Abstract
Background: Increasing age of persons undergoing elective surgery and progress in surgery methods have led to a higher number of planned orthopedic surgeries for older persons living with frailty. Frail older persons face a higher risk of post-surgery complications due to their reduced physiological capacity. Identifying frailty using ‘Comprehensive Geriatric Assessment’ holds the potential for an individualized prehabilitation approach. Studies indicate that prehabilitation can reduce postoperative complications in frail older patients with cancer, and that perioperative geriatric care can improve recovery after acute illness. Therefore, we co-designed a 4-week multicomponent prehabilitation and perioperative geriatric care intervention for frail older persons undergoing planned orthopaedic surgery. Our aim was to assess how the intervention was feasible across hospital and home settings.
Approach: This feasibility study recruited patients aged 65+ years referred to planned surgery in hip, knee, shoulder, or spine and assessed as frail by the Brief-Multidimensional Prognostic Index within the period from December 1, 2023 to March 22, 2024. In the hospital, the intervention was initiated by a geriatric nurse, an orthopedic physiotherapist, and a geriatrician. The nurse informed about nutritional supplementations, the physiotherapist planned an individualized training program, and the geriatrician reviewed and optimized the patients’ medication list. Prehabilitation was conducted at home where the project manager contacted the patient by phone twice a week and coached the patient until time for surgery. During hospitalization the geriatrician collaborated with the staff in the orthopedic ward, the general practitioner, and homecare to plan discharge and usual rehabilitation in the municipality. The intervention was co-designed with patient representatives, and hospital and community managers. Data on ‘Reach’ (whether the intended patients were offered the intervention) and ‘Dose’ (the quantity of what was implemented) were collected from electronic patient records and patient-reported outcome measures.
Results: Reach: Of 131 eligible patients, 39 (30%) were forwarded frailty screening. Of the screened patients, 18 (46%) were frail. Of those, 14 (78%) consented to participate. Ten (71%) completed the intervention and follow-up periods. Dose: The participants received an average of six of eight planned phone calls from the nurse. All participants took the advice of protein-rich diet supplements and consumed primarily milk, protein drink, curd, and cheese. Exercise adherence at 4-week intervention was on average 21 points (SD 4.4) measured by Exercise Adherence Rating Scale (range 0-24, higher score=higher adherence). All older participants had the planned medication review, each resulting in medication changes averaging one drug per person.
Implications: The findings of the feasibility study in terms of reach and dose indicate that frailty screening poses a challenge, as it is not yet a routine part of daily practice, despite its potential benefits. However, the intervention can be effectively integrated into standard surgical pathways. Its collaborative design, which involves patient representatives and community stakeholders, exemplifies a patient-centered approach that could enhance the relevance and effectiveness of the intervention. Moreover, the adherence to nutritional supplementation and exercise regimens demonstrates that frail older patients with osteoarthritis are receptive to lifestyle modifications that may improve their recovery trajectories.