Aging clinical and experimental research
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This manuscript centers on what surgeons, patients, and hospital administrations want and need to know about the crucial role of functional recovery and patients' reported outcome measure, above all in the elderly population. From all angles, it is clear that elderly patients are unique and their cancer care should be individualized and approached in a multidisciplinary fashion. ⋯ This includes proceeding with surgery and/or chemotherapy and utilizing minimally invasive techniques, when appropriate. In addition, quality of life should be a priority in the care of elderly patients and patient-reported outcomes should be assessed and reported.
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Increasing numbers of older patients require Emergency admission under General Surgery (EGS). This is a group of heterogeneous and often complex individuals with varying degrees of multimorbidity, polypharmacy, functional, mobility and cognitive impairment. Our article describes the benefits of comprehensive assessment coupled with patient-centred multiprofessional interventions and timely discharge planning. We discuss diverse service models and describe our experience in the planning, development and consolidation of a perioperative service for older EGS patients.
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Postoperative delirium (POD) is an adverse clinical outcome characterized by cognitive, affective and behavioral symptoms with typically an acute onset and a fluctuating course. POD is attributed to certain patients' predisposing factors as well as to treatment-related precipitating factors. ⋯ This involves strategies by multidisciplinary teams with additional geriatric consultation services to identify risk factors for POD and to modify their impact on the perioperative course. Some patients may profit from postponing an elective surgery and undergoing a prehabilitation program to optimize his/her resilience for the surgical and anesthesiologic stressors.
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Surgery in combination with risk factors such as poor physical and nutritional status have detrimental effects on short- and long-term aspects of recovery and quality of life, especially in elderly patients whose functional reserve is limited. Strategies to minimize these effects and accelerate return to baseline levels have focused on the intra- and post-operative period; however, this may not be the most opportune time to intervene. Instead, the preoperative period may be a more emotionally salient and physically enabling time to initiate an intervention aimed at attenuating surgical stress and enhancing recovery after surgery. ⋯ In general, individuals who are the least fit and the most sedentary have shown the most improvement when they initiate an exercise program. Since their physiologic reserve is limited, even small amounts of physical training can yield significant improvements. The interaction of physical activity and nutrition promotes anabolism, thereby preparing patients to better withstand the stress of surgery and subsequently mitigating the impact on postoperative outcome.
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Universally recognized goals of preoperative anesthesia assessment are the evaluation of patient's health status to define the entity of the surgical risk, and the anticipation of possible complications while optimizing and planning preventive strategies. Data obtained by Comprehensive Geriatric Assessment (CGA) and frailty evaluation are of extreme usefulness in surgical risk evaluation in older patients and in the decision about surgery. ⋯ These data should thus be used as reference points not only in preoperative assessment but also in planning the perioperative course, from pre-habilitation to adequate intraoperative management to complications prevention and care continuity after discharge. It is from such a far-seeing approach that issues emerged from preoperative evaluation can really contribute to decision-making about surgery in the elderly.