Preoperative malnutrition and immobility common risk factors for decline

Functional decline after surgery is common among older adults and is associated with geriatric risk factors such as preoperative malnutrition and immobility, researchers found.

Their study, published in JAMA Surgery, found that 20% of patients over the age of 80 showed evidence of functional decline 30 days after undergoing a non-orthopedic surgical procedure.

According to Lindsey M. Zhang, MD, MS, Division of Research and Optimal Patient Care, American College of Surgeons, Chicago, and colleagues, in the case of most older adults who have a chronic illness, “maintaining physical and cognitive function signifies a successful medical treatment, even more so than survival.”

Some studies have shown that up to 25% of older adults who undergo surgical procedures experience postoperative decline in the immediate postoperative period, with significant numbers continuing to experience cognitive decline in the months that follow.

However, “postoperative functional decline is an outcome that is poorly characterized and rarely prioritized or considered by health care systems,” Zhang and colleagues pointed out.

In this retrospective cohort study, the authors assess the prevalence of postoperative functional decline among adults 80 years or older in the 30 days after undergoing a non-orthopedic surgical procedure. They also examined the risk factors associated with this decline in order to identify ways of mitigating the outcome.

Zhang and colleagues, using patient data from the Geriatric Surgery Pilot Project, analyzed 2013 patients (56% women) who were 80 years or older, underwent a surgical procedure that required an inpatient stay at 1 of 23 hospitals enrolled in the the project from Jan. 1, 2015 to Dec. 31, 2018, and had preoperative and postoperative functional health status data available.

Of the patients in the study, most (88.3%) were independent before surgery. Zhang and colleagues determined that functional decline 30 days after the procedure was experienced by 20.2% of patients. The percentage of patients experiencing decline increased with age, with 26.3% of patients 90 years or older experiencing decline after 30 days compared to just 19.2% of patients aged 80 to 89 years.

On the other hand, just 17 patients (0.8%) experienced functional improvement 30 days after surgery. Among patients with 30-day functional decline, just 53.9% were living at home compared to 95.6% who lived at home before the procedure.

The most common operation performed was a colorectal resection (32.2%) followed by carotid endarterectomy (6.6%) and hysterectomy (5.8%).

Several geriatric-specific risk factors were found to be statistically significantly associated with 30-day functional decline, including:

  • Preoperative mobility aid use (odds ratio [OR] 1.76; 95% CI, 1.39-2.22).
  • Preoperative malnutrition (OR, 1.88; 95% CI, 1.04-3.43).
  • Postoperative delirium (OR, 2.20; 95% CI, 1.60-3.02).
  • Pressure ulcer (OR, 1.83; 95% CI, 1.02-3.30).
  • Mobility aid at discharge (OR, 2.49; 95% CI, 1.72-3.59).

Fall history was not significantly associated with 30-day functional decline (OR, 1.24; 95% CI, 0.75-2.06).

“These findings have substantial implications for surgical decision-making and quality improvement efforts to reduce postoperative functional decline,” wrote Zhang and colleagues. “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.”

In a commentary accompanying the study, Carolyn D. Seib, MD, MAS, and Shipra Arya, MD, SM, Stanford University School of Medicine, Stanford, wrote that it highlights “the ongoing need for standardized evaluation of geriatric outcomes and transdisciplinary care delivery models to address modifiable geriatric risk factors.”

They suggested that the data regarding functional health status in geriatric surgical care needs to be more granular so that patients get a more realistic assessment of the tradeoffs associated with surgical interventions. They also noted that measuring postoperative function at 30 days, as Zhang and colleagues did in this study, is likely too short a time period to accurately assess functional recovery.

“An investment in resources that provide granular, long-term postoperative functional assessments is needed,” Seib and Arya concluded. “These resources will inform patient decision-making and facilitate interventions to improve the quality of surgical care for older adults.”

  1. A retrospective cohort study found that functional decline is common in older adults who undego surgery, occuring in 20% of nonorthopedic surgeries.

  2. Functional decline was associated with geriatric risk factors such as malnutrition and the need for preoperative mobility aid.

Michael Bassett, Contributing Writer, BreakingMED™

Zhang reported receiving grants from The John A. Hartford Foundation during the conduct of the study.

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