An article contributed by Dr Sharmini Su Sivarajah and A/Prof Chew Min Hoe from Sengkang Hospital.
The PEERS team
It is projected that 20-25% of Singapore’s population will be above 65 years old by 2030. With an aging population and a longer life expectancy, the average age of the surgical patient is expected to increase. Frailty is a common condition among the elderly. This has immense health care implications as frail individuals do not just experience increased morbidity and mortality after surgical intervention; they are also likely to require nursing home and long term care facilities after surgery. Needless to say, these individuals can pose a significant healthcare financial and societal burden for the nation. There is evidence in medical literature that frailty can be reversed with appropriate prehabilitation and nutritional therapy. Thus, there exists a window of opportunity for surgeons to optimise frail individuals prior toelective surgery in the hope of achieving outcomes similar to that of non-frail individuals. The PEERS (Programme for Enhanced Elderly Recovery @ SKH) is a pilot programme to develop and validate a prehabilitation service for the frail and elderly. It is a 2-3 week programme which aims to intervene on frail individuals by optimising their nutritional and physical function before surgery. The patients are then provided with an individualised multi-disciplinary prehabilitation protocol targeted at their identified needs. Any intervention which can reverse or attenuate the frail state prior to surgery will improve patient outcomes with potential cost savings.
18 frail and elderly patients underwent the PEERS programme in Alexandra Hospital between 2017 and early 2018. The median age of the patients recruited was 79 years (i.q.r. 75 – 84 years). In this cohort, there was equal sex distribution (9 male: 9 female). 13 patients (72.2%) had either Stage 1 or Stage 2 disease. All patients developed improvement in their functional status post-prehab prior to surgery. There was no mortality reported and the morbidity rate was only 5.6% (1 out of 18 patients). The mean and median length of stay was 6.7 and 8 days respectively. All patients were discharged back to their own homes. 92.9% (13 out of 14 patients) professed equal or higher quality of life (QoL) scores at 3 months after surgery compared to QoL scores taken before surgery.
The outcomes for all these patients have been very favourable with low acceptable morbidity rates. There is improvement in functional status pre-surgery, reduced length of stay post-surgery, and rapid improvement back to baseline status after surgery. Our early pilot has validated the need for a pre-habilitation intervention programme for major surgery which in the long term helps to not only reduce the financial strain in managing an ageing population, but also increases the confidence in family members and patients to a successful positive outcome after major surgery.
With these encouraging results, we hope to recruit a larger sample of frail patients, so as to demonstrate significant cost effectiveness, a reduction of morbidity rates as well as an increase in quality of life in these patients. This in turn will drive the medical frontier to change how medical practitioners manage these frail patients, especially those who undergo major surgery in the future.