Robinson Thomas N, Eiseman Ben, Wallace Jeffrey I, Church Skotti D, McFann Kim K, Pfister Shirley M, Sharp Terra J, Moss Marc
Department of Surgery, University of Colorado at Denver School of Medicine, Aurora, CO, USA.
Ann Surg. 2009 Sep;250(3):449-55. doi: 10.1097/SLA.0b013e3181b45598.
(1) Determine the relationship of geriatric assessment markers to 6-month postoperative mortality in elderly patients. (2) Create a clinical prediction rule using geriatric markers from preoperative assessment.
Geriatric surgery patients have unique physiologic vulnerability requiring preoperative assessment beyond the traditional evaluation of older adults. The constellation of frailty, disability and comorbidity predict poor outcomes in elderly hospitalized patients.
Prospectively, subjects > or =65 years undergoing a major operation requiring postoperative intensive care unit admission were enrolled. Preoperative geriatric assessments included: Mini-Cog Test (cognition), albumin, having fallen in the past 6-months, hematocrit, Katz Score (function), and Charlson Index (comorbidities). Outcome measures included 6-month mortality (primary) and postdischarge institutionalization (secondary).
One hundred ten subjects (age 74 +/- 6 years) were studied. Six-month mortality was 15% (16/110). Preoperative markers related to 6-month mortality included: impaired cognition (P < 0.01), recent falls (P < 0.01), lower albumin (P < 0.01), greater anemia (P < 0.01), functional dependence (P < 0.01), and increased comorbidities (P < 0.01). Similar statistical relationships were found for all 6 markers and postdischarge institutionalization. Logistic regression identified any functional dependence (odds ratio 13.9) as the strongest predictor of 6-month mortality. Four or more markers in any one patient predicted 6-month mortality with a sensitivity of 81% (13/16) and specificity of 86% (81/94).
Geriatric assessment markers for frailty, disability and comorbidity predict 6-month postoperative mortality and postdischarge institutionalization. The preoperative presence of > or =4 geriatric-specific markers has high sensitivity and specificity for 6-month mortality. Preoperative assessment using geriatric-specific markers is a substantial paradigm shift from the traditional preoperative evaluation of older adults.
（1）确定老年评估指标与老年患者术后6个月死亡率之间的关系。（2）利用术前评估中的老年指标创建临床预测规则。
老年外科手术患者具有独特的生理脆弱性，需要进行超出传统老年人评估的术前评估。虚弱、残疾和共病的综合情况可预测老年住院患者的不良预后。
前瞻性地纳入年龄≥65岁、接受需要术后入住重症监护病房的大手术患者。术前老年评估包括：简易认知测试（认知）、白蛋白、过去6个月内跌倒情况、血细胞比容、卡茨评分（功能）和查尔森指数（共病）。结局指标包括6个月死亡率（主要指标）和出院后入住机构（次要指标）。
研究了110名受试者（年龄74±6岁）。6个月死亡率为15%（16/110）。与6个月死亡率相关的术前指标包括：认知障碍（P<0.01）、近期跌倒（P<0.01）、白蛋白水平较低（P<0.01）、贫血程度较重（P<0.01）、功能依赖（P<0.01）和共病增加（P<0.01）。所有6项指标与出院后入住机构之间也发现了类似的统计关系。逻辑回归确定任何功能依赖（比值比13.9）是6个月死亡率的最强预测因素。任何一名患者出现4项或更多指标可预测6个月死亡率，敏感性为81%（13/16），特异性为86%（81/94）。
虚弱、残疾和共病的老年评估指标可预测术后6个月死亡率和出院后入住机构情况。术前存在≥4项老年特异性指标对6个月死亡率具有较高的敏感性和特异性。使用老年特异性指标进行术前评估与传统的老年人术前评估相比是一个重大的范式转变。
