Lawrence Valerie A, Hazuda Helen P, Cornell John E, Pederson Thomas, Bradshaw Patrick T, Mulrow Cynthia D, Page Carey P
Veterans Evidence-based Research Dissemination and Implementation Center, a Veterans Affairs Health Services Research and Development Center of Excellence, South Texas Veterans Health Care System, San Antonio, TX, USA.
J Am Coll Surg. 2004 Nov;199(5):762-72. doi: 10.1016/j.jamcollsurg.2004.05.280.
Elders undergo approximately 40% of more than 1 million major abdominal operations annually. Yet evidence about recovery to preoperative levels of functional independence is limited. This study details course and predictors of functional recovery after elective major abdominal operations in the elderly.
This was a prospective cohort of 372 consecutive patients, 60 years old or more, enrolled from surgeons in private practice and two university-affiliated hospitals, assessed preoperatively and postoperatively at 1, 3, and 6 weeks, 3 and 6 months, using self-report and performance-based measures (Activities of Daily Living [ADL], Instrumental Activities of Daily Living [IADL], Medical Outcomes Study Short Form-36 Physical Component and Mental Component Scales [PCS, MCS], Geriatric Depression Scale [GDS], Folstein Mini-Mental State Exam [MMSE], timed walk, functional reach, hand grip strength).
Mean age was 69 +/- 6 years with 56% men, 47% nonHispanic Caucasian, and 42% Mexican American; hospital distribution was 49% private, 51% university-affiliated. Maximum functional declines (95% CI) occurred 1 week postoperatively: ADL, 2.8 points (2.4 to 3.2); IADL, 7.6 points (7 to 8.3); SF-36 PCS, 6.5 points (5.4 to 7.6); Mini-Mental State Exam, 0.5 points (0.2 to 0.7); timed walk, 6.8 seconds (5.2 to 8.4); functional reach, 1.7 inches (1.2 to 2.2); grip strength, 2 kilograms (1.3 to 2.7) (p < 0.001 for all). SF-36 mental component scale and Geriatric Depression Scale scores did not worsen. Mean recovery times were: Mini-Mental State Exam, 3 weeks; timed walk, 6 weeks; ADL, SF-36 PCS, and functional reach, 3 months; and IADL, 6 months. Mean grip strength did not return to preoperative status by 6 months. The incidence of persistent disability at 6 months, compared with preoperative status, was: ADL, 9%; IADL, 19%; PCS, 16%; mental component scale, 17%; timed walk, 39%; functional reach, 58%; and grip strength, 52%. Potentially modifiable independent predictors of ADL and IADL recovery were preoperative physical conditioning and depression plus serious postoperative complications.
The clinical course of functional recovery varied across different measures. Protracted disability at 6 months after operation was substantial. Several potentially modifiable factors consistently predicted recovery.
老年人每年接受超过100万台大型腹部手术中的约40%。然而，关于恢复到术前功能独立水平的证据有限。本研究详细阐述了老年患者择期大型腹部手术后功能恢复的过程及预测因素。
这是一项前瞻性队列研究，连续纳入372例60岁及以上患者，这些患者来自私人执业外科医生以及两家大学附属医院，术前及术后1周、3周、6周、3个月和6个月进行评估，采用自我报告和基于表现的测量方法（日常生活活动[ADL]、工具性日常生活活动[IADL]、医学结局研究简明健康调查36项量表身体成分和精神成分量表[PCS、MCS]、老年抑郁量表[GDS]、简易精神状态检查表[MMSE]、定时步行、功能性伸展、握力）。
平均年龄为69±6岁，男性占56%，非西班牙裔白种人占47%，墨西哥裔美国人占42%；医院分布为49%私立医院，51%大学附属医院。术后1周出现最大功能下降（95%CI）：ADL下降2.8分（2.4至3.2）；IADL下降7.6分（7至8.3）；SF-36 PCS下降6.5分（5.4至7.6）；简易精神状态检查表下降0.5分（0.2至0.7）；定时步行增加6.8秒（5.2至8.4）；功能性伸展减少1.7英寸（1.2至2.2）；握力下降2千克（1.3至2.7）（所有p<0.001）。SF-36精神成分量表和老年抑郁量表得分未恶化。平均恢复时间为：简易精神状态检查表3周；定时步行6周；ADL、SF-36 PCS和功能性伸展3个月；IADL 6个月。平均握力在6个月时未恢复到术前状态。与术前状态相比，6个月时持续残疾的发生率为：ADL 9%；IADL 19%；PCS 16%；精神成分量表17%；定时步行39%；功能性伸展58%；握力52%。ADL和IADL恢复的潜在可改变独立预测因素为术前身体状况、抑郁以及严重术后并发症。
不同测量方法的功能恢复临床过程各不相同。术后6个月持续残疾情况严重。几个潜在可改变因素始终能预测恢复情况。
