Predicting in-hospital mortality in older general surgical patients

Abstract

Introduction A significant number of emergency general surgical admissions occur in older patients. Clinical decision making in this group is challenging and current risk prediction tools extrapolate data from cohorts of younger patients. This is the first UK study to examine risk factors predicting in-hospital mortality in older acute surgical patients undergoing comprehensive geriatric assessment. Methods This was a prospective study of consecutive patients aged ≥75 years admitted non-electively to general surgery wards between September 2014 and February 2017 who were reviewed by an elderly medicine in-reach service. Results A total of 577 patients were included with a mean age of 82.9 years. There was a female predominance (56%). The majority were living at home alone or with carers (93%) and most were independent in basic activities of daily living (79%). Over two-thirds (69%) were mobile with no walking aids or use of a walking stick and overt here-quarters (79%) had no cognitive impairment. Seventy-seven per cent of patients were managed non-operatively. The in-hospital mortality rate was 6.9%. Female sex (p=0.031), dependence in activities of daily living (p<0.001), cognitive impairment (p<0.001) and incontinence (p<0.001) were predictors of in-hospital mortality. ASA (American Society of Anesthesiologists) grade ≥3 was also associated with increased in-hospital mortality (odds ratio: 5.3, 95% confidence interval: 2.6-10.7). Conclusions Older general surgical patients present a high level of complexity. This study highlights the predictive role of mobility, functional and cognitive impairment when assessing this population. Accurate risk stratification requires global assessment by teams experienced in care of the older patient rather than the traditional focus on co-morbidities.

Emergency laparotomy in the older patient: factors predictive of 12-month mortality—Salford-POPS-GS. An observational study

“…A further systematic review of risk assessment in all emergency laparotomy patients found that none of the tools for risk assessment in older patients could provide adequate discrimination of outcomes although APACHE II was generally the best predictor of mortality [ 21 ]. Frailty and other age-related syndromes such as sarcopenia are independent predictors of perioperative mortality [ 22 – 25 ]. We have shown in this study that patients who are frail often have worse long-term outcomes in terms of mortality.…”

Surgeon preference for treatment allocation in older people facing major gastrointestinal surgery: an application of the discrete choice experiment methodology

“…Multiple studies have emphasized the negative impact of major GI surgery on functional independence [15, 35, 36]; therefore it is not surprising that surgeons in this study were less likely to suggest major surgery with increasing levels of functional impairment. Functional impairment also correlates with physical inactivity, another predictor of poor outcomes in older patients [37].…”

Activities of daily living associated with postoperative intensive care unit survival in elderly patients following elective major abdominal surgery

“…ADL is a convenient way to assess a person's functional level, even small changes in the ADL functional level are associated with clinically relevant outcomes [14–18] . It has been reported that dependence in activities of daily living was one of the predictors of in-hospital mortality in older general surgical patients [24] . Dependency in ADL have been proved to influence survival in older patients attending the emergency department or being hospital with orthopaedic or trauma conditions [25–29] .…”

“…[14][15][16][17][18] It has been reported that dependence in activities of daily living was one of the predictors of in-hospital mortality in older general surgical patients. [24] Dependency in ADL have been proved to influence survival in older patients attending the emergency department or being hospital with orthopaedic or trauma conditions. [25][26][27][28][29] Frailty and delay in management are associated with poor surgical outcomes after emergency abdominal surgery in the elderly.…”