J. R. Berian1,2, K. Y. Bilimoria1,3, C. Y. Ko1,5, T. N. Robinson4, R. A. Rosenthal6 1American College Of Surgeons,Division Of Research And Optimal Patient Care,Chicago, IL, USA 2University Of Chicago,Department Of Surgery,Chicago, IL, USA 3Northwestern University,Department Of Surgery,Chicago, IL, USA 4University Of Colorado Denver,Department Of Surgery,Denver, CO, USA 5University Of California – Los Angeles,Department Of Surgery,Los Angeles, CA, USA 6Yale University School Of Medicine,Department Of Surgery,New Haven, CT, USA
Introduction: Geriatric-specific outcomes such as functional decline are critically relevant for older adults as they consider whether to undergo an operation.
Methods: The American College of Surgeons (ACS) National Surgical Quality Improvement Program (NSQIP) collects novel geriatric-specific data as part of the Geriatric Surgery Pilot Project. A retrospective analysis was conducted on a cohort of patients from 25 participating hospitals collected between January and September 2014. Functional status represents an individual’s ability to perform the activities of daily living. The main outcome of interest was decline in functional status from preoperative baseline compared to at the time of hospital discharge (independent preoperatively to partially or totally dependent postoperatively, or partially dependent preoperatively to totally dependent postoperatively). Excluded cases were orthopedic and spinal procedures, death within 30 days, and patients whose preoperative functional status was total dependence. Multivariable logistic regression was performed to identify significant predictors for functional decline.
Results: The study included 6,295 patients with the average age of 74±8 years. The rate of functional decline was 15% among patients <=65 years of age, 14% for ages 66-75 years, 23% for ages 76-85, and 39% for those over age 85 years. On multivariable regression, significant predictors for functional decline included age 76-85 or >85 (OR 1.6 and 2.6, respectively, 95% CI 1.1-2.3 and 1.7-4.0, respectively), female sex (OR 1.3, 95% CI 1.1-1.5), ASA class 3 or 4 (OR 2.7 and 3.3, respectively with 95% CI 1.1-7.2 and 1.3-9.0, respectively), history of COPD (OR 1.3, 95% CI 1.0-1.7), diabetes requiring insulin (OR 1.3, 95% CI 1.0-1.6), disseminated cancer (OR 1.6, 95% CI 1.2-2.1), having experienced a fall within 1 year prior to the operation (OR 1.6, 95% CI 1.3-2.0), or the use of a mobility aid preoperatively (OR 2.0, 95% CI 1.7-2.4). Additional factors associated with functional decline were an emergency operation (OR 2.3, 95% CI 1.8-2.9) or experiencing postoperative complication (OR 1.7, 95% CI 1.4-2.1). Factors found to be protective were overweight status (OR 0.8, 95% CI 0.7-0.9) and other race (non-white, non-Hispanic, non-black)(OR 0.4, 95% CI 0.3-0.5).
Conclusion: Functional decline occurs in older adults following surgery. This occurs in the ‘younger old’ as well as ‘oldest old’. Adjusted analysis finds that advancing age, female sex, high ASA class, certain comorbidities, prior falls and use of mobility aids are associated with functional decline. Counselling high-risk patients about the risk of losing independent functional status is an important component of preoperative decision-making for older adults.