Care for older adults undergoing surgery: Attitudes, knowledge, practices, and needs of geriatricians and trainees

The demand for surgical services is expected to increase as the world's population ages. Older adults have a higher prevalence of comorbidities, cognitive impairment, functional deficits, and frailty making them vulnerable to postoperative complications. To improve patient outcomes, the comprehensive geriatric assessment (CGA) and optimization have been employed in the management of older patients undergoing surgery.1 Evidence supports the involvement of geriatricians in perioperative care. Co-management models involving orthopedic surgeons and geriatricians demonstrated a reduction in the length of stay and mortality.2 The Peri-operative Optimization of Senior Health study (POSH) showed that collaboration between geriatricians and the surgical team reduced the length of stay, lowered the rates of readmission, increased the rates of discharge home under self-care, and reduced the rate of complications following elective abdominal surgery.3 However, despite the evidence and guideline recommendations for the integration of geriatricians into surgical care of older adults, Canadian and American geriatric medicine licensing bodies lack specific education objectives in this area. Canada, in particular, lags in implementing perioperative geriatric care models, establishing related quality standards, and providing formal education for the geriatrician workforce in perioperative geriatrics. The aim of this study was to understand the attitudes, knowledge, practices, and needs of geriatricians and geriatric medicine trainees regarding the care of older adults undergoing surgery in Canada. Between December 2021 and June 2022, we conducted a cross-sectional, online survey of geriatricians and geriatric medicine trainees in Canada. The self-administered questionnaire was organized into five domains: respondent characteristics, practices, attitudes, knowledge, and needs. The topics covered within these domains ranged from preoperative fasting recommendations and delirium prevention to postoperative cardiac monitoring, and opioid-sparing pain regimens. The items within the practice, attitude, and needs assessment domains were based on validated questionnaires.4-6 Practice questions were administered exclusively to geriatricians. A global attitude score was calculated based on eleven 5-point Likert scale questions by assigning point values from "strongly disagree" to "strongly agree." The average attitude score was categorized as negative, neutral, or positive. The knowledge items included awareness of six relevant guidelines and five multiple-choice scenarios based on perioperative guidelines. Items were scored based on Likert scale, free-text and multiple-choice options. Refer to Supplemental Table S1 for the Checklist for Reporting Results of Internet E-Surveys (CHERRIES) and refer to Supplementary Table S2 for the questionnaire. A total of 94 surveys were submitted, resulting in a 23% response rate. Geriatrician respondents had been in practice from less than two to over 30 years. Most geriatricians (58%) care for surgical patients less than 25% of the time. Preoperatively, a majority of geriatricians reported often or always performing a surgical risk assessment (58%), recommending an opioid-sparing pain regimen (68%), and assessing complications common to any surgery (65%). See Figure 1 for results. 91% of respondents reported a positive attitude toward caring for older surgical patients, with a mean attitude score of 42.5/55 (SD 4.4). None of the respondents had a negative attitude. Fifty-eight percent of the respondents identified challenges when caring for older surgical patients. Several themes emerged including inability to meet the demand for geriatric services before surgery; limited training opportunities in perioperative geriatrics; and lack of communication between geriatrics and the surgical team. See Figure 1 for results. Respondents' guideline awareness ranged from 30 to 70%. 70% were aware of the American Geriatrics Society Clinical Practice Guideline for Postoperative Delirium in Older Adults. 50% were aware of Enhanced Recovery After Surgery (ERAS) protocols, and 30% were aware of the British Geriatrics Society Guideline for People Living with Frailty Undergoing Elective and Emergency Surgery. In the knowledge test, respondents scored 75% (SD ± 15%). The scenario with the highest score assessed predisposing factors of delirium and the lowest score pertained to preoperative fasting recommendations. See Figure 1 for results. Most respondents expressed the need for additional training to care for older surgical patients. Eighty-seven percent expressed at least some need for further training in surgical risk assessment, 78% in surgical collaborative care models, 84% in prehabilitation, and 85% in perioperative medicine. See Figure 1 for results. This study represents the first national survey in North America that examines the contemporary attitudes, knowledge, practices, and needs of geriatricians and geriatric medicine trainees regarding the care of older adults undergoing surgery. Many respondents highlighted the lack of training opportunities in perioperative geriatrics. To address this gap, the Royal College of Physicians and Surgeons of Canada (RCPSC) and the American Board of Internal Medicine Geriatric Medicine could incorporate specific perioperative learning objectives. Training programs should provide dedicated instruction on perioperative topics while conferences should aim to disseminate knowledge, share best practices, and review perioperative evidence and guidelines. The needs identified in this study, such as surgical risk assessment, surgical collaborative care models, prehabilitation, and perioperative medicine, can serve as a starting point for teaching topics. Another challenge identified was the inability to meet the demand for geriatric services before surgery, necessitating an interdisciplinary approach or innovative use of the workforce to deliver geriatric care and sustain services. The strengths of this study include the representation of trainees and geriatricians, and the use of rigorous survey methodology, including questionnaire development, testing, and administration. The study utilized existing scales, and the knowledge test was based on perioperative guidelines rather than self-reporting. Limitations include the relatively low response rate of 23%, which was lower than the response rates of Chesney's 2018 study evaluating surgeons' and trainees' attitudes, knowledge, practices, and needs which were 55% and 33% respectively.4 Our lower response rate may potentially give rise to bias and limit the generalizability of the findings to the target population. Additionally, the study relied on self-reported responses rather than audits or direct observations. Survey research by nature has inherent limitations and may not provide a deep understanding of the views of geriatricians and geriatric medicine trainees regarding perioperative care but serves as a starting point for further discussion. Globally, there is increasing momentum for integrated proactive perioperative services for older adults. We need to leverage geriatricians' positive attitudes and equip them with the necessary knowledge and systems for collaborative perioperative geriatric services. Study conception: Miller, Chesney, Wong. Study design: Miller, Wong. Data acquisition: Miller. Data analysis: Miller. Data interpretation: Miller, Chesney, Wong. Manuscript writing: Miller. Manuscript revision: Chesney, Wong. We thank Dr. Eric Wong, Dr. Richard Norman, Dr. Dov Gandell, Dr. Jenny Huang, Dr. Corita Vincent, and Dr. Carla Rosario for pilot testing and reviewing the earlier versions of the questionnaire. The authors have no conflicts to declare. This work was supported by the Division of Geriatric Medicine at the University of Toronto. No sponsors have contributed to this research. Supplemental Table S1. Checklist for Reporting Results of Internet E-Surveys (CHERRIES). Supplemental Table S2. Electronic survey. Please note: The publisher is not responsible for the content or functionality of any supporting information supplied by the authors. Any queries (other than missing content) should be directed to the corresponding author for the article.