Book review: Perioperative Care of the Elderly
Shane O’Hanlon is a consultant geriatrician with a special interest in surgical liaison. He tweets @drohanlon
Thanks to the excellent work of the POPS team and many others around the UK, older people with surgical problems are now increasingly benefiting from specialised geriatric input. The evidence base has been strengthening, innovative new models have been explored and our surgical and anaesthetic colleagues have been enthusiastic advocates. So it’s great to see a full textbook devoted to the area, with 360 pages and 50 chapters.
The book is logically divided into Preoperative Evaluation, Preparation for Surgery, Intraoperative Management and Post-op management. This is convenient as it allows the reader to focus on their particular area of interest, but also gain an understanding of what happens in their colleagues’ practice. A final section on organisational issues is included that deals with models of care, hospital design and systems engineering.
The pre-op section provides information on how the traditional consultation is evolving to include geriatric assessment. It deals with individual issues such as polypharmacy, multimorbidity, cognitive assessment and functional reserve. One of the most challenging areas - decision-making about surgery - thankfully gets its own chapter. The informed consent chapter also goes through mental capacity assessment. And it’s not just elective surgery; there is also a chapter that goes through pre-op care in emergency surgery.
The section on preparation for surgery considers prehabilitation, optimisation, and prevention of cognitive complications. Nutritional assessment is given good coverage. There is also a chapter on the important role of specialist geriatric nurses in preparing older people for surgery.
Various surgical areas such as orthopaedic, cardiovascular, abdominal, etc., are covered in the extensive intraoperative management section. A diverse group of surgical authors write about the specific needs of older people - probably the most interesting part of the book from the perspective of a geriatrician. Tailoring the method of anaesthesia to the older patient is covered across two chapters. There is a very thoughtful chapter on entering the operating theatre that gives great practical advice for minimising anxiety.
The section on post-operative care is the most extensive, and goes from management in the recovery room all the way to planning for discharge. In between it explores pain control, common complications, enhanced recovery and prevention of post-operative geriatric syndromes. The scenario of post-op admission to the ICU is also considered, including ethical issues about setting appropriate ceilings of care and end of life care.
Overall it’s a very comprehensive volume that deserves a place on the surgical ward and operating theatre coffee room. UK readers may be irked by some of the language used, e.g. “The demented patient” and a frequent sprinkling of the word “elderly”. But the quality of the writing is otherwise excellent and it’s a very accessible book. I would have liked to see more on the specific risks that need to be covered in the consent process for older people with frailty. Indeed frailty itself is perhaps not given the prominence throughout the book that it deserves. There are some statements that do not appear evidence-based, such as the recommendation to stop anti-platelet therapy 5 days before any elective surgery. Also while warfarin is covered in the anticoagulation section, DOACs are not. Hopefully these will be re-examined in the next edition.
I would strongly recommend the book for specialty trainees in anaesthesia and surgery. Those in geriatric medicine will find certain sections of use, particularly to understand the work of our anaesthetic and surgical colleagues.