Carrick, Laura
(2021)
Determining the need for, effectiveness and feasibility of bed-side measures to determine physical fitness in the older surgical patient.
PhD thesis, University of Nottingham.
Abstract
Purpose.
The success of the NHS has resulted in a population which is aging[1], with those over 75 years of age undergoing surgery increasing[2]. Frailty, a geriatric syndrome[3], is an independent risk factor for morbidity, mortality and increased LoS in hospital[4][5]. With physical function[6][7][8][9][10] and sarcopenia linked with frailty and adverse outcomes[7][8], by addressing these modifiable factors through exercise interventions, there is the potential to improve older patient outcomes and QoL.
Methods.
A systematic review of the evidence for exercise-based therapies in the post-operative period was conducted. Bed-side tests of physical fitness were compared to CPET, and their ability to measure change following a 4-week exercise progamme assessed, in two healthy older volunteer studies. A RCT determining the feasibility and impact on physical function of a 6-month home-based exercise programme following major non-cardiac surgery in older patients was undertaken. Surveys of older patients and the health care providers were used to assess patient need.
Results.
The systematic review established that post-operative exercise programmes can lead to improvement in physical function in the older population. However, this was limited by the significant clinical heterogeneity in the small number of studios included. The results support the use of HGS as a bed-side test in the assessment of physical fitness, with predictive models derived. However, none of the bed-side tests or derived models were able to measure the elicited change in CRF following 4 weeks of exercise training. The RCT showed that it was not feasible to implement a home-based exercise training programme post-operatively in the older surgical population. The surveys, limited by poor response rates, showed a disparity in the recovery experiences of cognition and fatigue between patients and health care professionals, with an “expectation mismatch” highlighted by the GPs.
Conclusions.
As a body of work this has demonstrated the need for, and potential value of addressing physical function through the use of exercise interventions in the post-operative period for the older patient. With alternative tests of physical fitness, such as HGS, useful clinical tools. However, due to limitations experienced, further work is required in this field. This thesis has highlighted the need for greater collaboration between health care disciplines in order to understand patients’ needs along-side clinical outcomes, to improve patient and health care engagement in research ensuring future work leads to meaningful and better outcomes.
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