Enhanced Recovery After Surgery in Geriatric Patients

A Need to Fly in the Face of Convention

It is anticipated for the world population that in 2030, one in six people will be aged 60 years or above and in 2050, the population above 60 years will almost double that in present times. No surprise that the United Nations (UN) General Assembly declared 2021–2030 as the “UN Decade of Healthy Ageing.” In the majority of chronologically aged individuals, biological ageing–related syndrome of physiological decline in tissue function leads to frailty. After surgery, some develop chronic critical illness characterized by persistent inflammation, immunosuppression, and catabolism syndrome (CICS). If not taken care of perioperatively, frailty, dementia, and CICS are associated with poorer surgical outcomes, morbidity, and higher 1-year mortality after major surgery.[¹]

Evidence for the beneficial role of enhanced recovery after surgery (ERAS) protocols in improving surgical outcomes in elderly patients is emerging but yet insufficient. In the most recent systematic review and meta-analysis (six studies with a total of 1174 patients aged =65 years old undergoing colorectal surgery), the authors found a lower incidence of postoperative morbidity, shorter length of hospital stay, and faster return of bowel function with ERAS intervention. The limitations of this review are few eligible included studies, a single surgical cohort, and lack of generalization of findings and heterogeneous studies due to different ERAS steps followed in studies.[²]

Presently no guidelines or recommendations are available for perioperative care of the geriatric patient to enhance recovery after surgery. Future studies on the elderly on ERAS are needed with robust methodology, assessment of standardized patient-centric outcomes, and their reporting in a consistent format as per the reporting on ERAS compliance, outcomes, and elements research (RECOvER) checklist.[³] Furthermore, reviews of the existing or upcoming literature need mandatorily to be based on the grading of recommendations, assessment, development, and evaluation (GRADE) framework to identify the existing knowledge gap and address the inherent limitations of heterogeneity and indirectness of studies.

The majority of studies have assessed outcomes such as the length of hospital stay, decrease in intensive care stay, early recovery of ileus, and decrease in postoperative complications as markers of enhanced recovery. As the length of hospital stays is affected by many administrative, financial, and social factors, “time to readiness for discharge” is considered a superior outcome to assess. Similarly, from the patient’s perspective, enhanced recovery means achieving an optimal level of functional activity or activity of daily living or maybe an early return to the workplace after discharge from the hospital.[⁴] Another validated patient-centric outcome “days at home up to 30 days after surgery” encompasses the length of hospital stay, readmission, and any 30-day mortality after surgery. This requires accurate post-discharge follow-up with phone calls or app-based follow-up to acquire details of post-discharge convalescence, readmission in any other health facility, or early death.[⁵]

Measuring outcomes based on the chronology of recovery in the geriatric population is also necessary. Post-discharge recovery or late phases of recovery can be measured by cognitive decline, persisting pain after surgery, or self-reported physical activity with the 41-item questionnaire (Community Healthy Activities Model Program for Seniors [CHAMPS] instrument). Though items of this questionnaire are not sociocultural appropriate and feasible for all elderly patients.[⁶] Postoperative cognitive dysfunction (POCD) is a common, underreported postoperative complication that delays recovery in geriatric patients. It is imperative to assess whether optimizing preexisting cognitive impairment during prehabilitation or using intraoperative components of ERAS minimizes the incidence of POCD.

Another emerging aspect of research on ERAS is the influence of prehabilitation and rehabilitation on recovery in frail elderly. Knowing which component matters more and requires more stringent implementation will be interesting. Achieving good compliance with ERAS protocols is many times not possible, especially for the elderly. Compliance with nutritional and exercise-based rehabilitation at home is low and cannot be monitored. Prehabilitation regimes vary widely, are not customized for the elderly, and are too heterogeneous for different surgical cohorts. Desirable prehabilitation is also not possible in emergency surgeries and for the elderly with comorbid diseases. Achieving optimal functional rehabilitation in the elderly, especially after orthopedic surgery, sometimes requires using technology such as virtual reality–based exercise games and tools.

The principles of ERAS must be emphasized to all health-care providers at every level of care. Post-discharge, potential caregivers including physicians, nurses, and physical and occupational therapists of any acute care nursing facility or health-care facility must facilitate an effective transition to home-based rehabilitation. Self-care is a limited option for the elderly and family members need to be trained to recognize the early decline in functional and cognitive activity. Geriatric rehabilitation can be home-based, cost-effective, and preferable to an extended length of stay in the hospital.

Keeping in view the challenges of implementing ERAS in the elderly and our fixation with the convention, the advice of Kehlet[⁷] in his recent editorial is very apt for this situation. “Of the many barriers to close the ‘knowing-doing’ gap, most enhanced recovery recommendations probably include too many components that hinder their widespread implementation. Consequently, it is important to study more simple care bundles that can be used as easy quality metrics for monitoring and auditing performance in order to improve postoperative recovery.”[⁷]

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Conflicts of interest

There are no conflicts of interest.