Which octogenarians do poorly after major open abdominal surgery in our Asian population?

Functional Outcomes after Abdominal Surgery in Older Adults - How concerned are we about this?

Amidst trends of a rapidly ageing population with better surgical outcomes for geriatric patients, it is imperative to consider outcome measures beyond mortality and morbidity rates. In fact, the preservation of one's postoperative function has been cited as a key priority for older adults and is a crucial determinant of postoperative independence and survival. This review aims to examine the prevalence of perioperative function reporting amongst older surgical patients undergoing elective major abdominal surgery for cancer. We systematically reviewed studies from inception to December 2023 for studies which focused on the outcomes of older surgical patients undergoing elective major abdominal surgery for cancer. Relevant citations were screened (title, abstract and full article review) based on the inclusion and exclusion criteria. 103 studies were included, of which only 31 studies consisting of 20885 participants reported perioperative function. While the nominal number of studies which report perioperative function has been on a steady rise since 2018, the proportion of studies which do so remains low. Postoperative function is three times less likely to be reported than preoperative function, suggesting that functional recovery is not sufficiently assessed. This suggests that there is still a poor uptake of functional recovery as an outcome measure amongst surgeons, and any increase in perioperative function reporting is likely due to the increased administration of frailty assessments. These findings should urge greater efforts in quantifying and enabling functional recovery to improve the clinical outcomes and quality of care for older surgical patients.

Outcomes of ultra-old vs old patients after hip fracture surgery: a matched cohort analysis of 1524 patients

BACKGROUND

Surgical management of geriatric hip fractures yields improved functional outcomes with decreased morbidity and mortality. Cohort studies have suggested that the older patients within the geriatric age group have worse outcomes with surgery, However, these studies inherently report inflated risks due to poor handling of confounders and have inadequately age-stratified their geriatric population.

AIM

This study aims to investigate the effect of age alone on the 1-year mortality and functional status of geriatric patients after hip fracture surgery.

METHODS

This is a retrospective single institution cohort study based on the prospectively-maintained registry of hip fracture patients. 2603 patients aged 60 years and above were treated surgically under a geriatric-orthopaedic hip fracture pathway from January 2014 to December 2018. Patients were split into two age groups: ultra-old (≥ 85 years) vs old (< 85 years). Baseline demographics and the ASA (American Society of Anaesthesiologists) status and the Modified Barthel's Index (MBI) were obtained at admission and 1 year after the fracture. Adverse outcomes from the fracture and surgery were recorded during a follow-up period of minimally 2 years. A 2:1 matching process based on the gender, fracture type, ASA status, CCI and MBI categories was conducted.

RESULTS

There were 1009 and 515 patients in the old and ultra-old age groups, respectively. 1-year mortality was similar for both age groups (4.0% ultra-old vs 3.6% old, p = 0.703). 30-day morbidity was similar except for higher rates of postoperative pneumonia in the ultra-old (14.0 vs 6.3%, p < 0.001). MBI scores at 1-year were lower in the ultra-old (severe dependence: 16.4 vs 10.0%; p = 0.001). Ultra-old patients were less likely to be community ambulant at 12 months (21.2 vs 36.0%) with the deterioration in ambulatory status significant after correction for baseline status (p < 0.001).

CONCLUSION

The 1-year mortality of surgically-managed geriatric hip fracture patients older than 85 years of age is not determined by age alone. Patients aged 85 years and above are at higher risk for pneumonia postoperatively. Ultra-old hip fracture patients with an intertrochanteric fracture are more likely to have poorer function at 1 year after hip fracture surgery.

Colorectal cancer surgery in octogenarians

OBJECTIVE

The incidence of colorectal cancer becomes higher among octogenarians as the life expectancy increases. Whether advanced age is a risk factor for colorectal surgery is a matter of debate. In the present study, the clinical results of octogenarians who underwent colorectal cancer surgery are discussed to find an answer to this question.

MATERIAL AND METHODS

Data of 63 octogenarians who were operated in a tertiary colorectal surgery department between January 1, 2010 and December 31, 2013 were reviewed retrospectively. Demographic data and preoperative, peroperative, and postoperative parameters were evaluated.

RESULTS

Overall, 57.2% of the patients were men. The median age was 81 (80-89) years. Cancer was located at the right colon in 17.5%, left colon in 50.8%, and rectum in 31.7%. Eleven patients underwent emergency surgery (17.5%). The most common surgical procedure was low anterior resection in elective (22.2%) and Hartmann's procedure in the emergency setting (9.5%). Stoma creation was more frequent among patients undergoing emergency procedures (42% vs. 6.8%; p=0.0018). Histopathological diagnosis was adenocarcinoma in 90.5% of the patients, and 34.9% of the patients had stage IIIB disease. Surgical morbidity was significantly higher among patients who underwent rectal resection (66% vs. 10.2%; p=0.0124). Medical morbidity was observed in 10 (15.9%) patients. Preoperative blood transfusion was a risk factor for morbidity (83.4% vs. 29.8%; p=0.0170). Length of total hospital stay was 14 (3-39) days. Surgical (p=0.0004) and medical (p=0.0288) morbidity prolonged the length of total hospital stay. The overall mortality rate was 1.6%.

CONCLUSION

Colorectal surgery may be safely performed in octogenarians with acceptable morbidity and mortality in specialized centers.

Guideline versus non-guideline based management of rectal cancer in octogenarians

PURPOSE

The number of octogenarians with rectal adenocarcinoma is growing. Current guidelines seem difficult to apply on octogenarians which may result in non-adherence. The aim of this retrospective cohort study is to give insight in occurrence of treatment-related complications, hospitalisations and survival among octogenarians treated according to guidelines versus octogenarians treated otherwise.

METHODS

108 octogenarians with rectal adenocarcinoma were identified by screening of medical records. 22 patients were excluded for treatment process analysis because of stage IV disease or unknown stage. Baseline characteristics, diagnostic process, received treatment, motivation for deviation from guidelines, complications, hospitalisations and date of death were documented. Patients were divided in two groups depending on adherence to treatment guidelines. Differences in baseline characteristics, treatment-related complications and survival between both groups were evaluated.

RESULTS

Diagnosis and treatment according to guidelines occurred in 95 and 54% of the patients, respectively. When documented, patient's preference and comorbidities were major reasons to deviate from guidelines. 66% of patients who were treated according to guidelines experienced complications versus 34% of those treated otherwise (p = 0.02). After adjustment for differences in age and polypharmacy, this association was not significant. Patients treated according to the guideline had better survival 18 months after diagnosis (80 versus 56%, p = 0.02).

CONCLUSIONS

Treating octogenarians with rectal cancer according to guidelines seem to lead to better overall survival, but may lead to a high risk of complications. This may jeopardise quality of life. More and prospective studies in octogenarians with rectal cancer are needed to customize guidelines for these patients.

'Start to finish trans-institutional transdisciplinary care': a novel approach improves colorectal surgical results in frail elderly patients

AIM

The frail elderly surgical patient is at increased risk of morbidity after major surgery. A transdisciplinary Geriatric Surgery Service (GSS) has been shown to produce consistently positive results in our institution. A trans-institutional transdisciplinary Start to Finish (STF) programme was initiated incorporating seamless prehabilitation and rehabilitation to enhance the outcome further.

METHOD

Patients who underwent major colorectal resection in Khoo Teck Puat Hospital and were managed under the GSS from January 2007 to December 2014 were included in this prospective study. The STF programme was initiated from January 2012. The surgical outcome of patients managed under the GSS before the initiation of STF was compared with that after its implementation.

RESULTS

There were 57 patients after the initiation of the STF programme compared with 60 patients managed before STF. There were 26.4% and 25% of frail patients in the STF group compared with the non-STF group (P = 0.874). The mean length of hospital stay was significantly shorter in the STF group (8.4 days vs 11.0 days, P = 0.029). Functional recovery in patients available for follow-up at 6 weeks showed 100% (46/46) recovery in the elective STF group who received prehabilitation and 95.7% (45/47) in the elective non-STF group who did not (P = 0.157). There were no significant differences in a Clavien-Dindo complication score of Grade 3 or more and 30-day mortality between the two groups.

CONCLUSION

Through a trans-institutional transdisciplinary approach, we managed to achieve a significantly shorter hospital stay in frail patients having colorectal surgery. All elective patients who received prehabilitation achieved full functional recovery.

[Colorectal surgery in patients over 65 years of age]

BACKGROUND

There is a limited functional reserve in patients over 65 years of age which is conducive to more frequent postoperative complications. Disease extension at the time of diagnosis (clinical stage) and complete tumor resection are two independent risk factors that have a direct influence on survival.

AIMS

To describe the factors that influence morbidity and mortality in patients over 65 years of age after colorectal surgery.

MATERIAL AND METHODS

A retrospective, observational, descriptive study was carried out within the time frame of January 2004 and December 2009 on 105 colon cancer patients after colorectal surgery. They were divided into two groups, one under 65 years of age and the other over 65 years of age, in order to compare preoperative comorbidity, as well as morbidity and mortality 30 days after surgery.

RESULTS

Of the 105 patient total (53,3%), 56 were ≤ 65 years of age. There were complications in 42,8% of the patients, and those of early and less severe presentation were the most frequent; late complications were more frequent in patients ≤ 65 vs > 65 years of age (16,0% vs 10,2%). Overweight (BMI > 25 kg/m(2)) was observed in 35,0% of the study population. Patients > 65 years of age had fewer comorbidities. The most common causes of reintervention were anastomosis dehiscence and postoperative hemorrhage. Mortality in the group was 6,6% and sepsis was the most frequent cause of death.

CONCLUSIONS

Colorectal surgery in patients over 65 years of age has an acceptable complication frequency and a low mortality rate. Our results suggest that patients older than 65 years of age be treated with the same prospects for cure as younger patients.

Assessment for frailty is useful for predicting morbidity in elderly patients undergoing colorectal cancer resection whose comorbidities are already optimized

BACKGROUND

The clinical syndrome of frailty identified through the assessment of weight loss, gait speed, grip strength, physical activity, and physical exhaustion has been used to identify patients with reduced reserves. We hypothesized that frailty is useful in predicting adverse outcomes in optimized elective elderly colorectal surgery patients.

METHODS

A prospective study was conducted at 2 centers (Singapore and Japan). All patients over 75 years of age undergoing colorectal resection were assessed for the presence of the syndrome of frailty. All these patients had already had their comorbidities optimized for surgery. The outcome measure was postoperative major complications (defined as Clavien-Dindo type II and above complications).

RESULTS

Eighty-three patients were studied from February 2008 to April 2010. The mean age was 81.5 years (range 75-93 years). The mean comorbidity index was 3.37 (range 0-11). Twenty-six (31.3%) patients were an American Society of Anesthesiologists (ASA) score of 3 and above. Chi-square analysis revealed that the odds ratio of postoperative major complications was 4.083 (95% confidence interval, 1.433-11.638) when the patient satisfied the criteria for frailty. Albumin <35, ASA >3, comorbidity index >5, and Physiologic and Operative Severity Score for the enUmeration of Mortality and Morbidity (POSSUM) scores were not predictive of postoperative major complications.

CONCLUSIONS

Preliminary findings show that frailty is a potent adjunctive tool of predicting postoperative morbidity. Frailty can be used to identify elderly patients needing further optimization before major surgery.

Does patient age affect survival after radical cystectomy?

What's known on the subject? and What does the study add? Elderly patients have more years to compound comorbidities and it has previously been shown that comorbidity is an important predictor of overall survival in patients with bladder cancer, including those treated with radical cystectomy (RC). Other studies have also demonstrated higher stage at diagnosis, higher rate of upstaging on final pathology and a longer delay to definitive therapy for older patients. Because of these findings, elderly patients are being offered RC less often than younger patients. Whether or not this practice is justified has come under recent scrutiny and there has been much conflicting data in the literature. While some studies have shown worse outcomes for elderly patients, others have shown similar results for both elderly and younger patients. Large population-based databases have recently been used to try to determine whether age effects outcome after RC but their conclusions may not be as generalizable as ours for several reasons: billing code data was used to build patient cohorts, patients were generally recipients of Medicare, lack of pathological review, and lack of available and accurate clinical data. Our series is unique in that it comprises a large group of patients from two major tertiary care academic institutions using a very robust dataset. Pathological specimens were reviewed by dedicated genitourinary pathologists, including those recovered from peripheral hospitals. Our sample size is one of the largest single- or multi-institutional studies.

OBJECTIVE

• To analyse the impact of patient age on survival after radical cystectomy (RC).

PATIENTS AND METHODS

• After ethics review board approval, two databases of patients with bladder cancer (BC) undergoing RC at the University Heath Network, Toronto, Canada (1992-2008) and the University of Turku, Turku, Finland (1986-2005) were retrospectively analysed. • A total of 605 patients who underwent this procedure between June 1985 and March 2010 were included. • Patients were divided into four age groups: ≤ 59, 60-69, 70-79 and ≥ 80 years. • Demographic, clinical and pathological data were compared, as well as recurrence-free survival (RFS), disease-specific survival (DSS) and overall survival (OAS) rates.

RESULTS

• Compared with younger patients (age ≤ 79 years), elderly patients (age ≥ 80 years) had higher American Society of Anesthesiologists scores (P < 0.001), a greater number of lymph nodes removed during surgical dissection (P < 0.001), and underwent less adjuvant treatment (P < 0.001). • Choice of urinary diversion differed among the groups, with ileal conduit being used for all patients ≥ 80 years (P < 0.001). • No differences were noted between age groups with respect to RFS (P= 0.3), DSS (P= 0.4) or OAS (P= 0.4).

CONCLUSION

• Although RC is an operation with significant morbidity, it is a viable treatment option for carefully selected elderly patients. Senior patients (≥ 80 years) should not be denied RC if they are deemed fit to undergo surgery. • Senior adults do not suffer from adverse histopathological features as compared with younger patients.

Outcome of surgical treatment of colorectal cancer in the elderly

The aim of this study is to compare the clinical features and the perioperative and long-term outcomes after primary surgery for colorectal cancer (CRC) in the elderly population with those observed in younger patients. All the patients over the age of 55 who underwent primary surgery for CRC in our clinic from 1988 to 2008 were included in this study and divided into two age groups: 55-75 and >75 years considering the age of diagnosis. 914 consecutive patients were enrolled in the study (352 > 75 years). In the elderly group, tumors were predominantly right sided, and the overall number of comorbidities was statistical more frequent. Elderly patients underwent emergency surgery more than the control group (p = 0.0008). There were no significant differences between the two groups in terms of curative and palliative resections. The overall operative mortality rate was 5.9% in the study group compared with 2.1% in the control study (p = 0.0033). The overall 3-year, 5-year and 10-year survival rates were, respectively, 37, 16.2 and 5.1% in the study group, when compared with 52.3, 35.1 and 24.7% in the control group (p = 0.022, p = 0.0001 and p = 0.0001, respectively). More patients were lost during the follow-up in the elderly group (p = 0.0003) and more deaths unrelated to cancer were found in the study group compared with the control group (p = 0.0005). The cancer specific mortality was similar between the two groups. In conclusion, elderly patients that underwent major colorectal resection have an acceptable perioperative morbidity, mortality and survival rate when compared with younger patients. Age alone should not be considered a reason to deny surgery to these patients.

Renal Insufficiency Predicts Mortality in Geriatric Patients Undergoing Emergent General Surgery

Clinical predictors of perioperative mortality in geriatric patients undergoing emergent general surgery have not been well described. The purpose of this study was to determine the incidence of postoperative morbidity and mortality in geriatric patients and factors associated with mortality. A retrospective review of patients 65 years of age or older undergoing emergent general surgery at a public teaching hospital was performed over a 7-year period. Data collected included demographics, comorbidities, laboratory studies, perioperative morbidities, and mortality. Descriptive statistics and predictors of morbidity and mortality are described. The mean age was 74 years. Indications for surgery included small bowel obstruction (24%), diverticulitis (20%), perforated viscous (16%), and large bowel obstruction (9%). The overall complication rate was 41 per cent with six cardiac complications (14%) and seven perioperative (16%) deaths. Mean admission serum creatinine was significantly higher in patients who died (3.6 vs 1.5 mg/dL, P = 0.004). Mortality for patients with an admission serum creatinine greater than 2.0 mg/dL was 42 per cent (5 of 12) compared with 3 per cent (2 of 32) for those 2.0 mg/dL or less (OR, 10.7; CI, 1.7 to 67; P = 0.01). Morbidity and mortality in geriatric patients undergoing emergency surgery remains high with the most significant predictor of mortality being the presence of renal insufficiency on admission.

A collaborative transdisciplinary "geriatric surgery service" ensures consistent successful outcomes in elderly colorectal surgery patients

BACKGROUND

We hypothesized that a dedicated collaborative transdisciplinary Geriatric Surgery Service (GSS) will improve care for elderly colorectal surgery patients.

METHODS

Patients older than 75 years of age who underwent major colorectal surgery were included in this study. The Geriatric Surgery Service employed a transdisciplinary, collaborative model of care. There were frequent quality reviews and a patient-centered culture was ensured. Treatment protocols and checklists were instituted. Perioperative outcome data were collected prospectively between 2007 and 2009. These data were compared to those from similar patients not managed by the service. Success and failure of surgical treatment of the two groups were analyzed using CUSUM methodology. Failure was defined as mortality, prolonged hospital stay for any reason, including morbidity, and failure to regain preoperative function by 6 weeks.

RESULTS

Twenty-nine patients managed by the GSS were compared to 52 patients who underwent standard treatment. The median age of the patients managed by the GSS was higher but there was no difference in the ASA score and predicted morbidity scores based on the POSSUM model. The GSS achieved lower mortality and major complication rates. A large majority (84.6%) of the patients managed by the GSS returned to preoperative functional status by 6 weeks. The GSS was able to produce a trend of successively desired outcomes consistently leading to the CUSUM curve exhibiting a sustained downward slope. This was in contrast to patients not managed by the GSS.

CONCLUSION

The Geriatric Surgery Service, through its transdisciplinary, collaborative care processes, was able to achieve sustained superior outcomes compared to standard management.

Is Gastrectomy Safe in the Elderly? A Single Institution Review

The population of the United States is aging. Studies within the last several years have demonstrated that major abdominal operations in elderly patients can be done safely, but with increased rates of complications. We set out to determine the rates of morbidity and mortality in elderly patients undergoing gastric resection at a tertiary care university hospital. A retrospective analysis was performed of 157 consecutive gastric resections between January 1998 and July 2007. Group A (n = 99) consisted of patients < 75-years-old at surgery, whereas group B (n = 58) included patients who were ≥ 75 years of age at time of surgery. These two groups had their clinical and demographic data analyzed. Postoperative length of hospital stay, perioperative major morbidity, and in-hospital mortality were analyzed using analysis of variance, χ2, and multivariate analyses. The average age of patients in group A was 57 years, compared with 81 years in group B. We found no significant difference in the percentage of gastric resections for malignancy (group A, 49% vs group B, 62%) or emergency surgery (group A, 10% vs group B, 10%) between age groups. There was a significant increase in length of stay in the older patients (11.7 days vs 17.6 days; P = 0.032), as well as major complications (11.1% in group A vs 27.6% in group B; P = 0.008). The in-hospital mortality rates approached significance (group A, 4% vs group B, 12%; P = 0.057). Gastric resection in elderly patients carries with it longer hospital stays, higher risk of complications, and in-hospital mortality rates despite similarity in patient disease. This information is imperative to convey to the elderly patients in the preoperative period before gastric resection.

Laparoscopic colorectal surgery in elderly patients: a case-control study of 15 years of experience

INTRODUCTION

The aim of this study was to review the impact of age (≥75 years) on the short-term outcomes of laparoscopic colorectal surgery.

METHODS

Three hundred seventy-nine patients under 70 years of age and 91 patients 75 years and older were analyzed. Quantification of comorbidities was performed using the Charlson Weighted Comorbidity Index. Outcome measures were postoperative complications and 30-day mortality.

RESULTS

There was no difference in the occurrence of postoperative complications between the younger and older patients. Bivariate analysis revealed that patient age was not a risk factor of major complications (odds ratio = 1.2; 95% confidence interval, .6-2.3). Although bivariate analysis revealed that older age had a statistically significant odds ratio for 30-day mortality (odds ratio = 12.8; 95% confidence interval, 1.3-125.4), multivariate analysis revealed that it was a weighted comorbidity index score of 5 or more (P = .02) and long operative time (P = .01) that were independent predictors of 30-day mortality and not age per se.

CONCLUSIONS

Age is not an independent predictor of morbidity and mortality in laparoscopic colorectal cancer surgery.

[In-hospital mortality in surgical patients. Predictive factors]

OBJECTIVE

To analyze the value of patient and surgical variables as predictors of the survival until discharge of hospitalized surgical patients in a tertiary care hospital over the course of 1 year.

MATERIAL AND METHODS

The hospital records for patients admitted for surgery between January 1 and December 31, 2007, were consulted to extract age, sex, ASA physical status classification of the patient, type of admission and surgery (scheduled or emergency), surgical department assigned, and date of discharge or exitus. The data were subjected to multivariate survival analysis using the Cox regression model.

RESULTS

A total of 4184 patients underwent surgery in 2007; the median (25th-75th percentile) patient age was 56 (39-71) years. In 77.5% of the cases (3244 patients) surgery was scheduled; 23.1% of those patients had been admitted by the emergency department. The ASA classification was 1 for 21.8%, 2 for 44.2%, 3 for 28%, and 4 for 6%. Of patients classified as ASA 1-3, a total of 33.2% were aged 65 years or older; in contrast, 78.7% of ASA 4 patients were in that age bracket. Eighty-nine (2.1%) surgical patients died. Cox regression survival analysis showed that variables related to a lower likelihood of survival to discharge were a physical status classification of ASA 4, age 65 years or older, and emergency surgery (P < .0005 for all comparisons).

CONCLUSIONS

Patients over the age of 65 years, in an ASA 4 anesthetic risk category, admitted on an emergency basis for emergency surgery were at higher risk of death. Greater vigilance in the perioperative care of patients with these risk factors is advisable in the interest of reducing mortality.

Optimizing the management of elderly colorectal surgery patients

With the ever increasing number of geriatric surgical patients, there is a need to develop efficient processes that address all of the potential issues faced by patients during the perioperative period. This article explores the physiological changes in elderly surgical patients and the outcomes achieved after major abdominal surgery. Perioperative management strategies for elderly surgical patients in line with the practices of the Geriatric Surgical Team of Alexandra Health, Singapore, are also presented. A coordinated transdisciplinary approach best tackles the complexities encountered in these patients.

Colorectal surgery in octogenarian patients--outcomes and predictors of morbidity

INTRODUCTION

Surgery for elderly patients pose a constant challenge. This study aims to review the outcome and find predictors of adverse outcome in octogenarians undergoing major colorectal resection for cancer.

METHODS

A review of 121 octogenarians who underwent colorectal cancer surgery between September 1992 and May 2008 was performed. Comorbidities were quantified using the weighted Charlson Comorbidity Index and ASA classification. CR-POSSUM scores and ACPGBI scores and the predicted mortality rates were calculated. Outcome measures were morbidity rates and 30-day mortality rates.

RESULTS

The patients had a mean age of 83.5 years (range, 80-99). The mean index of comorbidity was 3.1 (2-7) and 12.5% of patients were classified ASA III and above. The mean predicted mortality rate based on CR-POSSUM and ACPGBI scoring models were 11.2% and 5.4% respectively. The overall observed morbidity rate was 30.7% and 30-day mortality was 1.6. Factors found on bivariate analysis to be significantly associated with an increased risk of morbidity were tumor presenting with complication, comorbid coronary heart disease, serum urea levels, ASA classification > or =3 and comorbidity index 3 of 5 > or = 5. Multivariate analysis revealed the latter two factors to be independent predictors of morbidity.

CONCLUSION

Octogenarians undergoing major colorectal resection have an acceptable perioperative morbidity and mortality rate and survival rate and should not be denied surgery based on age alone. Comorbidity index scores and ASA scores are useful tools to identify poor risk patients.

Postoperative complications in elderly patients and their significance for long-term prognosis

PURPOSE OF REVIEW

To outline perioperative risk factors for postoperative mortality in older patients, the relationship of these factors with long-term mortality, and to examine possible strategies to reduce mortality.

RECENT FINDINGS

For patients aged 70 years and over 30-day mortality is about 6%, whereas 20% are likely to have at least one complication during their hospital stay. The mortality risk increases by 10% for every year after age 70. Mortality is also strongly associated with preoperative status and postoperative complications, particularly systemic inflammation and renal impairment. Unplanned postoperative intensive care unit admission is an important predictor for mortality. Requirement for postoperative vasopressors or inotropes is associated with 50% mortality in patients aged 80 years or more. Early postoperative complications are likely to be associated with an increased long-term (a year or more later) mortality. Strategies such as critical care outreach may decrease both 30-day and long-term mortality.

SUMMARY

Strategies are needed to prevent, or at least adequately manage, complications in elderly patients. Agreed international definitions for risks and complications can help in assessing risks and benefits.