Yale study identifies risk factors for disability in elderly patients after surgery
The fear of losing independence due to possible disability or poor functional outcome after surgery is a major concern of older people undergoing major surgery.
Yale Daily News
it is projected that the number of Americans aged 65 and older will double from 46 million in 2014 to 98 million in 2060. A study by Yale researchers identified the main risk factors associated with loss of independence in elderly patients after major surgery.
This study, published on February 24 in the Journal of the American Geriatrics Society, was led by Professor of Geriatrics and Epidemiology Thomas Gill. As a geriatrician, Gill’s clinical work is primarily concerned with the elderly. He found that the most important thing for older patients “again and again” was their independence. After surgery, the ability to manage one’s personal care needs and not depend on family for day-to-day affairs was a crucial outcome for the patients. This study had two objectives: to identify subgroups at high risk of poor functional outcomes and to identify factors that could inform intervention in a co-management model or enlisting geriatricians to assist surgeons the care of elderly patients.
“Independence is very important for older people,” Professor of Geriatrics Leo Cooney told MED ’69. “The ability to take care of yourself allows you to stay in your own home, stay connected with your family and friends, continue to be a part of your community, and remain who you are into old age .”
The researchers followed 754 people in southern Connecticut aged 70 or older. From March 1997 to December 2017, 247 people underwent 327 major surgeries. The team identified ten factors associated with disability over a period of six months after major surgery.
These factors included age 85 years or older, female gender, black race or Hispanic ethnicity, neighborhood disadvantage, multimorbidity, frailty, one or more disabilities, low functional self-efficacy, smoking, and obesity. The study measured the risk of each factor related to the burden of disability: women had a 15 percent greater burden, those with frailty had a 19 percent greater burden, and being 85 years of age or older represented a 30 percent greater burden .
“Women are more prone to poorer functional outcomes after almost any disease,” Gill said. “And there are probably different explanations for that. One is that women tend to have lower mortality rates than men, so they have more opportunities to have poorer functional outcomes because they didn’t die.”
Gill explained that non-elective surgeries are, by definition, surgeries that “you don’t know [are] it will happen.” These urgent medical procedures justify post-surgery interventions. However, in elective surgeries, which are pre-planned procedures, interventions can be performed before the surgery and attempt to improve the physical ability of the person who survive the surgery and recovery process.
In assessing the risk of low socioeconomic status, Gill emphasized that Medicaid-eligible patients, and generally those with fewer economic resources, may not be able to afford co-payments and other requirements for post-hospital care, including rehabilitation. The co-payments that are not covered by insurance are often borne by the patient and his family. Gill speculated that co-payments could be a barrier to receiving the care that is recommended or required after surgery.
“After major surgery, patients often need rehabilitation to regain some of the lost function,” Gil said.
A subset of these ten identified factors could be addressed through interventions – specifically frailty, low functional self-efficacy, smoking and obesity. Preoperative screening for frailty and cognitive impairment after major elective surgery could trigger referral to a geriatrician for further assessment of susceptibility to disability after major surgery.
Major surgeries and hospital stays often lead to significant functional impairments, according to Gill. The team was interested in reducing these declines by developing interventions that could speed recovery after a serious disabling event like surgery. This study will provide evidence to support co-management models that could improve outcomes after surgery.
“Many programs across the country have transitioned to this co-management model,” Gil said. “Geriatricians are recruited to help care for elderly patients who need to undergo major surgery because the surgeons are either not trained in this type of management or don’t have the time being busy in the operating room. But there isn’t much evidence yet on whether this co-management model is effective or not, which is one of the reasons we conducted this research study.”
Assistant Professor of Geriatrics Marcia Mecca a study by Terri Fried, Professor of Geriatrics and Section Head of Geriatrics, published 20 years ago, outlines the prominent role that risk of functional dependence plays in older adult decision-making. Fried found that for critically ill patients who would die without treatment, more than 70 percent of older people would refuse treatment that causes severe functional impairment even if their survival were assured.
In the preoperative situation, she explained that it is crucial for older adults to understand both the expected benefits of surgery and the risks. Mecca urged healthcare providers to emphasize the potential impact on elderly patients’ independence after surgery when explaining health outcomes while discussing treatment options.
“DR. Gill and his colleagues have made an important contribution to our knowledge by identifying the factors associated with this new disability,” said Cooney. “This information will help healthcare facilities implement interventions aimed at Maintaining independence is a critical step in safeguarding the quality of life for older people.”
Gill is director of the Program on Aging and Pepper Older Americans Independence Centers and director of the Center on Disability and Disabling Disorders.