Microvascular decompression for trigeminal neuralgia in elderly patients

Object Although microvascular decompression (MVD) for patients with medically refractory trigeminal neuralgia (TN) is widely accepted as the treatment of choice, other “second-tier” treatments are frequently offered to elderly patients due to concerns regarding fitness for surgery. The authors sought to determine the safety and effectiveness of MVD for TN in patients older than 75 years of age. Methods The authors performed a retrospective review of medical records and conducted follow-up telephone interviews with the patients. The outcome data from 25 MVD operations for TN performed in 25 patients with a mean age of 79.4 years (range 75–88 years) were compared with those of a control group of 25 younger patients with a mean age of 42.3 years (range 17–50 years) who underwent MVDs during the same 30-month period from July 2000 to December 2003. Results Initial pain relief was achieved in 96% of the patients in both groups (p = 1.0). There were no operative deaths in either group. After an average follow-up period of 44 and 52 months, 78 and 72% of patients in the elderly and control groups, respectively, remained pain free without medication (p = 0.74). Conclusions Microvascular decompression is an effective treatment for elderly patients with TN. The authors' experience suggests that the rate of complications and death after MVD for TN in elderly patients is no different from the rate in younger patients.

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Typical Trigeminal Neuralgia: Comparison of Results between Patients Older and Younger than 65 Years Operated on with Microvascular Decompression by Retrosigmoid Approach

Journal of Neurological Surgery Part A Central European Neurosurgery ◽

10.1055/s-0039-1693126 ◽

2019 ◽

Vol 81 (01) ◽

pp. 028-032 ◽

Cited By ~ 1

Author(s):

Luciano Mastronardi ◽

Franco Caputi ◽

Alessandro Rinaldi ◽

Guglielmo Cacciotti ◽

Raffaelino Roperto ◽

...

Keyword(s):

Trigeminal Neuralgia ◽

Elderly Patients ◽

Microvascular Decompression ◽

Cerebrospinal Fluid Leak ◽

The Elderly ◽

Retrosigmoid Approach ◽

Younger Patients ◽

Significant Difference ◽

Elderly Cohort

Abstract Objective The incidence of typical trigeminal neuralgia (TN) increases with age, and neurologists and neurosurgeons frequently observe patients with this disorder at age 65 years or older. Microvascular decompression (MVD) of the trigeminal root entry zone in the posterior cranial fossa represents the etiological treatment of typical TN with the highest efficacy and durability of all treatments. This procedure is associated with possible risks (cerebellar hematoma, cranial nerve injury, stroke, and death) not seen with the alternative ablative procedures. Thus the safety of MVD in the elderly remains a topic of discussion. This study was conducted to determine whether MVD is a safe and effective treatment in older patients with TN compared with younger patients. Methods In this retrospective study, 28 patients older than 65 years (elderly cohort: mean age 70.9 ± 3.6 years) and 38 patients < 65 years (younger cohort: mean age 51.7 ± 6.3 years) underwent MVD via the keyhole retrosigmoid approach for type 1 TN (typical) or type 2a TN (typically chronic) from November 2011 to November 2017. A 75-year-old patient and three nonelderly patients with type 2b TN (atypical) were excluded. Elderly and younger cohorts were compared for outcome and complications. Results At a mean follow-up 26.0 ± 5.5 months, 25 patients of the elderly cohort (89.3%) reported a good outcome without the need for any medication for pain versus 34 (89.5%) of the younger cohort. Twenty-three elderly patients with type 1 TN were compared with 30 younger patients with type 1 TN, and no significant difference in outcomes was found (p > 0.05). Five elderly patients with type 2a TN were compared with eight younger patients with type 2a TN, and no significant difference in outcomes was noted (p > 0.05). There was one case of cerebrospinal fluid leak and one of a cerebellar hematoma, both in the younger cohort. Mortality was zero in both cohorts. Conclusions On the basis of our experience and the international literature, age itself does not seem to represent a major contraindication of MVD for TN.

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Microvascular Decompression for Trigeminal Neuralgia in the Elderly: A Review of the Safety and Efficacy

Neurosurgery ◽

10.1227/01.neu.0000137660.06337.c5 ◽

2004 ◽

Vol 55 (4) ◽

pp. 840-850 ◽

Cited By ~ 87

Author(s):

Keyoumars Ashkan ◽

Henry Marsh

Keyword(s):

Trigeminal Neuralgia ◽

Microvascular Decompression ◽

Older Patients ◽

Treatment Options ◽

Length Of Hospital Stay ◽

The Elderly ◽

Outcome Data ◽

Control Group ◽

Control Groups ◽

And Control

Abstract OBJECTIVE: To critically examine the efficacy and safety of microvascular decompression (MVD) for trigeminal neuralgia (TN) in elderly patients. METHODS: We performed a retrospective review of medical records, followed by prospective follow-up. The outcome data from 44 MVD operations for TN performed in 40 consecutive patients with a mean age of 65 years (range, 60–75 yr) in the period 1991 to 2001 were compared with those from 40 younger control subjects (mean age, 46 yr; range, 20–59 yr) operated on during the same period. RESULTS: The median time from diagnosis of TN to MVD in the older patients was 7 years (range, 1–22 yr), compared with 3 years (range, 3 mo to 20 yr) in the younger group (P = 0.02). With the exception of one, all patients in this study were classified as American Society of Anesthesiologist Grade 1 or 2. Initial pain relief was achieved in 98 and 100% of the patients in the study and control groups, respectively. There were no operative mortalities or life-threatening morbidities. Transient facial numbness and diplopia occurred in both groups. Headaches, nausea, and vomiting were more frequent in the younger patients, whereas wound infection and confusion were more common in the older patients. The mean length of hospital stay was 5.4 days (range, 3–10 d) for the older patients, compared with 5.3 days (range, 3–9 d) for the control group (P = 0.4). After average follow-ups of 30 and 33 months, the pain recurred in 24 and 27% of the patients in the elderly and control groups, respectively. CONCLUSION: MVD is underused in the elderly despite being both safe and effective. Fitness and not age should be the key in deciding the treatment options. It is proposed that any patient with medically refractory TN who is fit for general anesthesia should be given the opportunity to choose MVD.

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Long-term pain outcomes in elderly patients with trigeminal neuralgia: comparison of first-time microvascular decompression and stereotactic radiosurgery

Neurosurgical FOCUS ◽

10.3171/2020.7.focus20446 ◽

2020 ◽

Vol 49 (4) ◽

pp. E23

Author(s):

Kunal P. Raygor ◽

Anthony T. Lee ◽

Noah Nichols ◽

Doris D. Wang ◽

Mariann M. Ward ◽

...

Keyword(s):

Adverse Event ◽

Trigeminal Neuralgia ◽

Elderly Patients ◽

Microvascular Decompression ◽

Pain Control ◽

The Elderly ◽

Surgical Treatments ◽

First Time

OBJECTIVECommon surgical treatments for trigeminal neuralgia (TN) include microvascular decompression (MVD) and stereotactic radiosurgery (SRS). The use of MVD in elderly patients has been described but has yet to be prospectively compared to SRS, which is well-tolerated and noninvasive. The authors aimed to directly compare long-term pain control and adverse event rates for first-time surgical treatments for idiopathic TN in the elderly.METHODSA prospectively collected database was reviewed for TN patients who had undergone treatment between 1997 and 2017 at a single institution. Standardized collection of preoperative demographics, surgical procedure, and postoperative outcomes was performed. Data analysis was limited to patients over the age of 65 years who had undergone a first-time procedure for the treatment of idiopathic TN with at least 1 year of follow-up.RESULTSOne hundred ninety-three patients meeting the study inclusion criteria underwent surgical procedures for TN during the study period (54 MVD, 24 MVD+Rhiz, 115 SRS). In patients in whom an artery was not compressing the trigeminal nerve during MVD, a partial sensory rhizotomy (MVD+Rhiz) was performed. Patients in the SRS cohort were older than those in the MVD and MVD+Rhiz cohorts (mean ± SD, 79.2 ± 7.8 vs 72.9 ± 5.7 and 70.9 ± 4.8 years, respectively; p < 0.0001) and had a higher mean Charlson Comorbidity Index (3.8 ± 1.1 vs 3.0 ± 0.9 and 2.9 ± 1.0, respectively; p < 0.0001). Immediate or short-term postoperative pain-free rates (Barrow Neurological Institute [BNI] pain intensity score I) were 98.1% for MVD, 95.8% for MVD+Rhiz, and 78.3% for SRS (p = 0.0008). At the last follow-up, 72.2% of MVD patients had a favorable outcome (BNI score I–IIIa) compared to 54.2% and 49.6% of MVD+Rhiz and SRS patients, respectively (p = 0.02). In total, 0 (0%) SRS, 5 (9.3%) MVD, and 1 (4.2%) MVD+Rhiz patients developed any adverse event. Multivariate Cox proportional hazards analysis demonstrated that procedure type (p = 0.001) and postprocedure sensory change (p = 0.003) were statistically significantly associated with pain control.CONCLUSIONSIn this study cohort, patients who had undergone MVD had a statistically significantly longer duration of pain freedom than those who had undergone MVD+Rhiz or SRS as their first procedure. Fewer adverse events were seen after SRS, though the MVD-associated complication rate was comparable to published rates in younger patients. Overall, the results suggest that both MVD and SRS are effective options for the elderly, despite their advanced age. Treatment choice can be tailored to a patient’s unique condition and wishes.

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Typical trigeminal neuralgia in patients older than 65: Safety and efficacy of microvascular decompression by the retrosigmoid approach

Indonesian Journal of Neurosurgery ◽

10.15562/ijn.v1i1.2 ◽

2018 ◽

Vol 1 (1) ◽

Author(s):

Luciano Mastronardi ◽

Franco Caputi ◽

Alessandro Rinaldi ◽

Guglielmo Cacciotti

Keyword(s):

Trigeminal Neuralgia ◽

Elderly Patients ◽

Microvascular Decompression ◽

The Elderly ◽

Retrosigmoid Approach ◽

Csf Leak ◽

Old Patients ◽

Younger Patients ◽

Significant Difference

AbstractOBJECT: Incidence of typical trigeminal neuralgia (TN) increases with age and neurologists and neurosurgeons frequently observe patients with this disorder at the age of 65 or more. Microvascular decompression (MVD) of the trigeminal root entry zone in posterior cranial fossa is the only etiological therapy for typical TN with the highest efficacy and durability of all treatments. This procedure is associated with possible risks (cerebellar hematoma, cranial nerve injury, stroke, and death) not seen with the alternative ablative procedures. Thus, the safety of MVD in the elderly remains non definitively demonstrated. This study was conducted to determine whether MVD is a safe and effective treatment in elderly patients with TN in comparison to younger patients.METHODS: In this retrospective study, 25 patients older than 65 (mean age 70.1 ± 3.7 years) and 32 aging <65 (mean age 51.1 ± 6.2 years) underwent MVD by key-hole retrosigmoid approach for Type 1 TN (typical) or Type 2a TN (typical chronicized) from November 2011 to November 2016. A 75 y-o patient had Type 2b TN (atypical) versus 3 nonelderly patients were excluded. Elderly and younger groups were compared in relation to outcome and complication data.RESULTS: At a mean follow-up 23.0 ± 5.5 months, 22 old patients (88%) reported a very good outcome without necessity of any medication for pain, versus 28 (87,5%) of the younger group. Twenty elderly patients with Type 1 TN were compared with 24 younger patients with Type 1 TN, and no significant difference in outcomes was found (p > 0.05). Five elderly patients with Type 2a TN were compared with 8 younger patients with Type 2a TN, and no significant difference in outcomes was noted (p > 0.05). There was one case of CSF leak and one case of cerebellar hematoma both in the younger cohort. Mortality was zero in both groups.CONCLUSIONS: On the basis of our experience and of the international literature, age itself seems not to represent a major contraindication against MVD for TN. Keywords: Elderly, Microvascular Decompression, Retrosigmoid approach, Trigeminal neuralgia, Tic douloureux

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Safety of High-Dose Dabigatran in Elderly and Younger Patients with a Low Bleeding Risk: A Prospective Observational Study

Cardiology ◽

10.1159/000516368 ◽

2021 ◽

pp. 1-5

Author(s):

Aharon Erez ◽

Gregory Golovchiner ◽

Robert Klempfner ◽

Ehud Kadmon ◽

Gustavo Ruben Goldenberg ◽

...

Keyword(s):

Observational Study ◽

Elderly Patients ◽

Prospective Observational Study ◽

Bleeding Risk ◽

The Elderly ◽

High Dose ◽

World Population ◽

Younger Patients ◽

End Point

Introduction: In patients with atrial fibrillation (AF) at risk for stroke, dabigatran 150 mg twice a day (DE150) is superior to warfarin for stroke prevention. However, there is paucity of data with respect to bleeding risk at this dose in elderly patients (≥75 years). We aimed to evaluate the safety of DE150 in comparison to warfarin in a real-world population with AF and low bleeding risk (HAS-BLED score ≤2). Methods: In this prospective observational study, 754 consecutive patients with AF and HAS-BLED score ≤2 were included. We compared outcome of elderly patients (age ≥75 tears) to younger patients (age <75 years). The primary end point was the combined incidence of all-cause mortality, stroke, systemic emboli, and major bleeding event during a mean follow-up of 1 year. Results: There were 230 (30%) elderly patients, 151 patients were treated with warfarin, and 79 were treated with DE150. Fifty-two patients experienced the primary endpoint during the 1-year follow-up. Among the elderly, at 1-year of follow-up, the cumulative event rate of the combined endpoint in the DE150 and warfarin was 8.9 and 15.9% respectively (p = 0.14). After adjustment for age and gender, patients who were treated with DE150 had a nonsignificant difference in the risk for the combined end point as patients treated with warfarin both among the elderly and among the younger population (HR 0.58, 95% C.I = 0.25–1.39 and HR = 1.12, 95% C.I 0.62–2.00, respectively [p for age-group-by-treatment interaction = 0.83). Conclusions: Our results suggest that Dabigatran 150 mg twice a day can be safely used among elderly AF patients with low bleeding risk.

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Cochlear implantation in elderly patients: stability of outcome over time

The Journal of Laryngology & Otology ◽

10.1017/s0022215116008197 ◽

2016 ◽

Vol 130 (8) ◽

pp. 706-711 ◽

Cited By ~ 13

Author(s):

O Hilly ◽

E Hwang ◽

L Smith ◽

D Shipp ◽

J M Nedzelski ◽

...

Keyword(s):

Elderly Patients ◽

Cochlear Implantation ◽

Short Form ◽

Age Groups ◽

The Elderly ◽

Long Term Results ◽

Profound Hearing Loss ◽

Younger Patients ◽

Over Time

AbstractBackground:Cochlear implantation is the standard of care for treating severe to profound hearing loss in all age groups. There is limited data on long-term results in elderly implantees and the effect of ageing on outcomes. This study compared the stability of cochlear implantation outcome in elderly and younger patients.Methods:A retrospective chart review of cochlear implant patients with a minimum follow up of five years was conducted.Results:The study included 87 patients with a mean follow up of 6.8 years. Of these, 22 patients were older than 70 years at the time of implantation. Hearing in Noise Test scores at one year after implantation were worse in the elderly: 85.3 (aged under 61 years), 80.5 (61–70 years) and 73.6 (aged over 70 years;p= 0.039). The respective scores at the last follow up were 84.8, 85.1 and 76.5 (p= 0.054). Most patients had a stable outcome during follow up. Of the elderly patients, 13.6 per cent improved and none had a reduction in score of more than 20 per cent. Similar to younger patients, elderly patients had improved Short Form 36 Health Survey scores during follow up.Conclusion:Cochlear implantation improves both audiometric outcome and quality of life in elderly patients. These benefits are stable over time.

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Hemifacial Spasm: Comparison of Results between Patients Older and Younger than 70 Years Operated on with Microvascular Decompression

Journal of Neurological Surgery Part A Central European Neurosurgery ◽

10.1055/s-0040-1721018 ◽

2021 ◽

Author(s):

Hua Zhao ◽

Jin Zhu ◽

Yin-da Tang ◽

Lin Shen ◽

Shi-ting Li

Keyword(s):

Elderly Patients ◽

Hemifacial Spasm ◽

Microvascular Decompression ◽

Facial Palsy ◽

The Elderly ◽

Elderly Group ◽

Effective Treatment Option ◽

Younger Patients ◽

Significant Difference ◽

Csf Leakage

Abstract Objective The aim of the present study was to evaluate the efficacy and safety of microvascular decompression (MVD) for primary hemifacial spasm (HFS) in patients aged ≥70 years and to compare the outcome with a control cohort of younger patients(<70 years). Methods In this retrospective study, subjects were divided into two groups: an elderly group (patients who were ≥70 years) and a younger group. We compared demographic and clinical data, surgical outcome, MVD-related complications, and duration of operation and hospitalization after MVD between the two groups. Results At a mean follow-up of 32 ± 4.2 months, 188 elderly patients (90.4%) reported an effective outcome without need for any medication versus 379 (91.1%) of the younger cohort. There was no mortality in both cohorts. The prevalence of delayed facial palsy was 4.8% in the elderly group and 4.1% in the younger group. One (0.5%) patient in the elderly group and 3 (0.7%) patients in the younger group suffered cerebrospinal fluid (CSF) leakage. There was no significant difference between the two groups in terms of MVD-related complications, such as delayed facial palsy, hearing impairment, CSF leakage, and hematoma. Conclusions MVD is an effective treatment option in elderly patients with HFS as well as in younger patients. Age itself seems to be no relevant contraindication or, alternatively, risk factor regarding MVD.

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MICROVASCULAR DECOMPRESSION FOR TRIGEMINAL NEURALGIA IN THE ELDERLY

Neurosurgery ◽

10.1227/01.neu.0000350859.27751.90 ◽

2009 ◽

Vol 65 (3) ◽

pp. 477-482 ◽

Cited By ~ 46

Author(s):

Thomas Günther ◽

Venelin M. Gerganov ◽

Lennart Stieglitz ◽

Wolf Ludemann ◽

Amir Samii ◽

...

Keyword(s):

Pain Relief ◽

Trigeminal Neuralgia ◽

Microvascular Decompression ◽

The Elderly ◽

Safe Procedure ◽

Term Outcome ◽

Long Term Outcome ◽

Younger Patients ◽

The Mean

Abstract OBJECTIVE Multiple studies have proved that microvascular decompression (MVD) is the treatment of choice in cases of medically refractory trigeminal neuralgia (TN). In the elderly, however, the surgical risks related to MVD are assumed to be unacceptably high and various alternative therapies have been proposed. We evaluated the outcomes of MVD in patients aged older than 65 years of age and compared them with the outcomes in a matched group of younger patients. The focus was on procedure-related morbidity rate and long-term outcome. METHODS This was a retrospective study of 112 patients with TN operated on consecutively over 22 years. The main outcome measures were immediate and long-term postoperative pain relief and neurological status, especially function of trigeminal, facial, and cochlear nerves, as well as surgical complications. A questionnaire was used to assess long-term outcome: pain relief, duration of a pain-free period, need for pain medications, time to recurrence, pain severity, and need for additional treatment. RESULTS The mean age was 70.35 years. The second and third branches of the trigeminal nerve were most frequently affected (37.3%). The mean follow-up period was 90 months (range, 48–295 months). Seventy-five percent of the patients were completely pain free, 11% were never pain free, and 14% experienced recurrences. No statistically significant differences existed in the outcome between the younger and older patient groups. Postoperative morbidity included trigeminal hypesthesia in 6.25%, hypacusis in 5.4%, and complete hearing loss, vertigo, and partial facial nerve palsy in 0.89% each. Cerebrospinal fluid leak and meningitis occurred in 1 patient each. There were no mortalities in both groups. CONCLUSION MVD for TN is a safe procedure even in the elderly. The risk of serious morbidity or mortality is similar to that in younger patients. Furthermore, no significant differences in short- and long-term outcome were found. Thus, MVD is the treatment of choice in patients with medically refractory TN, unless their general condition prohibits it.

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Abstract 12127: Integrated Flow-Mediated Vasodilation Response Predicts Cardiovascular Events in Elderly Patients at Cardiovascular Risk Factor

Circulation ◽

10.1161/circ.130.suppl_2.12127 ◽

2014 ◽

Vol 130 (suppl_2) ◽

Author(s):

Tomoyuki Kabutoya ◽

Satoshi Hoshide ◽

Yukiyo Ogata ◽

Kazuo Eguchi ◽

Kazuomi Kario

Keyword(s):

Risk Factor ◽

Cardiovascular Risk ◽

Elderly Patients ◽

Cardiovascular Risk Factor ◽

Cardiovascular Events ◽

The Elderly ◽

Detection Algorithm ◽

Younger Patients ◽

Flow Mediated Vasodilation

Introduction: The integrated flow-mediated vasodilation (FMD) response was shown to be associated with cardiovascular risk factors, but the association between the integrated FMD response and consequent cardiovascular events has been unclear. Hypothesis: We assessed the hypothesis that the integrated FMD response predicts consequent cardiovascular events. Methods: We enrolled 575 patients who had at least one cardiovascular risk factor (hypertension, dyslipidemia, diabetes, or smoking). We measured the FMD magnitude of the percentage change in peak diameter (ΔFMD), and we measured the integrated FMD response calculated as the area under the dilation curve during a 120-sec dilation period (FMD-AUC 120 ) using a semiautomatic edge-detection algorithm. The primary outcome was defined as any cardiovascular event (a composite of cardiovascular death, and hospitalization for myocardial infarction, stroke, or heart failure). Results: The mean duration of follow-up was 35±22 months (range: 1-74 months). During the follow-up period, 34 cardiovascular events were recorded. Among the elderly patients (age[[Unable to Display Character:  ]]≥[[Unable to Display Character:  ]]65 yrs, n[[Unable to Display Character:  ]]=[[Unable to Display Character:  ]]281), the patients with the lowest tertile of FMD-AUC 120 (FMD-AUC 120 <[[Unable to Display Character:  ]]5.6) suffered a higher incidence of cardiovascular events compared with the patients with the higher two tertiles (FMD-AUC 120 ≥[[Unable to Display Character:  ]]5.6) (log rank 4.16, p=0.041). The association remained significant after adjusting for age, gender and office systolic blood pressure (hazard ratio 1.25, p=0.039). In the younger patients (age[[Unable to Display Character:  ]]<[[Unable to Display Character:  ]]65 yrs, n[[Unable to Display Character:  ]]=[[Unable to Display Character:  ]]294), cardiovascular events were similar among the patients with the lowest tertile and those with the higher two tertiles of FMD-AUC 120 . Cardiovascular events were also similar in the patients with the lowest tertile and the higher two tertiles of ΔFMD in both the elderly and younger patients. Conclusions: The integrated FMD response, but not ΔFMD, predicted cardiovascular events in elderly patients with a cardiovascular risk factor.

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Outcome after resective epilepsy surgery in the elderly

Journal of Neurosurgery ◽

10.3171/2021.4.jns204013 ◽

2021 ◽

pp. 1-10

Author(s):

Attila Rácz ◽

Kathryn Menne ◽

Valeri Borger ◽

Kevin G. Hampel ◽

Hartmut Vatter ◽

...

Keyword(s):

Elderly Patients ◽

Epilepsy Surgery ◽

Seizure Control ◽

Surgical Complication ◽

The Elderly ◽

Neurological Deficits ◽

Control Group ◽

Chi Square ◽

Postoperative Seizure

OBJECTIVE The objective of this study was to compare complications, seizures, and neuropsychological outcomes after resective epilepsy surgery in patients ≥ 60 years of age who underwent operations to younger and matched controls. METHODS Charts of 2243 patients were screened for operated patients in the authors’ center between 2000 and 2015. Patients with available postsurgical follow-up data who were operated on at the age of 60 years or older and matched (by gender, histopathology, and side of surgery) controls who were between 20 and 40 years of age at the time of surgery were included. Outcomes regarding postoperative seizure control were scored according to the Engel classification and group comparisons were performed by using chi-square statistics. RESULTS Data of 20 older patients were compared to those of 60 younger controls. Postoperative seizure control was favorable in the majority of the elderly patients (Engel classes I and II: 75% at 12 months, 65% at last follow-up), but the proportion of patients with favorable outcome tended to be larger in the control group (Engel classes I and II: 90% at 12 months, p = 0.092; 87% at last follow-up, p = 0.032, chi-square test). The surgical complication rate was higher in the elderly population (65% vs 27%, p = 0.002), but relevant persistent deficits occurred in 2 patients of each group only. Neuropsychological and behavioral assessments displayed considerable preoperative impairment and additional postoperative worsening, particularly of verbal skills, memory (p < 0.05), and mood in the elderly. CONCLUSIONS The overall favorable postsurgical outcome regarding seizure control and the moderate risk of disabling persistent neurological deficits in elderly patients supports the view that advanced age should not be a barrier per se for resective epilepsy surgery and underscores the importance of an adequate presurgical evaluation and of referral of elderly patients to presurgical assessment.

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