 0.3 0.1-1.3 0.10 0.7 0.2-2.1 0.48 0.3 0.1-1.3 0.10

* Charlson Comorbidity Index; † according to the classification of the Charlson Comorbidity Index;

‡ Vascular – POSSUM scoring system

83

References

1. Story DA, Leslie K, Myles PS, et al. Complications and mortality in older surgical patients

in Australia and New Zealand (the REASON study): a multicentre, prospective,

observational study. Anaesthesia. 2010;65(10):1022-30.

2. Blansfield JA, Clark SC, Hofmann MT, et al. Alimentary tract surgery in the nonagenarian:

elective vs. emergent operations. J Gastrointest Surg. 2004;8(5):539-42.

3. Hubbard RE, Story DA. Patient frailty: the elephant in the operating room. Anaesthesia.

2014;69 Suppl 1:26-34.


2012;41(2):142-7.

5. Leung JM, Tsai TL, Sands LP. Brief report: preoperative frailty in older surgical patients is

associated with early postoperative delirium. Anesth Analg. 2011;112(5):1199-201.



7. Inouye SK, Westendorp RG, Saczynski JS. Delirium in elderly people. Lancet.

2014;383(9920):911-22.



9. Quinlan N, Rudolph JL. Postoperative delirium and functional decline after noncardiac

surgery. J Am Geriatr Soc. 2011;59 Suppl 2:S301-4.

10. Portegijs E, Buurman BM, Essink-Bot ML, et al. Failure to regain function at 3 months after

acute hospital admission predicts institutionalization within 12 months in older patients. J

Am Med Dir Assoc. 2012;13(6):569 e1-7.

11. Cole MG, Ciampi A, Belzile E, et al. Persistent delirium in older hospital patients: a

systematic review of frequency and prognosis. Age Ageing. 2009;38(1):19-26.

84

12. McRae PJ, Peel NM, Walker PJ, et al. Geriatric Syndromes in Individuals Admitted to

Vascular and Urology Surgical Units. J Am Geriatr Soc. 2014;62(6):1105-9.



14. Hodkinson HM. Evaluation of a mental test score for assessment of mental impairment in

the elderly. Age Ageing. 1972;1(4):233-8.

15. Ferguson M, Capra S, Bauer J, et al. Development of a valid and reliable malnutrition

screening tool for adult acute hospital patients. Nutrition. 1999;15(6):458-64.

16. Sternberg SA, Wershof Schwartz A, Karunananthan S, et al. The identification of frailty: a

systematic literature review. J Am Geriatr Soc. 2011;59(11):2129-38.

17. Partridge JS, Dhesi JK, Cross JD, et al. The prevalence and impact of undiagnosed cognitive

impairment in older vascular surgical patients. J Vasc Surg. 2014;60(4):1002-11.

18. Inouye SK, van Dyck CH, Alessi CA, et al. Clarifying confusion: the confusion assessment

method. A new method for detection of delirium. Ann Intern Med. 1990;113(12):941-8.

19. Inouye SK, Leo-Summers L, Zhang Y, et al. A chart-based method for identification of

delirium: validation compared with interviewer ratings using the confusion assessment

method. J Am Geriatr Soc. 2005;53(2):312-8.

20. Saczynski JS, Kosar CM, Xu G, et al. A tale of two methods: chart and interview methods

for identifying delirium. J Am Geriatr Soc. 2014;62(3):518-24.

21. Mudge AM, O'Rourke P, Denaro CP. Timing and risk factors for functional changes

associated with medical hospitalization in older patients. Journals of Gerontology Series A-

Biological Sciences & Medical Sciences. 2010;65(8):866-72.

22. Organisation WH 2008;Pages. Accessed at World Health Organisation at

http://www.whoint/ageing/publications/Falls_prevention7Mar.pdf.

23. European Pressure Ulcer Advisory Panel, Panel. NPUA 2009;Pages. Accessed at National

Pressure Advisory Panel at http://www.npuap.org/wp-

content/uploads/2012/03/Final_Quick_Prevention_for_web_2010.pdf on August 21 2012.

http://www.whoint/ageing/publications/Falls_prevention7Mar.pdf



85

24. Neary WD, Heather BP, Earnshaw JJ. The Physiological and Operative Severity Score for

the enUmeration of Mortality and morbidity (POSSUM). Br J Surg. 2003;90(2):157-65.

25. Charlson ME, Pompei P, Ales KL, et al. A new method of classifying prognostic

comorbidity in longitudinal studies: development and validation. J Chronic Dis.

1987;40(5):373-83.

26. Ambler GK, Brooks DE, Al Zuhir N, et al. Effect of frailty on short- and mid-term

outcomes in vascular surgical patients. Br J Surg. 2015.

27. Dasgupta M, Rolfson DB, Stolee P, et al. Frailty is associated with postoperative

complications in older adults with medical problems. Arch Gerontol Geriatr. 2009;48(1):78-

83.

28. Makary MA, Segev DL, Pronovost PJ, et al. Frailty as a predictor of surgical outcomes in

older patients. J Am Coll Surg. 2010;210(6):901-8.

29. Karam J, Tsiouris A, Shepard A, et al. Simplified frailty index to predict adverse outcomes

and mortality in vascular surgery patients. Ann Vasc Surg. 2013;27(7):904-8.

30. Pol RA, van Leeuwen BL, Visser L, et al. Standardised frailty indicator as predictor for

postoperative delirium after vascular surgery: a prospective cohort study. Eur J Vasc

Endovasc Surg. 2011;42(6):824-30.

31. Farhat JS, Velanovich V, Falvo AJ, et al. Are the frail destined to fail? Frailty index as

predictor of surgical morbidity and mortality in the elderly. J Trauma Acute Care Surg.

2012;72(6):1526-30.

32. Revenig LM, Canter DJ, Taylor MD, et al. Too frail for surgery? Initial results of a large

multidisciplinary prospective study examining preoperative variables predictive of poor

surgical outcomes. J Am Coll Surg. 2013;217(4):665-70 e1.

33. Anaya DA, Johanning J, Spector SA, et al. Summary of the panel session at the 38th Annual

Surgical Symposium of the Association of VA Surgeons: what is the big deal about frailty?

JAMA Surg. 2014;149(11):1191-7.

86

34. de Castro SM, Unlu C, Tuynman JB, et al. Incidence and risk factors of delirium in the

elderly general surgical patient. Am J Surg. 2014;208(1):26-32.

35. Koebrugge B, van Wensen RJ, Bosscha K, et al. Delirium after emergency/elective open

and endovascular aortoiliac surgery at a surgical ward with a high-standard delirium care

protocol. Vascular. 2010;18(5):279-87.

36. Merani S, Payne J, Padwal RS, et al. Predictors of in-hospital mortality and complications in

very elderly patients undergoing emergency surgery. World J Emerg Surg. 2014;9:43.

37. Harari D, Hopper A, Dhesi J, et al. Proactive care of older people undergoing surgery

('POPS'): designing, embedding, evaluating and funding a comprehensive geriatric

assessment service for older elective surgical patients. Age Ageing. 2007;36(2):190-6.

38. Chen CC, Lin MT, Tien YW, et al. Modified hospital elder life program: effects on

abdominal surgery patients. J Am Coll Surg. 2011;213(2):245-52.


consistent successful outcomes in elderly colorectal surgery patients. World J Surg.

2011;35(7):1608-14.

40. Ellis G, Spiers M, Coutts S, et al. Preoperative assessment in the elderly: evaluation of a

new clinical service. Scott Med J. 2012;57(4):212-6.

41. Partridge JS, Harari D, Martin FC, et al. The impact of pre-operative comprehensive

geriatric assessment on postoperative outcomes in older patients undergoing scheduled

surgery: a systematic review. Anaesthesia. 2014;69 Suppl 1:8-16.

42. Damrauer SM, Gaffey AC, DeBord Smith A, et al. Comparison of risk factors for length of

stay and readmission following lower extremity bypass surgery. J Vasc Surg. 2015.

43. Tadros RO, Faries PL, Malik R, et al. The effect of a hospitalist comanagement service on

vascular surgery inpatients. J Vasc Surg. 2015;61(6):1550-5.

44. Hshieh TT, Yue J, Oh E, et al. Effectiveness of multicomponent nonpharmacological

delirium interventions: a meta-analysis. JAMA Intern Med. 2015;175(4):512-20.

87

45. Partridge JS, Fuller M, Harari D, et al. Frailty and poor functional status are common in

arterial vascular surgical patients and affect postoperative outcomes. Int J Surg. 2015;18:57-

63.

46. Joseph B, Pandit V, Sadoun M, et al. Frailty in surgery. J Trauma Acute Care Surg.

2014;76(4):1151-6.

88

Chapter 5. Conclusion

89

This thesis describes the occurrence of geriatric syndromes in surgical ward patients and confirms

them as a common complication. It identifies the contribution of key risk factors including frailty,

non-elective admission, higher illness severity and surgical severity to the development of geriatric

syndromes in surgical ward patients, and the impact of these variables on discharge outcomes in

this group. Key findings and their contribution to the literature are summarized below.

Key findings

1. The literature review in Chapter 2 identified that there are few estimates of geriatric

syndromes (other than post-operative delirium) in the broader surgical population cared for

in usual care wards. We described the occurrence of delirium, falls and pressure ulcers and

provided the first estimates of functional decline which ranged from 14 - 25% of

participants in our cohort studies. Delirium and functional decline were the most common

geriatric syndromes. Given evidence for overlapping risk factors and consequences of

common geriatric syndromes, we also reported on a combined outcome for the first time in

surgical ward patients, in line with similar work in medical and cardiology patients and

community elders. In the studies in Chapter 3 and 4, we found that approximately one-third

of older patients admitted to a surgical ward developed one or more geriatric syndromes. In

addition, these are the first estimates in an Australian hospital setting. These studies build on

the evidence for the occurrence of geriatric syndromes in older patients admitted to surgical

wards.

2. In Chapter 3, we found that baseline impairment in ADLs (which may be a unidimensional

measure of frailty) was an important risk factor for geriatric syndromes. In Chapter 4, we

used a simple multi-dimensional measure of frailty and confirmed that frailty was an

independent predictor of geriatric syndromes and discharge to a higher level of care, and

was also associated with longer hospital stay. Our studies add to the growing evidence that

frailty is an important predictor of geriatric syndromes in older surgical patients and build

on the evidence that frailty is associated with poor discharge outcomes.

3. Non-elective surgical ward patients are at very high risk of geriatric syndromes and poor

discharge outcomes. In Chapter 3 we found that non-elective admissions were much more

likely to develop geriatric syndromes and in Chapter 4 we found they were significantly

more likely to develop geriatric syndromes and be discharged to a higher level of care.

90

There was a trend to longer length of stay. Our studies add to the evidence that non-elective

admissions are increased risk of negative outcomes. Finally, they highlight frail and non-

elective patients are at increased risk of geriatric syndromes and poor discharge outcomes

and interventions to improve outcomes may be particularly important in these groups.

4. In Chapters 3 and 4, we found multiple risk factors for geriatric syndromes, consistent with

previous studies. Frailty, non-elective admission, higher physiological severity scores and

surgical severity scores were more strongly associated with geriatric syndromes than

surgical sub-specialty unit, older age and comorbidity burden. In Chapter 4, frailty, non-

elective admission and comorbid diabetes with end organ damage were stronger predictors

of discharge outcomes than higher physiological and operative severity scores, older age or

comorbidity burden. Our findings add to the evidence on risk factors associated with

discharge outcomes. Importantly, our studies identify a number of risk factors to consider

when designing or evaluating future intervention studies.

Future directions

Over the past four years, I have been the project lead for a project to improve care for hospitalised

elders at RBWH. In 2011, we introduced an interdisciplinary care model called Eat Walk Engage

(EWE) on a general medical ward as a quality improvement initiative. EWE focuses on ensuring

adequate nutrition and hydration, early mobilization and independence in activities of daily living

and cognitive stimulation to minimize geriatric syndromes and support functional recovery. We

found a sustained reduction in acute length of stay. We incorporated this model into the intervention

arm of the before-and-after study to improve care of vascular surgical elders. The intervention

combined a medical co-management model with EWE to optimize comorbidity management and

prevent or manage medical complications as well as reduce geriatric syndromes. The encouraging

preliminary results from the implementation of Eat Walk Engage in the general medical ward and

the enhanced interdisciplinary care model in the vascular surgical ward has resulted in substantial

funding to conduct a cluster RCT to test the feasibility and scaleability of Eat Walk Engage in

medical and surgical wards at four Queensland facilities. I have been employed as the project

manager and I am an associate investigator for this research project. I have the opportunity to work

with a team of very experienced national and international researchers which will assist me to

continue build my skills in health service research and my track record.

91

Areas for future research

Geriatric syndromes

The incidence of post-operative delirium is relatively well-documented but there remain relatively

few studies documenting geriatric syndromes such as functional decline, falls, pressure ulcers and

incontinence in surgical ward patients during hospitalization. There is a need for additional

estimates of these syndromes and future studies should sample a variety of surgical populations

using a prospective cohort design; use validated measures of geriatric syndromes; report on a

combined measure of geriatric syndromes, and include non-elective admissions and participants

with cognitive impairment should be included in studies to improve generalizability of findings. It

would be useful to specifically examine the occurrence of geriatric syndromes in non-operative

cases compared to operative cases because recent studies suggest that non-operative cases who

represent a substantial proportion of older patients admitted to surgical wards, may be vulnerable

just like older medical patients and require similar models of care.

Frailty

In Chapter 4, we used a measure of frailty that had not previously been validated. A variety of

validated and non-validated measures have been described in studies of surgical cohorts. While our

findings suggest good face validity and predictive validity of this measure, it would be useful to

examine the correlation of this brief measure of frailty with a well-validated measure such as the

Frailty Index in larger prospective cohort studies of older surgical ward patients. Progressing this

work will be important in order to develop and validate practical measures of frailty that can be

implemented in every-day clinical practice.

Relationship between frailty, geriatric syndromes and discharge outcomes

We found that our frailty measure was strongly associated with geriatric syndromes and discharge

outcomes. The association between frailty and poor discharge outcomes may in part be mediated by

geriatric syndromes but we were unable to explore this further due to the small sample size in our

prospective cohort study. It would be useful to investigate the potential mediating effect of geriatric

syndromes on discharge outcomes using mediation analyses in larger prospective cohort studies of

older surgical patients. This would help to establish both the joint and separate contribution of

frailty and geriatric syndromes to discharge outcomes and provide information to guide future

intervention studies to improve outcomes.

92

Improving care and outcomes of older surgical patients

In Chapter 3 and 4 we found that geriatric syndromes were common and identified multiple risk

factors for geriatric syndromes and discharge outcomes. Our findings suggest that high risk vascular

surgical ward patients may benefit from care models that aim to minimize geriatric syndromes. In

view of shared risk factors and potentially interacting impact on outcomes, future studies should

move away from the traditional model of focusing on the prevention of a single syndrome

(commonly post-operative delirium) and investigate the effectiveness of interventions on a

combined measure of geriatric syndromes. The development of an agreed definition of a combined

measure of geriatric syndromes would assist to compare the effectiveness of studies.

This study quantifies the extent and impact of risk factors to help identify patients at risk, but now

an understanding of processes of inpatient care that may modify that risk is needed, applicable to

elective, non-elective and non-operative surgical ward patients.

Conclusion

This thesis adds to the evidence that geriatric syndromes are common complications in older

surgical ward patients. It contributes to the design of future studies by identifying that frail and non-

elective patients are at increased risk and should be the target of interventions to reduce geriatric

syndromes and therefore improve outcomes; and identifies multiple risk factors for geriatric

syndromes and discharge outcomes to be considered when designing or evaluating interventions.

These studies have informed the design of a before-and after study of an enhanced interdisciplinary

model to prevent geriatric syndromes and improve outcomes of vascular surgical elders at RBWH.

93

Appendices

94

Appendix 1 Ethics Approvals

Table 6.1 Ethics Approvals for included studies

Study HREC Approval Number

Identifying Interdisciplinary Care

Needs In Older Surgical Patients

Royal Brisbane and Women’s

Hospital

HREC/11/QRBW/370

An Interdisciplinary Model To

Enhance Care Of Surgical Elders

Royal Brisbane and Women’s

Hospital

HREC/12/QRBW/101

95

Appendix 2 Glossary of terms

Activities of daily living Basic self-care skills required for independent living: dressing,

bathing, eating, transfers, toileting, mobility

Acute length of stay Length of stay under the treating surgical team

Delirium Acute decline in attention and cognition

Discharge destination Mode of formal separation form an admitted episode of care,

excluding death, and including discharge to usual residence, new

admission to residential aged care, or transfer to a rehabilitation

facility or other hospital setting

Elective admission An individual booked on an elective surgery list before admission to

hospital

Non-elective admission An individual admitted directly from the emergency or outpatient

department and inter-hospital transfers

Falls Inadvertently coming to rest on the ground or other lower level

Frailty An increased vulnerability to external stressors

Functional decline Increase in dependency in activities of daily living

Depression Mental and emotional disorder affecting older people

Geriatric syndromes Non-disease specific health conditions / complications, common in

older people

Malnutrition A state of nutrition in which a deficiency of energy, protein and/or

other nutrients causes measurable adverse effects on tissue/body

form, composition, function or clinical outcome

Pressure ulcer Localised injury to the skin or underlying tissue as a result of

pressure, shear or friction

Operative Managed surgically in an operating theatre

Non-operative Undergoing diagnostic / therapeutic imaging or managed

conservatively

Surgical patients Patients undergoing operative management

Surgical ward patients Patients admitted to a surgical ward

Urinary incontinence Involuntary loss of control of urine

96

97

Appendix 3 PRISMA Checklist 2009 Chapter 2

Section/topic # Checklist item Reported on page #

TITLE

Title 1 Identify the report as a systematic review, meta-analysis, or both. 12

ABSTRACT

Structured summary 2 Provide a structured summary including, as applicable: background; objectives; data sources; study eligibility criteria, participants, and interventions; study appraisal and synthesis methods; results; limitations; conclusions and implications of key findings; systematic review registration number.

14

INTRODUCTION

Rationale 3 Describe the rationale for the review in the context of what is already known. 15

Objectives 4 Provide an explicit statement of questions being addressed with reference to participants, interventions, comparisons, outcomes, and study design (PICOS).

15

METHODS

Protocol and registration 5 Indicate if a review protocol exists, if and where it can be accessed (e.g., Web address), and, if available, provide registration information including registration number.

N/A

Eligibility criteria 6 Specify study characteristics (e.g., PICOS, length of follow-up) and report characteristics (e.g., years considered,

language, publication status) used as criteria for eligibility, giving rationale. 16,17

Information sources 7 Describe all information sources (e.g., databases with dates of coverage, contact with study authors to identify additional studies) in the search and date last searched.

16,17,33

Search 8 Present full electronic search strategy for at least one database, including any limits used, such that it could be repeated.

16,17

Study selection 9 State the process for selecting studies (i.e., screening, eligibility, included in systematic review, and, if applicable,

included in the meta-analysis). 17

98

Data collection process 10 Describe method of data extraction from reports (e.g., piloted forms, independently, in duplicate) and any processes for obtaining and confirming data from investigators.

17,21

Data items 11 List and define all variables for which data were sought (e.g., PICOS, funding sources) and any assumptions and simplifications made.

16

Risk of bias in individual studies

12 Describe methods used for assessing risk of bias of individual studies (including specification of whether this was done at the study or outcome level), and how this information is to be used in any data synthesis.

16

Summary measures 13 State the principal summary measures (e.g., risk ratio, difference in means). 17

Synthesis of results 14 Describe the methods of handling data and combining results of studies, if done, including measures of consistency

(e.g., I2) for each meta-analysis.

N/A

Page 1 of 2

Section/topic # Checklist item Reported on page #

Risk of bias across studies 15 Specify any assessment of risk of bias that may affect the cumulative evidence (e.g., publication bias, selective reporting within studies).

N/A

Additional analyses 16 Describe methods of additional analyses (e.g., sensitivity or subgroup analyses, meta-regression), if done, indicating which were pre-specified.

N/A

RESULTS

Study selection 17 Give numbers of studies screened, assessed for eligibility, and included in the review, with reasons for exclusions at each stage, ideally with a flow diagram.

17,22

Study characteristics 18 For each study, present characteristics for which data were extracted (e.g., study size, PICOS, follow-up period) and provide the citations.

23-26, 36-38

Risk of bias within studies 19 Present data on risk of bias of each study and, if available, any outcome level assessment (see item 12). N/A

Results of individual studies 20 For all outcomes considered (benefits or harms), present, for each study: (a) simple summary data for each intervention group (b) effect estimates and confidence intervals, ideally with a forest plot.

N/A

Synthesis of results 21 Present the main results of the review. If meta-analyses done, include for each confidence intervals and measures of consistency.

17-20,

33-34

Risk of bias across studies 22 Present results of any assessment of risk of bias across studies (see Item 15). N/A

Additional analysis 23 Give results of additional analyses, if done (e.g., sensitivity or subgroup analyses, meta-regression [see Item 16]). N/A

DISCUSSION

99

Summary of evidence 24 Summarize the main findings including the strength of evidence for each main outcome; consider their relevance to key groups (e.g., healthcare providers, users, and policy makers).

20, 34-35

Limitations 25 Discuss limitations at study and outcome level (e.g., risk of bias), and at review-level (e.g., incomplete retrieval of identified research, reporting bias).

21,35

Conclusions 26 Provide a general interpretation of the results in the context of other evidence, and implications for future research. 21,35

FUNDING

Funding 27 Describe sources of funding for the systematic review and other support (e.g., supply of data); role of funders for the systematic review.

21

From: Moher D, Liberati A, Tetzlaff J, Altman DG, The PRISMA Group (2009). Preferred Reporting Items for Systematic Reviews and Meta-Analyses: The PRISMA Statement. PLoS Med 6(6): e1000097. doi:10.1371/journal.pmed1000097

For more information, visit: www.prisma-statement.org. Page 2 of 2

100

Appendix 4 STROBE Checklist Chapter 3

STROBE Statement—Checklist of items that should be included in reports of cohort studies

Item

No Recommendation

Reported

on page

Title and abstract 1 (a) Indicate the study’s design with a commonly used term in the

title or the abstract

45

(b) Provide in the abstract an informative and balanced summary

of what was done and what was found

45

Introduction

Background/rationale 2 Explain the scientific background and rationale for the

investigation being reported

47

Objectives 3 State specific objectives, including any prespecified hypotheses 47

Methods

Study design 4 Present key elements of study design early in the paper 47

Setting 5 Describe the setting, locations, and relevant dates, including

periods of recruitment, exposure, follow-up, and data collection

47

Participants 6 (a) Give the eligibility criteria, and the sources and methods of

selection of participants. Describe methods of follow-up

48

(b) For matched studies, give matching criteria and number of

exposed and unexposed

Variables 7 Clearly define all outcomes, exposures, predictors, potential

confounders, and effect modifiers. Give diagnostic criteria, if

applicable

48,49

Data sources/

measurement

8* For each variable of interest, give sources of data and details of

methods of assessment (measurement). Describe comparability

of assessment methods if there is more than one group

48

Bias 9 Describe any efforts to address potential sources of bias 51

Study size 10 Explain how the study size was arrived at 49

Quantitative variables 11 Explain how quantitative variables were handled in the analyses.

If applicable, describe which groupings were chosen and why

49

Statistical methods 12 (a) Describe all statistical methods, including those used to

control for confounding

49

(b) Describe any methods used to examine subgroups and

interactions

N/A

(c) Explain how missing data were addressed 50

(d) If applicable, explain how loss to follow-up was addressed N/A

(e) Describe any sensitivity analyses N/A

Results

Participants 13* (a) Report numbers of individuals at each stage of study—eg

numbers potentially eligible, examined for eligibility, confirmed

49

101

eligible, included in the study, completing follow-up, and

analysed

(b) Give reasons for non-participation at each stage N/A

(c) Consider use of a flow diagram N/A

Descriptive data 14* (a) Give characteristics of study participants (eg demographic,

clinical, social) and information on exposures and potential

confounders

53

(b) Indicate number of participants with missing data for each

variable of interest

50

(c) Summarise follow-up time (eg, average and total amount) 49

Outcome data 15* Report numbers of outcome events or summary measures over

time

50

Main results 16 (a) Give unadjusted estimates and, if applicable, confounder-

adjusted estimates and their precision (eg, 95% confidence

interval). Make clear which confounders were adjusted for and

why they were included

49, 59

(b) Report category boundaries when continuous variables were

categorized

59

(c) If relevant, consider translating estimates of relative risk into

absolute risk for a meaningful time period

Other analyses 17 Report other analyses done—eg analyses of subgroups and

interactions, and sensitivity analyses

N/A

Discussion

Key results 18 Summarise key results with reference to study objectives 50

Limitations 19 Discuss limitations of the study, taking into account sources of

potential bias or imprecision. Discuss both direction and

magnitude of any potential bias

51,52

Interpretation 20 Give a cautious overall interpretation of results considering

objectives, limitations, multiplicity of analyses, results from

similar studies, and other relevant evidence

50,51

Generalisability 21 Discuss the generalisability (external validity) of the study

results

51,52

Other information

Funding 22 Give the source of funding and the role of the funders for the

present study and, if applicable, for the original study on which

the present article is based

Included

in

published

manuscript

*Give information separately for exposed and unexposed groups.

Note: An Explanation and Elaboration article discusses each checklist item and gives methodological background and

published examples of transparent reporting. The STROBE checklist is best used in conjunction with this article (freely

102

available on the Web sites of PLoS Medicine at http://www.plosmedicine.org/, Annals of Internal Medicine at

http://www.annals.org/, and Epidemiology at http://www.epidem.com/). Information on the STROBE Initiative is

available at http://www.strobe-statement.org.

103

Appendix 5 STROBE Checklist Chapter 4

STROBE Statement—Checklist of items that should be included in reports of cohort studies

Item

No Recommendation

Reported

on page

Title and abstract 1 (a) Indicate the study’s design with a commonly used term in the

title or the abstract

67

(b) Provide in the abstract an informative and balanced summary

of what was done and what was found

67,68

Introduction

Background/rationale 2 Explain the scientific background and rationale for the

investigation being reported

69

Objectives 3 State specific objectives, including any prespecified hypotheses 69,70

Methods

Study design 4 Present key elements of study design early in the paper 70

Setting 5 Describe the setting, locations, and relevant dates, including

periods of recruitment, exposure, follow-up, and data collection

70

Participants 6 (a) Give the eligibility criteria, and the sources and methods of

selection of participants. Describe methods of follow-up

70

(b) For matched studies, give matching criteria and number of

exposed and unexposed

Variables 7 Clearly define all outcomes, exposures, predictors, potential

confounders, and effect modifiers. Give diagnostic criteria, if

applicable

71,72,73

Data sources/

measurement

8* For each variable of interest, give sources of data and details of

methods of assessment (measurement). Describe comparability

of assessment methods if there is more than one group

71

Bias 9 Describe any efforts to address potential sources of bias 76

Study size 10 Explain how the study size was arrived at 73

Quantitative variables 11 Explain how quantitative variables were handled in the analyses.

If applicable, describe which groupings were chosen and why

72

Statistical methods 12 (a) Describe all statistical methods, including those used to

control for confounding

72

(b) Describe any methods used to examine subgroups and

interactions

(c) Explain how missing data were addressed 79

(d) If applicable, explain how loss to follow-up was addressed

(e) Describe any sensitivity analyses N/A

Results

Participants 13* (a) Report numbers of individuals at each stage of study—eg

numbers potentially eligible, examined for eligibility, confirmed

73,77

104

eligible, included in the study, completing follow-up, and

analysed

(b) Give reasons for non-participation at each stage

(c) Consider use of a flow diagram 77

Descriptive data 14* (a) Give characteristics of study participants (eg demographic,

clinical, social) and information on exposures and potential

confounders

(b) Indicate number of participants with missing data for each

variable of interest

77

(c) Summarise follow-up time (eg, average and total amount) 73

Outcome data 15* Report numbers of outcome events or summary measures over

time

73

Main results 16 (a) Give unadjusted estimates and, if applicable, confounder-

adjusted estimates and their precision (eg, 95% confidence

interval). Make clear which confounders were adjusted for and

why they were included

83

(b) Report category boundaries when continuous variables were

categorized

78,79, 80,81,

(c) If relevant, consider translating estimates of relative risk into

absolute risk for a meaningful time period

Other analyses 17 Report other analyses done—eg analyses of subgroups and

interactions, and sensitivity analyses

74

Discussion

Key results 18 Summarise key results with reference to study objectives 74,75

Limitations 19 Discuss limitations of the study, taking into account sources of

potential bias or imprecision. Discuss both direction and

magnitude of any potential bias

76

Interpretation 20 Give a cautious overall interpretation of results considering

objectives, limitations, multiplicity of analyses, results from

similar studies, and other relevant evidence

75,76

Generalisability 21 Discuss the generalisability (external validity) of the study

results

76

Other information

Funding 22 Give the source of funding and the role of the funders for the

present study and, if applicable, for the original study on which

the present article is based

Included in

submitted

manuscript

*Give information separately for exposed and unexposed groups.

Note: An Explanation and Elaboration article discusses each checklist item and gives methodological background and

published examples of transparent reporting. The STROBE checklist is best used in conjunction with this article (freely

available on the Web sites of PLoS Medicine at http://www.plosmedicine.org/, Annals of Internal Medicine at

105

http://www.annals.org/, and Epidemiology at http://www.epidem.com/). Information on the STROBE Initiative is

available at http://www.strobe-statement.org.

106

Appendix 6 Data Collection Form for Retrospective Cohort Study

Patient Details

Subject Code: NOS

Unit:

Ward:

Date of Admission

- - dd-mm-

yyyy

Admission Category

Elective1 Same Day OPD Emergency3

IHT4

Place of Residence Independent, living alone1 Independent, living with others2

Hostel / Assisted living3 Nursing Home4 Other5 ______________

Discharge Diagnosis

Co-morbidities

MI1

CCF1

PVD1

CVD1

Hemiplegia2

COPD1

Dementia1

CTD1

Ulcer Disease1

Renal Failure_mod-sev 2

Liver Disease_mild 1

Liver Disease_mod-

severe3

DM1

DM with Cx 2

any tumor2

metastatic solid tumor6

leukemia2

lymphoma2

AIDS6

Other:

Number of medications

on admission (not incl.

PRN)

Number of Prescribed medications _______ No complimentary

medications ______

Surgery Performed

(operation 1)

No Yes type:

- - dd-mm-yyyy ASA score:

Surgery Performed

(operation 2)

No Yes type:


Affix patient label or complete

Name:______________________________

UR:________________________________

DOB:_______________________________

M or F

107

Surgery Performed

(operation 3)

No Yes type:


ICU admission

No Yes Planned Unplanned

Date admitted to ICU - - dd-mm-yyyy

Date discharged from ICU - - dd-mm-yyyy

MERT

No Yes date 1st MERT - - dd-mm-yyyy

Number of MERTS

Risk Screening

Patient Risk Assessment No Yes Date completed - -

Cognition / Delirium Risk No Yes Not completed → check admission notes for history of

dementia / evidence of delirium on admission (within 48hrs) No Yes

Functional Decline Risk

assistance required on

admission compared to 2

weeks prior

No Yes Not completed →check admission notes for functional risk

ie: assistance required since 2 weeks prior No Yes

2 weeks prior to admission

Nil assistance required

On admission


Dressing Bathing Dressing Bathing

Eating Toileting Eating Toileting

Transfers Mobility Transfers Mobility

Independent with aid

__________ Independent with aid __________

Supervision Assist x 1 x 2 Supervision Assist x 1 x 2

Falls Risk

No Yes Not completed →check admission notes for

Previous history of falls: No Yes

108

Nutrition Risk

No Yes Not completed →check admission notes for nutrition risk

wt loss, ↓appetite : No Yes

Skin Integrity Risk No Yes Not completed → check admission notes for evidence of

pressure injury on admission? : No Yes

Elimination (Continence)

No Yes Not completed check admission notes for evidence of

urinary faeces incontinence: No Yes

Delirium

Is there any evidence from the chart of acute confusional state (eg. delirium, mental status change, inattention,

disorientation, hallucinations, agitation, inappropriate behaviour etc)? – review entire admission including medical,

nursing & consult notes. No0 Yes1 (if uncertain get consensus of 2 reviewers)

AIN special No0 Yes1 number of days

Risk Outcomes

Function

Is there any evidence from the chart of the functional level on discharge?

No0 Yes1 if Yes complete below


Dressing Bathing

Eating Toileting

Transfers Mobility Independent with aid __________; Supervision; Assist x 1 Assist x 2

Falls

Is there any evidence from the chart that the patient has had an in-hospital fall?

No0 Yes1 →Number _____ Injury No0 Yes1 9describe) __________________________________________

Nutrition

Is there any evidence from the chart that the patient has been assessed by a Dietition as having malnutrition?

No0 Yes1 →date of diagnosis - - dd-mm-yyyy

Skin Integrity

Is there any evidence from the chart that the patient has developed a new Pressure Injury during this admission?

No0 Yes1 → If Yes, stage if known ___________

Elimination (Continence)

Is there any evidence from the chart of a problem with continence?

109

No0 Yes1 → If Yes, comment ________________________________________________

Review

During this admission was there a documented chart entry from any of the following disciplines?

Physiotherapy

Occupational Therapy

Dietetics

Discharge

Planning^__________

General Physician

Specialty Physician*

Date 1st review - -

Date 1st review - -

Date 1st review - -

Date 1st review - -

Date 1st review - -

Date 1st review - -

Number of reviews

Number of reviews

Number of reviews

Number of reviews

Number of reviews

Number of reviews

_____________________

_____________________

_____________________

Date 1st review - -

Date 1st review - -

Date 1st review - -

Number of reviews

Number of reviews

Number of reviews

Discharge Information

Intrahospital transfer No0 Yes1 date of transfer - - dd-mm-yyyy

Transferred to Rehab (GARU)1 ECU2 Other Unit/ Ward3

Discharge (from hospital) Date : - - dd-mm-yyyy

Discharge Destination

Independent, living alone1

Hostel / assisted living3

Other hospital7

Independent, living with others2

Nursing Home4

Deceased8

Six (6) Month Readmission No0 Yes1 Planned Unplanned

Date of 1st

readmission - - dd-mm-yyyy

Number readmissions in 6 months

Reason for 1st

readmission

Pre operative bloods alb g/L

Hb g/L

Creat micromol/l

eGFR ml/min

Nadir renal function Creat micromol/l eGFR ml/min

110

Additional Notes (including discharge summary follow up service/recommendation to patient / GP or multiple

readmissions)

*also document specialties from ‘review’ section above

^ including discharge facilitation, social work, case managers

111

Appendix 7 Data Collection Form for Prospective Cohort Study

Patient Details

Subject Code:

Unit:

Admission Ward:

Weight:

Height:

Visit 1 date - -

dd-mm-yyyy

Delirium No Yes AIN special

Have you had a fall in the last 6 months? No Yes N/A MST………………

Abbreviated Mental Test Score Score 0 or 1

1. How old are you?

2. What is the time (nearest hour)?

3. Address for recall at the end of test – this should be repeated by the patient. E.g.

42 West Terrace

4. What year is it?

5. What is the name of this place?

6. Can the patient recognise two relevant people (e.g. nurse and doctor)

7. What is your date of birth?

8. What year did World War 2 start ?

9. Who is the prime minister?

10. Count down from 20 to 1 (no errors, no cues)

Total (out of 10)

Do you have any pain at the moment? No Yes Pain rating ………………… (scale 0 to 10)

Did you need help with any

of the following 2 weeks pre-

admission

Dressing Bathing Transfers Toileting Eating

Independent mobility with aid. If yes, specify type………………………

Mobility with supervision Mobility with assistance Bed/chairfast

Did you need help with any

of the following on Dressing Bathing Transfers Toileting Eating


Name:______________________________

UR:________________________________

DOB:_______________________________

M or F

112

admission (or at time of first

review)



Visit 2 date - - dd-mm-yyyy Delirium No Yes AIN special

Do you need help with any

of the following today






of the following today?




Do you have any pain at the moment? No Yes Pain rating ……………………………















113








Confusion assessment method (CAM) for diagnosis of delirium

Chart extraction

Subject Code:


Name:______________________________

UR:________________________________

DOB:_______________________________

M or F

Date of Admission

- - dd-mm-

yyyy

Admission Category

Elective1 Same Day OPD Emergency3 IHT4

Place of Residence

Independent, living alone1 Hostel / Assisted living3

Independent, living with others2 Nursing Home4

Other5 ………………………………..

114

Existing Services Nil Domiciliary Nurses Community Health Home help

Meals on Wheels Other ……………………………..

ADL admission Dressing Bathing Transfers Toileting Eating Mobilising

Alcohol use No Drinks Daily Amount ………………………………

Admission BMI Weight kg N/A Height cm N/A BMI

MST score

Co-morbidities

MI1

CCF1

PVD1

CVD1

Hemiplegia2

COPD1

Dementia1

CTD1

Ulcer Disease1

Renal Failure_mod-sev 2

Liver Disease_mild 1

Liver Disease_mod-

severe3

DM1

DM with Cx 2

Any tumor2

Metastatic solid tumor6

leukemia2

lymphoma2

AIDS6

Other:

Number of

prescribed

medications (admit)

cardiac drugs steroids warfarin

Signs of HF Dyspnoea due to lung disease on mod exertion on mild exertion at rest

Admission obs Pulse bpm BP / mmHg GCS /15

Admission ECG Normal AF Other no ECG

Pre-operative obs Pulse bpm BP / mmHg GCS /15

Surgery Performed

(operation 1)

No Yes type:

- - dd-mm-yyyy Minutes:

ASA score: Immediate (within 2 hr)

Blood loss: ml GA Block

Sedation

Repeat surgery No Yes type:

115

performed

(operation 2)


Blood loss: ml Immediate (within 2 hr)

GA Block

Sedation

Repeat surgery

performed

(operation 3)

No Yes type:


Blood loss: ml Immediate (within 2 hr)

GA Block

Sedation

Interventional

Procedures

Performed

No Yes type:

- - dd-mm-yyyy GA Block Sedation

Repeat Interventional

procedures

performed

No Yes type:



Outcome

ICU admission

No Yes Planned Unplanned

Date admitted to ICU - - dd-mm-yyyy

Date discharged from ICU - - dd-mm-yyyy

MERT

No Yes date 1st MERT - - dd-mm-yyyy

Number of MERTS

Falls

Is there any evidence from the chart that the patient had an in-hospital fall?

No0 Yes1 → Number ______

Did the patient sustain an injury from a fall during their admission?

No0 Yes1 (describe) ……………………………………

Nutrition Was the patient assessed by a dietician during this admission?

No0 Yes1

116

Is there any evidence from the chart that the patient has been assessed as having malnutrition?

No0 Yes1 → date of diagnosis - - dd-mm-yyyy

Skin integrity

Is there any evidence from the chart that the patient had a Pressure Injury on admission?

No0 Yes1 → Stage (if known) ___________

Is there any evidence that the patient developed a new Pressure Injury during this admission?

No0 Yes1 → Stage (if known) ___________

date of diagnosis - - dd-mm-yyyy

Delirium

Is there any evidence from the chart that the patient had delirium at admission?

No0 Yes1

Is there any evidence from the chart that the patient developed delirium during this admission?

No0 Yes1

Review

During this admission was there a documented chart entry from any of the following disciplines?

Physiotherapy

Occupational Therapy

Dietetics

Social Worker

Discharge Planning

Medical registrar

General Physician

Specialty Physician*

Date 1st review - -

Date 1st review - -

Date 1st review - -

Date 1st review - -

Date 1st review - -

Date 1st review - -

Date 1st review - -

Date 1st review - -

Number of reviews

Number of reviews

Number of reviews

Number of reviews

Number of reviews

Number of reviews

Number of reviews

Number of reviews

_____________________

_____________________

Date 1st review - -

Date 1st review - -

Number of reviews

Number of reviews

Discharge Information

Discharge Diagnosis

Number of prescribed

medications (disch)

ADL discharge Dressing Bathing Transfers Toileting Eating Mobilising

117

Intrahospital transfer No0 Yes1→ date of transfer - - dd-mm-yyyy

Subacute transfer No0 Yes1 → Rehab (GARU) GEM Other Unit/ Ward

Discharge date:

(from hospital) - - dd-mm-yyyy

Discharge Destination



Other hospital7:

…………………………..


Nursing Home4

Deceased8

Additional Notes (including discharge summary follow up service/recommendation to patient / GP or multiple

readmissions)

Complications

For each complication,

grade according to

ACCORDIAN severity

grading:

1 mild complication:

requires minor

symptomatic treatment,

allied health intervention

2 moderate: requires

drugs

3 severe: requires

invasive procedure

(interventional,

endoscopic or operative)

without GA

4 severe: reoperation

with GA

5 severe: organ failure*

6 severe: death

wound infection

wound dehiscence

urinary tract infection

pneumonia

systemic sepsis

haemorrhage

stroke

unplanned

intubation

respiratory failure

VTE

myocardial ischaemia

myocardial infarction

arrhythmia

acute renal failure

……………………………

118

The Viewer

Admission bloods

Alb g/L

Hb g/L

WCC . x 109/l

Na+ mmol/l

K+ . mmol/l

Creat micromol/l

Urea . mmol/l

Pre-operative bloods

Alb g/L

Hb g/L

WCC . x 109/l

Na+ mmol/l

K+ . mmol/l

Creat micromol/l

Urea . mmol/l

Nadir bloods

Creat micromol/l

eGFR ml/min

Alb g/L

Hb g/L

Admission in previous 6 months

No Yes

Date of most recent - - dd-mm-yyyy

Total number of days in previous 6 months

Follow-up

Readmission within six (6)

months of discharge No0 Yes1 → Planned Unplanned

Date of 1st

readmission - - dd-mm-yyyy

Unit of first admission

Number readmissions in 6 mths

Days admitted within 6 months

Reason for 1st

readmission

Telephone follow-up date - - dd-mm-yyyy

Living situation at follow-up



Other hospital7


Nursing Home4

Deceased8

Additional Notes

119

V-POSSUM scoring system

120

Charlson Comorbidity Index Scoring System

121

Appendix 8 Publication included in thesis

(Copied with permission from the Journal of the American Geriatrics Society)

122

Appendix 9 List of Presentations and awards relating to this thesis

McRae P*, Walker PJ, Peel NM, Mudge A. Relationship between geriatric conditions and adverse

outcomes in vascular surgical patients. ANZSVS Conference, 11-13 October 2014 Canberra ACT.

PODIUM PRESENTATION

McRae P*, Walker PJ, Peel NM, Mudge A. Relationship Between Frailty And Adverse Outcomes

In Vascular Surgical Patients. 23rd

Annual RBWH Healthcare Symposium, 13-17 October 2014.

POSTER PRESENTATION

McRae P, Walker PJ, Peel NM, De Looze J, Mudge A, Geriatric Conditions In Surgical Inpatients

– A Retrospective Study.22nd

Annual RBWH Research symposium, 14-18th

October 2013.

POSTER PRESENTATION

McRae P*, Mudge A, Walker P, Peel N, Understanding the interdisciplinary care needs of older

surgical patients, 45th

Australian Association of Gerontology Conference, Brisbane, Queensland 20-

23rd

November 2012, POSTER PRESENTATION


surgical patients, UQ Medicine & Surgery Research Day, Brisbane, 17 August 2012, PODIUM

PRESENTATION


surgical patients, 21st annual RBWH Healthcare Symposium, Brisbane, 8-12 October 2012,

POSTER PRESENTATION

Professor William Egerton Surgical Research Award, RBWH Healthcare Symposium, 2013

*Presenter

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