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Clin Colon Rectal Surg
DOI: 10.1055/s-0044-1786392
Review Article

Navigating the Surgical Pathway for Frail, Older Adults Undergoing Colorectal Surgery

Ana C. De Roo
1   Division of Colorectal Surgery, Department of Surgery, University of Wisconsin, Madison, Wisconsin
,
Srinivas J. Ivatury
2   Division of Colon and Rectal Surgery, Department of Surgery and Perioperative Care, University of Texas at Austin Dell Medical School, Austin, Texas
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Abstract

Adults ≥ 65 years of age comprise nearly 20% of the U.S. population and over half of surgical patients. Older adults, particularly when frail, may require additional preoperative evaluation and counseling, specialized hospital care, and may experience more noticeable physical and cognitive changes than younger or healthier patients. Surgeons can assess frailty and risk using several frailty measures, as data exist demonstrating worse perioperative outcomes among patients undergoing colorectal surgery. Prehabilitation programs have not been shown to improve surgical outcomes for colorectal surgery patients but may help maintain physical function or hasten recovery to baseline around the time of surgery, particularly for frail patients. Functional decline and delirium are common postoperatively in older adult patients, particularly those who are frail at baseline, and should be discussed with at-risk older adults. Primary care physicians and geriatricians can help with in-depth evaluation of frailty and geriatric syndromes. Special attention to the risks, outcomes, and care of older adults considering or undergoing colorectal surgery can help inform decision-making, which may facilitate goal-concordant care.

Keywords

older adults - surgery - frailty - prehabilitation - shared decision-making


Publication History

Article published online:
25 April 2024

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  • References

  • 1 US Census Bureau. Older People Projected to Outnumber Children for First Time in U.S. History. Accessed October 24, 2023 at: https://www.census.gov/newsroom/press-releases/2018/cb18-41-population-projections.html
    PubMed
  • 2 Jafari MD, Jafari F, Halabi WJ. et al. Colorectal cancer resections in the aging US population: a trend toward decreasing rates and improved outcomes. JAMA Surg 2014; 149 (06) 557-564
    CrossrefPubMedGoogle Scholar
  • 3 Hornor MA, Ma M, Zhou L. et al. Enhancing the American College of Surgeons NSQIP surgical risk calculator to predict geriatric outcomes. J Am Coll Surg 2020; 230 (01) 88-100.e1
    CrossrefPubMedGoogle Scholar
  • 4 American College of Surgeons. Optimal Resources for Geriatric Surgery. (American College of Surgeons, ed.). Accessed October 24, 2023 at: https://www.facs.org/quality-programs/accreditation-and-verification/geriatric-surgery-verification/standards/
    PubMed
  • 5 Saur NM, Davis BR, Montroni I. et al; Clinical Practice Guidelines Committee of the American Society of Colon and Rectal Surgeons. The American Society of Colon and Rectal Surgeons clinical practice guidelines for the perioperative evaluation and management of frailty among older adults undergoing colorectal surgery. Dis Colon Rectum 2022; 65 (04) 473-488
    CrossrefPubMedGoogle Scholar
  • 6 Dent E, Kowal P, Hoogendijk EO. Frailty measurement in research and clinical practice: A review. Eur J Intern Med 2016; 31: 3-10
    CrossrefPubMedGoogle Scholar
  • 7 Collard RM, Boter H, Schoevers RA, Oude Voshaar RC. Prevalence of frailty in community-dwelling older persons: a systematic review. J Am Geriatr Soc 2012; 60 (08) 1487-1492
    CrossrefPubMedGoogle Scholar
  • 8 Clegg A, Young J, Iliffe S, Rikkert MO, Rockwood K. Frailty in elderly people. Lancet 2013; 381 (9868): 752-762
    CrossrefPubMedGoogle Scholar
  • 9 Fried LP, Tangen CM, Walston J. et al; Cardiovascular Health Study Collaborative Research Group. Frailty in older adults: evidence for a phenotype. J Gerontol A Biol Sci Med Sci 2001; 56 (03) M146-M156
    CrossrefPubMedGoogle Scholar
  • 10 Mitnitski AB, Mogilner AJ, Rockwood K. Accumulation of deficits as a proxy measure of aging. ScientificWorldJournal 2001; 1: 323-336
    CrossrefPubMedGoogle Scholar
  • 11 McGovern J, Dolan RD, Horgan PG, Laird BJ, McMillan DC. The prevalence and prognostic value of frailty screening measures in patients undergoing surgery for colorectal cancer: observations from a systematic review. BMC Geriatr 2022; 22 (01) 260
    CrossrefPubMedGoogle Scholar
  • 12 Velanovich V, Antoine H, Swartz A, Peters D, Rubinfeld I. Accumulating deficits model of frailty and postoperative mortality and morbidity: its application to a national database. J Surg Res 2013; 183 (01) 104-110
    CrossrefPubMedGoogle Scholar
  • 13 Rockwood K, Song X, MacKnight C. et al. A global clinical measure of fitness and frailty in elderly people. CMAJ 2005; 173 (05) 489-495
    CrossrefPubMedGoogle Scholar
  • 14 Subramaniam S, Aalberg JJ, Soriano RP, Divino CM. New 5-factor modified Frailty Index using American College of Surgeons NSQIP data. J Am Coll Surg 2018; 226 (02) 173-181.e8
    CrossrefPubMedGoogle Scholar
  • 15 Fagard K, Leonard S, Deschodt M. et al. The impact of frailty on postoperative outcomes in individuals aged 65 and over undergoing elective surgery for colorectal cancer: a systematic review. J Geriatr Oncol 2016; 7 (06) 479-491
    CrossrefPubMedGoogle Scholar
  • 16 Michaud Maturana M, English WJ, Nandakumar M, Li Chen J, Dvorkin L. The impact of frailty on clinical outcomes in colorectal cancer surgery: a systematic literature review. ANZ J Surg 2021; 91 (11) 2322-2329
    CrossrefPubMedGoogle Scholar
  • 17 Shaw JF, Budiansky D, Sharif F, McIsaac DI. The association of Frailty with outcomes after cancer surgery: a systematic review and metaanalysis. Ann Surg Oncol 2022; 29 (08) 4690-4704
    CrossrefPubMedGoogle Scholar
  • 18 Artiles-Armas M, Roque-Castellano C, Fariña-Castro R, Conde-Martel A, Acosta-Mérida MA, Marchena-Gómez J. Impact of frailty on 5-year survival in patients older than 70 years undergoing colorectal surgery for cancer. World J Surg Oncol 2021; 19 (01) 106
    CrossrefPubMedGoogle Scholar
  • 19 Miller SM, Wolf J, Katlic M, D'Adamo CR, Coleman J, Ahuja V. Frailty is a better predictor than age for outcomes in geriatric patients with rectal cancer undergoing proctectomy. Surgery 2020; 168 (03) 504-508
    CrossrefPubMedGoogle Scholar
  • 20 Feliciano EMC, Hohensee C, Rosko AE. Association of prediagnostic frailty, change in frailty status, and mortality after cancer diagnosis in the Women's Health Initiative. JAMA Netw Open 2020 https://jamanetwork.com/journals/jamanetworkopen/article-abstract/2770549
    PubMedGoogle Scholar
  • 21 Mima K, Miyanari N, Morito A. et al. Frailty is an independent risk factor for recurrence and mortality following curative resection of stage I-III colorectal cancer. Ann Gastroenterol Surg 2020; 4 (04) 405-412
    CrossrefPubMedGoogle Scholar
  • 22 Al-Khamis A, Warner C, Park J. et al. Modified frailty index predicts early outcomes after colorectal surgery: an ACS-NSQIP study. Colorectal Dis 2019; 21 (10) 1192-1205
    CrossrefPubMedGoogle Scholar
  • 23 Gearhart SL, Do EM, Owodunni O, Gabre-Kidan AA, Magnuson T. Loss of independence in older patients after operation for colorectal cancer. J Am Coll Surg 2020; 230 (04) 573-582
    CrossrefPubMedGoogle Scholar
  • 24 Extermann M, Aapro M, Bernabei R. et al; Task Force on CGA of the International Society of Geriatric Oncology. Use of comprehensive geriatric assessment in older cancer patients: recommendations from the task force on CGA of the International Society of Geriatric Oncology (SIOG). Crit Rev Oncol Hematol 2005; 55 (03) 241-252
    CrossrefPubMedGoogle Scholar
  • 25 Stuck AE, Siu AL, Wieland GD, Adams J, Rubenstein LZ. Comprehensive geriatric assessment: a meta-analysis of controlled trials. Lancet 1993; 342 (8878): 1032-1036
    CrossrefPubMedGoogle Scholar
  • 26 Chow WB, Rosenthal RA, Merkow RP, Ko CY, Esnaola NF. American College of Surgeons National Surgical Quality Improvement Program, American Geriatrics Society. Optimal preoperative assessment of the geriatric surgical patient: a best practices guideline from the American College of Surgeons National Surgical Quality Improvement Program and the American Geriatrics Society. J Am Coll Surg 2012; 215 (04) 453-466
    CrossrefPubMedGoogle Scholar
  • 27 Gustafsson UO, Scott MJ, Hubner M. et al. Guidelines for perioperative care in elective colorectal surgery: enhanced recovery after surgery (ERAS®) Society Recommendations: 2018. World J Surg 2019; 43 (03) 659-695
    CrossrefPubMedGoogle Scholar
  • 28 Minnella EM, Carli F. Prehabilitation and functional recovery for colorectal cancer patients. Eur J Surg Oncol 2018; 44 (07) 919-926
    CrossrefPubMedGoogle Scholar
  • 29 Minnella EM, Awasthi R, Gillis C. et al. Patients with poor baseline walking capacity are most likely to improve their functional status with multimodal prehabilitation. Surgery 2016; 160 (04) 1070-1079
    CrossrefPubMedGoogle Scholar
  • 30 Newman AB, Simonsick EM, Naydeck BL. et al. Association of long-distance corridor walk performance with mortality, cardiovascular disease, mobility limitation, and disability. JAMA 2006; 295 (17) 2018-2026
    CrossrefPubMedGoogle Scholar
  • 31 Molenaar CJ, van Rooijen SJ, Fokkenrood HJ, Roumen RM, Janssen L, Slooter GD. Prehabilitation versus no prehabilitation to improve functional capacity, reduce postoperative complications and improve quality of life in colorectal cancer surgery. Cochrane Database Syst Rev 2023; 5 (05) CD013259
    PubMedGoogle Scholar
  • 32 Minnella EM, Bousquet-Dion G, Awasthi R, Scheede-Bergdahl C, Carli F. Multimodal prehabilitation improves functional capacity before and after colorectal surgery for cancer: a five-year research experience. Acta Oncol 2017; 56 (02) 295-300
    CrossrefPubMedGoogle Scholar
  • 33 Molenaar CJL, Minnella EM, Coca-Martinez M. et al. Effect of multimodal prehabilitation on reducing postoperative complications and enhancing functional capacity following colorectal cancer surgery: the PREHAB randomized clinical trial. JAMA Surg. Published online 2023. https://jamanetwork.com/journals/jamasurgery/article-abstract/2803109
    PubMedGoogle Scholar
  • 34 Fulop A, Lakatos L, Susztak N, Szijarto A, Banky B. The effect of trimodal prehabilitation on the physical and psychological health of patients undergoing colorectal surgery: a randomised clinical trial. Anaesthesia 2021; 76 (01) 82-90
    CrossrefPubMedGoogle Scholar
  • 35 Barberan-Garcia A, Ubré M, Roca J. et al. Personalised prehabilitation in high-risk patients undergoing elective major abdominal surgery: a randomized blinded controlled trial. Ann Surg 2018; 267 (01) 50-56
    CrossrefPubMedGoogle Scholar
  • 36 Fayers P, Bottomley A. EORTC Quality of Life Group, Quality of Life Unit, European Organisation for Research and Treatment of Cancer. Quality of life research within the EORTC-the EORTC QLQ-C30. Eur J Cancer 2002; 38 (Suppl. 04) S125-S133
    CrossrefPubMedGoogle Scholar
  • 37 Jenkinson C, Layte R, Jenkinson D. et al. A shorter form health survey: can the SF-12 replicate results from the SF-36 in longitudinal studies?. J Public Health Med 1997; 19 (02) 179-186
    CrossrefPubMedGoogle Scholar
  • 38 Ware JE, Snow KK, Kosinski M, Gandek B. The SF-36 health survey. Manual and interpretation guide. 1996;2. https://www.researchgate.net/profile/John-Ware-6/publication/313050850_SF-36_Health_Survey_Manual_Interpretation_Guide/links/594a5ac4a6fdcc89090c9cef/SF-36-Health-Survey-Manual-Interpretation-Guide.pdf
    PubMedGoogle Scholar
  • 39 Zhang LM, Hornor MA, Robinson T, Rosenthal RA, Ko CY, Russell MM. Evaluation of postoperative functional health status decline among older adults. JAMA Surg 2020; 155 (10) 950-958
    CrossrefPubMedGoogle Scholar
  • 40 Amemiya T, Oda K, Ando M. et al. Activities of daily living and quality of life of elderly patients after elective surgery for gastric and colorectal cancers. Ann Surg 2007; 246 (02) 222-228
    CrossrefPubMedGoogle Scholar
  • 41 Niemeläinen S, Huhtala H, Jämsen E. et al. One-year functional outcomes of patients aged 80 years or more undergoing colonic cancer surgery: prospective, multicentre observational study. BJS Open 2022; 6 (04) zrac094
    CrossrefPubMedGoogle Scholar
  • 42 Hamaker ME, Prins MC, Schiphorst AH, van Tuyl SAC, Pronk A, van den Bos F. Long-term changes in physical capacity after colorectal cancer treatment. J Geriatr Oncol 2015; 6 (02) 153-164
    CrossrefPubMedGoogle Scholar
  • 43 Blakely AM, Chanson D, Wong FL. et al. Health-related quality of life and oncologic outcomes after surgery in older adults with colorectal cancer. Support Care Cancer 2020; 28 (06) 2857-2865
    CrossrefPubMedGoogle Scholar
  • 44 De Roo AC, Li Y, Abrahamse PH, Regenbogen SE, Suwanabol PA. Long-term functional decline after high-risk elective colorectal surgery in older adults. Dis Colon Rectum 2020; 63 (01) 75-83
    CrossrefPubMedGoogle Scholar
  • 45 Finlayson E, Zhao S, Boscardin WJ, Fries BE, Landefeld CS, Dudley RA. Functional status after colon cancer surgery in elderly nursing home residents. J Am Geriatr Soc 2012; 60 (05) 967-973
    CrossrefPubMedGoogle Scholar
  • 46 Lee SH, Lim SW. Risk factors for postoperative delirium after colorectal surgery: a systematic review and meta-analysis. Int J Colorectal Dis 2020; 35 (03) 433-444
    CrossrefPubMedGoogle Scholar
  • 47 Jia Y, Jin G, Guo S. et al. Fast-track surgery decreases the incidence of postoperative delirium and other complications in elderly patients with colorectal carcinoma. Langenbecks Arch Surg 2014; 399 (01) 77-84
    CrossrefPubMedGoogle Scholar
  • 48 Inouye SK, van Dyck CH, Alessi CA, Balkin S, Siegal AP, Horwitz RI. Clarifying confusion: the confusion assessment method. A new method for detection of delirium. Ann Intern Med 1990; 113 (12) 941-948
    CrossrefPubMedGoogle Scholar
  • 49 Berian JR, Zhou L, Russell MM. et al. Postoperative delirium as a target for surgical quality improvement. Ann Surg 2018; 268 (01) 93-99
    CrossrefPubMedGoogle Scholar
  • 50 Robinson TN, Raeburn CD, Tran ZV, Angles EM, Brenner LA, Moss M. Postoperative delirium in the elderly: risk factors and outcomes. Ann Surg 2009; 249 (01) 173-178
    CrossrefPubMedGoogle Scholar
  • 51 Elie M, Cole MG, Primeau FJ, Bellavance F. Delirium risk factors in elderly hospitalized patients. J Gen Intern Med 1998; 13 (03) 204-212
    CrossrefPubMedGoogle Scholar
  • 52 Ramírez-Martín R, Pérez-Rodríguez P, Menéndez-Colino R. et al. Prehabilitation and perioperative geriatric care in patients aged over 80 years with colorectal cancer: results of a cross-specialty geriatrics program. J Geriatr Oncol 2022; 13 (06) 813-820
    CrossrefPubMedGoogle Scholar
  • 53 Raats JW, van Eijsden WA, Crolla RMPH, Steyerberg EW, van der Laan L. Risk factors and outcomes for postoperative delirium after major surgery in elderly patients. PLoS One 2015; 10 (08) e0136071
    CrossrefPubMedGoogle Scholar
  • 54 Scholz AFM, Oldroyd C, McCarthy K, Quinn TJ, Hewitt J. Systematic review and meta-analysis of risk factors for postoperative delirium among older patients undergoing gastrointestinal surgery. Br J Surg 2016; 103 (02) e21-e28
    CrossrefPubMedGoogle Scholar
  • 55 Gleason LJ, Schmitt EM, Kosar CM. et al. Effect of delirium and other major complications on outcomes after elective surgery in older adults. JAMA Surg 2015; 150 (12) 1134-1140
    CrossrefPubMedGoogle Scholar
  • 56 Wang YY, Yue JR, Xie DM. et al. Effect of the tailored, family-involved hospital elder life program on postoperative delirium and function in older adults: a randomized clinical trial. JAMA Intern Med 2020; 180 (01) 17-25
    CrossrefPubMedGoogle Scholar
  • 57 Inouye SK, Bogardus Jr ST, Charpentier PA. et al. A multicomponent intervention to prevent delirium in hospitalized older patients. N Engl J Med 1999; 340 (09) 669-676
    CrossrefPubMedGoogle Scholar
  • 58 Thillainadesan J, Yumol MF, Suen M, Hilmer S, Naganathan V. Enhanced recovery after surgery in older adults undergoing colorectal surgery: a systematic review and meta-analysis of randomized controlled trials. Dis Colon Rectum 2021; 64 (08) 1020-1028
    CrossrefPubMedGoogle Scholar
  • 59 Janssen TL, Steyerberg EW, Langenberg JCM. et al. Multimodal prehabilitation to reduce the incidence of delirium and other adverse events in elderly patients undergoing elective major abdominal surgery: an uncontrolled before-and-after study. PLoS One 2019; 14 (06) e0218152
    CrossrefPubMedGoogle Scholar
  • 60 Monk TG, Weldon BC, Garvan CW. et al. Predictors of cognitive dysfunction after major noncardiac surgery. Anesthesiology 2008; 108 (01) 18-30
    CrossrefPubMedGoogle Scholar
  • 61 Avidan MS, Evers AS. Review of clinical evidence for persistent cognitive decline or incident dementia attributable to surgery or general anesthesia. J Alzheimers Dis 2011; 24 (02) 201-216
    CrossrefPubMedGoogle Scholar
  • 62 Brodier EA, Cibelli M. Postoperative cognitive dysfunction in clinical practice. BJA Educ 2021; 21 (02) 75-82
    CrossrefPubMedGoogle Scholar
  • 63 Suwanabol PA, Li Y, Abrahamse P. et al. Functional and cognitive decline among older adults after high-risk surgery. Ann Surg 2022; 275 (01) e132-e139
    CrossrefPubMedGoogle Scholar
  • 64 De Roo AC, Vitous CA, Rivard SJ. et al. High-risk surgery among older adults: not-quite shared decision-making. Surgery 2021; 170 (03) 756-763
    CrossrefPubMedGoogle Scholar
  • 65 Chen LM, Farwell WR, Jha AK. Primary care visit duration and quality: does good care take longer?. Arch Intern Med 2009; 169 (20) 1866-1872
    CrossrefPubMedGoogle Scholar
  • 66 Abdelfatah E, Ramos-Santillan V, Cherkassky L, Cianchetti K, Mann G. High risk, high reward: frailty in colorectal cancer surgery is associated with worse postoperative outcomes but equivalent long-term oncologic outcomes. Ann Surg Oncol 2023; 30 (04) 2035-2045
    CrossrefPubMedGoogle Scholar
  • 67 Doolin JW, Halpin M, Berry JL, Hshieh T, Zerillo JA. Why focus on patient-reported outcome measures in older colorectal cancer patients?. Eur J Surg Oncol 2020; 46 (03) 394-401
    CrossrefPubMedGoogle Scholar
  • 68 Sudore RL, Fried TR. Redefining the “planning” in advance care planning: preparing for end-of-life decision making. Ann Intern Med 2010; 153 (04) 256-261
    CrossrefPubMedGoogle Scholar
  • 69 Elliott J, Stolee P, Boscart V, Giangregorio L, Heckman G. Coordinating care for older adults in primary care settings: understanding the current context. BMC Fam Pract 2018; 19 (01) 137
    CrossrefPubMedGoogle Scholar
  • 70 Fried TR, Bradley EH, Towle VR, Allore H. Understanding the treatment preferences of seriously ill patients. N Engl J Med 2002; 346 (14) 1061-1066
    CrossrefPubMedGoogle Scholar
  • 71 Bellera CA, Rainfray M, Mathoulin-Pélissier S. et al. Screening older cancer patients: first evaluation of the G-8 geriatric screening tool. Ann Oncol 2012; 23 (08) 2166-2172
    CrossrefPubMedGoogle Scholar
  • 72 Hall DE, Arya S, Schmid KK. et al. Development and initial validation of the risk analysis index for measuring frailty in surgical populations. JAMA Surg 2017; 152 (02) 175-182
    CrossrefPubMedGoogle Scholar
  • 73 Rolfson DB, Majumdar SR, Tsuyuki RT, Tahir A, Rockwood K. Validity and reliability of the Edmonton Frail Scale. Age Ageing 2006; 35 (05) 526-529
    CrossrefPubMedGoogle Scholar