Preoperative assessment of older adults

The relationship between pre-surgery self-rated health and changes in functional and mental health in older adults: insights from a prospective observational study

BACKGROUND

Elective surgeries are among the most common health stressors in later life and put a significant risk at functional and mental health, making them an important target of research into healthy aging and physical resilience. Large-scale longitudinal research mostly conducted in non-clinical samples provided support of the predictive value of self-rated health (SRH) for both functional and mental health. Thus, SRH may have the potential to predict favorable adaptation processes after significant health stressors, that is, physical resilience. So far, a study examining the interplay between SRH, functional and mental health and their relative importance for health changes in the context of health stressors was missing. The present study aimed at addressing this gap.

METHODS

We used prospective data of 1,580 inpatients (794 complete cases) aged 70 years or older of the PAWEL study, collected between October 2017 and May 2019 in Germany. Our analyses were based on SRH, functional health (Barthel Index) and self-reported mental health problems (PHQ-4) before and 12 months after major elective surgery. To examine changes and interrelationships in these health indicators, bivariate latent change score (BLCS) models were applied.

RESULTS

Our analyses provided evidence for improvements of SRH, functional and mental health from pre-to-post surgery. BLCS models based on complete cases and the total sample pointed to a complex interplay of SRH, functional health and mental health with bidirectional coupling effects. Better pre-surgery SRH was associated with improvements in functional and mental health, and better pre-surgery functional health and mental health were associated with improvements in SRH from pre-to-post surgery. Effects of pre-surgery SRH on changes in functional health were smaller than those of functional health on changes in SRH.

CONCLUSIONS

Meaningful changes of SRH, functional and mental health and their interplay could be depicted for the first time in a clinical setting. Our findings provide preliminary support for SRH as a physical resilience factor being associated with improvements in other health indicators after health stressors. Longitudinal studies with more timepoints are needed to fully understand the predictive value of SRH for multidimensional health.

TRIAL REGISTRATION

PAWEL study, German Clinical Trials Register, number DRKS00013311. Registered 10 November 2017 - Retrospectively registered, https://www.drks.de/drks_web/navigate.do?navigationId=trial.HTML&TRIAL_ID=DRKS00013311 .

Results of emergency colectomy in nonagenarians and octogenarians previously labeled as prohibitive surgical risk

PURPOSE

There are no standardized criteria for what constitutes prohibitive risk for emergency abdominal surgery.

METHODS

A retrospective review was performed comparing two groups of patients having emergent colectomy. One group had previously been labeled as being prohibitive surgical risk and the other was a contemporary, non-prohibitive risk group also requiring emergency colectomy. All operations were performed by a single surgeon.

RESULTS

There were 27 prohibitive risk patients and 81 non-prohibitive risk (control group) patients. The average age of the prohibitive risk group was 85 years (range 78-99) compared to the control group mean age of 52 years (18-79, p < 0.00001). Prohibitive risk was due to extremes of age combined with congestive heart failure in 44%, followed by chronic obstructive pulmonary disease combined with heart failure in 19%. The groups were closely matched by the type of colectomy performed. The total complication rate was much higher in the prohibitive risk group compared to the non-prohibitive risk patients (81% versus 48%, p 0.005). But the 30-day mortality rate was similar between groups (7% versus 4%, p 0.6).

CONCLUSION

Patients who are labeled as prohibitive surgical risk may be inaccurately assessed in the majority of cases. Additional research will need to be performed to evaluate the presence of quantifiable high-risk physiological conditions, and not just comorbidities, that place a patient at high risk of death after abdominal surgery. Until then, elderly patients should not be denied colectomy based upon comorbidities alone.

Applying Evidence-based Principles to Guide Emergency Surgery in Older Adults

Although outcomes for older adults undergoing elective surgery are generally comparable to younger patients, outcomes associated with emergency surgery are poor. These adverse outcomes are in part because of the physiologic changes associated with aging, increased odds of comorbidities in older adults, and a lower probability of presenting with classic "red flag" physical examination findings. Existing evidence-based perioperative best practice guidelines perform better for elective compared with emergency surgery; so, decision making for older adults undergoing emergency surgery can be challenging for surgeons and other clinicians and may rely on subjective experience. To aid surgical decision making, clinicians should assess premorbid functional status, evaluate for the presence of geriatric syndromes, and consider social determinants of health. Documentation of care preferences and a surrogate decision maker are critical. In discussing the risks and benefits of surgery, patient-centered narrative formats with inclusion of geriatric-specific outcomes are important. Use of risk calculators can be meaningful, although limitations exist. After surgery, daily evaluation for common postoperative complications should be considered, as well as early discharge planning and palliative care consultation, if appropriate. The role of the geriatrician in emergency surgery for older adults may vary based on the acuity of patient presentation, but perioperative consultation and comanagement are strongly recommended to optimize care delivery and patient outcomes.

Functional and Cognitive Decline Among Older Adults After High-risk Surgery

OBJECTIVE

The aim of this study was to determine whether older adults are at higher risk of lasting functional and cognitive decline after surgery, and the impact of decline on survival and healthcare use.

SUMMARY BACKGROUND DATA

Patient-centered outcomes after surgery are poorly characterized.

METHODS

Using data from the Health and Retirement Study linked with Medicare, we matched older adults (≥65 years) who underwent one of 163 high-risk elective operations (ie, inpatient mortality of ≥1%) with nonsurgical controls between 1992 and 2012. Functional decline was defined as an increase in the number of activities of daily living (ADLs) and/or instrumental activities of daily living (IADLs) requiring assistance from baseline. Cognitive decline was defined by worse response to a test of memory and mental processing from baseline. Using logistic regression, we examined whether surgery was associated with functional and cognitive decline, and whether declines were associated with poorer survival and increased healthcare use.

RESULTS

The matched cohort of patients who did not undergo surgery consisted of 3591 (75%) participants compared to 1197 (25%) who underwent surgery. Patients who underwent surgery were at higher risk of functional and cognitive declines [adjusted odds ratio (aOR) 1.52, 95% confidence interval (CI): 1.23-1.87 and aOR 1.32, 95% CI: 1.03-1.71]. Declines were associated with poorer long-term survival [hazard ratio (HR) 1.67, 95% CI: 1.43-1.94 and HR 1.35, 95% CI: 1.15-1.58], and were significantly associated with nearly all measures of increased healthcare utilization (P < 0.001).

CONCLUSION

Older adults undergoing high-risk surgery are at increased risk of developing lasting functional and cognitive declines.

Safety of bariatric surgery in patients older than 65 years

BACKGROUND

The increase in life expectancy along with the obesity epidemic has led to an increase in the number of older patients undergoing bariatric surgery. There is conflicting evidence regarding the safety of performing bariatric procedures on older patients.

OBJECTIVE

The purpose of this study was to compare the safety of laparoscopic sleeve gastrectomy (SG) and Roux-en-Y gastric bypass (RYGB) for older patients (>65 yr).

SETTING

Nationwide analysis of accredited centers.

METHODS

The Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program 2015 to 2017 database was used to identify nonrevisional laparoscopic RYGB and SG procedures. Comparisons were made based on patient age. Clinical outcomes included postoperative events and mortality.

RESULTS

There was a total 13,422 and 5395 matched pairs for SG and RYGB in comparing patients aged 18 years to those aged 65 and >65 years, respectively, and 5395 matched RYGB and SG procedures performed in patients >65 years. The complication rate was higher in older patients undergoing RYGB compared with SG (risk difference = 2.39%, 95% confidence interval: 1.57%-3.21%, P < .0001). When comparing older to younger patients, the older group had a higher complication rate for SG but not for RYGB (SG: risk difference = 1.01%, 95% confidence interval: .59%-1.43%, P < .0001, RYGB: risk difference = .59%, 95% confidence interval: -.29% to 1.47%, P = .2003).

CONCLUSIONS

Overall complication rates of bariatric surgery are low in patients >65 years. SG appears to have a favorable safety profile in this patient population compared with RYGB. The overall complication rate for RYGB is not significantly different between the older and younger groups.

Outcome of bariatric surgery in older patients

BACKGROUND

People are living longer than they were expected to 2 decades ago. Increased life expectancy and reduced mortality encompasses a simultaneous increase in the number of older adults with obesity that entails an increase of co-morbidities, such as diabetes, hypertension, cancer, and many other diseases. The aim of our study was to compare the outcomes of bariatric surgery in patients age ≥65 in comparison with younger patients.

METHODS

This retrospective study compares bariatric surgeries performed in a private institution between the years 2013 and 2015. The study included 9044 patients divided into an older group (451 patients) and the younger group (8593 patients).

RESULTS

In the younger group, bariatric surgery is distributed as follows: 77.68% sleeve gastrectomy, 12.72% gastric banding, 9.27% gastric bypass, and .33% duodenal switch or biliopancreatic diversion; in the older group: 70.51% sleeve gastrectomy, 15.08% gastric bypass, 13.97% gastric band, and .44% biliopancreatic diversion. In the control group 550 cases (6.4%) underwent revisional surgery; 64 cases (14.10%) underwent revision in the older group. Older patients lost less excess weight than younger patients (72.44% versus 86.11%, respectively). Older patients presented higher rates of complications (8.42% versus 5.59%), co-morbidities (77.60% versus 55.45%), and revisions (1.33% versus .77%). There was no statistical difference in hospital stay between older group and control group (2.27 versus 2.23, respectively). When performing a Clavien-Dindo classification, we demonstrated significant differences in class 3B and 4A and no differences in other classes. Two deaths occurred in the control group. Diabetes, fatty liver, and sleep apnea have been improved or remitted in >90% of patients in both groups, hypertension and hyperlipidemia by >80%, and hyperuricemia and ischemic heart disease were improved or resolved in >70% of the patients CONCLUSIONS: Bariatric surgery in the elderly has more complications, but it can still be considered safe.

Surgeons' Perceived Barriers to Palliative and End-of-Life Care: A Mixed Methods Study of a Surgical Society

BACKGROUND

Nearly 20% of colorectal cancer (CRC) patients present with potentially incurable (Stage IV) disease, yet their physicians do not integrate cancer treatment with palliative care. Compared with patients treated by primary providers, surgical patients with terminal diseases are significantly less likely to receive palliative or end-of-life care.

OBJECTIVE

To describe surgeon perspectives on palliative and end-of-life care for patients with Stage IV CRCs.

DESIGN

This is a convergent mixed methods study using a validated survey instrument from the Critical Care Peer Workgroup of the Robert Wood Johnson Foundation's Promoting Excellence in End-of-Life Care Project with additional qualitative questions.

SETTINGS

Participants were all current, nonretired members of the American Society of Colon and Rectal Surgeons.

MAIN OUTCOME MEASURES

Surgeon-perceived barriers to palliative and end-of-life care for patients with Stage IV CRCs were identified.

RESULTS

Among 131 Internet survey respondents (response rate 16.5%), 76.1% reported no formal education in palliative care, and specifically noted inadequate training in techniques to forgo life-sustaining measures (37.9%) and communication (42.7%). Over half (61.8%) of surgeons cited unrealistic expectations among patients and families as a barrier to care, which also limited discussion of palliation. At the system level, absence of documentation, appropriate processes, and culture hindered the initiation of palliative care. Thematic analysis of open-ended questions confirmed and extended these findings through the following major barriers to palliative and end-of-life care: (1) surgeon knowledge and training; (2) communication challenges; (3) difficulty with prognostication; (4) patient and family factors encompassing unrealistic expectations and discordant preferences; and (5) systemic issues including culture and lack of documentation and appropriate resources.

LIMITATIONS

Generalizability is limited by the small sample size inherent to Internet surveys, which may contribute to selection bias.

CONCLUSIONS

Surgeons valued palliative and end-of-life care but reported multilevel barriers to its provision. These data will inform strategies to reduce these perceived barriers.

Home-based preoperative rehabilitation (prehab) to improve physical function and reduce hospital length of stay for frail patients undergoing coronary artery bypass graft and valve surgery

Background

Evidence suggests that elective cardiac patients are at risk of functional and psychological deterioration in the time preceding surgery. This poses a risk to successful post-operative rehabilitation. This prospective one-group pre-test, post-test evaluation was designed to assess a clinical Pre-operative Rehabilitation (PREHAB) home-based exercise programme, to optimise pre-operative physical function and frailty in patients awaiting elective Coronary Artery By-Pass Graft (CABG) or Valve Surgery.

Method

Consenting patients awaiting cardiac surgery, with wait time ≥ 6 weeks were referred to a Senior Physiotherapist for baseline assessment. Patients were offered PREHAB in the form of functional home-based exercise that was prescribed from baseline physical outcomes. All patients were followed up via telephone to ensure progression of exercise and any problems associated with it. This continued weekly until the patient attended Surgical Pre-assessment clinic, where all outcome measures were re-assessed.

Results

Twenty two patients, out of a total number of 36 patients seen in the surgical clinic between March 2016 and August 2016, participated in the prehab clinical evaluation. Twenty patients completed their prescribed exercises on a weekly basis prior to surgery. No adverse events or cardiac symptoms were reported as a result of the home exercise intervention. Paired t-Test analyses revealed a significant mean difference in clinical frailty score (CFS) of −0.53 ± 0.51 (95% CI [−0.774, −0.279], P = 0.0003). Significant mean difference in six-minute walk test (6MWT) distance of 42.5 ± 27.8 m (95% CI [23.840, 61.251], P = 0.0005), 6MWT walking speed of 0.5 ± 0.4kmh (95% CI, [0.2433, 0.7567], P = 0.001), and short physical performance battery (SPPB) total score of 2.2 ± 1.7, (95% CI [3.066, 1.200], P = 0.0002) were also observed. The change in 6MWT distance was shown to be significantly associated with hospital length of stay (LOS) (r = 0.7; P = 0.03).

Conclusion

This small exploratory evaluation suggests that providing a home-based PREHAB programme for frail patients undergoing CABG or Valve surgery may be able to improve functional ability and reduce hospital length of stay for those patients undergoing cardiac surgery. A frailty score with greater sensitivity may be required to elucidate the influence frailty could have in reducing length of stay. A large randomised controlled study is required to reveal the potential beneficial effects of PREHAB in this patient population.

The outcome of surgical treatment for elderly patients with gastric carcinoma

BACKGROUND

The aim of this study was to clarify the operative mortality and long-term survival of gastrectomy for elderly patients with gastric cancer.

METHODS

A total of 461 patients who underwent gastrectomy for gastric cancer in our hospital were classified as elderly group (≥80 years-old, 95 patients) and control group (60-69 years-old, 366 patients).

RESULTS

The frequency of comorbidities was significantly (P < 0.05) higher in elderly group (74.7%) than that in the control group (49.5%). No significant difference of the postoperative complication rate was found between the elderly group (23.2%) and the control group (23.2%). Adjuvant chemotherapy was 9.5% in the elderly group, which was significantly less than 29.0% of the control group (P < 0.05). Stage II and III elderly patients had worse disease specific survival (DSS) than controls did. In the elderly, overall survival (OS) was significantly worse than DSS in stage I patients (P < 0.05).

CONCLUSIONS

The operative complication rate of elderly patients was comparable to the control group. Comorbidity and occurrence of secondary malignant disease should be followed for elderly patients at stage I. For stage II and III disease patients, a novel drug which is acceptable for the elderly is needed as a postoperative therapy.

Perioperative management of elderly patients

The older population only represents 13.7% of the US population but has grown by 21% since 2002. The centenarian population is growing at a faster rate than the total US population. This unprecedented growth has significantly increased surgical demand. The establishment of quality and performance improvement data has allowed researchers to focus attention on the older patient population, resulting in an exponential increase in studies. Although there is still much work to be done in this field, overlying themes regarding the perioperative management of elderly patients are presented in this article based on a thorough literature review.

Evaluating the Association of Preoperative Functional Status and Postoperative Functional Decline in Older Patients Undergoing Major Surgery

This prospective cohort study sought to identify predictors of functional decline in patients aged 65 years or older who underwent major, nonemergent abdominal or thoracic surgery in our tertiary hospital from 2006 to 2008. We used the Stanford Health Assessment Questionnaire–Disability Index (HAQ-DI) to evaluate functional decline; a 0.1 or greater increase was used to indicate a clinically significant decline. The preoperative Duke Activity Status Index (DASI) and a physical function score (PFS), assessing gait speed, grip strength, balance, and standing speed, were evaluated as predictors of decline. We enrolled 215 patients (71.2 ± 5.2 years; 56.7% female); 204 completed follow-up HAQ assessments (71.1 ± 5.3 years; 57.8% female). A significant number of patients had functional decline out to 1 year. Postoperative HAQ-DI increases of 0.1 or greater occurred in 45.3 per cent at 1 month, 30.1 per cent at 3 months, and 28.3 per cent at 1 year. Pre-operative DASI and PFS scores were not predictors of functional decline. Male sex at 1 month (odds ratio [OR], 3.05; 95% confidence interval [CI], 1.41 to 6.85); American Society of Anesthesiologists class (OR, 3.41; 95% CI, 1.31 to 8.86), smoking (OR, 3.15; 95% CI, 1.27 to 7.85), and length of stay (OR, 1.09; 95% CI, 1.01 to 1.16) at 3 months; and cancer diagnosis at 1 year (OR, 2.6; 95% CI, 1.14 to 5.96) were associated with functional decline.

Preoperative geriatric assessment: comprehensive, multidisciplinary and proactive

With the changing global demographic pattern, our health care systems increasingly have to deal with a greater number of elderly patients, which consequently also takes its toll on our surgical services. The elderly are not simply older adults. They represent a heterogeneous branch of the population with specific physiological, psychological, functional and social issues that require individualised attention prior to surgery. Increased acknowledgement that chronological age alone is not an exclusion criterion, along with advances in surgical and anaesthetic techniques have today lead to decreased reluctance to deny the elderly surgical treatment. In order to ensure a safe perioperative period, we believe that a comprehensive, multidisciplinary and proactive preoperative assessment will be helpful to detect the multiple risk factors and comorbidities common in older patients, to assess functional status and simultaneously allow room for early preoperative interventions and planning of the intra- and postoperative period. In this review we outline the currently available preoperative geriatric risk assessment tools and provide an insight on how a comprehensive, multidisciplinary and proactive approach can help improve perioperative outcome.

The impact of old age on surgical outcomes after pancreaticoduodenectomy for distal bile duct cancer

Backgrounds/Aims

To compare surgical results and survival of two groups of patients, age ≥70 vs. age <70, who underwent pancreaticoduodenectomy and to identify the safety of this procedure for elderly patients for the treatment of distal common bile duct (CBD) cancer.

Methods

Between January 2003 and December 2009, 55 patients who underwent pancreaticoduodenectomy for the treatment of distal CBD cancer at Keimyung University Dong San Medical Center were enrolled in our study.

Results

Of 55 patients, 28 were male and 27 female. Nineteen were over 70 years old (older group) and 36 were below 70 years (younger group). The mean ages of the two groups of patients were 73.5 years and 60.5 years respectively. Although patients of the older group had significantly more comorbid diseases, perioperative results including operation time, amount of intraoperative bleeding, duration of postoperative hospital stay and postoperative complications were not significantly different. A higher level (more than 5 mg/dl) of preoperative initial bilirubin showed significant correlations with operative morbidity by univariate analysis, and age was not an independent risk factor of operative morbidity. Overall 5 year survival of older and younger groups were 45.9% and 39.5% respectively (p=0.671) and disease-free 5-year survival were 31.7% and 31.1%, respectively (p=0.942).

Conclusions

Surgical outcomes of elderly patients were similar to those of younger patients, despite a higher incidence of comorbid disease. This results shows that pancreaticoduodenectomy can be applied safely to elderly patients.

Outcomes of damage-control celiotomy in elderly nontrauma patients with intra-abdominal catastrophes

OBJECTIVE

Damage-control laparotomy, initially developed for trauma patients, has expanded into the general surgery arena. Little evidence exists regarding the utility of damage-control celiotomy (DCCT) in elderly nontrauma patients. Our objective was to review the management and outcomes of DCCT in elderly patients with intra-abdominal catastrophes.

METHODS

Retrospective chart review from 1998 to 2008 identified cases of DCCT. Demographics, comorbidities, surgical techniques, morbidity, long-term disposition, and mortality were analyzed.

RESULTS

From 210 patients with emergency surgeries, 88 (42%) patients with DCCT were identified, 33 (38%) were greater than 65 years old and 55 (63%) were ≤ 65 years old. The average APACHE IV score for the elderly was 84 ± 2 versus 68 ± 2 for the younger group (p < .001). Elderly patients had significantly higher comorbidites with respect to cardiovascular, pulmonary, and renal disease. When comparing the 2 groups, there were no significant differences in-hospital or intensive care unit lengths of stay or ventilator days. There were also no significant differences in complications and disposition. Using Cox proportional hazards analysis, age was not an independent predictor of 30-day mortality.

CONCLUSIONS

Age is not an independent predictor of worse outcomes in patients managed by the DCCT technique after intra-abdominal catastrophes. This management technique should be considered for elderly patients who require DCCT.

AVAS Best Clinical Resident Award (Tied): management and outcomes of the open abdomen in nontrauma patients

BACKGROUND

Little is known regarding the morbidity and mortality of the open abdomen technique in older nontrauma patients.

METHODS

A retrospective chart review identified cases of emergency laparotomy in which open abdomens were used.

RESULTS

Eighty-eight patients with open Acute Physiology and Chronic Health Evaluation (APACHE) abdomens were identified. An overall mortality rate of 34%, consistent with mortality predicted by APACHE IV score, was seen. Common complications included ventilator-associated pneumonia (30%) and acute renal failure (22%). A perioperative APACHE IV score of greater than 65 and an albumin level less than 2.5 g/dL were found to predict an increased likelihood of long-term assisted care placement after discharge from the acute care setting.

CONCLUSIONS

The use of the open abdomen technique in older nontrauma patients carries acceptable morbidity and mortality given the acuity of disease. Focus on ventilator-associated pneumonia prevention and aggressive fluid resuscitation to avoid acute renal failure may improve outcomes. Need for long-term assisted care placement can be predicted early after admission based on the APACHE IV score or albumin level.

Risk factors for postoperative systemic complications in elderly patients with brain tumors. Clinical article

OBJECT

In elderly patients with brain tumors, the prevention of postoperative systemic complications is extremely important, and identification of the risk factors would be useful for planning therapy. The authors investigated ways to avoid postoperative complications by identifying risk factors.

METHODS

The study population included 84 patients, 70 years of age or older, who underwent surgical brain tumor removal. The following independent factors were assessed by univariate and multivariate analyses: sex, age, preoperative underlying diseases and complications, histopathological findings, preoperative Karnofsky Performance Scale (KPS) score, preoperative whole blood hemoglobin (Hb) level, preoperative serum total protein (TP) level, operation time, intraoperative blood loss, change in Hb level (difference between pre- and postoperative values), and change in TP level (difference between pre- and postoperative values). The cutoff values for significant independent factors were also determined.

RESULTS

Overall, 35 (41.7%) of the 84 patients had a total of 56 postoperative systemic complications. Univariate analysis identified the preoperative KPS score, intraoperative blood loss, change in Hb level, and change in TP level as risk factors for postoperative complications, and multivariate analysis extracted the following risk factors: the preoperative KPS score (p = 0.0450, OR 4.020), intraoperative blood loss (p = 0.0104, OR 6.571), and change in Hb levels (p = 0.0023, OR 9.301). The cutoff values were: KPS score < 80%, intraoperative blood loss >or= 350 ml, and change in Hb level >or= 2.0 g/dl.

CONCLUSIONS

In elderly patients with brain tumors, low preoperative KPS score, high intraoperative blood loss, and a large difference between pre- and postoperative Hb levels are significant risk factors for postoperative systemic complications.

Postoperative renal failure

Acute renal failure (ARF) or acute kidney injury (AKI) is a common problem occurring in about 1% to 5% of all hospitalized patients. It leads to poor quality of life and increased length of stay (LOS), cost of care, morbidity, and mortality. The survival rate for ARF has not drastically changed over the past 4 decades because of the aging population and presence of multiple comorbid conditions. About 200 patients per million population develop severe ARF each year. Approximately one-third of these patients require ICU care. Recent studies have shown that even milder forms of renal dysfunction are associated with increased LOS and mortality.

[Acute orthogeriatric care (II). Clinical aspects]

The present article reviews the clinical principles of acute orthogeriatric care. The application of geriatric medicine to patients with hip fracture is explained. The principal stages of geriatric intervention in this process are mentioned, as are the interventions to be carried out by the geriatric team. Subsequently, we discuss the management of several frequent problems in these patients, such as high surgical risk, pain management, anaemia, delirium, malnutrition, and discharge planning. Lastly, the characteristics of several kinds of patients with special characteristics are mentioned, such as those diagnosed with dementia, nursing home residents or the oldest-old. Areas of improvement in the acute phase are also reviewed, such as mortality reduction, functional outcome improvement and the need for more efficient resource use in patients in the acute phase of hip fracture.

Perioperative management of maxillofacial tumor and reconstruction patients

Patients who undergo maxillofacial tumor surgery and reconstruction present many perioperative management challenges. This patient population commonly presents with significant medical comorbidities in addition to the site-specific challenges of these tumors and the complexity of the reconstructive surgeries. This article combines a review of the relevant literature and the experience of a busy regional maxillofacial tumor and reconstruction referral center to provide a concise reference for management of patients. In addition to the valuable system-specific information presented, the article outlines a daily clinical pathway, which is easily adapted to any clinical practice performing complex maxillofacial surgery.

[Nutritional risk in surgery evaluated by body mass index adjusted or not to elderly patients]

BACKGROUND

Standard body mass index cut-off points for malnutrition are routinely used for adults independently of their age. The hypothesis of this study was that a cut-off point higher than the usual for the diagnosis of malnutrition might be more precise to access the nutritional risk of aged surgical patients.

AIM

To evaluate the morbimortality in aged surgical patients and its association with nutritional status assessed by body mass index using either the standard and a higher cut-off point for malnutrition.

PATIENTS AND METHODS

All patients admitted for operative procedures (n = 1,912) were allocated to either two groups: <65 years (n = 1,627) or >65 years old (n = 285). The body mass index was used to access the nutritional status. Two different cut-off points for malnutrition (18.5 or 24 kg/m(2)) were used in the group of older patients. Endpoints of the study were length of stay, morbidity and mortality.

RESULTS

Length of stay was higher in patients over 65 years (6 [1-75] days vs. 4 [1-137] days). Both postoperative complications (37/285; 13.0% vs. 109/1627; 6.7%; OR 2.1; IC95% 1.40-3.09) and deaths (15/285; 5.3% vs. 34/1627; 2.1%; OR 2.6; IC95% 1.40-4.84) were most common in the older group. Using a higher cut-off (24 kg/m(2)), the length of stay (8 [1-75] days vs. 4 [1-43] days), postoperative complications (28/152; 18.4% versus 9/133; 6.8%; OR 3,1; IC95% 1.41-6.86) and re-operations (16/152; 10.5% versus 3/133; 2.2%; OR 5.1; IC95% 1.45-17.91) were greater in malnourished patients. However these correlations were not statistically significant with the cut-off point for malnutrition in 18.5 kg/m(2).

CONCLUSIONS

Morbimortality is higher in surgical patients over 65 years old. In these, the cut-off point set in 24 kg/m(2) was most associated with the occurrence of postoperative complications, re-operations and length of stay.

Preoperative assessment of elderly cancer patients

The incidence of most types of cancers is age-dependent and progressive ageing is rapidly increasing the number of elderly people who need treatment for cancer. It is an ethical dilemma how aggressive one should be when it comes to treating cancer in the older population. Presumed fear of increased postoperative morbidity and mortality often results in delivery of sub-optimal cancer surgery. A careful evaluation of the general and organ-related conditions of the patients is absolutely necessary for planning the right treatment. Nevertheless, preoperative removal of risk factors and postoperative rehabilitation are as important as the use of the best techniques of anaesthesia and surgery to achieve good postoperative outcomes in these patients. In this review article we take into consideration physiology of the aged and tools available to assess surgical risks in elderly patients, in the aim of increasing awareness on optimising surgical management of elderly patients with cancer. MEDLINE and EMBASE.com (search terms: "elderly", "preoperative", "surgery"), bibliographies of articles retrieved and the authors' reference files have been used as data sources. Independent extraction has been performed by the authors using predefined criteria, including study quality indicators.

Management of anaesthesia in elderly patients

Increasing numbers of very elderly patients require surgery. Elderly patients are at increased risk of perioperative morbidity and mortality because of the high incidence of co-existing age-related diseases. With greater experience, outcomes from major operations in octogenarians have improved. The increased risks of surgery in the elderly must, however, be individually weighed against the benefits to be gained from symptom relief and improved quality of life.

Surgical innovations: impact on the quality of life of the older patient

As surgery has been extended into the elderly population, health-related quality of life (HRQOL) has been appropriately added as a parameter to evaluate surgical success. Surgery remains of significant risk in older patients, and an estimate of the type of outcome, including morbidity, mortality, and HRQOL can aid in that decision. New techniques, such as laparoscopic or minimally invasive surgery show great promise for reduction in perioperative stress and improved HRQOL in younger patients, but have not been extensively used in the older and frail patients for whom the benefits potentially may be greater.

Isolated limb perfusion in regional melanoma

Adjuvant perfusion to excision of a primary melanoma cannot be recommended because of its limited effect. In patients who have frequently recur-ring resectable locoregional melanoma, perfusion may provide valuable loco-regional disease control by decreasing the number of recurrences and lesions per recurrence. Randomized studies are needed to further establish the role of perfusion as an adjuvant treatment for resectable recurrences of melanoma. Unresectable limb melanoma is the primary indication for perfusion. Better response rates tend to be seen when TNF-a is used in patients who have a high tumor load. Repeat perfusion is feasible, resulting in response rates similar to those of a first perfusion for locoregional melanoma. Older age itself is not a contraindication for perfusion. The long-term health-related quality of life of survivors of melanoma who underwent treatment with perfusion is comparable to that of their healthy peers in the general Dutch population.

["FRAGILE"-Old people and surgery]

As life expectancy and modern surgical and intensive care techniques develop, the number of old patients in surgery is rising. Associated are problems with the indication for surgical intervention and rising incidence of "typical" peri- and postoperative complications such as postoperative delirium. Geriatric assessment serves to identify patients at risk of developing complications, to describe the postoperative course of functional and cognitive abilities, and to adjust therapeutic strategies to the individual needs of these patients. The most important instruments of geriatric assessment are described. Postoperative delirium, the most prevalent complication in surgical geriatric patients, is discussed in detail with regard to risk factors, prevalence, diagnosis, and therapeutic options.

Identification of seniors at risk: process evaluation of a screening and referral program for patients aged > or =75 in a community hospital emergency department

Reports on the authors' experience with a patient safety quality improvement program, intended to reduce the incidence and severity of adverse outcomes for emergency department (ED) patients aged > or = 75. The Identification of Seniors at Risk scale was used for screening, and those at high risk were referred for appropriate intervention. The plan-do-study-act improvement cycle was followed, conducting process evaluation to diagnose and correct implementation difficulties. Reports that: implementing an ED screening and referral program is deceptively difficult; process evaluation multidisciplinary working group meetings are an essential improvement tool; screening inclusion criteria had to be adapted to the subject population in order to make efficient use of staff time; the screening questions and process required ongoing assessment, revision, and local adaptation in order to be useful; and high-risk screening in the ED is critical to a hospital system's ability to anticipate clinical problems; the plan-do-study-act improvement cycle is a practical and useful tool for improving quality and systems in a real care setting.

Cutaneous oncologic and cosmetic surgery in geriatric patients

A wide array of surgical procedures is available to geriatric patients. These interventions can enhance the appearance of patients and facilitate the removal of skin cancers. Pre-existing medical conditions of geriatric patients must be considered comprehensively when selecting and performing cutaneous surgical procedures. Many older patients suffer from a variety of diseases and take a variety of medications and herbal supplements to ameliorate the consequences of such diseases. In general, skin surgery can be performed safely on even very old patients, provided precautions are followed. The biopsychosocial well-being and essence of patients must also be addressed when performing dermatologic surgery. If patients are treated holistically and comprehensively, their surgical experience can be enhanced and their health and appearance improved.

Preoperative assessment

Although anaesthetic and surgical procedures should be individualised for every patient, in practice many preoperative protocols and routines are used generally. In this article, we aim to emphasise: why preoperative assessment is important; how it should be done, and by whom; what can be expected; and the importance of test selection based on patients' needs and on scientific evidence of effectiveness. We outline the roles of preoperative medical assessment in otherwise healthy patients. Clinical history, preoperative questionnaires, physical examination, routine tests, individual risk-assessment, and fasting policies are investigated by review of published work. Cost of routine preoperative assessment, the anaesthetist's legal responsibility, and patients'views in the preoperative process are also considered. A thorough clinical preoperative assessment of the patient is more important than routine preoperative tests, which should be requested only when justified by clinical indications. Moreover, this practice eliminates unnecessary cost without compromising the safety and quality of care. Education and training of medical doctors should be more scientifically guided, emphasising the relevance of effectiveness, and cost-effectiveness in clinical decision-making and complemented by audit.

Cutaneous surgery in the elderly: ensuring comfort and safety

Increasingly, cutaneous surgeons are asked to treat cancers and the visible signs of aging in extremely elderly patients. While many elderly patients have functional status similar to that of younger patients, some older patients may have co-morbities and special needs that must be monitored and accommodated by the skin surgeon. A rational approach to surgery can increase the comfort and safety of surgery in such patients. Overall, cutaneous surgery is well-tolerated in even the oldest patients.

Pathophysiological changes in the elderly

Demographic data indicate an increasing workload of geriatric anaesthesia due to advancing life expectancy and reduced thresholds for high-invasive and high-risk surgery in the elderly. Chronological and biological age may be inconsistent, and the existence of age-related changes may vary between organ systems in the same individual. Age itself is not an illness, but is the most important contributing factor for perioperative complications and adverse outcome when the overall narrowed margins of organ function reserve are transgressed during the perioperative period. Age-related changes in the cardiovascular, pulmonary, nervous, metabolic and locomotive systems that are frequently present in the elderly are discussed with regard to their potential relevance to anaesthesiology. In conclusion, listing current diagnoses will not be sufficient in the assessment of the geriatric patient because age-related changes do not necessarily manifest as pathological entities. Rather, pre-operative examination should focus on determination of individual margins of organ function reserve.

Psychosocial issues and their relevance to the cosmetic surgery patient

Psychosocial issues permeate the field of cosmetic surgery: 1. The preoperative psychological profile of cosmetic surgery patients is likely to differ from that of people who don't come for surgery. Despite several decades of research, this difference is not well understood. 2. Cosmetic surgery patients often look for more than changes in their physical appearance. If these procedures do not lead to improvements in body satisfaction, self-esteem, or quality of life, then what is their purpose? 3. Patient-surgeon rapport is not simply a nice plus if it happens. Patient satisfaction, reduced legal liability, and improved surgical outcome can all be direct reflections of the surgeon's mastery of relationship-building techniques. 4. Identifying and screening out patients who should not have cosmetic surgery can prevent both patient and surgeon frustration and more extreme adverse outcomes. 5. A wide range of studies document the use of psychological techniques to improve surgical outcome.

Perioperative care for the elderly patient

As the population survives longer, surgery has become a much more common consideration. Preoperative management of these patients requires a working knowledge of changes associated with aging and the physiology of surgery and anesthesia. Using this information, patients can be clinically evaluated effectively and plans made for their perioperative care to minimize complications.

Safety and efficacy of isolated limb perfusion in elderly melanoma patients

BACKGROUND

Older patients are assumed to have a higher risk of complications from isolated limb perfusion (ILP). A study was performed evaluating the safety and efficacy of ILP in patients older than 75 years with advanced melanoma of the limbs.

METHODS

A total of 218 therapeutic ILPs with melphalan with or without tumor necrosis factor alpha were performed in 202 patients with advanced measurable melanoma and were analyzed retrospectively. Fifty-three patients (28%) were 75 years or older.

RESULTS

Complete response rates were 56% for those older than 75 years and 58% for the younger group (P =.79). Locoregional relapse occurred in 56% of the older group versus 51% in the younger group (P =.61). Limb toxicity, systemic toxicity, local complications, and long-term morbidity were similar in both age groups. Perioperative mortality was low, with one procedure-related death in the older group. Older patients stayed in the hospital for a median of 23 days (younger patients, 19 days; P <.01).

CONCLUSIONS

ILP results in similar response rates in the elderly with recurrent melanoma, without increased toxicity, complications, or long-term morbidity compared with younger patients. Older age in itself is not a contraindication for ILP.

Dermatologic surgery in geriatric patients: psychosocial considerations and perioperative decision-making

BACKGROUND

Dermatologic surgery, both for cutaneous malignancies and for management of the visible signs of photodamage, is frequently performed on older persons.

OBJECTIVE

To review common psychologic and physiologic limitations among the elderly that may affect their ability to tolerate cutaneous surgery and to outline a stepwise approach for management of these conditions during the perioperative period.

METHODS

Literature review, MEDLINE (1966-2001) search, and personal experience.

RESULTS

Communication with patients, their families, and their physicians, management of patients' underlying medical problems, and special sensitivity to patients' cognitive and physiologic limitations can minimize perioperative risk during cutaneous surgery in the elderly.

CONCLUSION

Given appropriate physician management, elderly patients can usually safely undergo cutaneous surgery.

The impact of performance status on survival in patients of 80 years and older with vulvar cancer

OBJECTIVE

There are no data available on the impact of performance status on outcome in patients with vulvar cancer. It was the objective of this study to determine the impact of performance status on survival in a group of elderly patients.

METHODS

A retrospective review of records of patients with vulvar cancer aged 80 years or greater and treated in a gynecological referral center was performed. Multiple clinical and pathological variables together with performance status were assessed and the impact on overall survival was determined both by univariate and multivariate analysis.

RESULTS

Of 75 patients aged 80 years or older, 57 (76%) had standard treatment. The patients who had standard treatment were characterized by an earlier clinical stage and a better performance status compared with patients who had nonstandard treatment. When preoperatively available parameters of all patients were assessed in relation to survival in the total group, Eastern Cooperative Oncology Group (ECOG) performance status was the only independent prognostic indicator for survival. When all clinical and histopathological variables were assessed in the subgroup who had standard treatment, both ECOG performance status and extracapsular lymph node involvement were independent prognostic variables for overall survival. Age was not a significant prognostic variable.

CONCLUSIONS

ECOG performance status is the only available pretreatment variable with independent prognostic value for survival in this group of elderly patients with vulvar cancer. These data show the importance of individualizing the treatment of patients with vulvar cancer. Performance status takes a more important place than age in the management process of these patients.

[Geriatric management of the frail elderly with hip fracture may improve their clinical outcome]

BACKGROUND

The treatment of osteoporotic hip fracture requires the intervention of different medical specialties. The purpose of this study was to know the clinical profile of patients with an acute hip fracture referred for assessment and management to a geriatric assessment team (GAT) and the influence of this kind of geriatric care in their hospital outcome.

PATIENTS AND METHOD

All patients 65 year-old or older admitted in a teaching hospital for a hip fracture in a 12 month period were included. The clinical, functional, cognitive and social status were assessed at admission and at discharge in both groups: the patients managed by the GAT and the patients that were not. The patients' characteristics of both groups were compared, and a multivariant analysis was applied to search the variables independently associated wit a better clinical course.

RESULTS

On admission, the GAT patients (n = 202) were significantly (p < 0.05) older (84.4 vs 81.7 years), had more previous functional impairment (Barthel index 72 vs 79), more previous diseases (5.4 vs 3.3) and medications (3.2 vs 1.9), presented more frequency of cognitive impairment (52 vs 41%), of high surgical risk (54 vs 26%) and more need of social assistance at home (57 vs 38%) than non-referred patients (n = 200). At discharge, GAT patients had better functional status (Barthel index 38.5 vs 34), had been surgically treated (92 vs 84%), had received physiotherapy (83.7 vs 66.5%) and walked more (56.1% vs 33.8%) than others. In the multivariant analysis, the GAT intervention shows like an independent variable associated to higher frequency of surgical treatment (OR 4.21; CI, 2.80-6.34), to recovery of walking ability (OR, 8.26; CI, 5.23-13.04) and to receive more medical diagnosis (OR, 79.69; CI: 55.48-114.45). The GAT intervention was not associated to a longer hospital stay.

CONCLUSIONS

The patients with hip fracture in acute phase required for management by a GAT are more complex than those who were not consulted. In these patients GAT intervention improve their clinical outcome and the efficiency of hospital admission.

Perioperative care of the elderly surgical patient

Elderly surgical patients undergo approximately 20% or more of all surgical procedures in acute care hospitals across the country. Elderly people also are more at risk for surgical intervention because of age-related system changes and comorbid conditions. In recent years, greater knowledge about aging and advanced surgical, anesthetic, and monitoring technology has made it possible for many elderly people to undergo surgery without significant mortality. This article is intended to increase the ability of perioperative nurses to anticipate, plan, and provide care for their elderly surgical patients.