Anaesthesia
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Comprehensive geriatric assessment is an established clinical approach. It reduces mortality and improves the physical wellbeing of older people in the community or hospitalised for medical reasons. Pre-operative comprehensive geriatric assessment seems a plausible method for reducing adverse postoperative outcomes. ⋯ The heterogeneity of study methods, populations, interventions and outcomes precluded meta-analysis. Based on this narrative synthesis, pre-operative comprehensive geriatric assessment is likely to have a positive impact on postoperative outcomes in older patients undergoing elective surgery, but further definitive research is required. Clinical services providing pre-operative comprehensive geriatric assessment for older surgical patients should be considered.
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Outcomes are essential measures of healthcare effectiveness and efficiency. Traditional measures of outcome, such as mortality and length of stay, are important and easy to measure but have significant limitations when evaluating the peri-operative care of elderly patients. ⋯ However, few measurement tools have been developed or validated specifically for the elderly surgical patient. This paper describes the outcome measures currently in use, explores how they might be used to improve the quality of care provision, and indicates priority areas for peri-operative outcomes research in the elderly surgical patients.
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The elderly have the ethical and legal equivalence of younger adults, yet are treated differently by society. Numerous recent reports have exposed poor inpatient care resulting in part from institutional ageism, which has moral and legal implications for healthcare providers. ⋯ Legally, numerous changes in human rights, equality, consent, capacity, and end-of-life laws and professional guidance have consistently re-emphasised the need for greater communication between doctors, patients, their relatives and carers. This review describes current ethical thinking and legal precedent (in England and Wales), and directs readers to consider areas in which the law might change in the near future, particularly with regard to the end-of-life care of elderly surgical patients.
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Review
Pre-operative co-morbidity and postoperative survival in the elderly: beyond one lunar orbit.
Mortality is a good measure of killing, but it is a poor measure of cure, palliation or the maintenance of function. Nevertheless, it has remained the primary metric of hospital care for 200 years. ⋯ This article discusses how disparate factors can usefully combine to generate an 'elderly' group with a monthly mortality in excess of 1% and a median life expectancy less than 3.5 years. A downloadable spreadsheet is provided that combines risk factors to generate mortality risks and their associated survival curves, emphasising the importance of looking beyond one postoperative month.
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A number of recent reports have highlighted the inadequate provision of pain relief for older inpatients. Despite the availability of numerous validated pain measures, pain remains poorly assessed in some cases and, particularly, in the cognitively impaired. ⋯ Most drugs and techniques that are used for analgesia in younger patients are also suitable for older patients, although dosages may have to be adjusted to avoid the side-effects that are consequent upon age-related changes in drug pharmacokinetics and pharmacodynamics, co-morbidity, frailty, cognitive impairment and polypharmacy. This paper reviews current guidelines and methods of assessing pain in the older adult, and describes the use of, and problems with, mild, moderate, strong, adjuvant and local anaesthetic drugs in the older population for analgesia, advocating multimodal intervention to reduce dose-related side-effects, particularly of opioids.