Association of Functional, Cognitive, and Psychological Measures With 1-Year Mortality in Patients Undergoing Major Surgery

Abstract

IMPORTANCE More older adults are undergoing major surgery despite the greater risk of postoperative mortality. Although measures, such as functional, cognitive, and psychological status, are known to be crucial components of health in older persons, they are not often used in assessing the risk of adverse postoperative outcomes in older adults.OBJECTIVE To determine the association between measures of physical, cognitive, and psychological function and 1-year mortality in older adults after major surgery. DESIGN, SETTING, AND PARTICIPANTS Retrospective analysis of a prospective cohort study of participants 66 years or older who were enrolled in the nationally representative Health and Retirement Study and underwent 1 of 3 types of major surgery.EXPOSURES Major surgery, including abdominal aortic aneurysm repair, coronary artery bypass graft, and colectomy. MAIN OUTCOMES AND MEASURESOur outcome was mortality within 1 year of major surgery. Our primary associated factors included functional, cognitive, and psychological factors: dependence in activities of daily living (ADL), dependence in instrumental ADL, inability to walk several blocks, cognitive status, and presence of depression. We adjusted for other demographic and clinical predictors. RESULTSOf 1341 participants, the mean (SD) participant age was 76 (6) years, 737 (55%) were women, 99 (7%) underwent abdominal aortic aneurysm repair, 686 (51%) coronary artery bypass graft, and 556 (42%) colectomy; 223 (17%) died within 1 year of their operation. After adjusting for age, comorbidity burden, surgical type, sex, race/ethnicity, wealth, income, and education, the following measures were significantly associated with 1-year mortality: more than 1 ADL dependence (29% vs 13%; adjusted hazard ratio [aHR], 2.76; P = .001), more than 1 instrumental ADL dependence (21% vs 14%; aHR, 1.32; P = .05), the inability to walk several blocks (17% vs 11%; aHR, 1.64; P = .01), dementia (21% vs 12%; aHR, 1.91; P = .03), and depression (19% vs 12%; aHR, 1.72; P = .01). The risk of 1-year mortality increased within the increasing risk factors present (0 factors: 10.0%; 1 factor: 16.2%; 2 factors: 27.8%). CONCLUSIONS AND RELEVANCEIn this older adult cohort, 223 participants (17%) who underwent major surgery died within 1 year and poor function, cognition, and psychological well-being were significantly associated with mortality. Measures in function, cognition, and psychological well-being need to be incorporated into the preoperative assessment to enhance surgical decision-making and patient counseling.

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“…As the US population progressively ages, patients' impending PC needs will continue to exceed the number of PC specialists available, thus mandating more surgeonspecific application of PPC skills. The prevalence of PC needs for a given surgical patient varies according to comorbidities, prognosis, acuity, physical and cognitive frailty, and the risks of any proposed procedures (43)(44)(45)(46)(47)(48)(49)(50)(51)(52). In a study of the surgical patient population being treated for advanced pancreatic cancer (where survival is measured in months), one third of the inpatients had no documented discussions about their goals of care or preferred code status (53).…”

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“…The authors found a monotonic relationship between an increasing number of impairments and increasing risk of 1‐year mortality following major surgery. In particular, dependence in at least one activity of daily living was significantly associated with 1‐year mortality (adjusted hazard ratio (HR) = 2.76, P = .001) 11 …”

“…In particular, dependence in at least one activity of daily living was significantly associated with 1-year mortality (adjusted hazard ratio (HR) = 2.76, P = .001). 11 Understanding the relationship between frailty and mortality can be helpful when counseling older adults considering surgery, but there are limitations to only considering mortality as an outcome. In our surgical urology practice, older adults display less interest in length of life and instead ask probing questions about the hospitalization itself in the short term and the chances of returning to baseline preoperative function in the long term.…”

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