Introduction
The proportion of older people undergoing surgery is increasing faster
than the rate of population ageing1-2. This is
representative of advances in surgical and anaesthetic techniques.
However, it is well established that this patient group are more
susceptible to adverse outcomes2-3. Complications in
the perioperative period are typically medical and are closely linked to
geriatric syndromes including frailty, sarcopenia and cognitive
deficits. Collaborative, multidisciplinary models of care including
proactive identification of the most pertinent risk factors may allow
targeted intervention to minimise perioperative morbidity and mortality.
Older people undergoing vascular surgery are a particularly vulnerable,
high-risk group. This frequently reflects the presence of multiple
comorbidities including hypertension, diabetes, ischaemic heart disease
and additional lifestyle risk factors such as smoking. In particular,
the incidence and prevalence of peripheral vascular disease increases
with age; complex bypass surgery therefore forms a significant
proportion of work in arterial centres4.
Decision-making with regards to patient selection for surgical
intervention is challenging. Advances in endovascular surgery in the
modern era have rendered some types of surgery less physiologically
challenging. Societal attitudes and expectations have also evolved.
Determining which patients are likely to benefit most from intervention,
and in whom the elevated risk profile is acceptable is complex.
Decisions have historically been made on the basis of age alone as a
proxy for frailty and comorbidity5. Despite an
elevated risk profile, older patients can have good outcomes from
vascular surgery. However, limited data have been reported describing
outcomes for matched patients not undergoing surgery. The natural
history of vascular disease at advanced age is therefore somewhat less
clear6. Recognition of patients nearing the end of
their life and utilising effective palliative care is important in these
scenarios, although in many cases surgery has an important palliative
symptomatic role7-8. Nonetheless, the postoperative
period is often protracted in older patients and syndromes such as
delirium commonly lead to functional decline and increased dependency.
The provision of proactive multidisciplinary team working ensures that
surgical intervention can be provided to those for whom quality of life
and independence can be restored, whilst balancing the risks and
benefits of surgery and ensuring an opportunity for risk factor
modification and optimisation.
Perioperative Comprehensive Geriatric Assessment (CGA) utilised in the
context of older patients undergoing vascular surgery has been shown to
reduce length of stay (LOS)9-10. Replicating aspects
of the CGA service evaluated in the randomised control trial conducted
(RCT) by Partridge et al, we aimed to assess the impact of daily
provision of senior-led medical liaison provided for patients aged 65
years and older admitted to our regional tertiary vascular centre. Prior
to the introduction of this service development, ad hoc reactive
review was provided on demand by the duty medical registrar. Our primary
outcome measure was reduction in LOS. Our secondary outcome measure was
reduction in the number of postoperative complications. We also aimed to
determine the impact of age on our primary and secondary outcome
measures.