Achieving better outcomes in older surgical patients

It is well established that older adults undergoing surgery have higher perioperative morbidity and mortality. Age-related physiological changes and geriatric syndromes such as frailty, increase the risk of adverse postoperative outcomes. Intervention studies to improve outcomes in older surgical adults have infrequently reported on hospital-acquired geriatric syndromes such as postoperative functional decline and delirium. Recently, recommendations about the care of older surgical adults have been put forward in the form of practice guidelines, quality indicators and hospital standards. Collaborative models of care that embed geriatricians in the surgical team have been recommended. Geriatricians utilise comprehensive geriatric assessment and management (CGA) to identify and manage geriatric syndromes, and deliver patient-centred care. The evidence base for geriatrician-led CGA in surgical patients is established for patients undergoing hip fracture surgery. The vascular surgical population have multiple vascular comorbidities, highly prevalent geriatric syndromes including cognitive impairment and frailty, and undergo high-stress procedures. There is emerging evidence for the role of geriatric comanagement of older non-orthopaedic surgical patients, but further studies are needed, in particular, to determine whether geriatric comanagement reduces the incidence of hospital-acquired geriatric syndromes. The overall aims of this thesis were to appraise the evidence for geriatric interventions in older non-orthopaedic surgical patients, evaluate the current provision of geriatrics surgical services in hospitals across Australia and New Zealand, explore the association between patient characteristics in particular frailty, care processes and clinical outcomes in a hospitalised older vascular surgery cohort, and develop and evaluate a geriatric comanagement model of care for older vascular surgery inpatients