Redefining geriatric preoperative assessment using frailty, disability and co-morbidity.

OBJECTIVES: (1) Determine the relationship of geriatric assessment markers to 6-month postoperative mortality in elderly patients. (2) Create a clinical prediction rule using geriatric markers from preoperative assessment. BACKGROUND: Geriatric surgery patients have unique physiologic vulnerability requiring preoperative assessment beyond the traditional evaluation of older adults. The constellation of frailty, disability and comorbidity predict poor outcomes in elderly hospitalized patients. METHODS: Prospectively, subjects > or =65 years undergoing a major operation requiring postoperative intensive care unit admission were enrolled. Preoperative geriatric assessments included: Mini-Cog Test (cognition), albumin, having fallen in the past 6-months, hematocrit, Katz Score (function), and Charlson Index (comorbidities). Outcome measures included 6-month mortality (primary) and postdischarge institutionalization (secondary). RESULTS: One hundred ten subjects (age 74 +/- 6 years) were studied. Six-month mortality was 15% (16/110). Preoperative markers related to 6-month mortality included: impaired cognition (P < 0.01), recent falls (P < 0.01), lower albumin (P < 0.01), greater anemia (P < 0.01), functional dependence (P < 0.01), and increased comorbidities (P < 0.01). Similar statistical relationships were found for all 6 markers and postdischarge institutionalization. Logistic regression identified any functional dependence (odds ratio 13.9) as the strongest predictor of 6-month mortality. Four or more markers in any one patient predicted 6-month mortality with a sensitivity of 81% (13/16) and specificity of 86% (81/94). CONCLUSIONS: Geriatric assessment markers for frailty, disability and comorbidity predict 6-month postoperative mortality and postdischarge institutionalization. The preoperative presence of > or =4 geriatric-specific markers has high sensitivity and specificity for 6-month mortality. Preoperative assessment using geriatric-specific markers is a substantial paradigm shift from the traditional preoperative evaluation of older adults.

Postoperative delirium in the elderly: diagnosis and management.

Delirium is a common but often undiagnosed complication in the elderly following a major operation. Recognizing the presentation of delirium and the criteria to establish the diagnosis of delirium will improve a clinician's ability to detect this complication. Treating delirium with environmental, supportive, and pharmacologic interventions reduces the incidence and side effects of postoperative delirium. The purpose of this review is to describe the diagnosis and treatment of postoperative delirium.

Military medical surge capacity in times of war and natural disaster.

BACKGROUND: The military medical services need demand-based strategies to ensure the best possible care of the injured in combat and natural disasters without compromising peacetime health care commitments at home and abroad. METHODS: A review of steps that have already been taken suggests that they are being used to their fullest extent commensurate with the public will. In fact, the situation has driven preliminary exploration of a special health care personnel draft. We believe the answer lies not in expanding the full-time, active duty US medical and nursing corps, but rather in tapping identifiable reservoirs of trained trauma care physicians, nurses, and allied health care workers in the United States and elsewhere. RESULTS: A rudimentary analysis suggests the most promising novel considerations are: developing special, trauma-trained reserve units within the US civilian trauma care community; seeking temporary attachments of an allied country's military medical officers, or a complete medical battalion; and contracting with US and foreign trauma surgeons, nurses and allied health personnel through a medical private military firm, analogous to those that have provided food, housing, transportation, and special combat units in support of our major military campaigns and peacekeeping operations. CONCLUSION: These considerations have important pros and cons that deserve in-depth evaluation by the best military and civilian trauma/critical care and organizational minds within a structured organization committed to the needs of military medicine. We believe that a Military Medical Think Tank within the Uniformed Services University's postgraduate division should be that organization.

When blue turns gray: postwarranty performance.

OBJECTIVE: The objective of this study was to review the lifestyle and expectations of a group of 86- to 87-year-old Yale College graduates at the time of their 65th reunion and to compare the results with equivalent data from the general public. METHODS: A five-page questionnaire was sent to the 263 living survivors of the Yale College class of 1939 at the time of their 65th reunion. RESULTS: One hundred fifty-one replies were received, some only partially completed. Median survival was 79 years. Among the more interesting results was a wide discrepancy (optimism) between the perceived quality of life and that which one would anticipate from the many physical disabilities of the study group. CONCLUSION: This is by nature a self-selected group of male octogenarians, but their lifestyle and medical disabilities fit with the general population; their attitude toward being elderly is remarkably positive, and their personal and civic performance continues beyond expectations.

Ultrasound measurement of mandibular arterial blood supply: techniques for defining ischemia in the pathogenesis of alveolar ridge atrophy and tooth loss in the elderly?

PURPOSE: To adapt ultrasound methods used to measure blood flow in the extremities to quantify mandible blood flow in order to determine the role of ischemia in the pathogenesis of mandible atrophy and tooth loss in the elderly. PATIENTS AND METHODS: Doppler and duplex ultrasound techniques as used in measurement of arterial pulse in the extremities were adapted for recording the intraoral pulse profile at 7 sites in 57 patients of varying ages. RESULTS: After omitting the large number (26 patients) with signals of indeterminate strength, the mental artery pulse was strong in 11 of 12 (92%) in those younger than 65 versus 9 of 19 (47% in those older than 65 years; P = .02). The equivalent figures for the sublingual artery were 15 of 15 strong for those younger than 65 and 11 of 17 (65%) for those older than 65 years ( P = .02). The varying depth of soft tissue overlying the inferior alveolar artery made its signal difficult to evaluate, but there was no statistically significant age-related difference in the inferior alveolar artery signals. In 4 elderly patients (2 with established carotid artery disease), Doppler and duplex scanning showed reversal of mental artery flow, indicating collateral flow to the mandible. CONCLUSIONS: Ultrasound Doppler techniques used for measuring peripheral arterial flow can be adapted to quantify mandible alveolar ridge perfusion. This provides means to evaluate the role of arterial obstruction in mandible alveolar ridge atrophy and tooth loss in the elderly. The mental artery is the best site for this purpose. Preliminary data suggest an age-related reduction in mental artery flow.