General surgical care in the nursing home patient: results of a dedicated geriatric surgery consult service.
BACKGROUND
Although recent interest has centered on diseases that require operation in the elderly, few data are available about the effects of surgical intervention on the frail nursing home patient.


METHODS
A longitudinal study was conducted of the nature of illness requiring operation and intervention in residents of a geriatric center associated with a tertiary care medical center. A unique consult service for the patients was established and all referrals were prospectively followed up.


RESULTS
The actuarial 18-month survival of patients referred was 35 percent. Although maintenance care (e.g., decubitus ulcer, stoma, and enteral tube care) made up a substantial number of referrals (32.5 percent), common surgical diseases of the abdomen, breast, and vascular system were routinely encountered (55 percent). In patients undergoing surgery, the 30-day mortality rate was 8.5 percent, and the complication rate 9.4 percent. Although patients undergoing major abdominal and vascular procedures had a higher complication rate (17.6) percent than those undergoing lesser procedures (6.3 percent, p = 0.05), there was no difference in the 30-day mortality (9.8 compared with 6.3 percent, respectively) or 18-month actuarial survival (33 compared with 32 percent, respectively) rates. The overall actuarial survival was adversely affected by the presence of coronary artery disease (relative risk [RR], 3.27) and dementia (Mini-Mental State Examination score less than 24; RR, 2.39) and age older than 70 years (RR, 2.03). The overall survival was unaffected by the actual need for operation, the magnitude of the procedure performed, gender, the number of comorbid conditions, and the preoperative code (resuscitative) status.


CONCLUSIONS
Although nursing home patients referred for surgical intervention have poor survival rates, the use of surgical procedures does not adversely affect overall survival. This supports the idea that care for this patient population is not futile, and quality of life, patient dignity, and relief of suffering can provide a alternative to curative therapy.
Zenilman
M E
ME
Department of Surgery, Johns Hopkins Bayview Medical Center, Baltimore, MD, USA.
Bender
J S
JS
Magnuson
T H
TH
Smith
G W
GW
D000206:Actuarial Analysis; D000368:Aged; D000369:Aged, 80 and over; D015897:Comorbidity; D005260:Female; D016330:Frail Elderly; D006299:Health Services for the Aged; D006707:Homes for the Aged; D006801:Humans; D008137:Longitudinal Studies; D008297:Male; D009735:Nursing Homes; D010166:Palliative Care; D016016:Proportional Hazards Models; D011788:Quality of Life; D012017:Referral and Consultation; D013514:Surgical Procedures, Operative / Q000401:mortality / Q000706:statistics & numerical data*; D016019:Survival Analysis