Swarbrick, Claire
(2025)
The impact of frailty and multimorbidity on postoperative outcomes in older patients.
PhD thesis, University of Nottingham.
Abstract
Older adults represent a growing proportion of the surgical population, with surgical interventions offering potential benefits including increased longevity and improved symptom management. However, older patients, particularly those living with frailty and multimorbidity, are at heightened risk of poor postoperative outcomes. Whilst evidence suggests that perioperative medicine services, especially those incorporating comprehensive geriatric assessment and optimisation, can improve these outcomes, the prevalence of frailty and multimorbidity amongst older surgical patients and their specific impact on postoperative outcomes have not been comprehensively described in a large, generalisable UK population.
This thesis, based on the 3rd Sprint National Anaesthesia Project (SNAP-3) body of work, explores the impact of frailty and multimorbidity on older surgical patients and examines the provision of perioperative medicine services.
First, a narrative review outlines evidence-based interventions to reduce postoperative delirium. Second, the methodologies of a large, inclusive observational cohort study and two national surveys are detailed and critically appraised. Third, the availability of perioperative medicine services across UK and Irish hospitals is described, revealing inconsistencies in service provision, particularly regarding the identification of frailty. Fourth, a survey of on-call medical registrar referrals for older surgical patients highlights the effect of perioperative medicine services on both patient care quality and medical team workload.
Fifth, the cohort of older surgical patients is characterised, revealing that 19% were living with frailty and 63% with multimorbidity. Sixth, analysis of specific surgical subgroups provides further insight into key issues, including day surgery; non-elective pathways; shared decision-making; and the organisation of perioperative medicine services. Seventh, the impact of frailty and multimorbidity on postoperative outcomes is modelled, demonstrating that increasing frailty is associated with longer hospital stays, higher odds of delirium, morbidity, and mortality up to one year. Notably, an increase in odds is observed amongst those classified as ‘living with very mild frailty’ or ‘prefrail’.
In conclusion, this thesis highlights the substantial impact of frailty on postoperative outcomes and the variation in perioperative medicine services designed to identify and manage frailty and multimorbidity in older surgical patients. These findings reinforce the national drive to expand perioperative medicine services, particularly with the expertise of geriatricians. Chapters 3, 4, 5, 6, 7, 8 and 10 contain published works. Further outputs from SNAP-3 will include a detailed analysis of postoperative delirium and its consequences, the influence of frailty, multimorbidity, and delirium on quality of life, readmission rates, and long-term mortality, and a refined study of multimorbidity using alternative definitions beyond simple comorbidity counts.
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