Frailty results in a 3- to 8-fold increase in risk of postoperative delirium, independent of the EuroSCORE II. "Frail" and "fit" may be considered 2 ends of a continuum, and the risk of postoperative delirium grows as one becomes increasingly frail. The addition of frailty improves the ability of the EuroSCORE II to predict postoperative delirium, pointing to opportunities for improved prevention and management.

A n 89-year-old man with a history of a repaired abdominal aortic aneurysm was admitted to hospital for weight loss of 9 kg over the previous 6 months, which was due to progressive dysphagia to both solids and liquids. Esophagogastroduodenoscopy showed an atypical esophageal mass (Figure 1A), but suspecting possible vascular ectasia, we decided not to biopsy the lesion. Chest radiography showed cardiomegaly with left atrial enlargement (Figure 1B). Computed tomography of the chest did not show a discrete esophageal mass; however, it did show a tortuous thoracoabdominal aneurysm that measured 6.7 cm at the level of the hiatus and 9.5 cm at the level of the celiac artery. It also showed an enlarged left atrium measuring 7.8 cm in maximal dimension (Figure 1C and Appendix 1, available at www.cmaj.ca/ lookup/doi/10.1503/cmaj.200427/tab-related-content). A subsequent barium esophagram showed substantial hold up of contrast at the lower esophagus, consistent with extrinsic compression and age-related dysmotility (Figure 1D). Our patient opted for conservative management, given the substantial risks of surgical repair. We consulted with nutrition services who were able to help his dysphagia with a soft diet. Dysphagia aortica refers to problems swallowing because of extrinsic compression of the esophagus by an enlarged aorta. Dysphagia megalatriensis refers to the external compression of the esophagus by an enlarged left atrium. Both are uncommon, and the combination, as in our patient, is rare. 1 Esophagram and esophageal manometry can help with establishing the diagnosis. 2 For dysphagia aortica, case reports have shown improvements with surgical repair, while for dysphagia megalatriensis, treatment of the underlying cardiac condition may improve symptoms. 1,3,4 For patients who cannot tolerate surgery, treatment options include insertion of a percutaneous feeding tube or a switch to soft and minced foods. 5

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