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During the 11-year period 1975 through 1985, seven hundred ninety-five patients 90 years of age and older underwent operative procedures at the Mayo Clinic, Rochester, Minn. Overall serious morbidity within 48 hours after surgery was 9.4%, and the mortality was 1.6%. The 30-day, 1-year, and 5-year mortality rates were 8.4%, 31.4%, and 78.8%, respectively. Short-term morbidity and both short- and long-term mortality were highly associated with the American Society of Anesthesiologists physical status classification of the patient. Emergency procedures carried a significantly higher risk for morbidity and mortality within the 48-hour period and, to a lesser extent, for long-term mortality. Overall, poorer patient survival was associated with higher American Society of Anesthesiologists class; male sex; preoperative renal, liver, and central nervous system impairment; and surgery on the mouth, nose, or pharynx. When compared with age-, sex-, and calendar year--matched peers from the general population, there was a modest decrease in patient survival at 1 year that reversed by 2 years, with observed survival at 5 years comparable to the rate expected.

Persons greater than or equal to 90 years of age represent a rapidly growing subset of the population, but little data exist on their utilization of the health care system. Population-based data capabilities of the Rochester/Olmsted County Epidemiology Project were used to study the performance of surgery among persons greater than or equal to 90 years of age for the 11-year period, 1975-1985. During this time, 224 residents of Olmsted County, Minnesota underwent 301 separate operations. The annual operation rate increased over the course of the study (trend test, p less than 0.001), reaching a plateau of 89.0 per 1000 person-years. This suggests a potential for nearly 91,000 operations annually in this age group based on 1987 U.S. Census estimates. Ninety-two per cent were discharged from the hospital alive, and 5-year survival was consistent with that expected (23% vs. 17%). Increased longevity of the general population, combined with increased performance of surgery in this rapidly growing segment of the population, may have significant implications for health care planning.

SummaryPeri-operative morbidity and mortality and long term outcome of patients over 90 years of age who underwent either total hip arthroplasty or transurethral prostate resection were studied retrospectively. The outcomes of patients who received regional or general anaesthesia were compared. One hundred and forty-one patients underwent total hip arthroplasty and 44 patients underwent transurethralprostate resection during the study period (1975)(1976)(1977)(1978)(1979)(1980)(1981)(1982)(1983)(1984)(1985). Overall in-hospital mortality was 4.9%. Mortality at 30 days was 5.3% in patients who underwent hip arthroplasty during regional anaesthesia, compared with 6.8% in those who received general anaesthesia. Long term survival was similar for these two groups and was longer than projected for age and Correspondence should be addressed to Dr M. A. Warner, please. Accepted 20 July 1988. Forum 143gender-matched general population cohorts. The 30-day mortality rate was 3.2% for patients who underwent prostatic resection under regional anaesthesia; no deaths occurred in the general anaesthesia group. This difference was not statistically significant. Long term survival was similar for patients in both groups and was better than predicted. Anaesthetic technique did not influence short term morbidity and mortality or long term outcome for these procedures.

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al. Birth cohort changes in manic and depressive disorders in relatives of bipolar and schizoaffective patients. Arch Gen Psychiatry. 1987;44:314-319. 4. Giles DE, Roffwarg HP, Kupfer DJ, et al. Secular trend in unipolar depression: a hypothesis. J Affective Disord. 1989;16:71-75.In Reply.\p=m-\ The seasonal disorder hypothesis discussed by Dr Mueller is an interesting one and one we did not consider, partly because the Epidemiologic Catchment Area with the five-site data did not show an effect of season on rates of major depression.Since the article was published, we have identified other population studies, using the Diagnostic and Statistical Manual of Mental Disorders, Third Edition, or Research Diagnostic Criteria, undertaken in China, Taiwan, and Texas, thus giving us a broader range of latitudes to explore. The reason why a seasonal disorder would be increasing is unclear.Our article entitled "Increasing Rate of Depression" does end with a large question. We think that the evidence for secular change in the rate of depression, based on thousands of persons from different countries and different investigations, is not entirely an artifact and that the absence of secular change in some parts of the world based on studies using secular methods is intriguing and worthy of pursuit. The reason for the differential trends is unclear.The advance that has made these types of comparisons possible is the availability of standardized diagnostic assessments and specified criteria. The subjects in all the studies reported were diagnosed by similar methods and meet DSM-III criteria for major depression. While the work by Giles et al is inter¬ esting, reduced sleep REM latency is a research tool and not a method for diag¬ nosing major depression currently used in clinical practice. Nor would its sensi¬ tivity or specificity warrant its general use as yet. We agree with Dr Waziri and did not suggest that all younger persons meet¬ ing DSM-III criteria for major depres¬ sion should receive medication. Our own clinical trial and that of a recent National Institute of Mental Health Collaborative Study on the treatment of depression show the value of brief psy¬ chological treatment as well. The deci¬ sion about the type of treatment should be made on the basis of severity of symptoms and the history. A secular change in the rate of any disorder suggests that environmental factors are at play. What they are and why they do not operate in Puerto Rico, in Korea, or among Mexican Americans are intriguing questions. More Than 90 Years Old To the Editor. \p=m-\Thereport by Hosking et al1 raises some perplexing questions about the adequacy and application of survival-based studies that fail to include data about patients' quality of life. As the researchers point out, surgical outcomes, in terms of increased longevity for patients, continue to improve. At the same time, concerns about rising medical care costs, allocation of critical care beds and other valuable resources,and what constitutes medically futile treatment have entered th...