Case Presentation: An 87yo woman with dementia presented with a large right adrenal mass consistent with pheochromocytoma with lymph node metastases based on biochemical testing and MIBG scan. Non-operative management with iobenguane-131 (Azedra) was considered because of her surgical risk. However, given her underlying dementia, comorbid conditions, and frailty, she was appropriately identified as high risk for admission complications, and her surgical team proactively reached out to perioperative geriatric experts from the outpatient preoperative medicine clinic and inpatient geriatrics consult service. Iobenguane-131 is a radiopharmaceutical requiring hospitalization for administration. Additionally, the risk for exposure to the radiopharmaceutical agent requires staff to have minimal physical contact with the patient after administration. Geriatric assessment revealed that she had moderate to severe dementia and had been hospitalized at least seven times in the antecedent year for COPD and acute HFpEF, in addition to having a prior history of inpatient delirium. She was capable of very short distance ambulation at her assisted living facility but was otherwise wheelchair dependent. Physical therapy assessment noted limited insight, impulsivity, and falling due to inability to followed directions with one-person assistance. Based on review of her global cognitive-functional status, comorbid medical issues, and overall frailty, the geriatrics and surgical teams shared significant concerns about her probable admission course, and the high risk of inpatient adverse events, including delirium and falls. Furthermore, her treatment protocol would require relative seclusion during her admission and compounded by her inability to independently use her call button, there was significant concern her medical needs would not be timely identified and managed A palliative care consultation was scheduled for the patient and her family although they ultimately decided to forego treatment independent of this consultation. Over the next month, she was admitted twice for cardiopulmonary reasons. On the second admission, she transitioned to hospice care and died in the hospital.
Discussion: This case highlights a complex, frail, cognitively impaired elder for whom the geriatrics teams believed that even under the best circumstances, hospitalization would have caused accelerated cognitive decline, almost certain delirium, and ultimately a high probability of progressive and even accelerated functional decline, leading to a suboptimal outcome: significantly increased 1-year morbidity and mortality, possibly cutting even shorter the time she would have to spend with her loved ones. Her passing within the short time of preoperative consult indicates that she would have had a high likelihood of passing away during her admission for cancer treatment.
Conclusions: This case demonstrates the critical role of perioperative and periprocedural medicine, particularly for older adults. Coordination between perioperative medicine and inpatient geriatrics through pre-existing clear channels led to thoughtful conversations with surgical colleagues which ultimately helped to guide the patient and family to make the best decision possible for the patient. This case demonstrates the value and necessity of interdisciplinary teaming when caring for older adults. It also demonstrates that perioperative medicine can be a focal point to integrate patient’s care across many facets of a health system.