title: The impact of the type of anaesthesia on cognitive status and delirium during the first postoperative days in elderly patients A global clinical measure of fitness and frailty in elderly people Frailty as a predictor of surgical outcomes in older patients. Functional independence after major abdominal surgery in the elderly. "Timed Up & Go": A Screening Tool for Predicting 30-Day Morbidity in Onco-Geriatric Surgical Patients? A Multicenter Cohort Study The Cochrane Collaboration’s tool for assessing risk of bias in randomised trials Evaluating the Association of Preoperative Functional Status and Postoperative Functional Decline in Older Patients Undergoing Major Surgery Preoperative and operative predictors of delirium after cardiac surgery in elderly patients. Reducing delirium after hip fracture: a randomized trial. Preoperative mild cognitive dysfunction predicts pulmonary complications after coronary artery bypass graft surgery. Patient Empowerment Improved Perioperative Quality of Care in Cancer Patients Aged ≥ 65 Years – A Randomized Controlled Trial The outcome of primary total hip and knee arthroplasty in patients aged 80 years or more. The impact of frailty status on survival after transcatheter aortic valve replacement in older adults with severe aortic stenosis: a single-center experience. An Evaluation of a Proactive Geriatric Trauma Consultation Service Importance of a comprehensive geriatric assessment in prediction of complications following thoracic surgery in elderly patients. A clinical prediction rule for delirium after elective noncardiac surgery. Gender Differences in Stroke Risk Among the Elderly After Coronary Artery Surgery Nutrition and health risks in the elderly: the nutrition screening initiative. Shall we operate? Preoperative assessment in elderly cancer patients (PACE) can help. A SIOG surgical task force prospective study. Pre-existing cerebral infarcts as a risk factor for delirium after coronary artery bypass graft surgery. Preoperative anxiety as a predictor of mortality and major morbidity in patients aged >70 years undergoing cardiac surgery. Age and sex differences in perioperative myocardial infarction after cardiac surgery. Frailty predicts outcome of elective laparoscopic cholecystectomy in geriatric patients Multifactorial index of cardiac risk in noncardiac surgical procedures. Cumulative deficit model of geriatric assessment to predict the postoperative outcomes of older patients with solid abdominal cancer. Risk factors for nursing home placement following major nonemergent surgery. One-year Outcome After Neurosurgery for Intracranial Tumor in Elderly Patients Components of geriatric assessments predict thoracic surgery outcomes. Comprehensive geriatric assessment of risk factors associated with adverse outcomes and resource utilization in cancer patients undergoing abdominal surgery. Cardiac prognosis in noncardiac geriatric surgery. Preoperative protein and energy intake and postoperative complications in well-nourished, non-hospitalized elderly cardiac surgery patients. Activities of Daily Living and Quality of Life of Elderly Patients After Elective Surgery for Gastric and Colorectal Cancers Assessment for frailty is useful for predicting morbidity in elderly patients undergoing colorectal cancer resection whose comorbidities are already optimized. Preoperative cognitive dysfunction is related to adverse postoperative outcomes in the elderly.
abstract: Background and objectives : Postoperative confusion and delirium is a common complication in the elderly with a poorly understood pathophysiology . The aim of this study was to examine whether the type of anaesthesia ( general or regional ) plays a role in the development of cognitive impairment in elderly patients during the immediate postoperative period . Methods : Forty‐seven patients > 60 yr of age and undergoing major surgery were r and omly allocated to receive either regional or general anaesthesia .  The mental status of the patients was assessed preoperatively and during the first three postoperative days with the Mini Mental State Examination . The incidence of delirium was also examined during the same period with the use of DSM III criteria . Results : Overall , during the first three postoperative days , the mean Mini Mental State Examination score decreased significantly ( P < 0.001 ) . However , this decline was very significant only in patients assigned to receive general anaesthesia ( P < 0.001 ) compared to regional anaesthesia . Nine patients developed delirium but the type of anaesthesia did not affect its incidence . The only important factor for the development of delirium was pre‐existing cardiovascular disease irrespective of anaesthesia type ( P < 0.025 ) . Conclusions : Elderly patients subjected to general anaesthesia  displayed more frequent cognitive impairment during the immediate postoperative period in comparison to those who received a regional technique Background : There is no single generally accepted clinical definition of frailty . Previously developed tools to assess frailty that have been shown to be predictive of death or need for entry into an institutional facility have not gained acceptance among practising clinicians . We aim ed to develop a tool that would be both predictive and easy to use . Methods : We developed the 7-point Clinical Frailty Scale and applied it and other established tools that measure frailty to 2305 elderly patients who participated in the second stage of the Canadian Study of Health and Aging ( CSHA ) . We followed this cohort prospect ively ; after 5 years , we determined the ability of the Clinical Frailty Scale to predict death or need for institutional care , and correlated the results with those obtained from other established tools . Results : The CSHA Clinical Frailty Scale was highly correlated ( r = 0.80 ) with the Frailty Index . Each 1-category increment of our scale significantly increased the medium-term risks of death ( 21.2 % within about 70 mo , 95 % confidence interval [ CI ] 12.5%–30.6 % ) and entry into an institution ( 23.9 % , 95 % CI 8.8%–41.2 % ) in multivariable models that adjusted for age , sex and education . Analyses of receiver operating characteristic curves showed that our Clinical Frailty Scale performed better than measures of cognition , function or comorbidity in assessing risk for death ( area under the curve 0.77 for 18-month and 0.70 for 70-month mortality ) . Interpretation : Frailty is a valid and clinical ly important construct that is recognizable by physicians . Clinical judgments about frailty can yield useful predictive information BACKGROUND Preoperative risk assessment is important yet inexact in older patients because physiologic reserves are difficult to measure . Frailty is thought to estimate physiologic reserves , although its use has not been evaluated in surgical patients . We design ed a study to determine if frailty predicts surgical complications and enhances current perioperative risk models . STUDY DESIGN We prospect ively measured frailty in 594 patients ( age 65 years or older ) presenting to a university hospital for elective surgery between July 2005 and July 2006 . Frailty was classified using a vali date d scale ( 0 to 5 ) that included weakness , weight loss , exhaustion , low physical activity , and slowed walking speed . Patients scoring 4 to 5 were classified as frail , 2 to 3 were intermediately frail , and 0 to 1 were nonfrail . Main outcomes measures were 30-day surgical complications , length of stay , and discharge disposition . Multiple logistic regression ( complications and discharge ) and negative binomial regression ( length of stay ) were done to analyze frailty and postoperative outcomes associations . RESULTS Preoperative frailty was associated with an increased risk for postoperative complications ( intermediately frail : odds ratio [ OR ] 2.06 ; 95 % CI 1.18 - 3.60 ; frail : OR 2.54 ; 95 % CI 1.12 - 5.77 ) , length of stay ( intermediately frail : incidence rate ratio 1.49 ; 95 % CI 1.24 - 1.80 ; frail : incidence rate ratio 1.69 ; 95 % CI 1.28 - 2.23 ) , and discharge to a skilled or assisted-living facility after previously living at home ( intermediately frail : OR 3.16 ; 95 % CI 1.0 - 9.99 ; frail : OR 20.48 ; 95 % CI 5.54 - 75.68 ) . Frailty improved predictive power ( p < 0.01 ) of each risk index ( ie , American Society of Anesthesiologists , Lee , and Eagle scores ) . CONCLUSIONS Frailty independently predicts postoperative complications , length of stay , and discharge to a skilled or assisted-living facility in older surgical patients and enhances conventional risk models . Assessing frailty using a st and ardized definition can help patients and physicians make more informed decisions BACKGROUND Elders undergo approximately 40 % of more than 1 million major abdominal operations annually . Yet evidence about recovery to preoperative levels of functional independence is limited . This study details course and predictors of functional recovery after  elective major abdominal operations in the elderly . STUDY DESIGN This was a prospect i ve cohort of 372 consecutive patients , 60 years old or more , enrolled from surgeons in private practice and two university-affiliated hospitals , assessed preoperatively and postoperatively at 1 , 3 , and 6 weeks , 3 and 6 months , using self-report and performance-based measures ( Activities of Daily Living [ ADL ] , Instrumental Activities of Daily Living [ IADL ] , Medical Outcomes Study Short Form-36 Physical Component and Mental Component Scales [ PCS , MCS ] , Geriatric Depression Scale [ GDS ] , Folstein Mini-Mental State Exam [ MMSE ] , timed walk , functional reach , h and grip strength ) . RESULTS Mean age was 69 + /- 6 years with 56 % men , 47 % nonHispanic Caucasian , and 42 % Mexican American ; hospital distribution was 49 % private , 51 % university-affiliated . Maximum functional declines ( 95 % CI ) occurred 1 week postoperatively : ADL , 2.8 points ( 2.4 to 3.2 ) ; IADL , 7.6 points ( 7 to 8.3 ) ; SF-36 PCS , 6.5 points ( 5.4 to 7.6 ) ; Mini-Mental State Exam , 0.5 points ( 0.2 to 0.7 ) ; timed walk , 6.8 seconds ( 5.2 to 8.4 ) ; functional reach , 1.7 inches ( 1.2 to 2.2 ) ; grip strength , 2 kilograms ( 1.3 to 2.7 ) ( p < 0.001 for all ) . SF-36 mental component scale and Geriatric Depression Scale scores did not worsen . Mean recovery times were : Mini-Mental State Exam , 3 weeks ; timed walk , 6 weeks ; ADL , SF-36 PCS , and functional reach , 3 months ; and IADL , 6 months . Mean grip strength did not return to preoperative status by 6 months . The incidence of persistent disability at 6 months , compared with preoperative status , was : ADL , 9 % ; IADL , 19 % ; PCS , 16 % ; mental component scale , 17 % ; timed walk , 39 % ; functional reach , 58 % ; and grip strength , 52 % . Potentially modifiable independent predictors of ADL and IADL recovery were preoperative physical conditioning and depression plus serious postoperative complications . CONCLUSIONS The clinical course of functional recovery varied across different measures . Protracted disability at 6 months after operation was substantial . Several potentially modifiable factors consistently predicted recovery Objective To determine the predictive value of the “ Timed Up & Go ” ( TUG ) , a vali date d assessment tool , on a prospect i ve cohort study and to compare these findings to the ASA classification , an instrument commonly used for quantifying patients ’ physical status and anesthetic risk . Background In the onco-geriatric surgical population it is important to identify patients at increased risk of adverse post-operative outcome to minimize the risk of over- and under-treatment and improve outcome in this population . Methods 263 patients ≥70 years undergoing elective surgery for solid tumors were prospect ively recruited . Primary endpoint was 30-day morbidity . Pre-operatively TUG was administered and ASA-classification was registered . Data were analyzed using multivariable logistic regression analyses to estimate odds ratios ( OR ) and 95 % confidence intervals ( 95%-CI ) . Absolute risks and area under the receiver operating characteristic curves ( AUC ’s ) were calculated . Results 164 ( 62.4 % ) patients ( median age : 76 ) underwent major surgery . 50 ( 19.5 % ) patients experienced major complications . 50.0 % of patients with high TUG and 24.8 % of patients with ASA≥3 experienced major complications ( absolute risks ) . TUG and ASA were independent predictors of the occurrence of major complications ( TUG : OR 3.43 ; 95%-CI = 1.13–10.36 . ASA1 vs. 2:OR 5.67 ; 95%-CI = 0.86–37.32 . ASA1 vs. 3&4:OR 11.75 ; 95%-CI = 1.62–85.11 ) . AUCTUG was 0.66 ( 95%-CI = 0.57–0.75 , p<0.001 ) and AUCASA was 0.58 ( 95%-CI = 0.49–0.67 , p = 0.09 ) . Conclusions Twice as many onco-geriatric patients at risk of post-operative complications , who might benefit from pre-operative interventions , are identified using TUG than when using ASA Flaws in the design , conduct , analysis , and reporting of r and omised trials can cause the effect of an intervention to be underestimated or overestimated . The Cochrane Collaboration ’s tool for assessing risk of bias aims to make the process clearer and more This prospect i ve 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 Question naire – Disability Index ( HAQ-DI ) to evaluate functional decline ; a 0.1 or greater increase was used to indicate a clinical ly significant decline . The preoperative Duke Activity Status Index ( DASI ) and a physical function score ( PFS ) , assessing gait speed , grip strength , balance , and st and ing speed , were evaluated as predictors of decline . We enrolled 215 patients ( 71.2 ± 5.2 years ; 56.7 % female ) ; 204 completed follow-up HAQ assessment s ( 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 OBJECTIVES Delirium is a common complication in elderly patients after cardiac surgery and is associated with adverse outcomes including prolonged hospital stay and increased mortality . Therefore , prevention or early detection of delirium is indicated . Our objective was to identify preoperative and operative characteristics that could predict delirium after cardiac surgery in elderly patients . METHODS We conducted a prospect i ve cohort study in which we analysed 201 patients of 70 years and older who underwent cardiac surgery , for developing a delirium . Patients were assessed daily using the Confusion Assessment Method -Intensive Care Unit . RESULTS Sixty-three patients ( 31 % ) developed a delirium after cardiac surgery . The Mini-Mental State Examination ( MMSE ) score prior to surgery was lower in the delirious patients when compared with the non-delirious patients ( 27 vs. 28 , P = 0.026 ) , creatinine level was higher ( 98 vs. 88 μmol/l , P = 0.003 ) and extracorporeal circulation ( ECC ) time was longer ( 145 vs. 113 min , P < 0.001 ) . Mortality during the first 30 days after surgery in patients with delirium was significantly higher than that in the non-delirious patients ( 14 vs. 0 % , P < 0.001 ) . CONCLUSIONS Low MMSE score and high creatinine level prior to surgery as well as increased ECC time are important independent predictors of delirium . In addition , delirium is an important predictor of 30-day mortality . Patients with a substantial risk for delirium should be c and i date s for interventions to reduce postoperative delirium and to potentially improve overall surgical outcomes OBJECTIVES Delirium ( or acute confusional state ) affects 35 % to 65 % of patients after hip-fracture repair , and has been independently associated with poor functional recovery . We performed a r and omized trial in an orthopedic surgery service at an academic hospital to determine whether proactive geriatrics consultation can reduce delirium after hip fracture . DESIGN Prospect i ve , r and omized , blinded . SETTING Inpatient academic tertiary medical center . PARTICIPANTS 126 consenting patients 65 and older ( mean age 79 + /- 8 years , 79 % women ) admitted emergently for surgical repair of hip fracture . MEASUREMENTS Detailed assessment through interviews with patients and design ated proxies and review of medical records was performed at enrollment to ascertain prefracture status . Subjects were then r and omized to proactive geriatrics consultation , which began preoperatively or within 24 hours of surgery , or " usual care . " A geriatrician made daily visits for the duration of the hospitalization and made targeted recommendations based on a structured protocol . To ascertain study outcomes , all subjects underwent daily , blinded interviews for the duration of their hospitalization , including the Mini-Mental State Examination ( MMSE ) , the Delirium Symptom Interview ( DSI ) , and the Memorial Delirium Assessment Scale ( MDAS ) . Delirium was diagnosed using the Confusion Assessment Method ( CAM ) algorithm . RESULTS The 62 patients r and omized to geriatrics consultation were not significantly different ( P>.1 ) from the 64 usual-care patients in terms of age , gender , prefracture dementia , comorbidity , type of hip fracture , or type of surgical repair . Sixty-one percent of geriatrics consultation patients were seen preoperatively and all were seen within 24 hours postoperatively . A mean of 10 recommendations were made throughout the duration of the hospitalization , with 77 % adherence by the orthopedics team . Delirium occurred in 20 /62 ( 32 % ) intervention patients , versus 32 / 64 ( 50 % ) usual-care patients ( P = .04 ) , representing a relative risk of 0.64 ( 95 % confidence interval ( CI ) = 0.37 - 0.98 ) for the consultation group . One case of delirium was prevented for every 5.6 patients in the geriatrics consultation group . There was an even greater reduction in cases of severe delirium , occurring in 7/ 60 ( 12 % ) of intervention patients and 18 / 62 ( 29 % ) of usual-care patients , with a relative risk of 0.40 ( 95 % CI = 0.18 - 0.89 ) . Despite this reduction in delirium , length of stay did not significantly differ between intervention and usual-care groups ( median + /- interquartile range = 5 + /- 2 days in both groups ) , likely because protocol s and pathways predetermined length of stay . In subgroup analyses , geriatrics consultation was most effective in reducing delirium in patients without prefracture dementia or activities of daily living ( ADL ) functional impairment . CONCLUSIONS Proactive geriatrics consultation was successfully implemented with good adherence after hip-fracture repair . Geriatrics consultation reduced delirium by over one-third , and reduced severe delirium by over one-half . Our trial provides strong preliminary evidence that proactive geriatrics consultation may play an important role in the acute hospital management of hip-fracture patients OBJECTIVES In elderly patients with mild cognitive impairment , noncompliance with respiratory exercises , ineffective expectoration , reluctance in mobilization , and difficulty in learning the use of drugs such as inhalers were observed in the early postoperative period after coronary artery bypass graft surgery . It was hypothesized that respiratory complications may be more frequent in these patients , and so the postoperative respiratory complications in patients with preoperative mild cognitive impairment were compared with the postoperative respiratory complications of a control group . DESIGN A prospect i ve cohort control . SETTING A university hospital . PARTICIPANTS Patients undergoing elective coronary artery bypass graft surgery . INTERVENTIONS Investigators separated 48 patients > 70 years old who were scheduled for elective coronary artery bypass graft surgery into two groups : patients with preoperative mild cognitive impairment  ( group A , n = 25 ) and patients with no cognitive impairment  ( control group ; group B , n = 23 ) . The patients ' cognitive status was evaluated preoperatively by the Montreal Cognitive Assessment test . MEASUREMENTS AND MAIN RESULTS Pulmonary functions and respiratory complications were evaluated via chest x-rays and spirometry tests preoperatively and postoperatively . A significant difference was observed between the groups , particularly with regard to atelectasis and prolonged ventilation ( p<0.001 and p<0.05 ) . No significant impairment was observed in the spirometry tests of the control group . However , a significant deterioration was observed in the postoperative spirometry tests of patients with preoperative mild cognitive impairment . CONCLUSIONS This study suggested that mild cognitive impairment was associated with pulmonary complications after coronary artery bypass graft surgery Purpose This r and omized controlled , clinical prospect i ve interventional trial was aim ed at exploring the effect of patient empowerment on short- and long-term outcomes after major oncologic surgery in elderly cancer patients . Methods This trial was performed from February 2011 to January 2014 at two tertiary medical centers in Germany . The study included patients aged 65 years and older undergoing elective surgery for gastro-intestinal , genitourinary , and thoracic cancer . The patients were r and omly assigned to the intervention group , i.e. patient empowerment through information booklet and diary keeping , or to the control group , which received st and ard care . R and omization was done by block r and omization in blocks of four in order of enrollment . The primary outcome were 1,postoperative length of hospital stay ( LOS ) and 2 . long-term global health-related quality of life ( HRQoL ) one year postoperatively . HRQoL was assessed using the EORTC QLQ C30 question naire . Secondary outcomes encompassed postoperative stress and complications . Further objectives were the identification of predictors of LOS , and HRQoL at 12 months . Results Overall 652 patients were included . The mean age was 72 ± 4.9 years , and the majority of patients were male ( 68.6 % , n = 447 ) . The ^median of postoperative length of stay was 9 days ( IQR 7–14 day ) . There were no significant differences between the intervention and the control groups in postoperative LOS ( p = 0.99 ) or global HRQoL after one year ( women : p = 0.54 , men : p = 0.94 ) . While overall complications and major complications occurred in 74 % and 24 % of the cases , respectively , frequency and severity of complications did not differ significantly between the groups . Patients in the intervention group reported significantly less postoperative pain ( p = 0.03 ) than the control group . Independent predictors for LOS were identified as severity of surgery , length of anesthesia , major postoperative complications , nutritional state , and pre-operative physical functional capacity measured by the Timed Up and Go-test by multiple robust regressions . Conclusion Patient empowerment through information booklet and diary keeping did not shorten the postoperative LOS in elderly onco-surgical patients , but improved quality of care regarding postoperative pain . Postoperative length of stay is influenced by pre-operative nutritional state , pre-operative functional impairment , severity of surgery , and length of anesthesia . Trial Registration Clinical trials.gov . Identifier Primary arthroplasty may be denied to very elderly patients based upon the perceived outcome and risks associated with surgery . This prospect i ve study compared the outcome , complications , and mortality of total hip ( TKR ) and total knee replacement ( TKR )  in a prospect ively selected group of patients aged ≥ 80 years with that of a control group aged between 65 and 74 years . There were 171 and 495 THRs and 185 and 492 TKRs performed in the older and control groups , respectively . No significant difference was observed in the mean improvement of Oxford hip and knee scores between the groups at 12 months ( 0.98 , ( 95 % confidence interval ( CI ) -0.66 to 2.95 ) , p = 0.34 and 1.15 ( 95 % CI -0.65 to 2.94 ) , p = 0.16 , respectively ) . The control group had a significantly ( p = 0.02 and p = 0.04 , respectively ) greater improvement in the physical well being component of their SF-12 score , but the older group was more satisfied with their THR ( p = 0.047 ) . The older group had a longer hospital stay for both THR ( 5.9 versus 9.0 days , p < 0.0001 ) and TKR ( 6.2 versus 8.3 days , p < 0.0001 ) . The rates of post-operative complications and mortality were increased in the older group OBJECTIVES This study sought to evaluate the impact of frailty in older adults undergoing transcatheter aortic valve replacement ( TAVR ) for symptomatic aortic stenosis . BACKGROUND Frailty status impacts prognosis in older adults with heart disease ; however , the impact of frailty on prognosis after TAVR is unknown . METHODS Gait speed , grip strength , serum albumin , and activities of daily living status were collected at baseline and used to derive a frailty score  among patients who underwent TAVR procedures at a single large-volume institution . The cohort was dichotomized on the basis of median frailty score into frail and not frail groups . The impact of frailty on procedural outcomes ( stroke , bleeding , vascular complications , acute kidney injury , and mortality at 30 days ) and 1-year mortality was evaluated . RESULTS Frailty status was assessed in 159 subjects who underwent TAVR ( age 86 ± 8 years , Society of Thoracic Surgery Risk Score 12 ± 4 ) .  Baseline frailty score was not associated with conventionally ascertained clinical variables or Society of Thoracic Surgery score . Although high frailty score was associated with a longer post-TAVR hospital stay when compared with lower frailty score ( 9 ± 6 days vs. 6 ± 5 days , respectively , p = 0.004 ) , there were no significant crude associations between frailty status and procedural outcomes , suggesting adequacy of the st and ard selection process for identifying patients at risk for periprocedural complications after TAVR . Frailty status was independently associated with increased 1-year mortality ( hazard ratio : 3.5 , 95 % confidence interval : 1.4 to 8.5 , p = 0.007 ) after TAVR . CONCLUSIONS Frailty was not associated with increased periprocedural complications in patients selected as c and i date s to undergo TAVR but was associated with increased 1-year mortality after TAVR . Further studies will evaluate the independent value of this frailty composite in older adults with aortic stenosis Objective : To describe and evaluate an  inpatient geriatric trauma consultation service ( GTCS ) . Background : Delays in recognizing the special needs of older trauma patients may result in suboptimal care . The GTCS is a proactive geriatric consultation model aim ed at preventing and managing age-specific complications and discharge planning for all patients 60 years or older admitted to the St Michael 's Hospital Trauma Service . Methods : This was a before and after case series of patients admitted pre-GTCS ( March 2005–August 2007 ) and post-GTCS ( September 2007–March 2010 ) . Study data were derived from a review of the medical records and from the St Michael 's Hospital trauma registry . Abstract ed data included demographics , type of geriatric issues addressed , rate of adherence to recommendations made by the GTCS , geriatric-specific clinical outcomes , trauma quality indicators , consultation requests , and discharge destinations . Results : A total of 238 pre-GTCS patients and 248 post-GTCS patients were identified . The rate of adherence to recommendations made by the GTCS team was 93.2 % . There were fewer consultation requests made to Internal Medicine and Psychiatry in the post-GTCS group ( N = 31 vs N = 18 , P = 0.04 ; and N = 33 vs N = 18 , P = 0.02 ; respectively ) . There were no differences in any of the prespecified complications except delirium ( 50.5 % pre-GTCS vs 40.9 % post- GTCS , P = 0.05 ) . Among patients admitted from home , fewer were discharged to long-term care facilities among the post-GTCS group ( 6.5 % pre-GTCS vs 1.7 % post-GTCS , P = 0.03 ) . Conclusions : A proactive geriatric consultation model for elderly trauma patients may decrease delirium and discharges to long-term care facilities . Future studies should include a multicenter r and omized trial of this model of care BACKGROUND The prevalence of comorbidities and functional impairment among elderly patients may enhance the risk of operation-related complications , but the importance of these conditions in elderly patients undergoing thoracic surgery remains unclear . METHODS One hundred twenty patients > /= 60 years of age who underwent thoracic surgery  were registered prospect ively and examined . A comprehensive geriatric assessment ( CGA ) that evaluated such diverse areas as functional status ( ie , performance status and activities of daily living [ ADLs ] using the Barthel index ) , comorbidity , nutrition ( ie , body mass index , arm-muscle circumference , albumin level , transferrin level , lymphocyte count , and cholinesterase level ) , and cognitive function ( ie ,  mini-mental state examination [ MMSE ] and negative emotions for operation )  was performed in the 2 weeks before patients underwent the operation . RESULTS The diseases of the 120 patients were as follows : lung cancer , 85 patients ; mediastinal tumor , 14 patients ; bullas , 12 patients ; and other diseases , 9 patients .  Postoperative complications developed in 20 patients ( 16.7 % ) . The patients with dependence for performing the ADLs , and dementia were more likely to develop postoperative complications ( p = 0.041 , and p = 0.0065 , respectively ) . The patients who experienced longer operation times ( ie , > /= 300 min ; p = 0.018 ) were more likely to have complications . The incidence of prolonged air leak in the patients with malnutrition increased seven-fold ( p = 0.045 ) and that of postoperative infectious diseases in those patients with obesity increased 24-fold ( p = 0.0013 ) , while all patients who developed delirium had low scores in the MMSE preoperatively ( p = 0.0003 ) . Using multiple logistic regression , the best model was obtained with a combination of MMSE ( p = 0.031 ) and the Barthel index ( p = 0.04 ) . When the operation variables were added to this model , the operation time had the strongest effect ( p = 0.016 ) . CONCLUSIONS Dependence for the performance of ADLs and impaired cognitive conditions are important predictors of postoperative complications , especially when the operation time is long . CGA is necessary in addition to the conventional cardiopulmonary functional assessment in elderly patients OBJECTIVE To develop and vali date a clinical prediction rule for postoperative delirium using data available to clinicians preoperatively . DESIGN Prospect i ve cohort study . SETTING General surgery , orthopedic surgery , and gynecology services at Brigham and Women 's Hospital , Boston , Mass. PATIENTS Consenting patients older than 50 years admitted for major elective noncardiac surgery between November 1 , 1990 , and March 15 , 1992 ( N = 1341 ) . MEASUREMENTS All patients underwent preoperative evaluations , including a medical history , physical examination , laboratory tests , and assessment s of physical and cognitive function using the Specific Activity Scale and the Telephone Interview for Cognitive Status . Postoperative delirium was diagnosed using the Confusion Assessment Method or using data from the medical record and the hospital 's nursing intensity index . Patients were followed up for the duration of hospitalization to determine major complication rates , length of stay , and discharge disposition . RESULTS Postoperative delirium occurred in 117 ( 9 % ) of the 1341 patients studied . Independent correlates included age 70 years or older ; self-reported alcohol abuse ; poor cognitive status ; poor functional status ; markedly abnormal preoperative serum sodium , potassium , or glucose level ; noncardiac thoracic surgery ; and aortic aneurysm surgery . Using these seven preoperative factors , a simple predictive rule was developed . In an independent population , the rule stratified patients into groups with low ( 2 % ) , medium ( 8 % , 13 % ) , and high ( 50 % ) rates of postoperative delirium . Patients who developed delirium had higher rates of major complications , longer lengths of stay , and higher rates of discharge to long-term care or rehabilitative facilities . CONCLUSIONS Using data available preoperatively , clinicians can stratify patients into risk groups for the development of delirium . Since delirium is associated with a variety of adverse outcomes , patients with substantial risk for this complication could be c and i date s for interventions to reduce the incidence of postoperative delirium and potentially improve overall surgical outcomes BACKGROUND : Previous studies have shown that women are at higher risk than men for stroke after coronary artery bypass graft ( CABG ) surgery , but gender differences in systemic atherosclerosis have not been studied adequately . We investigated gender differences in the incidence of craniocervical and ascending aortic atherosclerosis and other risk factors for stroke in elderly patients ( age ≥60 yr ) undergoing CABG surgery .  METHODS : Data were prospect ively collected on 720 patients ( 31.8 % women ) undergoing CABG surgery .  All patients underwent preoperative brain magnetic resonance imaging and angiography to assess for prior cerebral infa rct ions , carotid artery stenosis , and intracranial arterial stenosis . Epiaortic ultrasound was performed at the time of surgery to assess for atherosclerosis of the ascending aorta . Cognitive status was measured using the Hasegawa-dementia score in all patients before surgery and on the seventh postoperative day . RESULTS : Women were older and had more hypertension and intracranial arterial stenosis than did men . Men had significantly higher rates of hyperlipidemia , peripheral vascular disease , abdominal aortic aneurysm , smoking history , severe carotid artery stenosis , and severe aortic atherosclerosis than did women . Although there were no differences in prior cerebral infa rct ion or preoperative cognitive impairment , the rate of perioperative stroke was marginally higher in men than in women ( 3.9 % vs 1.3 % , P = 0.066 ) . Univariate predictors of perioperative stroke were prior cerebral infa rct ions , ascending aortic atherosclerosis , preexisting cognitive impairment , and peripheral vascular disease . Stepwise logistic regression analysis demonstrated that significant independent predictors of perioperative stroke were prior cerebral infa rct ions and aortic atherosclerosis . CONCLUSIONS : These data suggest that men are more likely than women to have risk factors for stroke , including severe carotid artery stenosis , severe aortic atherosclerosis , and peripheral vascular disease . The rates of prior cerebral infa rct ion and preoperative cognitive impairment were similar between genders OBJECTIVES The Nutrition Screening Initiative is a national collaborative effort committed to the identification and treatment of nutritional problems in older persons . METHODS A 14-item checklist of characteristics associated with nutritional status was administered to a r and om sample of Medicare beneficiaries , aged 70 years and older , in New Engl and . Regression analysis was used to derive item weights that would predict poor nutrient intakes and low perceived health status . Sensitivity and specificity values were review ed to define low , moderate , and high nutritional risk scores . RESULTS A revised checklist containing 10 yes/no items was adopted . Scores of 6 or more points defined persons at high nutritional risk . Twenty-four percent of the Medicare population was estimated to be at high nutritional risk according to the checklist . Among those in the high-risk group , 56 % perceived their health to be " fair " or " poor " and 38 % had dietary intakes below 75 % of the recommended dietary allowances for three or more nutrients . CONCLUSIONS The Nutrition Screening Initiative Checklist is a brief , easily scored instrument that can accurately identify noninstitutionalized older persons at risk for low nutrient intake and health problems BACKGROUND A number of elderly cancer patients do not receive st and ard surgery for solid tumors because they are considered unfit for treatment as a consequence of inaccurate estimation of the operative risk . To tailor treatment to onco-geriatric series , oncologists are now beginning to use a comprehensive geriatric assessment ( CGA ) . This study investigates the value of an extended CGA in assessing the suitability of elderly patients for surgical intervention . PATIENTS AND METHODS Preoperative assessment of cancer in the elderly ( PACE ) incorporates vali date d instruments including the CGA , an assessment of fatigue and performance status and an anaesthesiologist 's evaluation of operative risk . An international prospect i ve study was conducted using 460 consecutively recruited elderly cancer patients who received PACE prior to elective surgery .  Mortality , post-operative complications ( morbidity ) and length of hospital stay were recorded up to 30 days after surgery . RESULTS Poor health in relation to disability ( assessed using the instrumental activities of daily living ( IADL ) ) , fatigue and performance status ( PS ) were associated with a 50 % increase in the relative risk of post-operative complications . Multivariate analysis identified moderate/severe fatigue , a dependent IADL and an abnormal PS as the most important independent predictors of post-surgical complications . Disability assessed by activities of daily living ( ADL ) , IADL and PS were associated with an extended hospital stay . CONCLUSION PACE represents a valuable tool in enhancing the decision process concerning the c and idacy of elderly cancer patients for surgical intervention and can reduce inappropriate age-related inequity in access to surgical intervention . It is recommended that PACE be used routinely in surgical practice OBJECTIVES Delirium is a common and critical clinical syndrome in older patients . We examined whether abnormalities in the brain that could be assessed by magnetic resonance imaging predisposed patients to develop delirium after coronary artery bypass graft surgery . We also analysed the association between delirium and cognitive dysfunction after coronary artery bypass graft surgery . METHODS Data were collected prospect ively on 153 patients aged 60 years or older who consecutively underwent elective isolated coronary artery bypass graft surgery . All patients were assessed for prior cerebral infa rct ions and craniocervical artery stenosis by magnetic resonance imaging ( MRI ) and angiography of their brains . Atherosclerosis of the ascending aorta was examined by epiaortic ultrasound at the time of surgery .  Individual cognitive status was measured using four tests in all the patients before surgery and on the seventh postoperative day . A single psychiatrist diagnosed delirium using the Diagnostic and Statistical Manual of Mental Disorders 4th edition IV criteria . RESULTS Postoperative delirium occurred in 16 patients ( 10.5 % ) . Compared with patients who did not develop postoperative delirium , delirious patients had significantly higher rates of peripheral artery disease , preoperative decline in global cognitive function and pre-existing multiple cerebral infa rct ions on MRI . In addition , 9 ( 56 % ) of the delirious patients suffered postoperative cognitive dysfunction . Stepwise logistic regression analysis found significant independent predictors of postoperative delirium to be preoperative cerebral infa rcts on MRI ( odds ratio [ OR ] , 2.26 ; 95 % confidence interval [ CI ] 1.10 - 4.78 ) , preoperative decline in global cognitive function ( OR 4.54 ; 95 % CI 1.21 - 16.51 ) and atherosclerosis of the ascending aorta ( OR 2.44 ; 95 % CI 1.03 - 5.62 ) . CONCLUSIONS Our findings suggested that postoperative delirium was associated with pre-existing multiple cerebral infa rct ions on MRI , preoperative decline in global cognitive function and ascending aortic atherosclerosis in elderly patients undergoing coronary artery bypass graft surgery and increased risk of postoperative cognitive dysfunction The present study examined the association between patient-reported anxiety and postcardiac surgery mortality and major morbidity .  Frailty Assessment Before Cardiac Surgery was a prospect i ve multicenter cohort study of elderly patients undergoing cardiac surgery ( coronary artery bypass surgery and /or valve repair or replacement ) at 4 tertiary care hospitals from 2008 to 2009 . The patients were evaluated a mean of 2 days preoperatively with the  Hospital Anxiety and Depression Scale  , a vali date d question naire assessing depression and anxiety in hospitalized patients . The primary predictor variable was a high level of anxiety , defined by a Hospital Anxiety and Depression Scale score of ≥ 11 . The main outcome measure was all-cause mortality or major morbidity ( e.g. , stroke , renal failure , prolonged ventilation , deep sternal wound infection , or reoperation ) occurring during the index hospitalization . Multivariable logistic regression analysis examined the association between high preoperative anxiety and all-cause mortality/major morbidity , adjusting for the Society of Thoracic Surgeons predicted risk , age , gender , and depression symptoms . A total of 148 patients ( mean age 75.8 ± 4.4 years ; 34 % women ) completed the Hospital Anxiety and Depression Scale . High levels of preoperative anxiety were present in 7 % of patients . No differences were found in the type of surgery and Society of Thoracic Surgeons predicted risk across the preoperative levels of anxiety . After adjusting for potential confounders , high preoperative anxiety was remained independently predictive of postoperative mortality or major morbidity ( odds ratio 5.1 , 95 % confidence interval 1.3 to 20.2 ; p = 0.02 ) . In conclusion , although high levels of anxiety were present in few patients anticipating cardiac surgery , this conferred a strong and independent heightened risk of mortality or major morbidity We investigate age and sex differences in  acute myocardial infa rct ion ( AMI ) after cardiac surgery  in a prospect i ve study of 2038 consecutive patients undergoing cardiac surgery with cardiopulmonary bypass .  An age of ≥ 70 years implied changes in the type of AMI from the ST-segment elevation myocardial infa rct ion ( STEMI ) to non-ST-segment elevation myocardial infa rct ion ( non-STEMI ) . Men were more likely than women to suffer from AMI after cardiac surgery ( 11.8 % vs. 5.6 % ) , as a result of the higher frequency of STEMI ( 6 % of men vs. 1.8 % of women ; P < 0.001 ) in both age groups . A troponin-I ( Tn-I ) peak was significantly higher in patients ≥ 70 years old . In-hospital mortality was higher in patients ≥ 70 ( 7.3 % ) than in those < 70 years old ( 3.3 % ) , because of the increased mortality observed in men with non-AMI ( 2.1 % vs. 6.3 % ) and women with STEMI ( 0 % vs. 28.6 % ) and non-STEMI ( 0 % vs. 36.8 % , P < 0.05 ) . Old age was associated with a higher frequency of non-STEMI , Tn-I peak , mortality and length of stay in the intensive care unit ( ICU ) . Regardless of age , men more often suffer from AMI ( particularly STEMI ) . AMI in women had a notable impact on excess mortality and ICU stay observed in patients ≥ 70 years of age . Clinical and Tn-I peak differences are expected in relation to age and gender after AMI post-cardiac surgery Background Frailty is a phenotype characterized by complex and challenging medical problems and higher susceptibility to adverse health outcomes . It can be derived at by a multidimensional process known as comprehensive geriatric assessment ( CGA ) , which assesses the functional reserves of the elderly . In this study we report for the first time on a prospect i ve evaluation of the association between CGA and postoperative complications after elective laparoscopic cholecystectomy for biliary disease . Methods Fifty-seven patients older than 65 years who were to undergo elective laparoscopic cholecystectomy for uncomplicated biliary disease were prospect ively examined .  Preoperative CGA was performed and the patients were categorized as fit or frail . The main outcome of the study was the rate of any postoperative complication within 30 days of surgery . Results There were 29 women ( 50.9 % ) and the median ( interquartile range ) age of the cohort was 73 ( 8.8 ) years . Thirty-two patients ( 56.1 % ) were categorized as frail and 25 ( 43.9 % ) as fit . The overall incidence of postoperative complications was 23.7 % , most of which were grade I and II ( 18.8 % ) . Frail patients , according to the CGA assessment , experienced a significantly higher incidence of postoperative complications compared to their fit counterparts ( 84.6 vs. 15.4 % , p = 0.023 ) . Frail patients experienced a significantly higher frequency of prolonged ( more than 2 days ) postoperative hospital stay compared with their fit counterparts ( p = 0.023 ) . Conclusions Preoperative CGA may predict postoperative complications and prolonged postoperative hospital stay of elderly patients who undergo elective laparoscopic cholecystectomy . Larger-scale studies independently assessing this association are warranted To determine which preoperative factors might affect the development of cardiac complications after major noncardiac operations , we prospect ively studied 1001 patients over 40 years of age . By multivariate discriminant analysis , we identified nine independent significant correlates of life-threatening and fatal cardiac complications : preoperative third heart sound or jugular venous distention ; myocardial infa rct ion in the preceding six months ; more than five premature ventricular contractions per minute documented at any time before operation ;  rhythm other than sinus or presence of premature atrial contractions on preoperative electrocardiogram ;  age over 70 years ; intraperitoneal , intrathoracic or aortic operation ; emergency operation ; important valvular aortic stenosis ; and poor general medical condition . Patients could be separated into four classes of significantly different risk . Ten of the 19 postoperative cardiac fatalities occurred in the 18 patients at highest risk . If vali date d by prospect i ve application , the multifactorial index may allow preoperative estimation of cardiac risk independent of direct surgical risk OBJECTIVE The geriatric assessment ( GA ) has proven to be of great value for clinicians treating older patients . However , a clear consensus on the optimal set of GA instruments is lacking , particularly for surgical patients . Therefore , the aim of this prospect i ve study was to compare the prevalence of frailty , depending on the number of incorporated GA domains , and to evaluate its accuracy in predicting postoperative outcome . MATERIAL S AND METHODS Seventy-five patients aged 65 years and older , qualified for abdominal surgery due to solid cancer , were enrolled . The GA included a wide variety of vali date d tools that evaluate functional , mobility , nutritional , co-morbidity , polypharmacy , and psychosocial domains .  RESULTS Depending on the number of incorporated GA domains the frequency of frailty was 23 - 97 % . The cumulative score rather than individual components of the GA , turned out to be an independent risk factor of 30-day postoperative morbidity . In predicting 30-day " any " and " major " morbidities , the area under the curve was 0.67 - 0.72 and 0.70 - 0.82 ( model including the severity of the surgery ) vs. 0.57 - 0.66 and 0.50 - 0.65 ( model not including the severity of the surgery ) , respectively . CONCLUSION The number of incorporated GA domains has a great influence on the prevalence of frailty and on adequate surgical risk assessment . The summary deficit score based on Pre-operative Assessment of Cancer in the Elderly ( PACE ) or the GA consisting of functional , mobility , cognitive , depression , nutritional , co-morbidity , polypharmacy , and social support assessment domains can predict 30-day postoperative morbidity . However , only models with addition of the severity of surgery show moderate to good predictive value PURPOSE To determine the association between self-reported exercise tolerance and the risk of unanticipated postoperative nursing home placement in adults undergoing major surgery . METHODS Consecutive community-dwelling adults ( N = 586 ) referred to a medical clinic for evaluation before undergoing major nonemergent surgery at a tertiary care academic medical center were prospect ively followed between 1995 and 1997 . The main outcome measure was unanticipated postoperative nursing home placement . RESULTS Overall , 12 % ( 40/324 ) of patients with poor preoperative  exercise tolerance ( inability to walk four blocks and climb two flights of stairs without symptomatic limitation ) had unanticipated nursing home placement compared with 4 % ( 10/262 ) of patients with good exercise tolerance . Patient and surgical characteristics associated with nursing home placement in univariate analyses included poor preoperative exercise tolerance , increasing age , living alone , history of heart failure , taking five or more preoperative medications , longer anesthesia duration , and orthopedic surgery . Patients who were married were at lower risk . After adjusting for all other patient and surgical factors , poor preoperative exercise tolerance ( odds ratio [ OR ] = 2.8 ; 95 % confidence interval [ CI ] : 1.3 to 6.2 ) and serious postoperative complications ( OR = 4.7 ; 95 % CI : 2.1 to 10.5 ) remained associated with postoperative nursing home placement . CONCLUSION Poor preoperative exercise tolerance was an independent predictor of unanticipated nursing home placement following major nonemergent surgery Background The number of elderly patients proposed for brain tumor removal  is increasing . Only few data on long-term functional prognosis after intracranial surgery are available . Material s and Methods Prospect i ve , observational study of all patients greater than 70 year of age operated for intracranial tumors . Two scales for health status evaluation were used : Karnofsky Performance Scale ( KPS ) and Activities of Daily Living ( ADL ) score . Data were expressed as medians ( first to third quartiles ) . The primary endpoint was the probability to remain nondependant ( ADL>3 and KPS≥70 % ) after 1 year . Results Between 2003 and 2007 , 90 patients were included : 46 ( 51.1 % ) meningioma , 17 ( 18.9 % ) high- grade glioma , and 11 ( 12.2 % ) metastasis . At hospital admission , age was 73.50 years ( 71.25 - 76.00 ) , American Society of Anesthesiology  score 2 ( 2 to 3 ) , KPS 80 % ( 70–90 ) , ADL 5.5 ( 4.5 to 6.0 ) . Two patients died during the first 28 days , 3 others during the first year . Both KPS and ADL decreased after 1 year : KPS 80 % ( 70 to 90 ; mean : 80 % ) at hospital admission versus 80 % ( 60 to 90 ) at 1 year ( mean : 70 % ) , P=0.003 ; ADL 5.5 ( 4.5 to 6.0 ) at hospital admission versus 5.0 ( 3.25 to 5.50 ) at 1 year , P=0.001 . In multivariate analysis , 2 preoperative parameters were associated with autonomy at 1 year : the ADL at hospital admission and meningioma as histologic type . Conclusions In this series of elderly patients , intracranial tumor surgery was associated with low 1-year mortality . Meningioma was associated with a better postoperative functional outcome . Preoperative ADL score was a predictive of functional evolution 1 year after the surgery BACKGROUND No tool currently exists to rapidly allow surgeons to objective ly quantify surgical risk in geriatric patients . The goal of our prospect i ve study was to determine if individual questions extracted from vali date d screens for common geriatric syndromes would have predictive value for surgical risk in geriatric patients with thoracic neoplasms . METHODS Patients ≥ 70 y old were recruited to participate in a prospect i ve , IRB-approved study involving the preoperative administration of vali date d screening tests . Patients were given the  geriatric depression scale ( GDS ) , nutrition screening initiative nutritional health checklist ( NSI NHC ) , mini mental status exam ( MMSE ) , brief fatigue inventory ( BFI ) , and assessed for activities of daily living ( ADLs ) and instrumental activities of daily living ( IADLs ) .  All patients enrolled in this study were scheduled for thoracic surgery . RESULTS Patients who responded to having a dependency in the IADL " shopping " were more likely to have major complications and to be discharged to a non-home location than those without a dependency ( P = 0.011 , 0.003 ) . Patients who answered " yes " to questions 1 , 9 , and 10 of the NSI NHC had a longer mean length of stay compared with patients who answered " no " ( P = 0.039 , 0.010 , 0.031 ) . Answering " yes " to GDS question 2 correlated with the incidence of major complications ( r = 0.270 P = 0.037 ) . Answering " yes " to GDS question 12 increased the likelihood of being discharged to a non-home location postoperatively ( odds ratio = 11.64 , 95 % CI , 0.68 - 202.86 , P = 0.047 ) . CONCLUSIONS Our data indicate that an abbreviated , rapid presurgical assessment can be developed for estimating operative risk , length of stay , and discharge destination in geriatric patients with thoracic malignancies using individual questions from previously vali date d screening tools BACKGROUND The purpose of this prospect i ve study was to identify risk factors for adverse outcomes or increased re source utilization after  abdominal cancer surgery in geriatric patients . METHODS Baseline clinical and geriatric assessment variables  including functional status , nutritional status , comorbidity index , mental status , depression scale score , fatigue inventory scale , and polypharmacy scale were prospect ively recorded for patients age ≥65 undergoing intra-abdominal oncologic surgery .  Outcome variables included morbidity , mortality , discharge to nursing facility , prolonged hospital stay , and readmission . RESULTS Of 111 patients , surgery type was colorectal in 40 % , hepatopancreatobiliary in 30 % , and gastric/duodenal in 14 % . Variables associated with discharge to a nursing facility on multivariate analysis included weight loss ≥10 % ( OR 6.52 [ 95 % CI : 1.43 - 29.76 ] , P = 0.02 ) , ASA score ≥2 ( OR 5.08 [ 1.13 - 22.77 ] , P = 0.03 ) , and ECOG score ≥2 ( OR 4.51 [ 1.03 - 19.71 ] , P = 0.04 ) . Variables independently associated with prolonged hospital stay included weight loss ≥10 % ( OR 4.03 [ 1.13 - 14.43 ] , P = 0.03 ) , the presence of polypharmacy ( OR 2.45 [ 1.09 - 5.48 ] , P = 0.03 ) , and distant disease ( OR 0.37 [ 0.15 - 0.91 ] , P = 0.03 ) . No variables were associated with morbidity or readmission . CONCLUSIONS Pre-operative clinical and geriatric assessment tools can help predict the need for discharge to a nursing facility or increased length of stay . Future studies will be required to identify patients suitable for interventions to decrease hospital and post-discharge re source utilization Predictors of perioperative complications , including cardiac death , ventricular tachycardia or fibrillation , and heart failure or myocardial infa rct ion , were assessed in an initial study of 100 patients aged 65 years or older scheduled for elective abdominal or noncardiac thoracic surgery .  Preoperative history , results of physical examination , chest roentgenogram , electrocardiogram , laboratory data , Dripps ( American Society of Anesthesiologists ) class , and Goldman cardiac risk index were compared with rest and exercise radionuclide ventriculograms . Thirteen patients had perioperative cardiac complications , and 6 died . Multivariate analysis showed that an inability to do 2 minutes of bicycle exercise in the supine position to raise the heart rate above 99 beats/min ( sensitivity 85 % , specificity 64 % ) gave predictive information not available from clinical or radionuclide data . On prospect i ve testing involving 55 additional geriatric patients , inability to exercise was the only independent predictor of perioperative complications ( p less than 0.05 ) . Data from rest and exercise radionuclide ventriculography added little information for predicting perioperative cardiac risk BACKGROUND & AIMS Little is known about the impact of preoperative protein or energy intake in relation to the occurrence of postoperative complications in patients who are not undernourished but can not keep up their daily protein or energy requirements prior to cardiac surgery . Therefore , a prospect i ve study on intake in preoperatively well-nourished , non-hospitalized cardiac surgery patients ( > or= 65 y ) was carried out . METHODS Between December 2004 and November 2005 preoperative protein and energy intake and postoperative outcome data were collected from 100 consecutive patients undergoing cardiac surgery .  RESULTS Comparison of low protein intake ( < or= 0.98 g/kg/d ) with high protein intake ( > 0.98 g/kg/d ) showed a low protein intake did not result in more complications or prolonged length of stay . In low-risk operation patients in particular , a high-energy intake ( > 22 kcal/kg/d ) result ed in more postoperative complications than a low energy intake ( < or= 22 kcal/kg/d ) ( 33.3 % and 13.2 % , respectively ; ( OR 5.0 95 % CI [ 1.5 - 16.9 ] ) ) . A preoperative protein intake  < or= 0.80 g/kg/d was seen in 22.6 % , and an energy intake < or= 25 kcal/kg/d in 72.2 % of the patients . CONCLUSION The outcome of this study suggests that detecting and correcting a preoperative low protein or energy intake is of no clinical relevance in the well-nourished , non-hospitalized elderly cardiac surgery patients . Caloric overfeeding may be associated with an increased complication rate Objective : To establish reliable st and ards for surgical application to elderly patients 75 years old or older with gastric or colorectal cancer with special reference to the postoperative recovery of activities of daily living ( ADL ) and quality of life ( QOL ) . Summary Background Data : ADL and QOL are important outcomes of surgery for the elderly . However , there has been only limited evidence on the natural course of recovery of functional independence . Methods : Two hundred twenty-three patients 75 years old or older with gastric or colorectal cancer were prospect ively examined .  Physical conditions , ADL , and QOL  were evaluated preoperatively and at the first , third , and sixth postoperative month . Results : The mortality and morbidity rates were 0.4 % and 28 % , respectively . Twenty-four percent of patients showed a decrease in ADL at 1 month postoperatively , but most patients recovered from this transient reduction , with only 3 % showing a decline at the sixth postoperative month ( 6POM ) . ADL of these patients was likely to decrease after discharge from the hospital . QOL of the patients showed a recovery to an extent equal to or better than their average preoperative scores . Conclusions : Of the patients 75 years old or older who underwent elective surgery for gastric or colorectal cancer , only a few showed a protracted decline in ADL and most exhibited better QOL after surgery . This indicates that surgical treatment should be considered , whenever needed , for elderly patients 75 years old or older with gastric or colorectal cancer . Estimation of Physical Ability and Surgical Stress is useful for predicting postoperative declines in ADL and protracted disability ; this could aid in establishing a directed rehabilitation program for preventing protracted disability in elderly patients BACKGROUND The clinical syndrome of frailty identified through the assessment of weight loss , gait speed , grip strength , physical activity , and physical exhaustion has been used to identify patients with reduced reserves . We hypothesized that frailty is useful in predicting adverse outcomes in optimized elective elderly colorectal surgery patients . METHODS A prospect i ve study was conducted at 2 centers ( Singapore and Japan ) . All patients over 75 years of age undergoing colorectal resection were assessed for the presence of the syndrome of frailty .  All these patients had already had their comorbidities optimized for surgery . The outcome measure was postoperative major complications ( defined as Clavien-Dindo type II and above complications ) . RESULTS Eighty-three patients were studied from February 2008 to April 2010 . The mean age was 81.5 years ( range 75 - 93 years ) . The mean comorbidity index was 3.37 ( range 0 - 11 ) . Twenty-six ( 31.3 % ) patients were an American Society of Anesthesiologists ( ASA ) score of 3 and above . Chi-square analysis revealed that the odds ratio of postoperative major complications was 4.083 ( 95 % confidence interval , 1.433 - 11.638 ) when the patient satisfied the criteria for frailty . Albumin < 35 , ASA > 3 , comorbidity index > 5 , and Physiologic and Operative Severity Score for the enUmeration of Mortality and Morbidity ( POSSUM ) scores were not predictive of postoperative major complications . CONCLUSIONS Preliminary findings show that frailty is a potent adjunctive tool of predicting postoperative morbidity . Frailty can be used to identify elderly patients needing further optimization before major surgery BACKGROUND Preoperative risk stratification is commonly performed by assessing end-organ function ( such as cardiac and pulmonary ) to define postoperative risk . Little is known about impaired preoperative cognition and outcomes . The purpose of this study was to evaluate the impact of baseline impaired cognition on postoperative outcomes in geriatric surgery patients . STUDY DESIGN Subjects 65 years and older undergoing a planned elective operation requiring postoperative ICU admission were recruited prospect ively .  Preoperative baseline cognition was assessed using the vali date d Mini-Cog test . Impaired cognition was defined as a Mini-Cog score of ≤ 3 . Delirium was assessed using the Confusion Assessment Method -ICU by a trained research team . Adverse outcomes were defined using the Veterans Affairs Surgical Quality Improvement Program definitions . RESULTS One hundred and eighty-six subjects were included , with a mean age of 73 ± 6 years . Eighty-two subjects ( 44 % ) had baseline impaired cognition . The impaired cognition group had the following unadjusted outcomes : increased incidence of 1 or more postoperative complications ( 41 % vs 24 % ; p = 0.011 ) , higher incidence of delirium ( 78 % vs 37 % ; p < 0.001 ) , longer hospital stays ( 15 ± 14 vs 9 ± 9 days ; p = 0.001 ) , higher rate of discharge institutionalization ( 42 % vs 18 % ; p = 0.001 ) , and higher 6-month mortality ( 13 % vs 5 % ; p = 0.040 ) . Adjusting for potential confounders determined by univariate analysis , logistic regression found impaired cognition was still associated with the occurrence of 1 or more postoperative complications ( odds ratio = 2.401 ; 95 % CI , 1.185 - 4.865 ; p = 0.015 ) . Kaplan-Meier survival analysis revealed higher mortality in the impaired cognition group ( log-rank p = 0.008 ) . CONCLUSIONS Baseline cognitive impairment in older adults undergoing major elective operations is related to adverse postoperative outcomes including increased complications , length of stay , and long-term mortality . Improved underst and ing of baseline cognition and surgical outcomes can aid surgical decision making in older adults
target: Conclusion Geriatric syndromes are important prognostic factors for postoperative complications .
background: Background Elective surgeries can be associated with significant harm to older adults .
  The present study aim ed to identify the prognostic factors associated with the development of postoperative complications among older adults undergoing elective surgery .