What research proposals should be prioritized to improve perioperative care for geriatric patients with significant comorbidities undergoing surgery?

Priority Research Proposals for Geriatric Perioperative Anesthesiology

Research into postoperative delirium prevention and cognitive outcomes must be the highest priority, as these complications affect up to 50% of elderly surgical patients yet remain underdiagnosed with no established optimal prevention or treatment strategies. 1

Critical Research Gaps Requiring Immediate Investigation

Postoperative Cognitive Dysfunction Research

• Anesthetic depth and agent selection studies are urgently needed to establish causation (not just association) between specific anesthetic agents, depth of anesthesia, and long-term cognitive outcomes in geriatric patients 1

• Cerebral oxygen saturation monitoring protocols require validation through large-scale trials, as preliminary evidence suggests maintaining systolic blood pressure within 10% of baseline and oxygen saturation >95% may reduce postoperative delirium and cognitive decline 1

• Mechanistic studies must identify why elderly patients with cardio-/cerebrovascular disease and multimorbidity face significantly elevated risk of postoperative delirium (POD) and postoperative cognitive decline (POCD), beyond current descriptive epidemiology 2, 3

Preoperative Optimization Protocols

• Emergency surgery optimization research is critical, as current evidence supports nutritional supplementation for subclinical anemia ≥28 days preoperatively to reduce morbidity and mortality 2, 1, but optimal protocols for emergency cases (where delay increases mortality 2) remain completely unknown 1

• Shortened preoperative intervention timeframes need investigation, particularly for smoking cessation and alcohol abstinence in urgent surgery, as current recommendations (≥4 weeks cessation) are impractical for emergency or semi-urgent cases 1

• Simultaneous optimization during emergency surgery requires protocol development, since preoperative delay before hip fracture surgery and emergency laparotomy worsens outcomes, suggesting optimization must occur concurrently with surgical intervention rather than consecutively 2

System-Level Implementation Research

• Geriatric co-management model implementation studies are essential, as these models beginning preoperatively significantly reduce mortality, length of stay, and discharge to higher care levels 1, yet optimal implementation strategies across diverse healthcare systems remain undefined 1

• Enhanced Recovery After Surgery (ERAS) protocol modifications specific to elderly patients require validation, despite evidence showing 30-50% reductions in hospital length of stay and complications in patients >70 years 1

• Multidisciplinary team structure research must define optimal composition and timing of involvement, as rapid access to geriatricians, anaesthetists, intensivists and surgeons is recommended 2 but specific protocols are absent

Methodological and Evidence Quality Improvements

• High-quality randomized controlled trials are desperately needed, as most perioperative care recommendations for elderly patients currently rely on expert consensus opinion rather than robust evidence 2, 1

• National audit projects and outcomes research specifically involving elderly surgical patients must be expanded, as the evidence base remains poor 2

• Comparative effectiveness research between comprehensive geriatric care models is required, as a 2021 meta-analysis of 2,672 patients showed no significant differences in delirium prevalence, length of stay, 30-day readmission, or 30-day mortality 4, suggesting current models need refinement or better implementation

Demographic Urgency Driving Research Priorities

• By 2025, approximately 10% of the population will be aged >75 years, creating unprecedented economic and clinical burdens unless effectiveness and efficiency of surgical care rapidly improves 1

• Emergency surgery mortality disparities demand investigation, as emergency procedures carry 2-5 times higher mortality risk than elective surgery in elderly patients, with postoperative mortality increasing from 1% in patients <60 years to 10% in those >80 years 1

• Age-related physiological decline, multi-morbidity and frailty are independently associated with increased perioperative risk 2, yet standardized assessment and intervention protocols remain inadequately validated

Specific Clinical Research Needs

Risk Stratification Tools

• Frailty assessment validation requires large prospective studies, as rapid screening tools (Mini-Cog, Patient Health Questionnaire-2, Frail Non-Disabled Survey, Clinical Frailty Scale) 5 need validation for predicting specific perioperative outcomes beyond general risk

• Functional capacity measurement (<4 METs threshold) 6 needs correlation with specific anesthetic technique selection and postoperative outcomes in adequately powered trials

Anesthetic Technique Optimization

• Regional versus general anesthesia comparative trials in high-risk elderly patients are needed, as regional techniques are recommended when surgically feasible 6 but definitive outcome data comparing techniques in specific surgical populations are lacking

• Depth of anesthesia monitoring (BIS or entropy) requires validation specifically in elderly patients to prevent relative anesthetic overdose and prolonged hypotension 3, with outcomes beyond surrogate markers

Postoperative Care Protocols

• Multimodal analgesia protocols avoiding opioid-related complications need refinement, particularly regarding NSAIDs in elderly patients with peptic ulcer disease and multiple comorbidities 2, 3, as ketorolac and similar agents carry dose-dependent GI bleeding risk that increases dramatically with age 7

• Delirium prevention intervention bundles require component analysis to identify which specific interventions (medication avoidance, non-pharmacologic optimization) provide the greatest benefit 2, 3