Multi-Component Prehabilitation Program for Older Adults Undergoing Major Elective Surgery: A Pilot and Feasibility Study

Abstract

Background:

Prehabilitation may help older adults recover after surgery, yet adherence has been variable. We assessed the feasibility of a multi-component prehabilitation program.

Methods:

This single-arm trial was conducted at an academic medical center to test the feasibility of an individualized prehabilitation program before major surgery. The program consisted of twice-weekly physical therapy, weekly dietician consultations with daily protein supplementation, and weekly group meditation for 3 to 4 weeks. The primary outcome was adherence, as measured by the proportion of completed sessions. Secondary outcomes included changes in gait speed, chair stands, and grip strength after intervention and Patient-Reported Outcomes Measurement Information System (PROMIS)-Physical Function scores at 90 days post-surgery.

Results:

Of 95 eligible patients, 30 (31.6%) were enrolled (mean [SD] age, 75.3 [6.6] years; 12 [40.0%] women; 19 cardiac and 11 non-cardiac procedures) and 28 began the intervention. Adherence was 91.3% (190/208 sessions completed) for physical therapy, 76.9% (80/104 sessions completed) for dietician consultation, and 68.3% (71/104 sessions completed) for meditation, with 67.9% of the participants completing at least 50% of each component. Among 25 participants (89.3%) who completed the intervention, mean walking speed increased (0.2 m/s; 95% CI: 0.0 to 0.4), and mean time to complete 5 chair stands decreased (3.4 s; 95% CI: −6.9 to 0.0), but mean grip strength did not change significantly (1.6 kg; 95% CI: −2.1 to 5.3). Among 22 out of 23 participants (95.7%) who underwent surgery, the mean PROMIS-Physical Function score improved by 4.4 points (95% CI: 3.0 to 5.9) at 90-days post-surgery compared to baseline. Adverse events included gastrointestinal discomforts (3 events), musculoskeletal pain (3 events), and dizziness (1 event).

Conclusions:

This study demonstrates the feasibility of multicomponent prehabilitation in older patients scheduled for major elective surgery.

INTRODUCTION

Older patients experience high rates of postoperative complications and functional decline due to reduced physiologic reserve and frailty.¹ Prehabilitation has emerged as a promising approach to enhance functional capacity, improve postoperative outcomes, and accelerate recovery.² Currently, no universally accepted prehabilitation protocol exists and most programs have focused on a single component such as exercise.^2,3 Exercise-based prehabilitation improves physical performance compared to standard care after cardiac,⁴ thoracic,⁵ abdominal,⁶ and orthopedic surgery.⁷ Emerging evidence suggests the potential of meditation in improving pain and anxiety in the perioperative period.^8,9 Therefore, multi-component programs incorporating exercise, nutrition, and psychological interventions may provide greater benefits to older patients with complex health needs.^10,11 Importantly, few studies have measured patient-centered outcomes such as functional status and health-related quality of life.³ An adequately powered, randomized controlled trial (RCT) is needed to provide more precise efficacy estimates and inform strategies for implementation of prehabilitation in older adults.¹²

As a foundational step, we conducted a feasibility study of a multi-component prehabilitation program—including physical therapy, nutrition, and meditation—for older adults undergoing major elective surgery.

METHODS

Eligibility and Enrollment

This single-arm trial (NCT05752474) was conducted at Beth Israel Deaconess Medical Center (enrollment site) and Hebrew Rehabilitation Center (intervention site) in Boston, Massachusetts, from March 2023 to January 2025. The study was approved by the Institutional Review Board at both institutions. Patients 65 years or older scheduled for major abdominal, gynecological oncologic, urologic, and cardiovascular procedures were eligible. Major surgery is defined as an inpatient procedure involving general anesthesia, openings into the great cavities of the body, manipulation of major organs or vessels, significant physiologic stress, or intensive postoperative monitoring.^13,14 Exclusion criteria were: (1) surgery scheduled less than 21 days from the expected prehabilitation start date; (2) clinical ineligibility based on the surgeon’s assessment; (3) inability to speak English; (4) major neurocognitive disorders; and (5) inability to provide informed consent. Our study team received referrals from surgical clinics at Beth Israel Deaconess Medical Center. Surgeons and nurse coordinators provided the names, medical record numbers, and contact information of potential participants via email. Informed consent was obtained through either in-person or virtual meetings. We initially targeted older adults with frailty, but challenges in frailty screening by surgeons led us to revise the protocol to allow referrals based on the surgeons’ clinical judgment of high surgical risk.

Baseline Assessment

Research staff collected age, sex, chronic conditions, and body mass index from electronic medical records and self-reported race and ethnicity (White, Black, Asian, Hispanic, other), ability to perform 7 activities of daily living, 7 instrumental activities of daily living, and 8 physical tasks (e.g., climbing stairs, walking a half mile), and weight loss during a video interview. A physical therapist from Hebrew Rehabilitation Center conducted in-person assessments of gait speed, 5-chair stands, and handgrip strength. A comprehensive geriatric assessment-based frailty index was calculated (<0.15 [robust], 0.15 to <0.25 [prefrailty], 0.25 to <0.35 [mild frailty], ≥0.35 [moderate-to-severe frailty]).^15-17

Prehabilitation

We developed an individualized, multi-component program to optimize the physical, nutritional, and psychological state of older patients, guided by the available evidence (Figure 1).^10,11 While prehabilitation durations in the literature range from 2 to 8 weeks,^4-7 we chose a 3-to-4 week timeframe, aligning with the typical interval between the clinic visit and surgery. The specific duration—3 or 4 weeks—was determined by the time remaining before their scheduled surgery. The program included the following components:

Figure 1. Conceptual model of a multi-component prehabilitation program.

Patients aged 65 years and older, scheduled for major elective surgery at least 21 days in advance, were enrolled. The prehabilitation program comprised three to four weeks of individualized physical therapy, nutritional counseling with protein supplementation, and guided meditation. Patient-centered outcomes were assessed at 30 and 90 days post-operatively.

1. Physical therapy: Participants received two one-hour individual sessions per week, delivered by a physical therapist at the Hebrew Rehabilitation Center. These sessions, based on the National Institute on Aging Go4Life guidebook,¹⁸ focused on flexibility, strength, and endurance (Supplementary Table 1). The first and last sessions were in-person for baseline and final assessments. Other sessions in-between could be done in person (on-site or at home) or virtually, according to the participant’s preference. Exercises were tailored and progressed based on the participants’ health status and performance, with modifications to accommodate physical limitations. Participants were given home exercise instructions and encouraged to engage in at least 30 minutes of any type of exercise four or more days per week. Those awaiting cardiac surgery were advised against intensive upper arm exercise, which produced higher heart rate and blood pressure responses than lower-body exercises.

2. Nutrition: Participants received a one-hour individual nutritional counseling virtually by a registered dietitian. They were supplied with a protein bar or drink containing 20 grams of protein and instructed to consume daily, preferably within 30 minutes of exercise, to maximize muscle protein synthesis.¹⁹ The dietician conducted a 24-hour dietary recall and made recommendations to improve dietary quality and increase protein intake, considering comorbidities such as diabetes (low sugar supplement was recommended), chronic kidney disease (protein supplement was not recommended to avoid kidney function decline), personal preference (protein bar or drink) and dietary restrictions (e.g., plant-based supplement). Participants were also educated on meal timing, nutrient-dense snacks, and hydration strategies.

3. Meditation: A meditation instructor at the Beth Israel Deaconess Medical Center Sadhguru Center for a Conscious Planet led a weekly one-hour virtual group meditation session. These sessions focused on breathing techniques and mindfulness practices to alleviate psychological stress, manage anxiety, and promote mental well-being.²⁰ Participants were also given access to meditation videos and encouraged to practice self-guided meditation for 12 minutes daily. Additionally, participants received weekly check-in calls from the research team to discuss their short- and long-term goals and review their progress. Participation in the prehabilitation program was offered at no cost to the participants.

Outcomes

The primary outcome was the feasibility of the prehabilitation program, measured by the proportion of completed sessions for each component and the proportion of participants receiving an adequate dose (≥50% of sessions) across all components. We determined that a minimum of 50% adherence was necessary to achieve positive outcomes, based on evidence from previous literature.²¹ Secondary outcomes included Patient-Reported Outcomes Measurement Information System (PROMIS) scores at baseline, after the intervention, 30- and 90-day post-surgery; and adverse events during the intervention period. The PROMIS Profile-29 computer adaptive tests²² were administered via e-mail or telephone by research staff to assess seven domains (anxiety, depression, fatigue, pain interference and intensity, sleep disturbance, physical function, and participation in social roles).²³ Except for global pain (range: 0 to 10), all domains were reported in T-scores (mean 50 and standard deviation [SD] 10). Minimum clinically important differences (MCID) is 3 points for PROMIS T-scores²⁴ and 1 point for global pain. Exploratory outcomes included physical performance (gait speed, 5-chair stand time, and handgrip strength) at baseline and after the intervention; delirium evaluated using the 3-D Confusion Assessment Method²⁵ within 3 days after surgery; the severity of complications measured using the Comprehensive Complication Index (0 [none], 1-20 [mild], 21-40 [moderate], and 41-100 [severe])²⁶; length of stay, 30-day readmission, and mortality over 90 days post-surgery recorded from a review of electronic medical records and during the 30-day and 90-day interviews. MCIDs were defined as 0.1 m/s for gait speed,²⁷ 3 seconds for 5-chair stand time,²⁸ and 2.7 kg for handgrip strength.²⁹

Statistical Analysis

Study population characteristics and outcomes were summarized using means and SDs, medians and interquartile range (IQR), or frequencies and percentages. Although this study was not powered to evaluate clinical outcomes, we explored the mean change and 95% confidence interval (CI) in each physical performance and PROMIS domain scores from baseline through post-intervention, 30-day, and 90-day post-surgery using random-intercept linear models that included indicator variables for each assessment time. Statistical analysis was performed using Python version 3.11.9 (Python Software Foundation, 2023).

RESULTS

Enrollment and Participant Characteristics

Out of 146 patients screened, 95 patients were eligible, and 30 patients (31.6% of those eligible) were enrolled (Supplementary Figure 1). After enrollment, one patient was disenrolled as the surgery was rescheduled to an earlier date, and another withdrew consent due to a high treatment burden. Among 28 participants who initiated the intervention, surgery was canceled due to disease progression (n=1) or improvements in disease symptoms after completing the intervention (n=2). Two participants withdrew from the study due to high treatment burden (n=1) and anxiety (n=1), and 23 underwent surgery. The mean (SD) age of the enrolled participants was 75.3 (6.6) years, with 18 (60.0%) male, 27 (90.0%) non-Hispanic Whites, 19 patients (62.5%) undergoing cardiac surgery, and 5 (16.7%) with frailty (Table 1). Eight participants were scheduled for cancer surgery, and surgical procedures are listed in Supplementary Table 2.

Table 1. Baseline Characteristics of Study Participants (N=30).

Characteristics	Mean (SD) or n (%)
Age, years	75.3 (6.6)
Female	12 (40.0)
Race
Non-Hispanic Blacks	3 (10.0)
Non-Hispanic Whites	27 (90.0)
Marital status
Married	16 (53.3)
Divorced	4 (13.3)
Widowed	5 (16.7)
Single	5 (16.7)
Medical conditions
Hypertension	23 (76.7)
Diabetes	10 (33.3)
Cancer	11 (36.7)
Coronary artery disease	5 (16.7)
Heart failure	10 (33.3)
Chronic kidney disease	10 (33.3)
Chronic lung disease	6 (20.0)
Surgery type
Cardiac	19 (62.5)
Urologic	5 (15.6)
Gastrointestinal	3 (9.4)
Gynecologic	2 (4.7)
Vascular	1 (2.4)
Cancer surgery	8 (26.7)
CGA-based frailty index category
Robust (<0.15)	16 (53.3)
Pre-frailty (0.15 to <0.25)	9 (30.0)
Mild frailty (0.25 to <0.35)	4 (13.3)
Moderate-to-severe frailty (≥0.35)	1 (3.3)
Any ADL disability	0 (0)
Any IADL disability	8 (26.7)
Length of staya, days	3.7 (4.3)

Abbreviations: CGA, Comprehensive Geriatric Assessment; ADL, Activities of Daily Living; IADL, Instrumental Activities of Daily Living

^aCalculated from 23 patients who underwent surgery.

Feasibility and Safety of Prehabilitation

The overall completion rate was 82.0%, with 91.3% for physical therapy, 76.9% for nutrition, and 68.3% for meditation (Table 2). The proportion of participants who completed at least half of the sessions was 96.4% for physical therapy, 92.9% for nutrition, and 71.4% for meditation, with 67.9% completing at least half of all components. Of the 28 participants who initiated the intervention, 6 did not complete the 90-day follow-up and had lower adherence than those who did, as five were excluded during the intervention period (Supplementary Table 3). Twenty participants (71.4%) received physical therapy sessions in a hybrid format, while 8 (28.6%) attended all sessions in person. Eight participants reported adverse events: gastrointestinal discomforts from protein supplements (3 events); musculoskeletal pain (3 events) and dizziness (1 event) from exercise; and esophageal bleeding (1 event) unrelated to study participation.

Table 2.

Adherence to the Multi-Component Prehabilitation Program (N=28)

Components	Sessions offered n	Sessions completed n (%)	Participants with ≥50% sessions completed n (%)
Physical therapy (2/week)	208	190 (91.3)	27 (96.4)
Nutrition (1/week)	104	80 (76.9)	26 (92.9)
Meditation (1/week)	104	71 (68.3)	20 (71.4)
All 3 components	416	341 (82.0)	19 (67.9)

Changes in Physical Performance and PROMIS Scores

Changes in physical performance from baseline to post-intervention were measured in 25 out of 28 participants (89.3%) who completed prehabilitation (Table 3). The mean gait speed (95% CI) increased by 0.2 m/s (0.0 to 0.4), and the mean time to complete five chair stands decreased by 3.4 seconds (−6.9 to 0.0). However, grip strength did not change significantly. In addition, PROMIS scores were collected in 22 of 23 participants (95.7%) who underwent surgery. The mean PROMIS T-scores in all domains improved from baseline to 90 days post-surgery. The proportion of participants whose PROMIS domain score was improved by more than MCID at 90 days ranged from 32.0% for participation in social roles to 59.1% for physical function.

Table 3. Physical Performance and Patient-Reported Outcomes Before and After Multi-Component Prehabilitation Program.

Measures	N	Mean (SD)	Mean differencea (95% CI)	Clinically meaningful improvement n (%)b
Physical performance
Gait speed, m/s
Baseline	28	1.2 (0.3)	Reference	Reference
Post-prehabilitation	25	1.4 (0.3)	0.19 (0.0, 0.4)	16 (64.0)
Chair stands, seconds
Baseline	28	17.4 (7.5)	Reference	Reference
Post-prehabilitation	25	13.9 (5.3)	−3.44 (−6.9, 0.0)	12 (48.0)
Dominant handgrip strength, kg
Baseline	28	28.3 (7.2)	Reference	Reference
Post-prehabilitation	25	29.9 (6.5)	1.59 (−2.1, 5.3)	4 (16.0)
PROMIS-29 Profile c
Physical function
Baseline	28	43.6 (6.8)	Reference	Reference
Post-prehabilitation	25	44.1 (7.1)	1.5 (0.0, 3.0)	8 (32.0)
Postoperative 30 days	21	45.6 (11.6)	2.9 (1.5, 4.4)	8 (38.2)
Postoperative 90 days	22	48.0 (8.2)	4.4 (3.0, 5.9)	13 (59.1)
Anxiety
Baseline	28	49.5 (8.6)	Reference	Reference
Post-prehabilitation	25	49.0 (9.4)	−2.1 (−3.6, −0.6)	7 (28.0)
Postoperative 30 days	21	43.6 (8.6)	−4.2 (−5.7, −2.8)	13 (61.9)
Postoperative 90 days	22	44.2 (6.4)	−6.4 (−7.8, −4.9)	12 (54.5)
Depression
Baseline	28	44.7 (5.9)	Reference	Reference
Post-prehabilitation	25	45.5 (6.5)	−0.9 (−2.0, 0.2)	6 (24.0)
Postoperative 30 days	21	42.6 (6.5)	−1.7 (−2.8, −0.6)	10 (47.6)
Postoperative 90 days	22	42.7 (5.7)	−2.6 (−3.7, −1.5)	10 (45.5)
Fatigue
Baseline	28	51.7 (9.7)	Reference	Reference
Post-prehabilitation	25	50.1 (8.1)	−1.6 (−3.1, −0.1)	9 (36.0)
Postoperative 30 days	21	49.0 (8.9)	−3.2 (−4.7, −1.7)	10 (47.6)
Postoperative 90 days	22	46.7 (7.9)	−4.8 (−6.3, −3.3)	12 (54.5)
Sleep disturbance
Baseline	28	45.8 (10.0)	Reference	Reference
Post-prehabilitation	25	46.2 (9.5)	−1.0 (−2.7, 0.7)	4 (16.0)
Postoperative 30 days	21	46.1 (9.6)	−2.0 (−3.7, −0.3)	5 (23.8)
Postoperative 90 days	22	42.3 (9.6)	−3.0 (−4.7, −1.3)	9 (41.0)
Participation in social roles
Baseline	28	53.8 (10.7)	Reference	Reference
Post-prehabilitation	25	51.9 (9.2)	0.5 (−1.3, 2.4)	6 (24.0)
Postoperative 30 days	21	53.8 (10.5)	1.1 (−0.7, 2.9)	7 (33.3)
Postoperative 90 days	22	55.2 (10.9)	1.6 (0.2, 3.5)	7 (32.0)
Pain interference
Baseline	28	49.5 (10.1)	Reference	Reference
Post-prehabilitation	25	50.0 (8.8)	−2.0 (−3.6, −0.5)	4 (16.0)
Postoperative 30 days	21	46.3 (9.0)	−4.1 (−5.6, −2.5)	6 (28.6)
Postoperative 90 days	22	44.7 (6.5)	−6.1 (−7.7, −4.5)	8 (36.4)
Global pain
Baseline	28	2.6 (2.6)	Reference	Reference
Post-prehabilitation	25	2.2 (2.1)	−0.5 (−0.9, −0.1)	8 (32.0)
Postoperative 30 days	21	1.5 (2.0)	−1.0 (−1.3, −0.6)	10 (47.6)
Postoperative 90 days	22	1.2 (1.7)	−1.4 (−1.8, −1.1)	10 (45.5)

Abbreviations: PROMIS, Patient-Reported Outcomes Measurement Information System.

^aThe mean differences represent least squares means estimated from linear mixed effects models.

^bThe clinically meaningful improvement was defined as 0.1 m/s for gait speed, 3 seconds for 5-chair stand time, 2.7 kg for dominant handgrip strength, 3 points for all PROMIS measures, and 1 point for global pain score.

^cPROMIS scores are reported in T-scores with a mean of 50 points and a standard deviation of 10 points. Higher scores indicate a more desirable health state for physical function and participation in social roles, whereas lower scores indicate a more desirable health status in the other domains. The global pain score ranged from 0 to 10.

Other Postoperative Outcomes

Among 23 participants who received surgery, none developed delirium within 3 days of surgery. The median (IQR) length of stay was 2.0 (2.0 to 3.0) days. The median (IQR) Comprehensive Complication Index was 8.7 (0 to 25.7). The number of participants who developed no, mild, moderate, and severe complications were 10 (43.5%), 3 (13.0%), 8 (34.8%), and 2 (8.7%) (Supplementary Table 4). Three participants were readmitted within 30 days, and one died during the 90-day period.

DISCUSSION

We demonstrated the feasibility of essential steps for conducting an RCT to evaluate the efficacy of a multi-component prehabilitation program. Key achievements include: 1) successfully enrolling older patients 3 to 4 weeks before various major elective surgery (enrollment rate: 31.6%); 2) delivering a multi-component prehabilitation program with an overall completion rate of 82.0%; and 3) collecting patient-centered outcomes post-surgery, with a completion rate of 95.7%. We also observed improvements in physical performance and quality of life across multiple domains.

Systematic reviews of numerous RCTs^4-7 have shown that prehabilitation programs, primarily based on exercise, improve physical performance (e.g., 6-minute walk test, muscle strength) and may reduce the length of stay and pulmonary complications. A limited number of studies combined exercise with psychological interventions (e.g., relaxation techniques, cognitive behavioral strategies), nutritional strategies (e.g., nutrition education, protein supplementation), and adjunct therapies (e.g., acupuncture). These multi-component programs have the potential to provide greater benefits by addressing multiple modifiable risk factors; however, their efficacy remain uncertain due to the heterogeneity of study populations, interventions, and outcome measures.^10,11 Moreover, adherence is directly related to the effectiveness of the program³⁰ and ensuring adherence presents a significant challenge.¹¹

Our prehabilitation program has several strengths. Interventionists personally engaged with participants, tailoring interventions to their physical health (e.g., selecting appropriate exercises) and personal preferences (e.g., choosing protein supplements). For participants with advanced chronic kidney disease, where protein supplementation is not recommended, nutritional counseling focused on improving diet quality. A unique feature of our program is meditation, which builds on growing evidence of mindfulness-based interventions benefitting general and psychological health,³¹ including pain,³² cognition,³³ anxiety,³⁴ and sleep.³⁵ Although evidence specific to the perioperative setting is limited, early studies suggest that prehabilitation incorporating mind-body interventions is feasible⁸ and that meditation may help alleviate pain and anxiety.⁹ We found reductions in PROMIS anxiety and depression scores post-surgery.

Our pilot study encountered challenges related to screening and enrollment, intervention adherence, and follow-up retention. We summarized challenges, our strategies to overcome them, and lessons learned in Table 4. To maximize adherence, we implemented several strategies. Flexible scheduling and hybrid modalities ensured accessibility. Weekly telephone or video check-ins with research staff supported participant engagement and progress monitoring. We provided a tablet with cellular connectivity to those lacking internet access. We also covered ride service costs for the first and last on-site physical therapy sessions. Together, these strategies contributed to the program’s high overall adherence.

Table 4. Challenges encountered, strategies implemented, and lessons learned during a pilot study of a multi-modal prehabilitation program in older surgical patients.

Activity	Challenges	Strategies Implemented	Lessons Learned
Screening and Enrollment	Screening at preoperative assessment visit (1-2 weeks before surgery) left limited time for intervention. Low initial referral volume. Recruiting patients with frailty	Moved screening upstream to surgical clinic appointments. Expanded number of participating clinics. Sent both email and in-person reminders to surgeons. Simplify eligibility criteria to reduce burden on referring surgeons.	Enroll from surgical clinics to ensure sufficient time for intervention. Outreach proactively and minimize workflow disruption for consistent referrals.
Intervention delivery and adherence	Transportation barriers limited attendance at in-person sessions. Technological issues (e.g., internet access or using virtual platforms) reduced adherence. Competing clinical demands interfered with participation. Physical limitations limited ability to engage. Some participants did not like the provided protein supplements. Lower adherence to meditation.	Provided free ride services and home-based physical therapy. Supplied tablets with cellular data for virtual sessions. Offered flexible scheduling and both in-home and virtual physical therapy options. Tailored exercises based on participants’ capability. Allowed choice of protein bar or drink and multiple flavors. Increased availability of meditation sessions and simplified virtual registration.	Individualize interventions based on participants’ health status and preferences. Reduce participation barrier by offering flexible scheduling and format options. Provide technological support and proactive feedback loops with interventionists.
Outcome follow-up and retention	Some participants did not respond to telephone follow-up interviews. Missed follow-up due to surgery cancellation.	Used multiple contact methods (e.g., email, telephone, mail-in survey)	Offer a choice of contact methods and modality. Continue follow-up even if surgery is cancelled. Consider remote monitoring and financial incentives.

Limitations

Our study enrolled mostly non-Hispanic White patients, likely of high socioeconomic status, at a single academic center in Boston. Most participants in our study were robust or prefrail. As frailty status was not collected from the excluded patients, we could not compare how our participants differ from non-participants. Therefore, our study provides little information on the feasibility and acceptability of prehabilitation among older surgical patients with frailty. Given the resource requirement of our multi-modal prehabilitation program, this is an important limitation in targeting resource allocation. Our population included surgical procedures entailing variable risks and recovery trajectories, adding more complexity to future RCT design. Moreover, the prehabilitation was delivered by clinical experts with extensive experience in geriatric care. As a result, the feasibility we observed may not generalize to patients treated at other hospitals or those with more diverse racial, ethnic, or socioeconomic backgrounds. The absence of a control group without prehabilitation limits the ability to attribute observed outcomes solely to the intervention. Lastly, the PROMIS Profile-29 computer adaptive test uses only four questions per domain, which may not fully capture a modest quality-of-life change.

Conclusions

This pilot study demonstrates that a multicomponent prehabilitation, consisting of physical therapy, nutrition intervention, and meditation, is feasible before major elective surgery. These findings offer valuable information for designing an RCT to evaluate the program’s efficacy in clinical and patient-centered outcomes.

Impact statement:

We certify that this work is novel as it presents feasibility evidence of a multi-component rehabilitation program for older adults undergoing major elective surgery.

KEY POINTS.

• Prehabilitation may enhance functional capacity, reduce postoperative complications, and accelerate recovery in older adults after major surgery; however, the feasibility of multi-component prehabilitation remains uncertain.

• This study demonstrated that a multi-component prehabilitation program consisting of physical therapy, nutrition intervention, and meditation is feasible and safe.

WHY DOES THIS MATTER?

These findings inform the design of a larger, definitive, randomized controlled trial to assess the efficacy of a multi-component prehabilitation program.