Pre- and intra-operative variables associated with surgical complications in elderly patients with gynecologic cancer: the clinical value of comprehensive geriatric assessment

Incidence of postoperative delirium in older adults undergoing surgical procedures: A systematic literature review and meta-analysis

BACKGROUND

With the increase in life expectancy around the globe, the incidence of postoperative delirium (POD) among older people (≥65 years) is growing. Previous studies showed a wide variation in the incidence of POD, from 4% to 53%, with a lack of specific evidence about the incidence of POD by specific surgery type among older people. The aim of this systematic review and meta-analysis was to determine the incidence of POD by surgery type within populations 65 years and over.

METHODS

Databases including PubMed, Cochrane library, Embase, and CINAHL were searched until October 2020. Due to the relatively higher number of meta-analyses undertaken in this area of research, a streamlined systematic meta-analysis was proposed.

RESULTS

A total of 28 meta-analyses (comprising 284 individual studies) were reviewed. Data from relevant individual studies (n = 90) were extracted and included in the current study. Studies were grouped into eight surgery types and the incidence of POD for orthopedic, vascular, spinal, cardiac, colorectal, abdominal, urologic, and mixed surgeries was 20%, 14%, 13%, 32%, 14%, 30%, 10%, and 26%, respectively. POD detection instruments were different across the studies, with Confusion Assessment Method (CAM & CAM-ICU) being the most frequently adopted.

LINKING EVIDENCE TO ACTION

This study showed that POD incidence in older people undergoing surgery varied widely across surgery type. The more complex surgeries like cardiac and abdominal surgeries were associated with a higher risk of POD. This highlights the need to include the level of surgery complexity as a risk factor in preoperative assessments.

Low surgical Apgar score in older patients with gynecological cancer is a risk factor for postoperative complications and 1-year mortality: A multicenter retrospective cohort study

Little is known about preoperative and intraoperative risk factors for postoperative complications in older patients with gynecological cancer. The present retrospective multi-institutional study included 173 older patients with primary gynecological cancer between January 2015 and December 2015 at four institutions. The cancer stage, medical history, Charlson comorbidity score, body mass index (BMI), subjective global assessment, fall risk assessment, American Society of Anesthesiologists physical status classification, surgical Apgar score (SAS), type of surgery and 1-year postoperative mortality were investigated. Multivariate analysis revealed that BMI and mental illness were risk factors for postoperative complications, and low SAS increased the risk for both postoperative complications and mortality within 1 year. Receiver operating characteristic curve analysis of postoperative complications in terms of SAS revealed that low SAS predicted high risk with a sensitivity of 85.7% and a specificity of 46.5%, and high SAS predicted low risk with a sensitivity of 21.4% and a specificity of 95%. The present results suggest that SAS, which is an intraoperative assessment, may be useful for assessing the risks of postoperative complications and mortality within 1 year. It is important to develop a preoperative assessment tool that can predict a low SAS score and reflect the postoperative prognosis of older patients with gynecological cancer.

Nutritional status and interventions for patients with cancer - A systematic review

BACKGROUND

Malnourishment is commonly seen in ageing, cancer and many chronic conditions, and is associated with poorer prognosis.

AIM

We set out to collect all currently available evidence on the association between nutritional status assessed with a validated screening tool and prognosis or course of treatment in older patients with cancer, and on the benefit of nutritional interventions in improving these outcomes.

METHODS

A systematic search in MEDLINE and EMBASE.

RESULTS

We included 71 studies on the association between nutritional status and outcome in (older) patients with cancer and 17 studies on the benefit of nutritional interventions in improving outcomes in this patient population. There is a significant association between nutritional status and increased intermediate- and long-term mortality (hazard ratio 1.87 (95% confidence interval 1.62-2.17). Those with poorer nutritional status were less likely to complete oncologic treatment according to plan and had higher health care consumption. Benefit of dietary interventions was limited although dietary counselling may lead to improved quality of life while nutritional support may lead to a decrease in post-operative complication rates.

CONCLUSION

Nutritional status is associated with poorer survival, decreased treatment completion and higher health care consumption and nutritional interventions are only able to negate these negatives outcome to a very limited degree.

How do doctors choose treatment for older gynecological cancer patients? A Japanese Gynecologic Oncology Group survey of gynecologic oncologists

BACKGROUND

The proportion of elderly Japanese people (age ≥ 65 years) is currently 27.7%, and the average life span of women is 87.14 years, both of which are unprecedented. In gynecologic cancer, evidence of treatment for the elderly is scarce, and treatment policies are determined by each facility. The aim of the present study was to investigate the status of treatment policies for elderly patients with gynecologic cancer.

METHODS

A web-based questionnaire regarding how treatment strategies are currently determined for elderly patients with gynecologic cancer was conducted on gynecologic oncologists to develop a tool for the objective evaluation of treatment policy decisions for elderly patients.

RESULTS

The responses showed that 48% of the gynecologic oncologists were aware of comprehensive geriatric assessment (CGA), but only 6% had actually conducted CGA. Age, comorbidities, performance status, and pretreatment evaluations were regarded as important in determining the treatment strategy. Invasive treatments such as radical hysterectomy and para-aortic lymph node dissection tended to have age limits.

CONCLUSIONS

These findings suggest that awareness of CGA is low in Japan, and that elderly people may not be given standard therapy, which highlights the importance of building on these findings by gathering further evidence and developing a new tool for predicting treatment outcomes for elderly patients with gynecologic cancer.

A novel geriatric assessment tool that predicts postoperative complications in older adults with cancer

INTRODUCTION

Comprehensive geriatric assessment prior to oncologic surgery can help predict surgical outcomes. We tested whether an abbreviated geriatric assessment tool, the Vulnerable Elderly Surgical Pathways and outcomes Assessment (VESPA), would predict post-operative complications among older adults undergoing oncologic surgery.

METHOD

From 2008 to 2011, geriatric assessments were completed using the VESPA tool for patients age ≥ 70 seen in a pre-operative clinic. The VESPA assessed functional status, mood, cognition, and mobility, and can be completed in <10 min. We selected the subset of patients who underwent oncologic surgery and evaluated the VESPA's ability to predict post-operative surgical complications, geriatric complications (e.g., delirium), length of stay, and geriatric post-discharge needs (e.g., new functional dependence).

RESULTS

A total of 476 patients who underwent oncologic surgery received the assessment using VESPA. Compared to patients with low VESPA scores (<9), patients with high VESPA scores (≥9) had longer length of stay (mean 6.6 vs. 2.0 days; p < .001), more geriatric complications (39.5% vs. 5.7%; p < .001), more surgical complications (29.5% vs. 11.8%; p < .001), and more likely to have post discharge needs (76.0% vs. 31.7%; p < .001). Using logistic regression, each additional point on the VESPA scale was also associated with increased probability of geriatric complications (OR = 1.3; 95% CI = 1.2-1.4), surgical complications (OR = 1.2; 95% CI = 1.1-1.2), and geriatric post-discharge needs (OR = 1.3; 95% CI = 1.2-1.3).

CONCLUSION

The VESPA identifies older patients with cancer who are at risk for postoperative surgical and geriatric complications as well as functional needs at hospital discharge.

Predictive value of each geriatric assessment domain for older patients with cancer: A systematic review

BACKGROUND

A geriatric assessment (GA) is increasingly used to help guide treatment decisions in older patients with cancer. However, there is no consensus regarding which domains should be included in the GA. In addition, the field of geriatric oncology moves very fast and as a result many new studies have been published since the last review in 2015. Therefore, the objective of this systematic review is to evaluate which domains of the GA could predict patient-related treatment outcomes of older patients with cancer and thereby should be included in a GA.

METHODS

A systematic literature search was performed for publications in English or Dutch between September 2006 and July 2017 addressing the association between individual domains of the GA and mortality, postoperative complications, or systemic treatment-related outcomes in older patients with cancer.

RESULTS

Eight different domains were evaluated in 46 publications, namely functional status, nutritional status, cognition, mood, physical function, fatigue, social support, and falls. All eight domains were predictive for at least one of the investigated outcomes but the results were quite variable across studies. Physical function and nutritional status were the domains most often associated with mortality and systemic treatment-related outcomes, and the domain physical function was most often associated with postoperative complications.

CONCLUSION

Overall, this review demonstrates that the GA should minimally consist of physical function and nutritional status, when the aim is to predict patients-related outcomes of older patients with cancer, although the results are quite heterogeneous. For the other domains, the findings are too inconsistent to draw conclusions about their overall predictive ability.

Identifying Older Adults at Risk of Delirium Following Elective Surgery: A Systematic Review and Meta-Analysis

BACKGROUND

Postoperative delirium is a common preventable complication experienced by older adults undergoing elective surgery. In this systematic review and meta-analysis, we identified prognostic factors associated with the risk of postoperative delirium among older adults undergoing elective surgery.

METHODS

Medline, EMBASE, CINAHL, Cochrane Central Register of Controlled Trials, and AgeLine were searched for articles published between inception and April 21, 2016. A total of 5692 titles and abstracts were screened in duplicate for possible inclusion. Studies using any method for diagnosing delirium were eligible. Two reviewers independently completed all data extraction and quality assessments using the Cochrane Risk-of-Bias Tool for randomized controlled trials (RCTs) and the Newcastle-Ottawa Scale (NOS) for cohort studies. Random effects meta-analysis models were used to derive pooled effect estimates.

RESULTS

Forty-one studies (9384 patients) reported delirium-related prognostic factors. Among our included studies, the pooled incidence of postoperative delirium was 18.4% (95% confidence interval [CI] 14.3-23.3%, number needed to follow [NNF] = 6). Geriatric syndromes were important predictors of delirium, namely history of delirium (odds ratio [OR] 6.4, 95% CI 2.2-17.9), frailty (OR 4.1, 95% CI 1.4-11.7), cognitive impairment (OR 2.7, 95% CI 1.9-3.8), impairment in activities of daily living (ADLs; OR 2.1, 95% CI 1.6-2.6), and impairment in instrumental activities of daily living (IADLs; OR 1.9, 95% CI 1.3-2.8). Potentially modifiable prognostic factors such as psychotropic medication use (OR 2.3, 95% CI 1.4-3.6) and smoking status (OR 1.8 95% CI 1.3-2.4) were also identified. Caregiver support was associated with lower odds of postoperative delirium (OR 0.69, 95% CI 0.52-0.91).

DISCUSSION

Though caution must be used in interpreting meta-analyses of non-randomized studies due to the potential influence of unmeasured confounding, we identified potentially modifiable prognostic factors including frailty and psychotropic medication use that should be targeted to optimize care.

Patterns of Care and Outcome of Elderly Women Diagnosed With Cervical Cancer in the Developing World

Scarce data exist about the impact of age in cervical cancer (CC) patients in the developing world. The objective of the current study was to examine the patterns of care and outcome of elderly patients treated in a developing country. Medical records of patients treated from 2006-2009 at the Brazilian National Cancer Institute were reviewed. Patients were divided between women 70 years or older and women younger than 70 years. The χ tests were used and odds ratios were calculated. Survival was examined using the Kaplan-Meier method. Single and multivariate Cox proportional hazards modeling were used. A total of 1482 patients were analyzed: 1339 patients younger than 70 years and 143 patients 70 years or older. A marked difference in treatment was noted, even after stratifying by disease stage. Only 21% of the older patients underwent surgical treatment compared with 27.6% of the younger. After adjusting for confounding variables, the hazard ratio for death from CC in the elderly was 1.05 (95% confidence interval, 0.81-1.36; P = 0.11). These results corroborate previous data from developed countries: elderly patients have more advanced disease at diagnosis, and age is an important factor in the allocation of treatment for patients with CC. Worse outcome seemed to be mainly the result of more advanced stage and treatment allocation rather than age itself.

Identifying older adults at risk of harm following elective surgery: a systematic review and meta-analysis

BACKGROUND

Elective surgeries can be associated with significant harm to older adults. The present study aimed to identify the prognostic factors associated with the development of postoperative complications among older adults undergoing elective surgery.

METHODS

Medline, EMBASE, CINAHL, Cochrane Central Register of Controlled Trials, and AgeLine were searched for articles published between inception and April 21, 2016. Prospective studies reporting prognostic factors associated with postoperative complications (composite outcome of medical and surgical complications), functional decline, mortality, post-hospitalization discharge destination, and prolonged hospitalization among older adults undergoing elective surgery were included. Study characteristics and prognostic factors associated with the outcomes of interest were extracted independently by two reviewers. Random effects meta-analysis models were used to derive pooled effect estimates for prognostic factors and incidences of adverse outcomes.

RESULTS

Of the 5692 titles and abstracts that were screened for inclusion, 44 studies (12,281 patients) reported on the following adverse postoperative outcomes: postoperative complications (n =28), postoperative mortality (n = 11), length of hospitalization (n = 21), functional decline (n = 6), and destination at discharge from hospital (n = 13). The pooled incidence of postoperative complications was 25.17% (95% confidence interval (CI) 18.03-33.98%, number needed to follow = 4). The geriatric syndromes of frailty (odds ratio (OR) 2.16, 95% CI 1.29-3.62) and cognitive impairment (OR 2.01, 95% CI 1.44-2.81) were associated with developing postoperative complications; however, there was no association with traditionally assessed prognostic factors such as age (OR 1.07, 95% CI 1.00-1.14) or American Society of Anesthesiologists status (OR 2.62, 95% CI 0.78-8.79). Besides frailty, other potentially modifiable prognostic factors, including depressive symptoms (OR 1.77, 95% CI 1.22-2.56) and smoking (OR 2.43, 95% CI 1.32-4.46), were also associated with developing postoperative complications.

CONCLUSION

Geriatric syndromes are important prognostic factors for postoperative complications. We identified potentially modifiable prognostic factors (e.g., frailty, depressive symptoms, and smoking) associated with developing postoperative complications that can be targeted preoperatively to optimize care.