Risk prediction instruments in geriatric surgery are available but often ignored.

Abstract

Editor, The Editorial from Pinto et al.1 brings to the attention of anaesthesiologists the great amount of clinical, ethical and organisational dilemmas elderly patients pose to anaesthetists when surgical treatment is needed. This is due to a wide range of factors that include, among others, the ageing processes that deteriorate the stress response to surgical aggression and anaesthesia, comorbidities that reduce functional reserves, chronic medication (mostly when presenting with the features of poly-medication or inappropriate drug intake), impaired functional status ranging from minor impairment to total dependency, and frailty. As geriatric medicine is not taught to surgeons and anaesthesiologists in Europe, surgical professionals are often lacking in reference points and are challenged when facing older surgical patients. This has caused the emergence of two opposite trends: an excessive interventional attitude or excessive caution; neither is the right answer to patients’ needs. Whereas the first may be a result of production pressure exerted on professionals, the second is mostly related to both the predominance of ageism and insufficient knowledge. With at least three international guidelines on optimal preoperative evaluation2 and perioperative management3,4 of the elderly surgical patient, and despite the systematic exclusion of older patients from the majority of randomised controlled trials, in light of present knowledge one would expect an Editorial in the European Journal of Anaesthesiology on risk prediction and perioperative care in older patients to report and comment on both the current availability of clinical and methodological tools helpful in investigating surgical risk factors in the elderly and about methods for proactively and effectively managing those risks in clinical practice. We read instead the emphasis on ‘the risk that even minor surgical interventions can be followed by considerable post-interventional complications’ and on the ‘lack of high-quality quantitative risk assessment tools’ or ‘the difficulties in understanding concepts such as validation cohorts, calibration and external validation’ (concepts which often confuse both young and more expert professionals). Such statements lead anaesthetists to deny treatment to older patients, treatment which not only could prolong life (though some would see that as therapeutic overkill), but also would enable a higher quality of life, enhance mobility and/or eliminate pain and discomfort. In the elderly, anaesthetists need to understand that traditional anaesthesia consultations do not capture all those elements that are needed to assess the risk of complications and plan subsequent targeted perioperative strategies. However, interdisciplinary, comprehensive, team-based preoperative evaluation can significantly improve surgical outcome. Instead of excessively caution-inspired considerations, what anaesthesiologists need is a clear, updated, comprehensive and detailed guideline on preoperative risk assessment and perioperative care in older surgical patients: a task that the European Society of Anaesthesiology is still reluctant to perform. Emphasis should be mostly on the concept that age per se should never be considered a reason for denying surgery to older patients. Finally, it should be emphasised that geriatric medicine should be taught to anaesthetists during their postgraduate education and the domain included among the requirements for the European Diploma of Anaesthesia. This would allow today's anaesthesiologists to become what seems to be their prime objective: to be ‘perioperative doctors’ in the full sense of the term. Acknowledgements relating to this article Assistance with the letter: none. Financial support and sponsorship: none. Conflicts of interest: none.