1 Background

With improvements in health and social care in the preceding century, we are now seeing that the over-65-year-old cohort makes up a quarter of the population in the developed world. This change in the structure of society impacts the delivery of health care. As ageing is associated with an increase in the incidence of degenerative, neoplastic and vascular conditions, it is increasingly common for surgical teams to provide elective surgery as definitive treatment for older people. Whilst, there have been many advances in surgical and anaesthetic techniques allowing access to treatment for older people, they continue to have higher rates of perioperative morbidity and mortality in comparison to younger patients and incur higher health and social care costs.

For older patients undergoing emergency abdominal surgery, the mortality rate increases with age and the invasiveness of the procedure by up to 50% [1, 2].

Factors impacting increasing morbidity and mortality rates can be divided into patient factors, such as decreased physiological reserve, comorbidity, poly-pharmacy and frailty, and into environmental factors such as the quality of primary evaluation on arrival to the emergency department, the presence of staff trained to assess and deal with frailty and a standardised protocol of shared decision-making that is an essential component of patient-centred care to decrease futility in managing advanced surgical diseases in frail and older patients.

In a critical setting, above all during the night, in a short time for decision making, the assessment of frailty, risk factors for negative outcomes and medical complications such as pneumonia, cardiac or renal issues or geriatric syndromes including delirium, should be prioritised and standardised to improve the management of older patients and their quality of life, thereby decreasing morbidity, hospital length of stay (LOS), and in-hospital and 30 days-mortality [3, 4].

In the last 10 years, several studies investigated the impact of frailty on elective surgical activity and it is reported as the main risk factor for morbidity and postoperative mortality. The validity of clinical scores assessing frailty was also reported with high variability among tools implemented [3, 4].

As the first point of admission and management, emergency departments and their teams should develop focused and standardised strategies to take care of surgical emergency geriatric patients. A multidisciplinary approach is needed for such complex evaluation and decision-making as in frail emergency surgery patients.

2 Method

A focused review was carried out through MEDLINE (via PubMed), EMBASE, Google Scholar, and the Cochrane Central Register of Controlled Trials databases, using the following words “geriatric patient”, “frailty”, “comprehensive geriatric assessment”, “surgery”, “emergency”, “futility”, “realistic medicine”.

Papers were selected by a panel of experts and data reported according to the aim of our study.

2.1 The comprehensive geriatric assessment and frailty

The number of patients living with frailty is underestimated. The incidence of frailty in surgical patients differs according to specialty and practice setting, namely elective versus emergent.

A recent meta-analysis reported that after surgery, frail patients are more likely to experience complications (RR 1.48, 95%CI 1.35–1.61; p < 0.001), major complications (RR 2.03, 95%CI 1.26–3.29; p = 0.004), wound complications (RR 1.52, 95%CI 1.47–1.57; p < 0.001), risk of readmission (RR 1.61, 95%CI 1.44–1.80; p < 0.001) and discharge to skilled care (RR 2.15, 95%CI 1.92–2.40; p < 0.001). Furthermore, frail surgical patients are 4 times more likely to die after a surgical procedure [5].

Preoperative frailty evaluation, including cognition and functional status, is a crucial tool in assessing surgical risk and predicting postoperative complications for elderly surgical patients.

Frailty is characterized by a physiological multi-system decline resulting in greater vulnerability to stressors such as surgery, leading to higher rates of adverse postoperative outcomes. Frailty often coexists with cognitive impairment and as such, there is a relationship observed between pre-existing frailty and postoperative delirium. Postoperative delirium itself is associated with high rates of morbidity, prolonged hospital stay and mortality [6, 7].

The Comprehensive Geriatric Assessment (CGA) and optimisation is a multi-dimensional, multi-disciplinary process of care including the assessment of medical, mental, social and functional needs of the elderly people, and the formulation of an integrated and coordinated care plan that provides treatment and long-term follow-up with specific intervention tools in form of exercise regimes or tailored plan of re-adaptation and rehabilitation. The original tailored plan is reassessed at appropriate intervals with the interventions reconsidered accordingly [8].

CGA is considered the gold standard for screening, diagnosing and managing frailty and provides the coordinated work of a multidisciplinary team including geriatricians, geriatric nurses, anesthesiologists, surgeons, physiotherapists, occupational therapists and dietitians [9].

CGA methodology includes a comprehensive history taking and a multidisciplinary guided assessment, culminating in goals for current and future (curative or palliative) management, based on five main age-friendly care principles: [10]

  • What matters most to the patient;

  • Multi-complexity management;

  • Medication management;

  • Mentation;

  • Mobility.

This process is iterative, thus allowing the care plan remains responsive to the patient’s needs.

Different CGA-based models of care have been developed to improve the assessment of elderly surgical patients in a defined clinical pathway.

Several studies evaluated the CGA impact on postoperative outcomes in geriatric patients undergone elective abdominal, vascular, spinal, and orthopaedic surgery [11].

A recent meta-analysis [12], included 2672 patients from 4 RCTs and 7 non-RCTs and reported that there was no significant difference in the incidence of delirium, LOS, 30-day readmission, and 30-day mortality between the intervention and control groups. Further assessment of the studies included in this systematic review reveals that they did not fulfil the core components of CGA and optimisation methodology. For example, the intervention was not timely, did not use objective scores, was not delivered with a multidisciplinary team and employed non-evidence-based optimisation strategies. This reinforces the need to include only studies that show fidelity to the core concept of CGA and optimisation methodology.

According to a Cochrane review [13], CGA implementation is effective in decreasing mortality after hospital admission. Twenty-nine trials recruiting 13,766 participants were analysed and it was reported that CGA increases the likelihood that patients will be alive and in their own homes at 3 to 12 months follow‐up [(RR) 1.06, 95% (CI) 1.01 to 1.10].

CGA perioperative implementation was also found to be cost-effective in comparison to standard preoperative care in elective surgery [14].

An analysis of the National Emergency Laparotomy Audit (NELA) data focused on 93,415 patients older than 65 years old who underwent emergency laparotomy between 2014 and 2017 showed that older patients had higher 30-day (15.3 versus 4.9%, P < 0.001) and 90-day mortality (20.4 versus 7.2%, P < 0.001) rates, longer LOS (median 15.2 versus 11.3 days, P < 0.001) and greater likelihood of discharge to care-home accommodation compared with younger patients (6.7 versus 1.9%, P < 0.001). Over time, a mortality rate reduction was observed in older compared with younger patients, correlated with increased implementation of a geriatrician in postoperative care.

Post-operative geriatrician review was associated with reduced mortality (30-day odds ratio [OR] 0.38, confidence interval [CI] 0.35–0.42, P < 0.001; 90-day OR 0.6, CI 0.56–0.65, P < 0.001) [15].

The benefits of CGA implementation in elective surgery and emergency surgery are evident: a multidisciplinary and tailored preoperative/postoperative assessment of geriatric surgical patients, investigating the presence of chronic comorbidities, multidrug treatment, cognitive impairment and physical immobility can improve postoperative outcomes, decrease mortality and length of hospital stay.

2.2 The management of geriatric surgical patients in the emergency setting

How to best address and monitor frailty preoperatively in the emergency setting is not standardised.

In the acute care setting, delay in management increases the risk of negative outcomes and mortality. In this scenario, the main limits to CGA methodology implementation are the admission of a critically ill patient presenting with advanced surgical disease and signs of hemodynamic instability; the unavailability of a multidisciplinary team including a geriatrician at night; the lack of trained professionals in geriatric medicine and physiology in the emergency department and the necessity of making a prompt diagnosis and treatment to avoid poor outcomes and in-hospital death.

The management of elderly patients with acute abdomen is often challenging due to patients' confusion, dementia, anxiety, delirium and atypical clinical features compared with younger patients that may delay diagnosis and access to the operating room.

The primary evaluation of a geriatric patient should consider altered physiology due to polypharmacy, chronic diseases and less reserve, and supportive care should be tailored with timely intravenous (IV) fluids, correction of electrolyte disturbances, IV antibiotics in case of sepsis, and appropriate analgesia and monitoring [16].

In the emergency setting, it is often challenging to recognize whether the presenting surgical condition represents an end-of-life situation, and consideration of medical ethics, prior quality of life, and patient and family preferences of goals of care must be utilized to help avoid non-beneficial surgery. Deciding not to operate can be a difficult task for an emergency surgeon faced with the pressures of time, and of patient, family, and other health care professionals desires, even when there are low chances of surgical procedure success [17].

According to the principles of realistic medicine, the management of the patient in a critical setting should be evidence-based but also personalised, aimed to reduce harm and waste [18].

Quantitative futility, defined as the scientific assessment of the probability of the failure of treatment, was assessed in the NELA cohort of patients. The timeframe for quantitative futility surgery was defined as mortality occurring within 72 h after emergency laparotomy. Predictors of early post-laparotomy mortality included female sex, increasing age, higher American Soiciety of Anesthiologists (ASA) grade, perioperative hypotension, reduced Glasgow Coma Scale (GCS), the urgency of surgery, signs of cardiac or respiratory failure and frailty, increasing blood lactate and C-reactive protein (CRP) levels, and surgery for ischaemia or perforation [19].

The Acute Care for the Elderly (ACE) model was developed to control preventable functional decline experienced by older patients admitted to acute medical hospital wards, emphasizing a specialized environment, patient-centred care, medical review, and interdisciplinary care. It was associated with fewer falls, less delirium, less functional decline at discharge from baseline 2-week prehospital admission status, shorter LOS, fewer discharges to a nursing home, lower costs and more discharges to home [20].

The Elder-Friendly Approach to the Surgical Environment (EASE) study, a prospective, multicenter, non-randomised, controlled before and after study of 684 patients, including 139 frail patients, was designed to develop and assess clinical outcomes after the adoption of an EASE model. Based on the ACE model, the EASE model includes patient co-location, interdisciplinary team-based care, elderly-friendly evidence-based informed practices, patient-oriented rehabilitation, and early discharge planning. It was reported that EASE model implementation decreases in-hospital major complications or death by 19%, the median LOS by 3 days, and patients requiring an alternative level of care at discharge [21].

According to the Guideline for Preoperative Care for People Living with Frailty Undergoing Elective and Emergency surgery, in the emergency setting, even when there is no preoperative frailty team with expertise in CGA evaluation available, it is crucial to: [22]

  • Obtain a thorough history of the patient, including comorbidities, living arrangements, level of mobility and any aids used, functional status, mood and mental status, as soon as possible;

  • Optimise the management of physiological derangements and pain according to age and poly-pharmacy;

  • Share decision-making and treatment escalation planning with the patient, relatives and carers, using the appropriate legal framework;

  • Assess frailty with the Rockwood clinical frailty scale;

  • Screen for delirium using a validated tool, and manage and prevent it according to available guidelines.

Patients over 65 years of age should be assessed by a geriatrician pre-operatively and evidence-based elder-friendly practices should be utilized. If a geriatrician is not available in the pre-operative period, patients should be referred for postoperative follow-up [23].

A qualitative cross-sectional survey of emergency and acute care surgeons, all members of the World Society of Emergency Surgery, demonstrated a lack of knowledge about frailty assessment, available validated tools and about how to implement a CGA-based model for the care of elderly surgical patients in the emergency setting [24].

The implementation of CGA models in the emergency setting may assess promptly patients living with frailty and manage it in a multidisciplinary approach with an advanced plan of care, decreasing LOS and mortality of elderly patients after an emergency surgical procedure.

In practice, this organisational model is not employed as expected because of the lack of shared protocols, skilled and dedicated staff and funds.

Available data about the benefits of CGA models mainly referred to elective surgical procedures. Further (observational and prospective) studies are required to investigate the benefits of CGA models in the emergency setting as well as the cost/effectiveness of this approach.

Often elderly patients admitted to ED present with an advanced surgical disease that needs to be treated rapidly: in a short time, the emergency surgeon needs to be supported by clear evidence-based and focused guidelines in decision-making to take care of this group of patients, reducing mortality, futility and respecting patient and family desires.

3 Conclusions

Geriatric surgical patients require specialized evaluation and management.

Assessing frailty and identifying vulnerable patients without evident disability utilizing a multidisciplinary approach within a comprehensive geriatric assessment is crucial to improve outcomes and to decrease postoperative complications, risk of re-admission and risk of death.

The implementation of CGA-based models is the gold standard for properly managing elderly and frail surgical patients in the emergency setting, but it is still lacking.

When a preoperative frailty team with expertise in comprehensive geriatric assessment is not available, the emergency surgeon and the anaesthesiologist should follow the available guidelines based on the main principles of CGA.

A geriatrician should be involved in the postoperative care of a geriatric surgical patient submitted to emergency surgical procedures as soon as possible.

Educational programs and specific guidelines focused on the acute care setting and surgical geriatric patients have to be developed in a multidisciplinary consensus, based on CGA main principles.