Experience with dedicated geriatric surgical consult services: Meeting the need for surgery in the frail elderly
Rosemarie E Hardin1, Thierry Le Jemtel2, Michael E Zenilman1
1Department of Surgery, SUNY Downstate Medical Center, Brooklyn, NY, USA; 2Department of Medicine, Tulane Medical Center, New Orleans, LA, USA
Background: Surgeons are increasingly faced with consultation for intervention in residents of geriatric centers or in patients who suffer from end stage medical disease. We review our experience with consult services dedicated to the needs of these frail patients.
Study design: Patients were prospectively followed after being evaluated by three different geriatric surgical consult services: Group 1 was based at a geriatric center associated with a tertiary medical center, Group 2 was based at a community geriatric center, and Group 3 was based with an hospital-based service for ambulatory patients with end stage congestive heart failure.
Results: A total of 256 frail elderly patients underwent of 311 general surgical procedures ranging from major abdominal and vascular procedures to minor procedures such as debridement of decubitus ulcers, long-term intravenous access, enterostomy and enteral tube placement. Almost half of the surgical volume in Group 1 and 3 were ‘maintenance’ (decubitus debridement, long term intravenous or stomal or tube care); all of Group 2 were for treatment of decubiti. There was minimal morbidity and mortality from surgery itself, and overall one year survival for Groups 1, 2, and 3 was 46%, 60%, and 79%, respectively. Multivariate analysis showed that each group had its own unique indicators of decreased survival: Group 1 dementia and coronary artery disease, in Group 2 gender and coronary artery disease, and Group 3, gender alone. Age, number of comorbid illnesses, and type of surgery (major vs minor) were not significant indicators.
Conclusions: This is the first review of the role of dedicated surgical consult services which focused on residents of geriatric centers and frail elderly. Conditions routinely encountered in this population such as dementia, end stage disease, multiple comorbidities, polypharmacy, decreased functional and nutritional status are not frequently encountered by general surgeons. But the surgery is safe, and survival data is comparable to those in geriatric centers who did not undergo surgery. A multidisciplinary team approach gives the most effective care, with a primary goal of palliation.
Keywords: surgery in the elderly, geriatrics, surgical consultations, nursing home residents, congestive heart failure, frailty, palliative care, dementia, coronary artery disease, survival
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