Department of Geriatric Medicine, Concord Hospital, Sydney, New South Wales, Australia; Concord Clinical School, Faculty of Medicine and Health, University of Sydney, Sydney, New South Wales, Australia; Centre for Education and Research on Ageing, Sydney, New South Wales, Australia; Ageing and Alzheimer's Institute, Sydney, New South Wales, Australia.
Department of Geriatric Medicine, Concord Hospital, Sydney, New South Wales, Australia.
J Am Med Dir Assoc. 2020 Dec;21(12):1833-1843.e20. doi: 10.1016/j.jamda.2020.03.023. Epub 2020 May 14.
Managing older patients with surgical conditions is a major challenge for hospitals. There is therefore a growing interest in providing geriatric perioperative services. The aim of this systematic review and meta-analysis was to characterize and assess the impact of targeted perioperative geriatric interventions on clinical outcomes of older adults admitted to nonorthopedic surgical teams.
DESIGN, SETTING AND PARTICIPANTS: A systematic review and meta-analysis of studies of perioperative geriatric interventions in older adults hospitalized under nonorthopedic surgical teams.
Ovid MEDLINE, EMBASE, PsycINFO, Scopus, Cochrane Central Register of Controlled Trials, CINAHL, and trial registry databases were searched. Primary outcomes were change in functional status and length of stay (LOS).
Fifteen randomized controlled trials (RCTs) and 9 prospective before-and-after studies met the inclusion criteria (n = 3026 participants). Perioperative geriatric interventions included preoperative comprehensive geriatric assessment and management (CGA) (5 studies), multicomponent inpatient geriatric programs (8 studies), cognitive training (1 study), exercise (5 studies), and prehabilitation (5 studies). Exercise therapy [mean difference (MD) -1.90, 95% confidence interval (CI) -3.01, -0.80], multicomponent inpatient geriatric programs (MD -1.98, 95% CI -3.09, -0.88), and prehabilitation (MD -1.32, 95% CI -2.75, 0.11) reduced LOS. Functional decline was highly heterogeneous, with 4 of 8 studies reporting significantly less functional decline. Geriatric perioperative interventions reduced complications [exercise therapy risk ratio (RR) 0.74, 95% CI 0.48, 1.15; prehabilitation RR 0.61, 95% CI 0.47, 0.80] and delirium (multicomponent inpatient geriatric programs RR 0.49, 95% CI 0.27, 0.90; preoperative CGA RR 0.54, 95% CI 0.33, 0.89). There was no significant impact on mortality or readmissions.
Perioperative geriatric interventions targeted at older nonorthopedic surgical patients improve some clinically relevant outcomes. There is a need for these interventions to be further evaluated in high-quality studies, and future research should explore how to effectively implement these interventions within complex health care systems.
管理有手术条件的老年患者是医院面临的一大挑战。因此，人们越来越感兴趣的是提供老年围手术期服务。本系统评价和荟萃分析的目的是描述和评估针对非骨科手术团队收治的老年人的围手术期老年干预措施对临床结局的影响。
设计、地点和参与者：对非骨科手术团队收治的老年人进行围手术期老年干预的研究进行系统评价和荟萃分析。
检索 Ovid MEDLINE、EMBASE、PsycINFO、Scopus、Cochrane 对照试验中心注册库、CINAHL 和试验注册数据库。主要结果是功能状态和住院时间（LOS）的变化。
15 项随机对照试验（RCT）和 9 项前瞻性前后对照研究符合纳入标准（n=3026 名参与者）。围手术期老年干预措施包括术前综合老年评估和管理（CGA）（5 项研究）、多组分住院老年计划（8 项研究）、认知训练（1 项研究）、运动（5 项研究）和术前康复（5 项研究）。运动疗法[平均差值（MD）-1.90，95%置信区间（CI）-3.01，-0.80]、多组分住院老年计划（MD-1.98，95%CI-3.09，-0.88）和术前康复（MD-1.32，95%CI-2.75，0.11）减少 LOS。功能下降高度异质性，8 项研究中有 4 项报告功能下降显著减少。老年围手术期干预措施减少了并发症[运动疗法风险比（RR）0.74，95%置信区间（CI）0.48，1.15；术前 CGA RR 0.54，95%CI 0.33，0.89]和谵妄（多组分住院老年计划 RR 0.49，95%CI 0.27，0.90；术前 CGA RR 0.54，95%CI 0.33，0.89）。对死亡率或再入院率没有显著影响。
针对非骨科手术老年患者的围手术期老年干预措施改善了一些有临床意义的结局。需要进一步在高质量的研究中评估这些干预措施，未来的研究应探讨如何在复杂的医疗保健系统中有效地实施这些干预措施。
