GERIATRICS
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Editorial Comment: Older adults are prone to changes in numerous health parameters due to normal aging, comorbidity and pathophysiology. Detailed preoperative assessment has been promoted as a means to help identify older adults who might be at increased risk for complications following surgery and other forms of clinical treatment. This study examined whether comprehensive geriatric assessment across multiple functional domains could help predict or prevent postoperative morbidity and mortality in a cohort of 141 consecutive older adults undergoing elective surgical procedures. In logistic regression analysis cumulative impairments across domains were an independent predictor of surgical complications. Assessment methods have become standardized and more streamlined for many of these evaluations, and they can often be incorporated as part of the routine preoperative evaluation for older adults. This approach may help to uncover clinical issues that should be optimized preoperatively and also identify those who might be at increased risk for complications. Consultation with geriatric specialists might also be warranted for issues beyond the scope of routine care. Tomas L. Griebling, MD, MPH
Re: Incidence, Risk Factors, and Complications of Postoperative Delirium in Elderly Patients Undergoing Radical Cystectomy M. C. Large, C. Reichard, J. T. Williams, C. Chang, S. Prasad, Y. Leung, C. DuBeau, G. T. Bales and G. D. Steinberg Division of Urology, Department of Surgery, University of Chicago Pritzker School of Medicine, Chicago, Illinois Urology 2013; 81: 123e128.
Abstract available at http://jurology.com/ Editorial Comment: Radical cystectomy with urinary diversion is one of the most complex procedures performed in modern urology. It is the cornerstone of therapy for clinically localized muscle invasive bladder cancer. This condition occurs disproportionately in elderly patients, who may be among the most vulnerable due to underlying comorbidity, frailty and limitations in physiological reserve. These types of changes place older adults at greater risk for potential postoperative complications. Delirium is a common condition among older surgical patients that is associated with multiple negative outcomes, including higher rates of mortality, longer acute hospital stays and increased rates of discharge to nursing home care. This study identified an overall incidence of delirium of 29% among a cohort of 49 older adults undergoing radical cystectomy at a single academic institution. In this series readmission and reoperation rates were significantly higher in those with postoperative delirium, although short and long-term mortality rates were unchanged. Several preoperative factors appeared to identify those at increased risk for delirium. Urologists should have a high index of suspicion for this condition. Careful preoperative evaluation can help determine baseline cognitive function and identify those who might be at increased risk. Clinicians should also be prepared to diagnose and treat delirium following surgery to help minimize untoward outcomes. Tomas L. Griebling, MD, MPH
Suggested Reading Chang SS, Baumgartner RG, Wells N et al: Causes of increased hospital stay after radical cystectomy in a clinical pathway setting. J Urol 2002; 167: 208. Taub DA, Dunn RL, Miller DC et al: Discharge practice patterns following cystectomy for bladder cancer: evidence for the shifting of the burden of care. J Urol 2006; 176: 2612.
387
Editorial Comment: Older adults are prone to changes in numerous health parameters due to normal aging, comorbidity and pathophysiology. Detailed preoperative assessment has been promoted as a means to help identify older adults who might be at increased risk for complications following surgery and other forms of clinical treatment. This study examined whether comprehensive geriatric assessment across multiple functional domains could help predict or prevent postoperative morbidity and mortality in a cohort of 141 consecutive older adults undergoing elective surgical procedures. In logistic regression analysis cumulative impairments across domains were an independent predictor of surgical complications. Assessment methods have become standardized and more streamlined for many of these evaluations, and they can often be incorporated as part of the routine preoperative evaluation for older adults. This approach may help to uncover clinical issues that should be optimized preoperatively and also identify those who might be at increased risk for complications. Consultation with geriatric specialists might also be warranted for issues beyond the scope of routine care. Tomas L. Griebling, MD, MPH
Re: Incidence, Risk Factors, and Complications of Postoperative Delirium in Elderly Patients Undergoing Radical Cystectomy M. C. Large, C. Reichard, J. T. Williams, C. Chang, S. Prasad, Y. Leung, C. DuBeau, G. T. Bales and G. D. Steinberg Division of Urology, Department of Surgery, University of Chicago Pritzker School of Medicine, Chicago, Illinois Urology 2013; 81: 123e128.
Abstract available at http://jurology.com/ Editorial Comment: Radical cystectomy with urinary diversion is one of the most complex procedures performed in modern urology. It is the cornerstone of therapy for clinically localized muscle invasive bladder cancer. This condition occurs disproportionately in elderly patients, who may be among the most vulnerable due to underlying comorbidity, frailty and limitations in physiological reserve. These types of changes place older adults at greater risk for potential postoperative complications. Delirium is a common condition among older surgical patients that is associated with multiple negative outcomes, including higher rates of mortality, longer acute hospital stays and increased rates of discharge to nursing home care. This study identified an overall incidence of delirium of 29% among a cohort of 49 older adults undergoing radical cystectomy at a single academic institution. In this series readmission and reoperation rates were significantly higher in those with postoperative delirium, although short and long-term mortality rates were unchanged. Several preoperative factors appeared to identify those at increased risk for delirium. Urologists should have a high index of suspicion for this condition. Careful preoperative evaluation can help determine baseline cognitive function and identify those who might be at increased risk. Clinicians should also be prepared to diagnose and treat delirium following surgery to help minimize untoward outcomes. Tomas L. Griebling, MD, MPH
Suggested Reading Chang SS, Baumgartner RG, Wells N et al: Causes of increased hospital stay after radical cystectomy in a clinical pathway setting. J Urol 2002; 167: 208. Taub DA, Dunn RL, Miller DC et al: Discharge practice patterns following cystectomy for bladder cancer: evidence for the shifting of the burden of care. J Urol 2006; 176: 2612.
