Division of Geriatrics, Department of Medicine, University of California, San Francisco, San Francisco.
Division of Geriatrics, Veterans Affairs Medical Center, San Francisco, California.
JAMA Surg. 2020 May 1;155(5):412-418. doi: 10.1001/jamasurg.2020.0091.
More older adults are undergoing major surgery despite the greater risk of postoperative mortality. Although measures, such as functional, cognitive, and psychological status, are known to be crucial components of health in older persons, they are not often used in assessing the risk of adverse postoperative outcomes in older adults.
To determine the association between measures of physical, cognitive, and psychological function and 1-year mortality in older adults after major surgery.
DESIGN, SETTING, AND PARTICIPANTS: Retrospective analysis of a prospective cohort study of participants 66 years or older who were enrolled in the nationally representative Health and Retirement Study and underwent 1 of 3 types of major surgery.
Major surgery, including abdominal aortic aneurysm repair, coronary artery bypass graft, and colectomy.
Our outcome was mortality within 1 year of major surgery. Our primary associated factors included functional, cognitive, and psychological factors: dependence in activities of daily living (ADL), dependence in instrumental ADL, inability to walk several blocks, cognitive status, and presence of depression. We adjusted for other demographic and clinical predictors.
Of 1341 participants, the mean (SD) participant age was 76 (6) years, 737 (55%) were women, 99 (7%) underwent abdominal aortic aneurysm repair, 686 (51%) coronary artery bypass graft, and 556 (42%) colectomy; 223 (17%) died within 1 year of their operation. After adjusting for age, comorbidity burden, surgical type, sex, race/ethnicity, wealth, income, and education, the following measures were significantly associated with 1-year mortality: more than 1 ADL dependence (29% vs 13%; adjusted hazard ratio [aHR], 2.76; P = .001), more than 1 instrumental ADL dependence (21% vs 14%; aHR, 1.32; P = .05), the inability to walk several blocks (17% vs 11%; aHR, 1.64; P = .01), dementia (21% vs 12%; aHR, 1.91; P = .03), and depression (19% vs 12%; aHR, 1.72; P = .01). The risk of 1-year mortality increased within the increasing risk factors present (0 factors: 10.0%; 1 factor: 16.2%; 2 factors: 27.8%).
In this older adult cohort, 223 participants (17%) who underwent major surgery died within 1 year and poor function, cognition, and psychological well-being were significantly associated with mortality. Measures in function, cognition, and psychological well-being need to be incorporated into the preoperative assessment to enhance surgical decision-making and patient counseling.
尽管术后死亡率较高，但越来越多的老年人接受了大手术。尽管功能、认知和心理状态等措施被认为是老年人健康的重要组成部分，但它们通常不用于评估老年人术后不良结果的风险。
确定身体、认知和心理功能指标与老年人大手术后 1 年死亡率之间的关联。
设计、地点和参与者：对全国代表性的健康和退休研究中参与者的前瞻性队列研究进行回顾性分析，这些参与者年龄在 66 岁或以上，并接受了 3 种主要手术中的 1 种。
大手术，包括腹主动脉瘤修复、冠状动脉旁路移植术和结肠切除术。
我们的结局是大手术后 1 年内的死亡率。我们的主要相关因素包括功能、认知和心理因素：日常生活活动（ADL）依赖、工具性 ADL 依赖、无法走几个街区、认知状态和抑郁存在。我们调整了其他人口统计学和临床预测因素。
在 1341 名参与者中，平均（SD）参与者年龄为 76（6）岁，737 名（55%）为女性，99 名（7%）接受腹主动脉瘤修复，686 名（51%）接受冠状动脉旁路移植术，556 名（42%）接受结肠切除术；223 名（17%）在手术后 1 年内死亡。在调整年龄、合并症负担、手术类型、性别、种族/民族、财富、收入和教育后，以下措施与 1 年死亡率显著相关：ADL 依赖超过 1 项（29%比 13%；调整后的危险比[aHR]，2.76；P= .001），工具性 ADL 依赖超过 1 项（21%比 14%；aHR，1.32；P= .05），无法走几个街区（17%比 11%；aHR，1.64；P= .01），痴呆（21%比 12%；aHR，1.91；P= .03）和抑郁（19%比 12%；aHR，1.72；P= .01）。随着存在的风险因素数量的增加，1 年死亡率的风险也随之增加（0 个因素：10.0%；1 个因素：16.2%；2 个因素：27.8%）。
在这个老年人群体中，223 名（17%）接受大手术的参与者在 1 年内死亡，功能、认知和心理健康状况较差与死亡率显著相关。功能、认知和心理健康方面的措施需要纳入术前评估，以增强手术决策和患者咨询。
