Jeffrey J. Houlton, MD, assistant professor of otolaryngology at the University of Washington Medical Center in Seattle, opened the session on head and neck surgery in the elderly by describing the aging population in the United States. He explained that the current life expectancy in the United States is 78 years and that there are now 45 million Americans who are 65 years or older. Moreover, people aged 80 and older are one of the fastest growing U.S. demographics and, increasingly, they are high functioning. These elderly patients also have an increasing number of head and neck malignancies when compared with younger patients. In many cases, surgery is their only real therapeutic option. The question for surgeons then becomes, “How do we decide which elderly patients are going to respond well to surgery?”
Explore this issue:November 2017
How to Predict Postoperative Outcomes
Jason T. Rich, MD, assistant professor of otolaryngology–head and neck surgery at Washington University School of Medicine in St. Louis, Mo., talked the audience through the process of predicting postoperative outcomes. In the case of the elderly, these outcomes include not only traditional surgical outcomes, but also outcomes such as physical and mental function. Surgeons should acknowledge that there are limited data about the risks of surgery for elderly patients. Because of this, each surgeon must find his own specific way to counsel elderly patients.
“Each of us has a different style of interacting with our patients,” said Dr. Rich. But he also asked each surgeon to look closely at his own ageism bias to make sure that any advice given is not founded on prejudice or discrimination based on the patient’s age.
Surgeons can use tools to objectively stratify patients by risk. Specifically, the American College of Surgery National Surgical Quality Improvement Program (ACS NSQIP) has a risk calculator that predicts which patients will suffer complications or even mortality. Most studies agree, however, that age alone is not a prognosticator for outcomes, because not all elderly patients have a similar functional status. Instead, frailty is a better predictor of surgical outcome. Frailty, which can also be measured using the ACS NSQIP calculator, is a state of reduced physiologic reserve associated with increased susceptibility to disability.
Dr. Rich then presented his data (not yet published) on the prediction of mortality and morbidity in head and neck patients 80 years and older. The study included 219 patients who underwent 241 procedures. The patients had a mean age of 85 years, and 60% of them were male. Dr. Rich and colleagues found that, at 30 days post-surgery, one-third of the patients had serious complications, and approximately 75% of the patients had at least one complication. The 90-day mortality in the cohort was 10%.