Introduction

In response to the needs and demands of an aging population, geriatric medicine has grown rapidly during the past three decades and developed new models of care from new concepts like multimorbidity, frailty and geriatric syndromes.

Multimorbidity (Tinetti et al. 2012) is common in the older adult population, affects more than half of the elderly population and almost all hospitalized geriatric patients. Two terms, “comorbidity” and “multi-morbidity” have been mostly used. The term comorbidity refers to a combination of additional diseases beyond an index disorder. In contrast, multimorbidity (see Chapter 3) is defined as any co-occurrence of diseases in the same person indicating a shift of interest from a given index condition to individuals who suffer from multiple diseases (Marengoni et al. 2011). It has been reported than 65% of Medicare beneficiaries have two or more chronic diseases and 43% have three or more (Lee et al. 2009). Multimorbidity/comorbidity is an important determinant of health outcomes in older adults, responsible for a high treatment burden and for an increased risk of hospitalization and death (AGS 2012, Vetrano et al. 2016).

In parallel, the concept of frailty has been developed (Rockwood 2005, Fried et al. 2001). Frailty is considered to be highly prevalent with increasing age and to confer risk for adverse health outcomes, including mortality, institutionalization and hospitalization (Widagdo et al. 2015, Fried et al. 2001). Frailty has been considered synonymous with disability and comorbidity, but Fried et al. (2001) provides evidence that frailty is not synonymous, whereas comorbidity is an etiologic risk factor for and disability is an outcome of frailty.

In 2009, Collerton et al. (2009) speculated that disability, rather than disease, is the better predictor of mortality at these older ages, and that people who cope better with their disease(s), perhaps via enhanced functional reserve or adaptive capacity, are the survivors. This reflects the concept of geriatric syndromes (GSs), described since the 1980s. In most studies, GSs included the following main concepts: urinary incontinence, pressure ulcers, falls, delirium and functional decline (Inouye et al. 2007, Lee et al. 2009, Lakhan et al. 2011, Senn and Monod 2015). But, depending on the study, pain, dizziness, sleep disorders, malnutrition, hearing and visual impairment have also been cited (Kane et al. 2012, Koroukian et al. 2016; Vetrano et al. 2016).

Although different from the concept of multimorbidity or frailty, all these notions are associated and entangled. In this chapter we will firstly try to define GSs, and then we will detail their implications in the postoperative period. Understanding these concepts is pivotal in preventing their occurrence after surgery and in supporting the elderly surgical patient in the best way.

Geriatric Syndromes

Definition

GSs refer to “multifactorial health conditions that occur when the accumulated effects of impairments in multiple systems render [an older] person vulnerable to situational challenges” (Tinetti et al. 1995, Inouye et al. 2007). While heterogeneous, GSs share many common features. They occur in older, particularly frail persons, intermittently rather than either continuously or as single episodes. They are precipitated by one or more acute triggers, and are often linked to subsequent functional decline (Inouye et al. 2007). They have been shown to be as prevalent as chronic diseases, but despite their prevalence and outcomes (poor survival, poor quality of life), they may not be recognized and managed adequately (Oliver 2008).

Conceptual Model for Geriatric Syndromes (Inouye 2007)

Inouye et al. (2007) defined, or redefined, the concept of GSs (Figure 42.1). They proposed a unifying conceptual model, demonstrating that common risk factors may lead to these syndromes, which may in turn lead to frailty, with feedback mechanisms enhancing the presence of shared risk factors and GSs. Such self-sustaining pathways may result in poor outcomes involving disability-dependence, nursing home placement and ultimately death. In their study, four shared risk factors were identified across all the GSs: older age, cognitive impairment, functional impairment and impaired mobility.

Figure 42.1 Conceptual model for geriatric syndromes.

(Reproduced from: Inouye et al. 2007 with the permission of John Wiley)

Conceptual Model for Geriatric Syndromes (Bouchon 1984)

Jean-Pierre Bouchon (1984) defined – without naming it – GSs by the so-called “1+2+3” model (Figure 42.2). The “1” represents the physiological aging of an organ, the “2,” the pathological aging of an organ and the “3,” a triggering factor. Only the “2” can lead to organ failure, which may be nevertheless accelerated by the “3.” This concept and diagram reflect the complexity of geriatric medicine with the presence of multiple risk factors for one GS. For example, treating a pressure ulcer without considering malnutrition, arterial insufficiency and immobility, will not allow complete healing. Worse, it may lead to a new pressure ulcer at the same time.

Figure 42.2 Conceptual model for geriatric syndromes.

(Adapted from: Bouchon 1984)

Prognostic Impact of Geriatric Syndromes After Surgery

Surgery may have life-altering effects beyond those related to the condition that required surgery. Particularly in the elderly, both physical and psychological postsurgical stress can lead to an imbalance in autonomic, endocrine and immune functions that lowers the homeostatic threshold and increases their risk of postoperative adverse events, so hampering their return to independence after surgery. Some patients heal from the condition that required the operation, but become incontinent, or have an increased risk of fall or functional decline; the recovery trajectory varies depending on the patient’s preoperative physiologic reserve, associated conditions and clinical course. Evidence-based predictors are not available; however, advanced age, frailty and major surgery seem to be related to increased risk.

GSs after surgery often impact negatively on their lives and are also risk factors for negative outcomes (Stenhagen et al. 2013, Yang et al. 2015). For example, urinary incontinence, disability and falls have been associated with reduced perceived quality of life in the elderly, and weight loss and pressure ulcers with mortality and other negative events (Vetrano et al. 2016). Stenhagen et al. (2013) and Yang et al. (2015) found that an increased number of GSs were associated with a perceived lower quality of life.

Are Geriatric Syndromes After Surgery Preventable?

As GSs negatively impact quality of life and increase healthcare-related and social costs, their prevention is a major issue. It has been observed that the literature on interventions to reduce 30-day rehospitalization (a measure that is strictly – even though not exclusively – related to the frequency with which GSs occur after surgery), has significant limitations due to heterogeneity, susceptibility to bias and lack of reporting on important contextual factors (Dharmarajan and Krumholz 2014).

Different from what was reported in studies examining hospital-acquired conditions and infections, one or more dominant risk factors (for instance, prolonged bed rest or overuse of a medical device such as a UIC or endotracheal tube) have not been identified.

Nevertheless, important insights can be found in the number of papers that examine harmful routine events occurring during hospitalization to which only limited attention is often paid. This is especially evident with regard to the aged patient.

Malnutrition resulting in impaired wound healing, increased risk of infection and pressure ulcers was extensively reported by many authors. Krumholz (2013) reported reduced nutrient intake of less than 50% of their calculated maintenance energy requirements and prolonged fasting periods in a population of older hospitalized subjects. Friedmann et al. (1997) reported weight loss and decreased blood albumin levels after discharge to be strong predictors of readmission within 30 days in elderly patients.

The effects of decreasing hospital length of stay on change in functioning from prehospital admission to posthospital discharge in older patients have been recently investigated in a nationwide cohort study (van Villet et al. 2017). Results suggest that the decrease in hospital length of stay is associated with better functional outcomes and lower mortality.

On the cognitive front, older hospitalized patients often experience a variety of stressors, such as information overload, uncertainty about outcome, sleep deprivation and depression that can cause delirium, which is associated with increased risk of adverse events before and after discharge.

Pain and other discomforts are often inadequately addressed. They can lead to sleep disorders, mood disturbances and impaired cognitive functioning, and are known to influence immune and metabolic function. Moreover, medications to treat symptoms can negatively affect the early recovery period. Finally, hospitalized patients commonly become deconditioned, have impaired coordination and are consequently at increased risk of falling.

Whereas no specific studies have been conducted to investigate the relationships between these factors and the occurrence of GSs after surgery, studies on models of care for elderly hospitalized patients demonstrated their effectiveness in reducing delirium, pressure sores, falls and functional decline after discharge (see Chapter 45). Geriatric nursing protocols were also shown to be quintessential in preventing falls, functional decline and cognitive impairment in older hospitalized patients (Capezuti et al. 2008).

In the absence of defined, evidence-based preventive criteria, mitigating stressors during the hospital stay through the implementation of dedicated clinical pathways – such as Acute Care of the Elderly (ACE) Units or Proactive Care for Older Patients Undergoing Surgery (POPS) – and substantially meeting the patient’s explicit and implicit needs (that is the essence of quality) is the way to prevent the occurrence of GSs after a surgical operation in geriatric patients.

Conclusion

Usually, GSs are defined as urinary incontinence, pressure ulcers, falls, delirium and functional decline, with four major shared risk factors (with the possible addition of poor quality of care):

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  older age

  
  
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  cognitive impairment

  
  
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  functional impairment

  
  
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  impaired mobility.

GSs occur intermittently and are often linked to subsequent functional decline. All geriatric syndromes are partly inter-related and they are also related to the concept of multimorbidity and frailty. Koroukian et al. (2016) found that, rather than chronic conditions, the combination of functional limitations and/or GSs were the most prominent conditions in predicting health outcomes.

So, avoiding the appearance of GS during hospitalization, especially in the postoperative period, remains a major issue for all practitioners within the care team for elderly surgical patients.