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Abstract

Background: As the number of elderly undergoing surgical procedures increases with our aging population, the risk of adverse surgical outcomes also increases with reduced physiological reserve, multiple comorbidities, frailty and functional disability. Objectives: As Comprehensive Geriatric Assessment (CGA) is increasingly being integrated as part of good surgical care for older patients owing to better patient outcomes, this review aims to provide an overview of the current evidence regarding its benefit on geriatric surgical patients among different surgical specialties, with additional focus on patients with frailty and/ or sarcopenia. Methods: Using chosen keywords, searches were conducted using Pubmed, Google scholar and Cochrane Library. Inclusion criteria were surgery of various specialties with the exception of orthopaedic surgery, and studies published in English only. Exclusion criteria were orthopaedic surgery, and non-English articles. Prospective, retrospective, randomized controlled and cohort studies were considered given the limited number of studies published thus far. Relevant journal articles referenced in the chosen articles were also referenced in writing this narrative review. Only the most relevant articles from 2010 onwards were used as earlier ones were outdated. Results & Conclusion: There is evidence of good outcomes after performing CGA and screening for frailty and sarcopenia in elective surgical patients while evidence on the usage of CGA for emergency surgical patients perioperatively is limited. Future studies could focus on the challenges to integrating CGA (including screening for frailty and sarcopenia) as part of routine surgical care and healthcare outcomes.

Keywords

Comprehensive geriatric assessment frailty sarcopenia surgical elderly

Introduction

Singapore is currently transiting from being an aged (defined by the United Nations as a country where more than 14% of the population is aged 65 and above) to becoming a superaged society (where more than 20% of the population is aged 65 and above)) by 2030.¹ Across ageing societies, the number of older adults undergoing surgery has increased significantly.² A retrospective cohort study conducted in a Singapore tertiary hospital showed a nearly two-fold increase in the number of elderly undergoing surgical procedures under general anaesthesia from 1129 cases in 2008 to 2118 cases in 2019 across a 12-year period.³

Frail older adults undergoing surgery face a multitude of challenges. Reduced physiological reserve, multiple comorbidities and functional disability result in an increased risk of adverse surgical outcomes such as postoperative complications, longer hospitalization, functional decline, disability and mortality. In addition, the presence of Geriatric Syndromes (urinary incontinence, dementia, delirium, falls, frailty, hearing impairment, visual impairment, sarcopenia, malnutrition, immobility, gait disturbance, and pressure ulcers)⁴ compounds the risk of such adverse outcomes.⁵

Comprehensive Geriatric Assessment (CGA), the cornerstone of Geriatric Medicine practice, is defined as a “multidimensional interdisciplinary diagnostic process focused on determining a frail elderly person’s medical, psychological and functional capability in order to develop a coordinated and integrated plan for treatment and long-term follow-up”.⁶ This entails assessment of the following domains: (a) premorbid functional status, (b) mobility, (c) frailty, (d) cognition and psychological health, (e) socio-environmental factors, (f) nutrition, medications and comorbidities, after which a feasible action plan is formulated.

Aim

Currently, while there is much literature on the effect of CGA on healthcare outcomes of elderly hip fracture patients, there is less evidence on the utility of CGA in other surgical fields. As the types of general surgery in elderly patients are heterogenous and there is a knowledge gap of the role of CGA in such patients, we decided that conducting a narrative review would be most appropriate in examining the existing literature on this topic. The diversity in diagnoses, surgical procedures and models of care precludes meta-analysis. Of the various geriatric syndromes, we decided to focus on frailty and sarcopenia as these are the modern geriatric syndromes with more recent evidence showing the association between these two syndromes and negative health-related outcomes in elderly surgical patients. Hence our research aim was to examine the role of CGA in elderly patients undergoing surgery in general, with additional focus on frailty and sarcopenia.

Method

A literature search from 1960 to 2023 was conducted using keywords “Comprehensive Geriatric Assessment”, “Frailty”, “Sarcopenia”, “Surgical”, and “Elderly” on Pubmed, Google Scholar, and Cochrane Library. Inclusion criteria were surgery of various specialties with the exception of orthopaedic surgery, and studies published in English only. Exclusion criteria were orthopaedic surgery, and non-English articles. Prospective, retrospective, randomized controlled and cohort studies were considered given the limited number of studies published thus far. Relevant journal articles referenced in the chosen articles were also referenced in writing this narrative review. Only the most relevant articles from 2010 onwards were used as earlier ones were outdated. The selected articles were reviewed by the authors and deemed to be appropriate to be included for this narrative review.

CGA in surgery

The goals of CGA are to: 1) improve diagnostic accuracy, 2) guide the selection of interventions to restore or preserve health, 3) recommend an optimal environment for care, 4) predict outcomes, and 5) monitor clinical change over time.⁷ In recent years, CGA has increasingly become integrated as part of good surgical care for older patients resulting in good patient outcomes.

CGA can be performed preoperatively in various settings: surgical clinics, preoperative anesthetic assessment clinics, or the acute wards. There is strong evidence that CGA improves postoperative outcomes among elective surgical patients. A systematic review in 2013 showed preoperative CGA was more likely to have a positive impact on postoperative outcomes in older adults undergoing elective surgery.⁸

A prospective study on elderly undergoing intra-abdominal oncological surgery showed that preoperative clinical and geriatric assessment tools could help predict the need for discharge to a nursing facility or increased length of stay⁹ A randomized controlled trial in vascular surgery showed preoperative CGA assessment was associated with a shorter length of hospitalization.¹⁰ In this study, those who underwent assessment and optimization had a lower incidence of complications and were less likely to be discharged with a higher level of dependency.

On the other hand, a retrospective cohort and match-control study on elective elderly colorectal cancer surgical patients showed that preoperative CGA and intervention on higher risk patients did not demonstrate significant difference in mortality and postoperative delirium as compared to matched controls.¹¹

A prospective study on CGA for acutely admitted general surgery patients aged 70 and above demonstrated that proactive geriatrician’s input using CGA (either pre- or post-surgery) helped in identifying new medical diagnoses, geriatric syndromes, medication revisions and referrals to allied healthcare professionals.¹² There was also a statistically non-significant reduction in the mean length of stay of 0.55 bed days per patient.

An In-reach service for older emergency general surgical patients with proactive input by geriatricians including early CGA reported reduced adverse drug events and polypharmacy, early identification and treatment of complications, streamlined discharge planning, and optimization of the use of rehabilitative resources resulting in reduction in hospital length of stay, lower readmission rates and improvement in diagnostic coding of conditions.¹³

In term of postoperative outcomes, a best practice guideline published jointly by American College of Surgeons National Surgical Quality Improvement Program and American Geriatrics Society¹⁴ recommended geriatric assessment to address postoperative complications while a Cochrane review on the usage of CGA on surgical inpatients demonstrated reduction in mortality, discharge to an increased level of care, and financial costs as well as slightly shortened length of stay.¹⁵

Frailty

Definition

Frailty is conceptually defined as a clinically recognizable state in which the ability of older people to cope with every day or acute stressors is compromised by an increased vulnerability brought by age-associated declines in physiological reserve and function across multiple organ systems.¹⁶ It is a Geriatric Syndrome that increases in prevalence with age and has gained importance as an independent risk factor in determining fitness for surgery and surgical outcomes.

Assessment of frailty

Frailty measurement can be based on either the Phenotype model, the Cumulative Deficit model, or Mixed Physical and Psychosocial model.^17–19 Examples of Frailty assessment tools include Frailty Index (FI), Clinical Frailty Scale, simple FRAIL questionnaire, PRISMA-7 questionnaire, Time Up and Go Test (TUG), and Gérontopôle frailty screening tool (GFST). The Clinical Frailty Scale (CFS), initially introduced as a means of summarizing a multidimensional assessment in an epidemiological setting in the second examination of the Canadian Study of Health and Aging, has been widely used as a judgement-based tool to screen for frailty.¹⁸

Frailty assessment can be incorporated into CGA. However, the impact of frailty as a determinant of CGA outcome has not been widely studied.²⁰ One systematic review concluded that ward based CGA for frail older patient may result in reduced institutionalization rates.²¹

Association of frailty with outcomes in surgery

A review of studies on older elective cardiac and non-cardiac surgical patients cited the prevalence rate of frailty between 41.8 and 50.3%.²² It has been associated with post-surgical morbidity and mortality. A systematic review of studies on various surgical subspecialties, both elective and acute surgery, revealed that frailty in old-old (aged 75-85) and oldest old (aged above 85) surgical patients predicted postoperative mortality, complications, as well as prolonged length of stay.²³ A population-based cohort study showed frailty was associated with increased rates of mortality, institutional discharge, and resource use after emergency general surgery.²⁴ Results from the UK Observational Emergency Laparotomy and Frailty Study also demonstrated frailty was associated with greater risks of postoperative mortality and morbidity that was independent of age.²⁵ Another retrospective cohort study of 417,840 elective surgical patients showed frailty was associated with increased risk of complications as well as unplanned readmissions.²⁶

The importance of screening for frailty in preoperative care is increasingly being recognized. Screening surgical patients for frailty helps with risk stratification as well as identifying modifiable risk factors for optimization. In 2013, the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP), in collaboration with the American Geriatrics Society (AGS), issued best practice guidelines recommending the incorporation of preoperative frailty assessment into clinical practice.¹⁴ Similarly, Guidelines for Perioperative Care for People Living with Frailty Undergoing Elective and Emergency Surgery developed by Center for Perioperative Care and British Geriatric Society in 2021 also recommended screening for frailty status preoperatively.²⁷ The latest Ninth National Emergency Laparotomy Audit (NELA) Patient Report indicated frailty nearly doubled mortality risk of patients aged 65 and above (11 vs 5.9%).²⁸ A review by a geriatrician was associated with a reduction in mortality (5.9 vs 7.2% amongst non-frail patients, and 11.1 vs 15.7% among frail patients). As such, a formal assessment of frailty for all patients aged 65 and above has been recommended.

A 2014 British Geriatric Society (BGS) Best Practice Guidelines for frailty management recommended CGA as the gold standard for the care of people with frailty.²⁹ A Norwegian prospective study on elective colorectal cancer patients aged 70 and above used preoperative CGA to categorize patients into fit, intermediate and frail.³⁰ It demonstrated that frail patients have a significantly increased risk of severe complications postoperatively. Another prospective cohort study on assessing frailty using FI-CGA on elderly patients aged ≥70 undergoing intermediate- to high-risk surgery showed greater frailty was associated with increased 12-month mortality and 12-month hospital readmissions.³¹ However, it failed to demonstrate an association with perioperative or postoperative complications at 30 days, readmission within 30 days, length of stay or new discharge to residential aged care.

In the UK Observational Emergency Laparotomy and Frailty (ELF) Study, an observational multicenter study, 20% of older adults undergoing emergency surgery were frail (CFS score ≥5).²⁵ The presence of frailty was associated with increased risk of 90-day mortality and postoperative complications, increased length of postoperative hospital stay and intensive care unit (ICU) stay. In another population-based cohort study in Canada, frailty was associated with increased rate of mortality, institutional discharge, and resource use after emergency general surgery.²⁴

A prospective observational cohort study on frailty assessment using CFS in emergency department showed severe frailty was an independent risk factor for in-hospital death for patients aged 80 and above undergoing major surgical procedures.³²

Sarcopenia

Definition of sarcopenia

Based on the Asian Working Group for Sarcopenia 2019 (AWGS 2019) Consensus Update, sarcopenia is defined as the age-associated progressive and generalized skeletal muscle disorder that involves loss of muscle plus loss of muscle strength and/or reduced physical performance.³³

Sarcopenia in surgery

Sarcopenia has been identified as an independent risk factor for postoperative severe complications of Clavien-Dindo classification grade III or higher after radical gastrectomy for gastric cancer in a cohort study.³⁴ Incidence of postoperative complications was significantly higher in radical gastrectomy patients with sarcopenia than in those without in another prospective study (21.1% vs 7.3%).³⁵ In another retrospective analysis study, preoperative sarcopenia was associated with poor overall postoperative survival among pancreatic cancer patients.³⁶ A review article also showed sarcopenia was associated with reduced survival and increased postoperative complications among older patients of gastric cancer.³⁷ For colorectal cancer patients who underwent radical surgery, sarcopenia was an independent risk factor for postoperative complications and poor disease-free survival in a retrospective study.³⁸ A systematic review and meta-analysis on the impact of sarcopenia on outcomes in surgical patients showed it was associated with greater mortality, complication occurrence, length of hospital stay, and lower rates of discharge to home.³⁹

Assessment of sarcopenia

Assessment of sarcopenia involves 3 aspects: (a) muscle mass, (b) muscle strength, and (c) physical performance.

Muscle mass measurement

Modalities used to measure muscle mass include magnetic resonance imaging (MRI), computed tomography (CT), dual-energy X-ray absorptiometry (DXA), and Bioelectrical Impedance Analysis (BIA). Of these, DXA and BIA are the most commonly used modalities in Asia. While DXA is the gold standard of measurement, AWGS 2019 has recommended the use of either DXA or BIA, both height adjusted, for measuring muscle mass in the diagnosis of sarcopenia. However, due to cost and logistical concerns of DXA, BIA has been perceived to be the more practical modality.

Muscle strength

AWGS 2019 recommends the use of handgrip strength to measure skeletal muscle strength. The two most commonly used devices to measure muscle strength are the Smedley (spring-type) and Jamar (hydraulic type) Dynamometers. While there are differences in the positions of measurement (e.g.standing vs sitting position), AWGS 2019 has recommended the standing position with full elbow extension for the Smedley dynamometer and sitting position with 90° elbow flexion for the Jamar dynamometer. For older persons who have difficulties standing, sitting position is permitted. The handgrip strength measurement protocol recommended by AWGS 2019 is to take the maximum reading of at least 2 trials using either both hands or the dominant hand in a maximum-effort isometric contraction, rather than using a fixed acquisition time.

Physical performance

For physical performance, gait speed, TUG test, 6-min Walk Test, 400 m Walk Test, Stair Climb Test, 5-time repeated chair stand, Balance Test or even Short Physical Performance Battery have been used, of which gait speed is most often assessed. Based on AWGS 2019 guideline, the 5-time repeated chair stand is recommended. However, physical performance assessment on acute surgical patients may prove to be difficult if not impossible in patients with acute abdomen, lower limb injuries or hemodynamic instability. A SARC-F self-reported questionnaire for rapid screening was devised to obviate the need for physical performance measurement.⁴⁰ This includes components of Strength, Assistance in walking, Rise from a chair, Climb stairs, and Falls. It has been validated and demonstrated to have high specificity (above 90%) among older adults in both hospital⁴¹ as well as community settings.⁴² Another screening tool using a combination of low muscle strength, malnutrition/ risk of malnutrition, and/or abnormal physical performance was developed and achieved sensitivity, specificity, and accuracy of above 78% among surgical cancer patients even without muscle mass measurement.⁴³

Screening for sarcopenia

A prospective cohort study was conducted on gastric cancer patients undergoing gastrectomy to examine the predictive values of 5 sarcopenia screening tools.⁴⁴ Among them, it showed SARC-CalF, a combination of SARC-F and calf circumference, had better predictive values on clinical outcomes compared to other screening tools(including SARC-F alone).

Outcomes of sarcopenia screening in surgery

Sarcopenia was an independent predictor for postoperative complications, prolonged postoperative hospital stay, increased hospitalization expenditures, and 3-month hospital readmissions. Another retrospective cohort study using preoperative computed tomography skeletal muscle area measurement as part of sarcopenia assessment on older adults who underwent surgical aortic valve replacement demonstrated sarcopenia was associated with higher 30-day mortality, 30-day in-hospital events, and 1-year mortality⁴⁵.

Integrating CGA as part of surgical management

Integrating CGA as part of the management of surgically operated patients can done in the elective or acute setting.

Elective setting

The Enhanced Recovery After Surgery (ERAS) is an evidence-based, multimodal standardized perioperative care pathway designed to minimize the stress response to surgery, promote organ function and subsequently improve patient outcome and recovery for patients undergoing major surgery⁴⁶ A single-center observational study on elderly colonic cancer surgery patients showed the combination of ERAS protocols, geriatric assessment and support reduced the overall morbidity rate and improved 12-month oncologic outcomes.⁴⁷

Recommendations from the ERAS include preoperative geriatric assessment.⁴⁸ The American College of Surgeons also recommends Geriatric Vulnerability Screens be conducted preoperatively, followed by optimization of preoperative geriatric-specific risk factors, and standardized postoperative care with special attention to address specific complications pertinent to the geriatric age group, namely delirium, mobility and function, and nutrition and hydration.⁴⁹ Comprehensive Geriatric Assessment should be conducted preoperatively so that optimization of risk factors may be performed to improve outcome.

A systematic review of 16 studies on Enhanced Recovery Programs for colorectal surgery demonstrated that perioperative pathways for older people reduce the rate of complications and hence the duration of hospitalization as compared to traditional management.⁵⁰

Acute emergency setting

As a result of its success in improving patient outcomes and cost saving within elective surgery, ERAS has been adopted for use in geriatric emergency surgery. In a systemic review on geriatric emergency patients, postoperative complication rates and length of stay were reduced in patients receiving ERAS as compared to conventional care.⁵¹ The latest ERAS Society guidelines for emergency laparotomy recommended all elderly patients to be assessed for frailty, cognitive function and to receive delirium screening.⁴⁸ They should also be assessed by geriatricians perioperatively (preferably preoperative) and evidence-based elder-friendly practices should be used.

The Elder-Friendly Approaches to the Surgical Environment-Bedside reconditioning for Functional ImprovemenTs (EASE-BE FIT) was a reconditioning program for elder abdominal surgery patients.⁵² The interventions include co-locating older patients on a single unit, interdisciplinary care delivery involving geriatric specialists, rehabilitation providers, pharmacists, dieticians and social workers, implementation of evidence-informed practices, reconditioning program and transition optimization. It was adopted in an emergency surgical setting. While this was a multimodal bundled intervention including early geriatric assessment team involvement, results suggested there was a reduction in major complications or death, decreased hospital stays, and reduced number of patients being discharged to a facility providing a higher level of care.

Other factors to consider

Timing

Unstable acute surgical patients and those with life-threatening conditions requiring urgent surgery are likely to be excluded from preoperative CGA due to the prioritization of care needs. However, they would likely still benefit from postoperative CGA. For elective surgical patients, CGA with frailty and sarcopenia screening can be incorporated into the preoperative assessment. Artificial Intelligence (AI) assisted tools or apps that are embedded within the electronic medical system can be considered to better prognosticate post-surgical recovery and functional outcome.⁵³

Manpower

Conducting CGA requires manpower which is often the rate-limiting factor. Training of junior team doctors and nurse clinicians would help ease the process of CGA in the surgical ward.

Funding

Funding mechanisms that incentivize the clinicians to perform CGA and screen for frailty and sarcopenia include integrated care pathways, bundled care and value-added care. Funding for research to evaluate the outcomes of these pathways should be encouraged. A rapid research review on integrated care pathways showed reduced length of hospitalization, reduced healthcare cost, increased efficiency in operation theatre usage, reduced ICU admission, as well as potential reduction in nursing workload in some instances, compared to conventional care.⁵⁴

Research

Currently, there is a dearth of data showing positive outcomes of conducting CGA in surgical patients especially in the local setting. The establishment of a database of CGA in surgical patients with longitudinal follow-up and assessments would help advance research in this area significantly.

Models of care

The current care model for collaboration between the surgical teams and the geriatricians for hospitalized elderly surgical patients centers on reactive care models in which referrals are initiated by the primary surgical team to the Geriatrician for peri-operative assessment and management. The need for referral is often based on the surgical team’s clinical judgement. The limitations of such a model include timeliness of referral and assessment which may not promote patient-centered care.

Alternative models include a Geriatric Liaison Service which proactively screens and assesses high-risk surgical patients or a Geriatric Co-management aka Shared Care model, in which a Geriatric Medicine Team provides routine reviews and inputs that are tailored to a selected group with geriatric syndromes as part of co-management. A before-and-after study on an embedded geriatric surgical liaison service showed reduced length of stay in acute general and gastrointestinal surgery among emergency surgical admissions.⁵⁵ In the outpatient setting for elective surgical patients, a collaborative service embedding Geriatricians or Nurse Clinicians trained in CGA within preoperative assessment clinics could potentially enhance the implementation of CGA and screening for geriatric syndrome and sarcopenia for this group of patients.

Outcome measures

Another concern is that of outcome measures of post-acute surgery patients versus that of conservatively managed high-risk patients. There is currently a dearth of data in this area. While CGA and risk stratification can help identify patients who may benefit from emergency surgery, we do not have real world data on outcomes in conservatively managed patients. In addition, qualitative outcomes such as quality of life (QOL), and caregiver burden are not routinely measured. These would be useful in providing a more holistic assessment of post-surgical and conservatively managed patients.

Role of advance care planning/ serious illness conversations

Advance Care Planning (ACP) provides an opportunity to elicit patients’ values about QOL, goals, and preferences, in order to make informed medical decisions. A recent retrospective cohort study in 2023 highlighted the disparities in ACP rates that persist among emergency general surgery patients.⁵⁶ Currently, ACP is rarely conducted during discussions with patient and caregivers before or after emergency surgery. By stratifying patients based on frailty status, there may be utility in deciding which group of patients would benefit from surgery versus conservative management. In addition, a secondary analysis of a prospective, multicenter cohort study suggested a complex association with frailty and decisional regret among older surgical patients up to 1 year after elective non-cardiac surgery.⁵⁷ Taken together, early ACP discussions may avert unnecessary surgery. and incorporating ACP discussions into the CGA of frail elderly surgical patients could result in more holistic and realistic assessments of these patients.

Conclusion

As Singapore becomes a superaged society, there is growing need to integrate CGA as part of good surgical care of older surgical patients. Currently, there is evidence of improved outcomes after performing CGA and screening for frailty and sarcopenia in elective surgical patients while evidence on the usage of CGA for emergency surgical patients perioperatively is limited. Challenges to integrating CGA as part of routine surgical care include time constraints, manpower, funding, research and care models. The requirement for completion of preoperative CGA by a Geriatrician needs to be finely balanced with the need for expediting the patient for urgent imaging, urgent surgical review and emergency surgery. In terms of assessment tools for frailty and sarcopenia in the surgical setting, we would consider using CFS (for frailty assessment) and SARC-F with or without Calf Circumference (for sarcopenia assessment) when appropriate. Future avenues of development include exploring alternative models of care and assessing postoperative outcomes post-CGA in the local setting.

Footnotes

Author contributions

KFY and CCDS researched literature and conceived the review. KFY wrote the first draft of the manuscript. All authors reviewed and edited the manuscript and approved the final version of the manuscript.

Declaration of conflicting interests

The author(s) declared no potential conflicts of interest with respect to the research,authorship,and/or publication of this article.

Funding

The author(s) received no financial support for the research,authorship,and/or publication of this article.

Trial registration

Not applicable

Ethical statement

ORCID iDs

King Fan Yip

Sachin Mathur

Chuen Chai Dennis Seow

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