The Perioperative Optimization of Senior Health (POSH) program, launched by Duke in 2011, brings together surgical, anesthesia, and hospital care teams to help patients and families prepare for surgery and plan for recovery.
Charles D. Scales, MD, a Duke urologist, says the program has become an essential part of helping physicians assess surgical options for urologic procedures. “We see many frail patients with reduced physical reserves for tolerating surgery,” Scales says. “When I identify those cases—typically patients over 80 years old or any patient over 65 years old with significant comorbidities or impaired cognitive function—I always send them to POSH for evaluation.”
The POSH partnership is just one aspect of the collaboration between the 2 specialties, he says. Duke geriatricians regularly round on patients who have undergone urologic procedures to help with pain management, nausea, and other postoperative conditions. “If our patients require a hospital stay that extends beyond a single night, the geriatric team is part of our care partnership,” he says.
Shelly R. McDonald, DO, PhD, a geriatric care specialist who works with patients and families in the POSH program, says referrals are growing. “Increasingly, we come into the picture because a surgeon sees a patient and recognizes the challenges the individual will face after surgery,” she says.
As urologists respond to an aging population, patients with urinary tract symptoms have become more common. Men present frequently with urine flow issues, and both sexes often present with kidney stones. For such conditions, surgery can be curative. But urologists are cautious.
“Undergoing surgery when you are 75 or 80 years old is not an endeavor to be taken lightly,” Scales says. “The health of the patient and the invasiveness of the procedure are significant factors in our decision-making process.”
Patients with cognitive challenges often resist surgery even when it is needed, Scales says, because of fears about the effects of anesthesia. “The fact is, some patients need surgery, and, with some urologic conditions, the likely benefits outweigh the risks,” Scales says. In those cases, the POSH team provides planning, pre-operative preparation, and reassurance to patients and families.
POSH geriatricians help urologists evaluate patients’ readiness and tolerance for surgery. In some cases, they discourage the procedure. “Sometimes the POSH team says surgery is not a good idea,” Scales says. “This decision is reached after talking to the patient and the family and reviewing their overall goals. In those cases, we revert to a medical therapy, which must be sustained for the life of the patient.”