Considering self-reported baseline function and cognition in predicting post-operative complications among older adults

Introduction

Older adults experience disproportionately higher rates of postoperative complications and poorer outcomes than their younger counterparts (1,2). Despite efforts to promote optimal care for older patients, current perioperative risk assessments lack meaningful and specific measures, and have been cited as too time-consuming for busy surgeons (3). As such, our objective was to evaluate the association of self-reported preoperative functional and cognitive abilities with complications among older adults undergoing high-risk surgery. Such knowledge may better inform surgical decision-making and allow for earlier introductions to palliative care among this vulnerable patient population.

Methods

Using data from the Health and Retirement Study Survey linked to Centers for Medicare and Medicaid Services Part-A and B claims, we evaluated all adults ≥65 years old who underwent high-risk elective surgery (≥1% inpatient mortality) between 1992–2012 (4). Primary exposure variables included self-reported preoperative functional and cognitive abilities. Baseline functional status was determined by the number of activities of daily living (ADLs) and instrumental activities of daily living (IADLs) requiring assistance (0= none, 1–3= mild-moderate, ≥4= severe functional limitations) (5). Baseline cognitive status was determined by a 27-point scale encompassing memory, serial-7 subtractions, naming and orientation (≥11= normal, 7–10= mild, 0–6= moderate-severe cognitive impairment) (5). Secondary exposure variables included specific ADL and IADL deficiencies. The primary outcome was development of a serious postoperative complication within 30-days following index operation identified by ICD-9 codes (Table 1, footnote).

Table 1 Demographic data for patient’s ages 65 and older who underwent high-risk surgery
Full table

Student’s t-test was used to compare means and chi-square test was performed for categorical variables. Multivariable logistic regression was used to analyze outcomes with the following covariates: age, gender, comorbidity score, surgery type, functional status, cognitive status, and year of surgery (Table 1). Statistical significance was set at P<0.05 with two-sided tests. All analyses were performed with SAS version 9.4. This study was deemed exempt by the Michigan Medicine Institutional Review Board.

Results

Of 1,197 older adults who underwent high-risk surgery, 46% (n=545) were male with a mean age of 74.7 years (SD 6.3) (Table 1). Overall, 42% (n=501) developed ≥1 serious postoperative complication. Among primary exposure variables, moderate (aOR 1.52, 95% CI: 1.14–2.04) and severe (aOR 1.55, 95% CI: 1.00–2.46) functional limitations were independently associated with serious postoperative complications compared to no functional limitation (Table 1). Cognitive impairment was not associated with serious postoperative complications. Among secondary exposure variables, the inability to bathe (aOR 3.01, 95% CI: 1.59–5.71) or walk (aOR 1.79, 95% CI: 1.21–2.63) were independently associated with increased odds of developing serious postoperative complications (Figure 1).

Figure 1 Adjusted^† odds of serious postoperative complications based on activities of daily living (ADLs) and instrumental activities of daily living (IADLs). ^†, adjusting for demographics and clinical variables including age, race, gender, Elixhauser comorbidity index, surgery type, and year of surgery.

Discussion

Greater baseline functional deficits are an independent predictor of serious postoperative complications among older adults undergoing high-risk elective operations. Specifically, those who demonstrate the inability to bathe or walk are at higher risk of developing complications even when adjusting for demographic and clinical factors. These simple metrics are easy to assess in busy clinical settings and may help to improve surgical decision-making and manage expectations with patients and families. Self-reported measures may also be used to rapidly identify patients who might benefit most from preoperative optimization including nutritional counseling and prehabilitation measures. Finally, as surgical patients often underutilize palliative care services, this may represent an important opportunity to introduce palliative care approaches to surgical patients whose illness trajectories may not be predictable in the immediate postoperative setting but likely demonstrate decline over the long-term (7,8).

This study was limited by reliance on self-reported measures, which may lead to subjectivity, recall bias, and selection bias. Furthermore, given the data is from 1992 to 2012, it is unknown if complication rates would differ given recent advances in technology and improved surgical technique. However, our findings are drawn from a nationally representative cohort, which allows for generalizability of our results, as well as outcomes that are meaningful to patients. Importantly, our findings suggest that a brief, patient-centered approach is feasible to determine preoperative risk where quick decisions frequently have lasting consequences.

Acknowledgments

The authors wish to thank the American College of Surgeons for funding of this project.

Funding: This work is supported by the American College of Surgeons Thomas R. Russell Faculty Research Fellowship.

Footnote

Reporting Checklist: The authors have completed the STROBE reporting checklist. Available at http://dx.doi.org/10.21037/apm-20-816

Data Sharing Statement: Available at http://dx.doi.org/10.21037/apm-20-816

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at http://dx.doi.org/10.21037/apm-20-816). PAS serves as an unpaid editorial board member of Annals of Palliative Medicine from May 2019 to Apr 2021. PAS reports grants from American College of Surgeons Thomas R. Russell Faculty Research Fellowship, from null, outside the submitted work. The other authors have no other conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. This study was deemed exempt by the Michigan Medicine Institutional Review Board.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

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