This cohort study examines the incidence, risk factors, and implications of adverse physical outcomes after surgical treatment for patients 80 years or older.
Key Points
Question
What is the prevalence of 30-day postoperative functional decline in patients 80 years or older, and what are the associated risk factors?
Findings
In this cohort study of 2013 older adults who underwent a nonorthopedic surgical procedure, more than 20% experienced a functional decline after 30 days. Geriatric-specific factors statistically significantly associated with this outcome included preoperative mobility aid use and malnutrition as well as postoperative delirium, pressure ulcer, and the need for a new mobility aid at discharge.
Meaning
Results of this study suggest that prolonged functional decline is common in older surgical patients and is associated with several geriatric-specific factors, which may be modifiable and may serve as targets for quality improvement.
Abstract
Importance
Functional outcomes have value for older adults who undergo surgical procedures. Preventing postoperative functional decline in this patient population necessitates the identification of the factors associated with this outcome and minimizing their implications.
Objectives
To assess the prevalence of functional decline 30 days after a surgical procedure among older adults 80 years or older, examine the risk factors of this decline, and identify ways to minimize this decline by addressing its mutable factors.
Design, Setting, and Participants
This retrospective cohort study used patient data from the Geriatric Surgery Pilot Project, a multi-institutional data registry of the American College of Surgeons National Surgical Quality Improvement Program. Inclusion criteria were patients 80 years or older who underwent a surgical procedure that required an inpatient stay at 1 of 23 hospitals enrolled in the Geriatric Surgery Pilot Project from January 1, 2015, to December 31, 2018, and had preoperative and postoperative functional health status data. Data analysis was performed from January 7, 2019, to December 2, 2019.
Exposures
Adults 80 years or older who underwent an inpatient surgical procedure.
Main Outcomes and Measures
The primary outcome was 30-day postoperative functional decline defined by a change in functional health status from admission or before the surgical procedure (ie, from independent to partially or totally dependent, or from partially dependent to totally dependent). Functional health status was measured by a patient’s ability to perform activities of daily living. Secondary outcomes were hospital readmission and 30-day postoperative living location.
Results
Of the 2013 patients analyzed in this study, 1128 were women (56.0%) and the mean (SD) age was 84.9 (3.9) years. Functional decline at 30 days after the surgical procedure was present in 406 patients (20.2%). Prevalence of this outcome increased with age, with 337 of 1751 patients aged 80 to 89 years (19.2%) experiencing decline compared with 69 of 262 patients 90 years or older (26.3%). In a risk-adjusted model, the geriatric-specific risk factors statistically significantly associated with this outcome included preoperative mobility aid use (odds ratio [OR] 1.76; 95% CI, 1.39-2.22; P < .001) and malnutrition (OR, 1.88; 95% CI, 1.04-3.43; P = .04) as well as postoperative delirium (OR, 2.20; 95% CI, 1.60-3.02; P < .001), pressure ulcer (OR, 1.83; 95% CI, 1.02-3.30; P = .04), and mobility aid at discharge (OR, 2.49; 95% CI, 1.72-3.59; P < .001). Among patients with a 30-day functional decline, 106 (26.1%) required hospital readmission and only 219 (53.9%) were living at home compared with 388 patients (95.6%) living at home before the procedure.
Conclusions and Relevance
In this study, 1 in 5 older adults experienced a functional decline that persisted 30 days after a surgical procedure, an outcome that appeared to be associated with several geriatric-specific risk factors. Future trials are needed to evaluate whether the prevention or mitigation of these factors can decrease the rates of postoperative functional decline in this patient population.
Introduction
The US population is aging at a rapid rate, with the number of people 65 years or older projected to double from 46 million in 2015 to 98 million by 2060.1 Individuals 85 years or older represent the fastest growing segment of the population, which is expected to triple in number from 6 million to nearly 20 million in the next 30 years.1 The health care workforce has long recognized the challenge of caring for an aging population,2 and evidence suggests that surgeons are particularly affected.3 Given the increased risk for adverse outcomes among older adults after a surgical procedure,4,5 measuring and then improving on the surgical outcomes that older patients prioritize are vital.
For most older adults with chronic illness, maintaining physical and cognitive function signifies a successful medical treatment, even more so than survival.6 Decline in function after medical treatment is a life-altering outcome and is associated with substantially elevated rates of clinical depression for both the patient and the primary caregiver. In a qualitative study published by Fried and colleagues,6 physical impairment was listed as 1 of the 4 outcomes that older adults considered as unacceptable results of a medical treatment. Postoperative functional decline remains highly prevalent among older adults who undergo surgical procedures, with reported rates of more than 25% in the immediate postoperative period7 and 10% to 50% six months after the procedure.8 Even so, postoperative functional decline is an outcome that is poorly characterized and rarely prioritized or considered by health care systems.
The factors associated with the development of 30-day functional decline in older adults are not well understood. Therefore, we aimed to (1) assess the prevalence of 30-day postoperative functional decline among adults 80 years or older who underwent a nonorthopedic surgical procedure, (2) examine the risk factors of this decline, and (3) identify ways to minimize this outcome by addressing its mutable factors.
Methods
Data Source
This retrospective cohort study used data from the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) Geriatric Surgery Pilot Project, a multi-institutional clinical data registry of preoperative demographic information and comorbid illnesses as well as up to 30 days of postoperative outcomes.9,10,11 The Advarra Institutional Review Board deemed this study exempt from review because it posed minimal risk and used deidentified data. Informed consent was waived because of data deidentification and the impracticality of reaching out to deidentified persons.
In 2014, the ACS NSQIP Geriatric Surgery Pilot Project began collecting data from participating US hospitals on the surgical care of older adults to examine the feasibility and utility of identifying geriatric-specific risk factors and outcomes on a national basis for quality improvement. Several geriatric-specific variables were in the domains of surgical decision-making, cognition, function, and mobility. A subset of hospitals enrolled in the Geriatric Surgery Pilot Project (n = 23) volunteered to collect 30-day outcomes on their older adult patient population, but because the collection of such outcomes required increased effort to contact patients, the data abstractors were instructed to focus on the most vulnerable patients (ie, those aged ≥80 years). These data were clinically abstracted by the same trained and audited data abstractors as those for ACS NSQIP.
Inclusion and Exclusion Criteria
Inclusion criteria were age 80 years or older, a surgical procedure that required an inpatient stay at 1 of 23 hospitals enrolled in the Geriatric Surgery Pilot Project from January 1, 2015, to December 31, 2018, and available data on preoperative and 30-day postoperative functional health status. Exclusion criteria were totally dependent functional health status on admission (no possibility of functional decline); an American Society of Anesthesiologists Physical Status Classification of 5, indicating moribund status (class range: ASA 1-5, with 1 as healthy and 5 as moribund [no expectation to survive 24 hours with or without an operation]); death 30 days after the surgical procedure; or an orthopedic surgical procedure (given that functional trajectory associated with mobility was likely to be inherently altered by the surgical procedure).
Primary and Secondary Outcomes
The primary outcome of interest was 30-day postoperative functional decline, which was based on a patient’s functional health status on admission vs 30 days after the surgical procedure. We classified functional health status as independent, partially dependent, or totally dependent according to the patient’s documented ability to perform activities of daily living (ADLs), such as bathing, feeding, dressing, toileting, and transferring. Patients with independent functional health status required no assistance from another person to complete ADLs, including functioning independently with prosthetics, equipment, or other mobility devices. Patients with partially dependent functional health status needed some assistance from another person to perform ADLs. Patients with totally dependent functional health status required assistance for all ADLs. Patients who were independent experienced preoperative functional decline if they were classified as partially or totally dependent 30 days after the surgical procedure. Those with preoperative partial dependence experienced functional decline if they were classified as totally dependent 30 days after the operation. Secondary outcomes were hospital readmission and 30-day postoperative living location.
Geriatric-Specific Factors
Geriatric-specific factors may be identified and targeted for quality improvement. The preoperative geriatric-specific risk factors we examined were fall history, mobility aid use, and malnutrition. Fall history was described as a fall in the year before the surgical procedure. Although not directly mutable, fall history and mobility aid use were included in this study as markers of diminished mobility that can be addressed before the operation. Malnutrition was described as an unintentional weight loss of more than 10% within 6 months before the procedure.
The postoperative geriatric-specific risk factors we examined were delirium, new or worsened pressure ulcer, and the need for a new mobility aid at discharge. Delirium was captured through the following descriptive words in the medical record: mental status change, confusion, disorientation, agitation, delirium, inappropriate behavior, inattention, hallucinations, and combative behavior. New or worsened pressure ulcer was described as the development of a pressure ulcer or in-depth progression of an existing pressure ulcer. New mobility aid was the need for a mobility aid (eg, cane, walker, wheelchair, or scooter) at the time of discharge that was not present on admission.
Statistical Analysis
We calculated the overall rate and by-procedure-type rate of 30-day functional decline. Surgical procedure type was classified according to the Agency for Healthcare Research and Quality Clinical Classifications Software designation, a method for classifying Current Procedural Terminology (CPT) codes into clinically meaningful categories.12 We conducted bivariate analyses using unpaired, 2 -tailed χ2 tests and Mann-Whitney tests as appropriate. We developed a multivariable logistic regression model to evaluate geriatric-specific factors associated with 30-day functional decline. The model was adjusted for age, sex, emergency surgical procedure status, American Society of Anesthesiologists Physical Status Classification, body mass index, smoking history, corticosteroid use, and presence of comorbid illnesses or conditions that are commonly used to stratify surgical risk (diabetes, chronic obstructive pulmonary disease, congestive heart failure, ascites, dyspnea, kidney failure, need for dialysis, ventilatory dependence, sepsis, and disseminated cancer).
To account for the inherent differences in physiological stress between surgical procedures, we included a variable that denoted the occurrence of any major postoperative complication, including surgical site infection, wound disruption, pneumonia, unplanned intubation, pulmonary embolism, deep vein thrombosis, ventilator requirement for more than 48 hours, progressive kidney insufficiency, acute kidney failure, urinary tract infection, stroke, cardiac arrest, myocardial infarction, return to the operating room, and systemic sepsis. To further assess operative stress, we performed a sensitivity analysis that replaced a major postoperative complication with a variable that denoted linear morbidity and mortality risk factor by CPT code.
All statistical analyses were performed with SAS, version 9.4 (SAS Institute). Two-sided P < .05 was used to indicate statistical significance. Data were analyzed from January 7, 2019, to December 2, 2019.
Results
We identified a total of 4389 patients 80 years or older who underwent an inpatient, nonorthopedic surgical procedure at the 23 hospitals enrolled in the ACS NSQIP Geriatric Surgery Pilot Project between January 1, 2015, and December 31, 2018. Of these patients, 2200 had data on preoperative and 30-day functional health status. After excluding patients who had a totally dependent functional health status (required assistance with performing all ADLs), had an American Society of Anesthesiologists class of 5, or died within 30 days after the operation, a total of 2013 patients were included in the analysis. This sample comprised 1128 women (56.0%) and 885 men (44.0%) with a mean (SD) age of 84.9 (3.9) years (Table 1).
Table 1. Patient Characteristics and Bivariate Associations With 30-Day Functional Decline.
| Variable | No. (%) | P value | ||
|---|---|---|---|---|
| Total (N = 2013) | With 30-d functional decline (n = 406) | Without 30-d functional decline (n = 1607) | ||
| Non–geriatric-specific characteristics | ||||
| Age, y | .008 | |||
| 80-89 | 1751 (87.0) | 337 (83.0) | 1414 (88.0) | |
| ≥90 | 262 (13.0) | 69 (17.0) | 193 (12.0) | |
| Mean (SD) | 84.9 (3.9) | 85.5 (4.1) | 84.7 (3.8) | |
| Sex | .40 | |||
| Female | 1128 (56.0) | 235 (57.9) | 893 (55.6) | |
| Male | 885 (44.0) | 171 (42.1) | 714 (44.4) | |
| ASA Physical Status Classification | <.001 | |||
| 1-2 | 325 (16.1) | 42 (10.3) | 283 (17.6) | |
| 3 | 1340 (66.6) | 258 (63.6) | 1082 (67.3) | |
| 4 | 348 (17.3) | 106 (26.1) | 242 (15.1) | |
| BMI | .03 | |||
| <18.5 | 67 (3.3) | 20 (4.9) | 47 (2.9) | |
| 18.5-<25 | 803 (39.9) | 152 (37.4) | 651 (40.5) | |
| 25-<30 | 714 (35.5) | 133 (32.8) | 581 (36.2) | |
| ≥30 | 429 (21.3) | 101 (24.9) | 328 (20.4) | |
| Emergency surgical procedure | <.001 | |||
| No | 1677 (83.3) | 291 (71.7) | 1386 (86.2) | |
| Yes | 336 (16.7) | 115 (28.3) | 221 (13.8) | |
| COPD | .26 | |||
| No | 1829 (90.9) | 363 (89.4) | 1466 (91.2) | |
| Yes | 184 (9.1) | 43 (10.6) | 141 (8.8) | |
| CHF | .08 | |||
| No | 1975 (98.1) | 394 (97.0) | 1581 (98.4) | |
| Yes | 38 (1.9) | 12 (3.0) | 26 (1.6) | |
| Diabetes | .16 | |||
| No | 1633 (81.1) | 322 (79.3) | 1311 (81.6) | |
| Yes, receiving oral medications | 257 (12.8) | 51 (12.6) | 206 (12.8) | |
| Yes, receiving insulin | 123 (6.1) | 33 (8.1) | 90 (5.6) | |
| Hypertension | .91 | |||
| No | 526 (26.1) | 107 (26.3) | 419 (26.1) | |
| Yes | 1487 (73.9) | 299 (73.7) | 1188 (73.9) | |
| Ascites | .005 | |||
| No | 1999 (99.3) | 399 (98.3) | 1600 (99.6) | |
| Yes | 14 (0.7) | 7 (1.7) | 7(0.4) | |
| Kidney failure | .003 | |||
| No | 2005 (99.6) | 401 (98.8) | 1604 (99.8) | |
| Yes | 8 (0.4) | 5 (1.2) | 3 (0.2) | |
| Dialysis | .45 | |||
| No | 1986 (98.7) | 399 (98.3) | 1587 (98.8) | |
| Yes | 27 (1.3) | 7 (1.7) | 20 (1.2) | |
| Corticosteroid use | .22 | |||
| No | 1895 (94.1) | 377 (92.9) | 1518 (94.5) | |
| Yes | 118 (5.9) | 29 (7.1) | 89 (5.5) | |
| Smoking history | .84 | |||
| No | 1920 (95.4) | 388 (95.6) | 1532 (95.3) | |
| Yes | 93 (4.6) | 18 (4.4) | 75 (4.7) | |
| Dyspnea | .20 | |||
| No | 1805 (89.7) | 357 (87.9) | 1448 (90.1) | |
| Yes | 208 (10.3) | 49 (12.1) | 159 (9.9) | |
| Ventilator dependence | .14 | |||
| No | 2009 (99.8) | 404 (99.5) | 1605 (99.9) | |
| Yes | 4 (0.2) | 2 (0.5) | 2 (0.1) | |
| Preoperative sepsis | <.001 | |||
| No | 1817 (90.3) | 328 (80.8) | 1489 (92.7) | |
| Yes | 196 (9.7) | 78 (19.2) | 118 (7.3) | |
| Disseminated cancer | .001 | |||
| No | 1909 (94.8) | 372 (91.6) | 1537 (95.6) | |
| Yes | 104 (5.2) | 34 (8.4) | 70 (4.4) | |
| Major postoperative complication | <.001 | |||
| No | 1695 (84.2) | 257 (63.3) | 1438 (89.5) | |
| Yes | 318 (15.8) | 149 (36.7) | 169 (10.5) | |
| Geriatric-specific characteristics | ||||
| Fall history | <.001 | |||
| No | 1633 (81.1) | 292 (71.9) | 1341 (83.5) | |
| Yes | 380 (18.9) | 114 (28.1) | 266 (16.5) | |
| Preoperative mobility aid use | <.001 | |||
| No | 1120 (55.6) | 174 (42.9) | 946 (58.9) | |
| Yes | 893 (44.4) | 232 (57.1) | 661 (41.1) | |
| Preoperative malnutrition | <.001 | |||
| No | 1935 (96.1) | 375 (92.4) | 1560 (97.1) | |
| Yes | 78 (3.9) | 31 (7.6) | 47 (2.9) | |
| Postoperative delirium | <.001 | |||
| No | 1640 (81.5) | 246 (60.6) | 1394 (86.8) | |
| Yes | 355 (17.6) | 152 (37.4) | 203 (12.6) | |
| Unknown | 18 (0.9) | 8 (2.0) | 10 (0.6) | |
| Postoperative pressure ulcer | <.001 | |||
| No | 1920 (95.4) | 368 (90.6) | 1552 (96.6) | |
| Yes | 51 (2.5) | 27 (6.7) | 24 (1.5) | |
| Unknown | 42 (2.1) | 11 (2.7) | 31 (1.9) | |
| Mobility aid at discharge | <.001 | |||
| No | 1446 (71.8) | 229 (56.4) | 1217 (75.7) | |
| Yes | 465 (23.1) | 154 (37.9) | 311 (19.4) | |
| Unknown | 102 (5.1) | 23 (5.7) | 79 (4.9) | |
Abbreviations: ASA, American Society of Anesthesiologists (Physical Status Classification; class range: ASA 1-5, with 1 as healthy, 4 as severe [incapacitating disease process that is a constant threat to life], and 5 as moribund [no expectation to survive 24 hours with or without an operation]); BMI, body mass index (calculated as weight in kilograms divided by height in meters squared); CHF, congestive heart failure; COPD, chronic obstructive pulmonary disease.
Most patients (1777 [88.3%]) were independent before the procedure, and 246 patients (11.7%) were partially dependent. Functional decline 30 days after the procedure was present in 406 patients (20.2%). Prevalence of functional decline increased with age, with 30-day decline experienced by 337 of 1751 patients aged 80 to 89 years (19.2%) compared with 69 of 262 patients 90 years or older (26.3%). Functional improvement was noted in only 17 of 2013 patients (0.8%) at 30 days. Given the extremely low prevalence of this particular outcome, no additional statistical analysis was performed.
On bivariate analysis, patients with 30-day functional decline vs those without decline were older (mean [SD] age, 85.5 [4.1] years vs 84.7 [3.8] years), had more comorbid illnesses (eg, congestive heart failure: 12 of 406 [3.0%] vs 26 of 1607 [1.6%]), a higher prevalence of preoperative geriatric-specific risk factors (eg, preoperative mobility aid use: 232 [57.1%] vs 661 [41.1%]), and experienced more major postoperative complications (149 [36.7%] vs 169 [10.5%]) (Table 1). The most common operation performed was a colorectal resection (649 [32.2%]) followed by carotid endarterectomy (132 [6.6%]) and hysterectomy (116 [5.8%]). The top 10 most common procedure types accounted for 261 occurrences (64.8%) of the 30-day functional decline (Table 2).
Table 2. Ten Most Common Surgical Procedures.
| Procedure | No. (%) | ||
|---|---|---|---|
| Total (N = 2013) | With 30-d functional decline (n = 406) | Without 30-d functional decline (n = 1607) | |
| Colorectal resection | 649 (32.2) | 141 (34.7) | 508 (31.6) |
| Endarterectomy of the vessels of the head and neck | 132 (6.6) | 4 (1.0) | 128 (8.0) |
| Hysterectomy | 116 (5.8) | 20 (4.9) | 96 (6.0) |
| Cholecystectomy and/or common bile duct exploration | 98 (4.9) | 14 (3.4) | 84 (5.2) |
| Peripheral vascular bypass | 83 (4.1) | 23 (5.7) | 60 (3.7) |
| Small-bowel resection | 63 (3.1) | 21 (5.2) | 42 (2.6) |
| Ileostomy and other enterostomy | 62 (3.1) | 25 (6.2) | 37 (2.3) |
| Inguinal and femoral hernia repair | 45 (2.2) | 6 (1.5) | 39 (2.4) |
| Transurethral resection of prostate | 45 (2.2) | 1 (0.2) | 44 (2.7) |
| Nephrectomy, partial or complete | 42 (2.1) | 6 (1.5) | 36 (2.2) |
| Total | 1335 (66.3) | 261 (64.8) | 1074 (66.8) |
Among patients with 30-day functional decline (n = 406), 106 (26.1%) were readmitted to the hospital compared with 156 of 1607 patients (9.7%) without functional decline. Only 219 patients with 30-day functional decline (53.9%) were living at home after the surgical procedure, whereas 388 patients (95.6%) were living at home before the procedure. The mean (SD) length of stay was longer for patients with 30-day functional decline than for those without functional decline (10.2 [8.8] days vs 4.8 [4.4] days; P < .001) (Table 3).
Table 3. Rates of Hospital Readmission and Preoperative and Postoperative Living Location .
| Variable | No. (%) | P value | |
|---|---|---|---|
| With 30-d functional decline (n = 406) | Without 30-d functional decline (n = 1607) | ||
| Readmission | <.001 | ||
| No | 235 (57.9) | 1112 (69.2) | |
| Yes | 106 (26.1) | 156 (9.7) | |
| Unknown | 65 (16.0) | 339 (21.1) | |
| Living at home before procedure | .34 | ||
| No | 18 (4.4) | 48 (3.0) | |
| Yes | 388 (95.6) | 1559 (97.0) | |
| Living at home 30 d after procedure | <.001 | ||
| No | 174 (42.9) | 148 (9.2) | |
| Yes | 219 (53.9) | 1436 (89.4) | |
| Unknown | 13 (3.2) | 23 (1.4) | |
| Length of stay, mean (SD), d | 10.2 (8.8) | 4.8 (4.4) | <.001 |
In a multivariable logistic model that was adjusted for baseline patient characteristics and major postoperative complications, several geriatric-specific risk factors were found to be statistically significantly associated with 30-day functional decline (Table 4). These factors included preoperative mobility aid use (odds ratio [OR] 1.76; 95% CI, 1.39-2.22; P < .001), preoperative malnutrition (OR, 1.88; 95% CI, 1.04-3.43; P = .04), postoperative delirium (OR, 2.20; 95% CI, 1.60-3.02; P < .001), postoperative pressure ulcer (OR, 1.83; 95% CI, 1.02-3.30; P = .04), and mobility aid at discharge (OR, 2.49; 95% CI, 1.72-3.59; P < .001). Fall history was not statistically significantly associated with 30-day functional decline in this cohort of patients (OR, 1.24; 95% CI, 0.75-2.06; P = .41). Other patient characteristics statistically significantly associated with 30-day functional decline included emergency surgical procedure (OR, 1.64; 95% CI, 1.17-2.30; P = .004), preoperative sepsis (OR, 1.52; 95% CI, 1.01-2.29; P = .04), and disseminated cancer (OR, 2.14; 95% CI, 1.47-3.13; P < .001). In addition, having a major postoperative complication was statistically significantly associated with 30-day functional decline in older adults (OR, 3.41; 95% CI, 2.50-4.66; P < .001) (Table 4).
Table 4. Risk Factors for 30-Day Functional Decline (n = 2013)a.
| Risk factor | Odds ratio (95% CI) | P value |
|---|---|---|
| Non-geriatric specificb | ||
| Emergency surgical procedure | ||
| No | 1 [Reference] | Reference |
| Yes | 1.64 (1.17-2.30)c | .004c |
| Preoperative sepsis | ||
| No | 1 [Reference] | Reference |
| Yes | 1.52 (1.01-2.29)c | .04c |
| Disseminated cancer | ||
| No | 1 [Reference] | Reference |
| Yes | 2.14 (1.47-3.13)c | <.001c |
| Major postoperative complication | ||
| No | 1 [Reference] | Reference |
| Yes | 3.41 (2.50-4.66)c | <.001c |
| Geriatric specific | ||
| Fall history | ||
| No | 1.0 | Reference |
| Yes | 1.24 (0.75-2.06) | .41 |
| Preoperative mobility aid use | ||
| No | 1 [Reference] | |
| Yes | 1.76 (1.39-2.22)c | <.001c |
| Preoperative malnutrition | ||
| No | 1 [Reference] | Reference |
| Yes | 1.88 (1.04-3.43)c | .04c |
| Postoperative delirium | ||
| No | 1 [Reference] | Reference |
| Yes | 2.20 (1.60-3.02)c | <.001c |
| Unknown | 4.16 (1.92-9.04)c | <.001c |
| Postoperative pressure ulcer | ||
| No | 1 [Reference] | Reference |
| Yes | 1.83 (1.02-3.30)c | .04c |
| Unknown | 1.16 (0.65-2.06) | .61 |
| Mobility aid at discharge | ||
| No | 1 [Reference] | Reference |
| Yes | 2.49 (1.72-3.59)c | <.001c |
| Unknown | 1.32 (0.86-2.04) | .21 |
Multivariable logistic regression controlling for clustering at the hospital level.
Non–geriatric-specific factors used in regression analysis but without statistically significant findings included age; sex; American Society of Anesthesiologists Physical Status Classification; body mass index; smoking history; corticosteroid use; presence of diabetes, chronic obstructive pulmonary disease, congestive heart failure, ascites, dyspnea, or kidney failure; need for dialysis; and ventilatory dependence.
Statistically significant.
A sensitivity analysis that incorporated the CPT-coded linear morbidity and mortality risk variable in lieu of the major postoperative complication variable showed no difference in the geriatric-specific risk factors statistically significantly associated with 30-day functional decline.
Discussion
Long-term postoperative functional decline is a high-priority patient-centered outcome that can be devastating for older adults and their families and costly for the health care system. In this cohort study, 1 in 5 older adults who underwent an inpatient surgical procedure experienced functional decline 30 days after the operation. Older adults with 30-day functional decline were more likely to experience a hospital readmission and to live in a rehabilitation or care facility instead of at home. The 10 most common surgical procedures performed accounted for 64.8% of the incidences of 30-day functional decline. The high prevalence of postoperative functional decline and its frequent occurrence in the most common surgical procedures emphasize the importance of identifying and then addressing risk factors to improve outcomes for older surgical patients.
Patient characteristics that were associated with 30-day functional decline included undergoing emergency surgical procedure and having other markers of serious illness such as preoperative sepsis and disseminated cancer. Although recognizing the association of these factors with worse postoperative functional outcome at 30 days is important, these factors are either immutable or not easily modified. Instead, the results of this study suggest that geriatric-specific markers of frailty such as impaired mobility, malnutrition, and cognitive decline may be more realistic targets for modulation.13 Frailty, or an accumulation of age-related deficits, has been shown to be a risk factor with a stronger association with bad postoperative outcome than age alone; this finding places the onus on the surgical workforce to use proactive treatment strategies that mitigate the manifestations of frailty.14,15,16
In this study, the preoperative geriatric-specific risk factors statistically significantly associated with 30-day postoperative functional decline were mobility aid use and malnutrition. Although preoperative mobility aid use may not be a patient characteristic that can be changed at the time of surgical evaluation, its association with 30-day postoperative decline may be a proxy for diminished balance, coordination, and strength, which can be optimized through preadmission optimization programs or so-called prehabilitation.17,18 Prehabilitation programs, which aim to augment exercise capacity before a surgical procedure through exercise and strength training, have shown promise in reducing postoperative morbidity among older adults.19 In the American Society of Colon and Rectal Surgeons’ clinical practice guidelines for enhanced recovery from colorectal surgical procedure, moderate-quality evidence was found to support prehabilitation for patients with multiple comorbidities or considerable deconditioning.20 Preoperative fall history was not statistically significantly associated with 30-day functional decline in the present study. We defined fall history as a fall within 1 year before the surgical procedure, but this time window may have been too long to serve as an appropriate marker of impaired mobility. Furthermore, malnutrition can serve as a target for preoperative improvement given that preoperative nutritional supplementation has been shown to decrease surgical morbidity and mortality for patients with malnutrition.21
Given its high prevalence and value among older adults, postoperative functional decline and the likelihood of its occurrence should be discussed with patients before the surgical procedure. We believe this study facilitated the identification of preoperative considerations for older adult surgical candidates and aligned with previous studies that have presented methods of calculating preoperative risk scores for this patient population, such as the Risk Analysis Index by Hall et al.22 However, in the model used in this study, many postoperative geriatric-specific factors were associated with 30-day functional decline. This association remained even after adjustment for other major postoperative complications. For example, delirium was statistically significantly associated with 30-day functional decline. Previous research has demonstrated a connection between the occurrence of postoperative delirium and long-term functional decline.23 Postoperative delirium was shown to be preventable in more than 30% of cases when multicomponent delirium prevention interventions were used, such as the Hospital Elder Life Program.24 Such programs target the multifactorial origin of delirium with nonpharmacological interventions such as frequent reorientation, provision of vision and hearing aids, and basic sleep hygiene.25 In the American Geriatrics Society clinical practice guidelines for postoperative delirium, evidence was presented to support the implementation of multicomponent nonpharmacological intervention programs delivered by an interdisciplinary team to prevent delirium in older adults.26
A new or worsened pressure ulcer and the need for a new mobility aid at discharge were geriatric-specific postoperative factors that were also found to be associated with 30-day functional decline. Pressure ulcers are a common issue faced by frail patients and have been statistically significantly associated with increased mortality in older adults.27,28 Several strategies exist for preventing pressure ulcers in the perioperative setting, including appropriate positioning and padding in the operating room, early mobilization after the surgical procedure, and addressing impaired nutrition and continence.29 These strategies highlight that the development of pressure ulcers is modifiable and may be targeted in quality improvement efforts to help prevent functional decline in older surgical patients.
Similar to the preoperative mobility aid use, the need for a mobility aid at discharge likely serves as a proxy for the physical deconditioning associated with the surgical procedure and hospitalization. The need for a mobility aid at discharge may be modified by implementing early and frequent inpatient mobilization protocols for older adults, who are more likely to be subjected to fall prevention strategies predicated on immobility, including bed alarms and physical restraints.30
A previous analysis that used the ACS NSQIP Geriatric Surgery Pilot Project data identified a statistically significant association between geriatric-specific risk factors and postoperative functional decline at discharge, measured from admission to the end of the hospitalization.31 The current study adds to this previous work by investigating postoperative functional decline at 1 month, when many patients would be expected to have recovered from a surgical procedure. To our knowledge, this study is the first to publish rates of 30-day functional decline from a large, multi-institutional data registry. Findings from this study can better inform long-term functional outcome prognostication and emphasize the importance of a balanced and individualized assessment of the benefits and risks of surgical procedures in older adults.
The ACS recently launched the Geriatric Surgery Verification Quality Improvement Program, which uses evidence-based standards to help hospitals improve the quality and outcomes of surgical procedures for older adults.32 The standards require the evaluation and optimization of preoperative geriatric-specific risk factors, including impaired mobility and malnutrition, and the implementation of inpatient care protocols intended to mitigate age-related complications such as postoperative delirium, functional decline, and pressure ulcers. Results from this study suggest that programs such as the Geriatric Surgery Verification Quality Improvement Program, which address preoperative and postoperative geriatric risk factors, are crucial in addressing the high prevalence of postoperative functional decline in the older adult patient population.
Limitations
This study has limitations. First, because this research was performed retrospectively, we could not identify causal associations or rule out the presence of unmeasured confounding factors. Second, the more than 20% rate of functional decline at 30 days demonstrates the need to measure functional decline beyond 30 days to better understand the longer-term recovery trajectory for older adults. The burden of data collection restricted the period of functional outcome measurement in a multi-institutional data registry of this nature. Third, hospital participation in the Geriatric Surgery Pilot Project was voluntary; as a result, the hospitals and patients included in this study may not be representative of the older adult surgical population as a whole.
Conclusions
In this study, 30-day functional decline appeared to be a common occurrence among older adults who underwent inpatient surgical procedures. This outcome was associated with preoperative mobility aid use and malnutrition as well as postoperative delirium, new or worsened pressure ulcer, and new mobility aid need at discharge. These findings have substantial implications for surgical decision-making and quality improvement efforts to reduce postoperative functional decline. This research presents an argument for developing preoperative optimization strategies focused on balance, exercise, and nutrition as well as postoperative in-hospital interventions such as multicomponent delirium prevention protocols and early mobility programs. Future intervention trials are needed to evaluate whether the prevention or mitigation of geriatric risk factors can decrease rates of 30-day functional decline in older adults.
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