The role of geriatric consultation in elderly urologic patients.

Abstract

Geriatric assessment is effective in the management of elderly patients with multiple problems (1, 2). The ef­ fectiveness of this "technology" has been evaluated in differen t special hospital units (stroke, orthopedics, etc.) (3-6) but, as far as we know, not in urological ones. Urologic services are an appropriate target for geriatric assessment, because they have a high proportion of el­ derly patients, most with associated diseases, and a strictly urologic approach is usually not enough to fully assess these patients. The objective of this study was to determine the characteristics and effects of geriatric con­ sultation in elderly urologic inpatients . We carried out a descriptive , retrospective study in a tertiary care teaching hospital in Madrid. Patients over 65 years admitted for a surgical urologic proce­ dure were assessed over three consecutive years at the request of the urology service. The geriatric consul­ tation team consisted of an attending physician and a fellow. They evaluated the medical and functional status of the urologic patients, measured their surgical risks, rec­ ommended any appropriate measures to improve outcomes , and planned the discharge schedule and fol­ low-up . We used the Red Cross indices of physical and mental disability with a range from 0 (normal) to 5 (to­ tal disability). The surgical risk was evaluated with the ASA (American Society of Anesthesia) criteria (7), and the cardiac risk with the Goldman index (8). For complementary information, we compared some qualitative parameters (mean hospital stay and mortality dates) with those corresponding to the year before the introduction of the geriatric consultation team, when peri-operative evaluation was performed by internists or cardiologists . During the three con­ secutive years (1990-1992), 773 patient s (133 wom­ en) older than 64 were evaluated. Mean age was 76.3±6 .9 years. Mean time interval between the consult request by the urologist and the geriatric evaluation was 1.2 days . There was a mean of 2.3 peri­ operative visits per patient. Table 1 indicates the number of medical problems found in the patients. Only 10% of the patients were free of significant medical problems. The most com­ mon urologic diseases were: prostatic adenoma (44.7%); bladder urothelioma (25 .1%); and prostatic carcinoma (13.2%). The extra-urological diseases found are shown in Table 2. Moderate to severe physical functional disability (grades 3 to 5 of the Red Cross Index) was found in 23.5% of patients. Moderate to severe psychologic functional disability (grade 3 to 5 of the Red Cross In­ dex) was found in 3.5% of patients. High surgical risk (ASA III or IV) was noted in 14.5% of patients, and high Goldman 's cardiac risk (III or IV) in 13 .9% of pa­ tients . The assessment-derived recommendations were: none in 10% of the patients; minor (including in­ creased hydration and nutrit ional measures , physio­ therapy, postural recommendations, or monitoring measures) in 30%; and major (non-routine diagnostic procedure recommendations, changes in the actual pharmacologic treatment, or indications for enteral or parenteral nutrition) in 60% of cases. As complementary data, we observed that mean hospital stay was reduced from 29 .9 days in 1986 (the last year in which no elderly urological patient was evaluated by the geriatric consultation team) to 20.1 days during the three years analyzed in this study. Hos­ pital deaths decreased from 4.3% to 2.7% during these same periods. This kind of geriatric assessment with urological pa­ tients enabled a better knowledge not only of the surgical risks, but also the associated problems and dis­ eases, and allowed us to establish different recom­ mendations and an optimal discharge in an important proportion of subjects. Th e assessment covers the main objectives of preoperative geriatric assessment: 1) to identify medical problems; 2) to establish risk fac