23 Jul Prehabilitation Seeks to Improve Outcomes in Frail Older Patients
MedicalResearch.com Interview with:
Rakesh Arora MD PhD
Department of Surgery, Max Rady College of Medicine
University of Manitoba, Winnipeg, Canada
Cardiac Sciences Program
St Boniface Hospital
Winnipeg, Manitoba, Canada
MedicalResearch.com: What is the background for this study? What are the main findings?
Response: It is increasingly understood that patients with heart disease are getting older and sicker. In Canada, over 5.7 million people are estimated to be aged over 65 years and as a result a greater number of older adults often complex other health issues are now require cardiac procedures. This places some patients, particular those who are more frail at a higher vulnerability to poorer postoperative outcomes and a complicated recovery process after cardiac surgery. In addition, such patients experience a reduced quality of life as a result of loss of the ability to independently perform activities of daily living (i.e. as cooking, cleaning, bathing activities, toileting etc).
During the preoperative waiting period, the cardiac symptoms and anxiety induces inactivity that in turn compounds the physical and mental deconditioning. In order to improve the functional capacity and enhance postoperative recovery, prehabilitation (“prehab”), a component of the Enhanced Recovery Protocols (ERPs), may be of particular importance.
Prehabilitation (a.k.a. “prehab”) has been described as a preoperative cardiac rehabilitation intervention, a combination of exercise training, education, and social support, affecting patients’ physical and psychological readiness for surgery with the overarching goal to reduce postoperative complications and hospital length of stay as well as ideally improving the transition from the hospital to the community.
MedicalResearch.com: What should readers take away from your report?
Response: In this article, we describe a “3-way approach to prehab that is targeted towards improving Nutritional status (N), Exercise capacity (E) and Worry reduction (W) (“NEW” approach) that may improve the patient journey through their operation and alleviae the surgical stress-related health deconditioning. In this review, the “NEW” approach and its potential benefits on postoperative outcomes as well as an implementation model to aid institutional level implementation were described.
- a) The PREHAB is a Canadian multicentre study that endeavors to provide further safety information on the utility of prehab in this vulnerable patient population.
- b) The PERFORM-TAVR new multicenter study, that will soon begin enrolling at the time of writing, seeks to improve patient-centered outcomes and transitions of care in frail older adults undergoing transaortic valvular implantation.
MedicalResearch.com: What recommendations do you have for future research as a result of this work?
Response: In spite of some evidence to support the effectiveness of prehab, these types of programs are not widespread. There are several reasons for this, however, fundamentally, we need more research to answer some important questions. In particular
– The target populations who might derive the most benefit from prehab are not well defined. It maybe that once someone has advance frailty that prehab may not provide benefit and as such seeking to help patients in the early or “pre-frail” stages may receive the biggest benefit.
– The specific characteristics of a prehab program have also not been well defined and several important factors remain to be adequately investigated. Is it necessary to include all 3 exercise, nutritional, and anxiety-reduction components? For an exercise program, what is the optimal length, frequency, and composition?
There are two Canadian studies that are seeking to answer some of these questions.
MedicalResearch.com: Is there anything else you would like to add?
Response: We urgently need to identify methods to optimize the vulnerable older adult. Recent information suggests that ERPs that are design to help the high-risk, frail cardiac patients may derive benefits towards enhancing preoperative care with a goal of improving nutritional status, functional capacity and reducing anxiety during the preoperative period can enhance the post-procedure recovery process.
Sound Bite: “There is urgent need for the heart team to focus on ensuring that patients don’t just survive but thrive after provide care in the hospital”.
Disclosures: I have received an unrestricted educational grant from Pfizer Canada Inc and honoraria from Mallinckrodt Pharmaceuticals for work unrelated to this paper.
Can J Cardiol. 2018 Jul;34(7):839-849. doi: 10.1016/j.cjca.2018.03.020.
“NEW” Prehabilitation: A 3-Way Approach to Improve Postoperative Survival and Health-Related Quality of Life in Cardiac Surgery Patients.
Arora RC, Brown CH 4th, Sanjanwala RM, McKelvie R.
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