Perioperative Considerations in Nonagenarians

Abstract

Objective: The nation’s aging population presents novel perioperative challenges.Potential benefits of operative interventions must be scrutinized in relation to recoverable quality of life (QOL). The purpose of this study is to evaluate common risk calculators utilized for medical decision making in a nonagenarian patient population. Methods: Retrospective chart review was performed on patients 90 or older who underwent operative interventions requiring anesthesia at a large academic medical center between January 1, 2013 and December 31, 2017. GraphPad-8.2.1 was used for statistical analysis. Results: Significant differences were found when data was stratified by age for elective versus emergent cases (p-value<0.0001), ability to return to baseline function (p value=0.0062),and mortality (p-value<0.0001). Significant differences were found in emergent and elective cases, ability to return to baseline function, readmissions, and mortality (all p-values<0.0001) when stratified by ASA score. Ability of patients to return to baseline functionality after intervention was influenced by their pre-intervention level of functionality (p-value=0.0008). ACS and P-POSSUM risk calculators underestimated the need for rehabilitation and overestimated mortality for this population (all p-values<0.0001). Conclusion: Perioperative cares of the extreme geriatric population are complex, and should be approached collaboratively. Rehabilitation and postoperative assistance resources should be assessed and utilized fully. Input from palliative care teams should be sought appropriately. End-of-life and escalation-of-care discussions should ideally be organized prior to emergent interventions. Frailty and risk calculators should be utilized, and considered for formal implementation into the preoperative workflow.