A PSH for the Frail Elderly (Phase 3): Prehabilitation of Frail Elderly

From the moment Daniel I. McIsaac, MD, MPH, FRCPC entered medicine, he knew his career would involve research. On joining faculty at the University of Ottawa, he was confident his research program would focus on health systems and observational research. However, after receiving a 2016 IARS Mentored Research Award for his study on “A PSH for the Frail Elderly (Phase 3): Prehabilitation of Frail Elderly,” and gaining valuable new knowledge from that experience, his path took an unexpected turn. Now, as an Associate Professor of Anesthesiology & Pain Medicine, Epidemiology & Public Health and Research Chair in Innovative Perioperative Care at University of Ottawa, Dr. McIsaac spends the majority of his research time running innovative randomized clinical trials, and quite successfully at that. The success of his IMRA-led study helped his research group to receive national funding for a 11-center, 850-participant multicenter trial of an enhanced home-based exercise and nutritional prehabilitation trial for older patients with frailty. Currently one of the largest prehabilitation trials in the world, he is hopeful that it will eventually inform real world implementation of prehabilitation. Below, he shares some insight on his journey in research, how IMRA catapulted his progress as a scientist, and his forward-thinking goals for the future of the specialty.

1. What is your current position? How long have you been in this position? What was your role when you were first funded by IARS?

Associate Professor of Anesthesiology & Pain Medicine, Epidemiology & Public Health; Research Chair in Innovative Perioperative Care, University of Ottawa (Previously, Assistant Professor of Anesthesiology & Pain Medicine)

2. What drew you to academic anesthesiology and to your particular area of research? Has your research subject area evolved since the award?

From the moment I entered medicine, I knew that research would be part of my career. When I entered anesthesiology research, I thought my focus would be on health systems, specifically observational and comparative effectiveness research. In part thanks to the experience gained through the project support by the IMRA (a 2-center RCT of prehabilitation), I have now focused much of my research time and efforts on running innovative clinical trials.

3. What was the goal of your initial research project? Was it met?

At a high level, we wanted to know if we could feasibly and effectively help older people with frailty prehabilitate before major cancer surgery. Our specific objective was to estimate whether enrollment of older individuals with frailty in a home-based exercise prehabilitation program prior to cancer surgery would result in improved functional recovery after surgery. Our objective was met. We enrolled 200 participants with frailty and learned many important insights. First, it was feasible to prehabilitate older people with frailty at home before surgery. But our findings also really demonstrated that achieving adequate adherence was a big challenge. Because some people really struggled to prehabilitate due to the fatigue of chemo, pre-existing pain and competing demands on their time (eg, appointments), across all comers prehabilitation was not efficacious. However, when we zoomed in on the group that was doing at least 80% of their exercises we found large and meaningful improvements in outcomes like functional recovery and complication rates.

4. How did your findings impact patient care?

These findings, along with related findings in the field, have made it clear that for prehabilitation to be effective in real world care, substantial focus is required in supporting patients to be able to fully participate in prescribed exercise and nutritional programing.

Moving forward, we’ve built more personalization into our programming, worked with patients to develop strategies to manage fatigue and pain, and added a bigger focus on nutrition.

5. How did your research impact the field of anesthesiology?

We have advanced our knowledge of how to optimize some of our highest risk patients before surgery.

We’ve also made novel inroads into collaborating with surgeons and geriatricians around prehabilitation of vulnerable older adults. Because prehabilitation takes time, we recruit directly from our surgical colleagues’ clinics to get people prehabbing as early as possible. We also try to incorporate the holistic approach to care demonstrated to be effective by geriatricians using comprehensive geriatric assessment. For our team, based on an initial frailty assessment, we can target the source of frailty-specific deficits like poor physical function, malnutrition and stress and anxiety management before surgery.

6. How did the award affect your research/professional trajectory?

The IMRA had a major impact on my career. Based on the success of our IMRA-funded trial, we received national funding for a 11-center, 850-participant multicenter trial of an enhanced home-based exercise and nutritional prehabilitation trial for older patients with frailty. This trial has a major focus on implementation and adherence. It is currently one of the largest prehab trials in the world and will complete enrollment in early 2024. We’ve also received funding to support a pragmatic, registry linked prehab trial – not focused only on people with frailty – that should directly inform real world implementation of prehabilitation.

In addition, by building a prehab-focused research program, we have brought together a multidisciplinary network of patients, scientists, clinicians and health system leaders (the Prehabilitation Knowledge Network), which is leading knowledge synthesis in the field of prehabilitation.

7. How do you feel about having received the IARS Mentored Research Award?

Receipt of the IMRA award was a major stepping stone in developing my research program and career.

8. What is something that someone would be surprised to learn about you?

Before I was running multicenter prehab trials, I was milking cows on my family’s dairy farm.

9. What is your vision for the future of anesthesia research?

We need to be constantly looking for opportunities to enhance care and outcomes across the perioperative journey. The role of the anesthesiologist should start as soon as a surgical procedure is being considered, and stretch to the time where a patient is home and back to baseline function. Many of the lessons learned in optimizing care provided in the operating room can be transferred to the wider perioperative landscape, and we should not limit our impacts only to locations equipped with anesthetic machines.