Pre‐habilitation (ii): time for a patient‐doctor contract?

Recent data from the UK's Office for National Statistics would seem to add further weight to concerns that we may be facing a ‘demographic time bomb’ 1. There are now just under half a million people aged ninety years and over in England and Wales, a number that has increased by a third in the last decade alone 2. With an increasingly older population, which is predicted only to expand in the future 3, one can expect that many more individuals will be undergoing major surgery and other physiologically demanding interventions at an older age. Indeed, the latest report from the UK's National Joint Registry has yet again confirmed the trend of sustained annual increases in the number of patients undergoing hip and knee joint replacement procedures, the majority of whom are over sixty years of age 4. Major surgery, in particular that under general anaesthesia, represents a significant challenge to the physiology of the older patient, owing largely to a decline in functional reserves that is seen across all the major body systems as a part of normal human senescence 5-9. The decline in cardiovascular performance can perhaps be illustrated by examining ‘elite’ older athletes’ best times for various running events. Figure 1 shows the world 1500 m record for different age categories 10. Not surprisingly, as individuals age the times lengthen, perhaps more so after the age of eighty years for reasons that are not clear. Set in the context of this anticipated increase in demand for surgery on older patients, coupled with their diminished physiological reserves, the concept of ‘pre-habilitation’ has entered the literature in recent years. In much the same way as rehabilitation, after the event, seeks to optimise patient outcomes after surgery, pre-habilitation may serve to prepare the body, physiologically speaking, for the insults of surgery that lie ahead – perhaps by incremental increases in function as Durrand et al. outline in an accompanying editorial 11. The current consensus from the nascent literature on this topic seems to be that there is as yet a paucity of good data from well-powered randomised controlled trials to support the implementation of specific pre-habilitation programmes into current clinical practice 12. Nonetheless, the principles behind pre-habilitation appear solid, and there have been a number of individual studies that have demonstrated significant improvements across a range of physiological parameters following cardiopulmonary ‘training’ programmes. For instance, in their study of older subjects aged seventy years and above who performed aerobic interval training three times per week for three months, Molmen et al. found that this intensive exercise regimen significantly improved the older subjects’ diastolic function compared with baseline values 13. Diastolic dysfunction, wherein the problem lies in the heart's ability to fill with blood rather than to expel it, is known to be a major factor accounting for reduced cardiovascular performance with increasing age 14-16, and any measure that can ameliorate such an age-related physiological disadvantage should be welcomed with open arms by any clinician who has to manage older patients in the peri-operative setting 17. While larger, randomised controlled trials would be necessary to support the widespread implementation of specific pre-habilitation programmes as clinically effective intervention measures for older patients undergoing major surgery, there is a wider issue that is raised here. Should patients play a greater part in their own medical management, in part by improving their overall physical fitness? The process of ‘self regulation’ needs to be started early, with schools promoting more activity. We believe the answer to be self-evident, especially in the context of increasing burdens on the healthcare sector. The often heard phrase “I can't exercise because of my bad knee or hip” does pose a problem for any new pre-habilitation programme but there are other services that might help these individuals. Comprehensive geriatric assessment 18, including a thorough drug review, would potentially have a greater influence on outcome than any nascent pre-habilitation programme. It must be emphasised that any changes we propose will probably take years to work through into benefits for the health service. Of course, population ageing is not the only spectre with which the clinician will have to contend in the years to come. The obesity ‘time bomb’ is another 19. At the same time that the Office for National Statistics was highlighting the growing older population, it was also producing a disturbing report on the state of the UK waistline. The UK is now the ‘fat man of Europe’ 20; in 1993, 13% of the adult male population in England was classed as obese, a figure that had almost doubled to 24% by 2011 21. More alarming still are the data for children. In 2011, almost one third of children aged two to fifteen years were classed as overweight or obese 21, children who no doubt will grow up to be obese adults in due course. Any measure that seeks to ‘pre-habilitate’ the patient population cannot ignore the need for weight reduction as part of this endeavour, given the known deleterious consequences of obesity for both baseline health and peri-operative management 22. But do we really need specific pre-habilitation programmes to achieve this aim? What about aiming to improve the overall fitness of the population? The focus for the drive to increase awareness of, and participation in, activities that improve the health of the nation must be inclusive and involve the Government and the population as a whole. We are sure that many in primary care already encourage their patients to become more active. The government has also recently announced a £94 million investment to enable some towns and cities to improve their cycling and walking infrastructure 23, but there are many who feel that this does not go far enough. As Gabriel Scally points out in a recent BMJ blog, £94 million represents an insignificant sum when compared against the overall transport budget 24, and would build only four miles of motorway at 2009 costs! This is hardly a move that is likely to improve the safety of walking and cycling across the whole of the UK, or encourage patients to get off their sofas and walk or cycle around the block. Are there any ways that patients could be encouraged to engage in a healthier lifestyle? How about walking to the local hospital or cycling along a secure cycleway, with secure bicycle storage once they had reached the hospital for their outpatient appointment? A new hospital in the East of England was recently completed with a total of 2000 car parking spaces and just 160 spaces for bicycles 25. Could the NHS workforce take the lead and show patients the way? There are cycle-to-work schemes, but without adequate infrastructure that allows individuals to feel safe, will these really be taken up? We suspect that many bicycles, purchased with the good intent of reducing the car parking burden, are gathering dust in sheds and garages and many have never been used to cycle to work. By improving the physical fitness of our patients, we may be able to mitigate not only the age-related decline in physiological performance but also the increased burden on healthcare resources, which is an inevitable consequence of a rapidly ageing and increasingly obese population. While there undoubtedly needs to be a ‘big society’ change, with strong Government support, in how we move around our towns and cities, we must not neglect the need for individual engagement with this project. For our part as healthcare professionals, we have a duty to encourage physical activity whenever we encounter patients. But there also needs to be an understanding that cooperation between patient and doctor involves obligations on both sides, and pre-habilitation may represent one way in which our patients can help us to help them manage their health conditions. Such a spirit of cooperation would not only help to offset the resource burden on struggling healthcare systems but would also give patients a sense of empowerment in taking greater responsibility for their own health. It may be better to replace the clumsy term ‘pre-habilitation’ with ‘normal activities of living’, such as walking to the shops, cycling to work and walking up the stairs instead of using the lift. This is not going to be a ‘quick fix’, and will take a generation to work. One author is starting his medical career, another is coming to the end of his; will the situation be different in 2044? No external funding and no competing interests declared.