Comorbidity scores associated with limited life expectancy in the very elderly with nonmelanoma skin cancer.

BACKGROUND: There is controversy regarding treatment of nonmelanoma skin cancer (NMSC) in very elderly individuals, with some suggesting that this population may not live long enough to benefit from invasive treatments. Tools to assess limited life expectancy (LLE) exist, but performance in the population of very elderly individuals with NMSC has not been well defined. OBJECTIVE: Define comorbidity scores associated with LLE in very elderly individuals presenting for management of NMSC. METHODS: A retrospective review of 488 patients age 85 or older presenting for NMSC management between July 1999 through December 2014 was performed. Comorbidities were scored by using the Adult Comorbidity Evaluation-27 (ACE-27) and age-adjusted Charlson comorbidity index (ACCI). Dates of death, follow-up, and overall survival were determined. RESULTS: ACE-27 and ACCI scores were associated with overall survival; at scores of 3 and 7+, respectively, both were associated with less than 50% survival at 4 years. Patients who underwent Mohs micrographic surgery survived a median of 20 months longer than patients who did not. LIMITATIONS: Retrospective study design and referral bias. CONCLUSIONS: ACE-27 and ACCI scores predicted LLE. The cohort presenting for Mohs micrographic surgery had improved survival, despite similar intercohort comorbidity. This suggests that additional factors contributed to survival and that age and comorbidities alone are inadequate for making NMSC treatment decisions in very elderly individuals.

Intraoperative ketamine for prevention of postoperative delirium or pain after major surgery in older adults: an international, multicentre, double-blind, randomised clinical trial.

BACKGROUND: Delirium is a common and serious postoperative complication. Subanaesthetic ketamine is often administered intraoperatively for postoperative analgesia, and some evidence suggests that ketamine prevents delirium. The primary purpose of this trial was to assess the effectiveness of ketamine for prevention of postoperative delirium in older adults. METHODS: The Prevention of Delirium and Complications Associated with Surgical Treatments [PODCAST] study is a multicentre, international randomised trial that enrolled adults older than 60 years undergoing major cardiac and non-cardiac surgery under general anaesthesia. Using a computer-generated randomisation sequence we randomly assigned patients to one of three groups in blocks of 15 to receive placebo (normal saline), low-dose ketamine (0·5 mg/kg), or high dose ketamine (1·0 mg/kg) after induction of anaesthesia, before surgical incision. Participants, clinicians, and investigators were blinded to group assignment. Delirium was assessed twice daily in the first 3 postoperative days using the Confusion Assessment Method. We did analyses by intention-to-treat and assessed adverse events. This trial is registered with clinicaltrials.gov, number NCT01690988. FINDINGS: Between Feb 6, 2014, and June 26, 2016, 1360 patients were assessed, and 672 were randomly assigned, with 222 in the placebo group, 227 in the 0·5 mg/kg ketamine group, and 223 in the 1·0 mg/kg ketamine group. There was no difference in delirium incidence between patients in the combined ketamine groups and the placebo group (19·45% vs 19·82%, respectively; absolute difference 0·36%, 95% CI -6·07 to 7·38, p=0·92). There were more postoperative hallucinations (p=0·01) and nightmares (p=0·03) with increasing ketamine doses compared with placebo. Adverse events (cardiovascular, renal, infectious, gastrointestinal, and bleeding), whether viewed individually (p value for each >0·40) or collectively (36·9% in placebo, 39·6% in 0·5 mg/kg ketamine, and 40·8% in 1·0 mg/kg ketamine groups, p=0·69), did not differ significantly across groups. INTERPRETATION: A single subanaesthetic dose of ketamine did not decrease delirium in older adults after major surgery, and might cause harm by inducing negative experiences. FUNDING: National Institutes of Health and Cancer Center Support.