Comprehensive geriatric assessment reduces complications, mortality in vascular patients

Vascular-Geriatric Service (VGS), the first formal Geriatric Liaison Service for surgical patients in a tertiary hospital in Singapore, has resulted in a significant decrease in medical complications and 30-day mortality in older frail patients with multimorbidity, reports a study.

“Using Comprehensive Geriatric Assessment (CGA), VGS was able to reduce pneumonia, delirium, and mortality rates despite the increased risk of perioperative complications that is associated with the risk factors present in the VGS cohort,” the researchers said.

“CGA is a validated multidomain assessment of an older person’s myriad issues that has shown positive medical outcomes in surgical settings,” they explained.

After VGS, patients were less likely to experience pneumonia (2.2 percent vs 10.8 percent; p=0.021) and delirium (1.1 percent vs 18.3 percent; p<0.001) as compared with pre-VGS. [Proc Singap Healthc 2023;doi:10.1177/20101058231192781]

In addition, patients referred to VGS had a 79-percent lower chance of 30-day mortality when compared with those not referred to VGS (controls; odds ratio, 0.21, 95 percent confidence interval [CI], 0.05‒0.86; p=0.030). However, the VGS group experienced a 48-percent increased risk of a prolonged hospital stay as compared to the control group (risk ratio, 1.48, 95 percent CI, 1.11‒1.97; p=0.008).

“Considering the gaps identified in the current structure, next plans include building surgical staff capabilities in geriatric care, incorporating multidisciplinary meetings, instituting daily reviews, and facilitating care coordination to improve patient care and outcomes,” the researchers said.

Under VGS, patients at risk for swallowing issues were referred to a speech therapist and given appropriate diet and fluid consistency to reduce the risk of aspiration pneumonia. They also had constant reinforcement of early mobilization and regular sitting out of bed to reduce atelectasis.

Cognitive impairment

Of the VGS cohort, 32 percent had cognitive impairment, indicating an increased risk for delirium. Thus, proactive delirium prevention measures were warranted, according to the researchers.

In an earlier study, multicomponent nonpharmacologic interventions targeting risk factors for delirium helped reduce its incidence as compared with usual care. [N Engl J Med 1999;340:669–676]

Under VGS, these nonpharmacologic measures included regular review of medications, bowels and nutrition, proactive optimization of pain control, frequent reorientation, and early mobilization.

“One of the main challenges in the implementation of these measures is that the patients were in nongeriatric acute wards and staff were not specifically trained in geriatric care,” the researchers said. “The VGS team also only rounded twice a week; hence, interventions that were planned may not have been optimally followed up.”

These challenges, however, did not prevent VGS to significantly reduce the incidence of delirium (1.1 percent vs 18.3 percent; p<0.001).

This quality improvement prospective cross-sectional study included vascular patients aged ≥65 years admitted between November 2018 to October 2019 referred to the VGS at the surgeon’s discretion if they had acute medical issues, cognitive concerns, or functional decline.

The researchers then conducted a pre- and postanalysis for outcomes of medical complications, as well as a multivariate analysis to assess length of stay, 30-day unplanned medical readmissions, and 30-day mortality rates.