Boosting recovery for frail elderly after surgery

Mr Tan Cheng Hong, 90, benefited from the transdisciplinary care at KTPH when he underwent surgery in May. Monitoring his progress are senior physiotherapist Kylie Siu and Dr Tan Kok Yang, head of surgery.
Mr Tan Cheng Hong, 90, benefited from the transdisciplinary care at KTPH when he underwent surgery in May. Monitoring his progress are senior physiotherapist Kylie Siu and Dr Tan Kok Yang, head of surgery.ST PHOTO: ONG WEE JIN

Fewer deaths, complications for patients who eat better and exercise more before operation

A different way of treating frail patients at Khoo Teck Puat Hospital (KTPH) has resulted in far fewer deaths and complications following colorectal and abdominal surgery. And its success has spurred other hospitals to introduce similar programmes.

The treatment's secret: Prehabilitation, or getting patients to eat better and exercise more before the operation to boost their health.

Ten years ago, when 100 frail elderly patients were operated on for colon cancer at KTPH, about 10 would die within 30 days of surgery, while 31 would suffer from major complications that could see them admitted to the intensive care unit.

Currently, with the new treatment, two die and five have major complications such as infections and respiratory or organ failure.

This means that out of 100 patients, eight more survive and 26 are spared from major complications. On top of that, they spend 21/2 days fewer in the hospital, with 98 per cent recovering full use of their functions within six weeks of surgery.

A frail person is one who has low functional reserves, tires easily, has decreased muscle strength and is highly susceptible to diseases.

Other hospitals have since taken a leaf from the book of KTPH. Associate Professor Chew Min Ho - who heads surgery at Sengkang Hospital and is currently at Alexandra while waiting for the new hospital to open - said the hospital's programme for the elderly was conceptualised "after discussions with and learning from key members" of the KTPH team. Since its launch in March, Prof Chew said the complication rate is low and "patients and caregivers have increased confidence in the surgery and have fewer fears and worries".

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    Mr George Toh, a senior dietitian at Khoo Teck Puat Hospital, said half of the hospital's elderly patients who go for colon surgery are malnourished.

    This is largely due to them not getting enough protein and energy in the form of carbohydrates and fats.

    So, in the two to three weeks before surgery, he said the hospital's main aim is to increase their protein and energy intake to optimise their nutritional and functional status.

    They are told to eat more high-protein and energy food such as fish, chicken or tofu. They should eat a 11/2 palm-size amount for lunch and dinner. Breakfast could be cheese, eggs and a thick layer of peanut butter on bread.

    For those who cannot eat much, Mr Toh suggested they eat high-protein and energy snacks in between meals, such as peanut butter or egg sandwiches, soya bean curd, milkshakes or liquid Chinese desserts like sesame paste.

    He also said older people should eat protein-rich food and carbohydrates first before high-fibre food. This is because fibre can make them feel full, resulting in them not eating enough protein or carbohydrates, which is more important for the elderly.

    Salma Khalik

Dr Tan Kok Yang, head of surgery at KTPH, said it all started 10 years ago when doctors at the hospital decided they needed better ways to treat the frail elderly, as too many were dying or suffering from major complications after surgery.

Then in 2012, a Japanese study showed that frail patients were four times more likely to suffer from major complications. So the KTPH team started to treat frailty as it would any other disease, by making sure that a patient's condition and constitution are optimised before surgery.

Dr Tan said: "If the patients' reserves are not enough and go down with surgery, they have nothing left. So we try to increase their reserves through prehabilitation."

This includes better nutrition and exercise to build up muscle strength.

Aside from prehabilitation, KTPH set up transdisciplinary teams of doctors, nurses, therapists, dietitians and pharmacists who worked together to decide how to treat the patient.

Instead of just being focused on the outcome of surgery, Dr Tan said "the surgeon has to be ultimately accountable for all short-term and longer-term outcomes for patients he operates on".

So the surgeon would also need to know the concerns that geriatricians and therapists, for instance, have for the patient.

This arrangement is unlike multidisciplinary teams that most hospitals have, as those provide input but do not plan the patient's treatment as a team.

Dr Tan said one of the key goals of the team is for patients to retain their functional abilities, such as being able to walk or eat on their own.

"If we can't get them to return to their previous level of functionality, we are not achieving anything for the elderly," he said. "Many patients are more fearful of disability and loss of independence than death."

With the transdisciplinary approach, 98 per cent of patients recover functionality within six weeks of surgery, compared with 84 per cent previously.

Mr Tan Cheng Hong, 90, was a beneficiary of this transdisciplinary care when he was diagnosed with a 9cm tumour in his colon. He had fallen, fractured a couple of vertebrae and had a rod put in his spine last year at another hospital. His weight dropped to 38kg and his movements were very slow.

Then, he was diagnosed with colon cancer.

The KTPH team got him to exercise and eat better to build up his reserves for the surgery in May. He was able to get up and walk just two to three days after his operation. His weight has gone up from 38kg to 44kg.

His daughter, Mrs Yean See, 49, said what happened to her father has convinced her that KTPH's team is "a very special" one. She said: "He's happy and eats well."

A version of this article appeared in the print edition of The Straits Times on September 30, 2017, with the headline 'Boosting recovery for frail elderly after surgery'. Print Edition | Subscribe