Department of Surgery, Johns Hopkins Bayview Medical Center, Baltimore, MD.
Department of Geriatric Medicine, Johns Hopkins Bayview Medical Center, Baltimore, MD.
J Am Coll Surg. 2020 Apr;230(4):573-582. doi: 10.1016/j.jamcollsurg.2019.12.021. Epub 2020 Mar 12.
Disease-free survival is the cornerstone for colorectal cancer outcomes. Maintenance of independence may represent the preferred cancer outcome in older patients. Frailty and cognitive impairment are associated with adverse clinical outcomes after operation in patients ≥65 years. The aim of this study was to determine the impact of frailty and cognitive impairment on loss of independence (LOI) among colorectal cancer patients.
From 2016 to 2018, patients undergoing operation for colorectal cancer and having geriatric-specific American College of Surgeons NSQIP variables recorded were included. Frailty was assessed using the modified frailty index. Loss of independence was defined by the need for assistance with activities of daily living. Complications were assessed using the Clavien-Dindo (CD) scoring system. Multivariable analyses examining LOI, length of stay (LOS), and 30-day postoperative complication and readmission were performed.
There were 1,676 patients included. Preoperatively, 118 (7%) patients reported cognitive impairment, 388 (23%) patients used a mobility aid, and 82 (5%) patients were partially or totally dependent. Loss of independence upon discharge was seen in 344 (20.5%) patients and was independently associated with an increase in LOS (incidence rate ratio [IRR] 1.44, 95% CI 1.30 to 1.59) and major complication (odds ratio [OR] 1.86, 95% CI 1.36 to 2.53). Risk factors predictive of LOI upon discharge were increasing age, cognitive impairment, use of mobility aid, and postoperative delirium. In patients ≥80 years old, 93 (18%) had LOI at 30 days. Risk factors predictive of LOI at 30 days included a preoperative mobility aid, postoperative delirium, and the need for a new mobility aid.
One of 5 older patients undergoing operation for colorectal cancer experience LOI, and risk factors include a decline in cognition and mobility. Future studies should evaluate risks for long-term LOI and explore interventions to optimize this patient population.
无病生存期是结直肠癌治疗结果的基石。对于老年患者而言，保持独立可能是更理想的癌症治疗结果。虚弱和认知障碍与 65 岁以上患者术后的不良临床结局相关。本研究旨在确定虚弱和认知障碍对结直肠癌患者丧失独立性（LOI）的影响。
本研究纳入了 2016 年至 2018 年期间行结直肠癌手术且记录有特定于老年患者的美国外科医师学会 NSQIP 变量的患者。使用改良的衰弱指数评估衰弱情况。LOI 通过日常生活活动辅助需求来定义。并发症使用 Clavien-Dindo（CD）评分系统进行评估。进行多变量分析以检查 LOI、住院时间（LOS）以及术后 30 天并发症和再入院情况。
共有 1676 例患者纳入本研究。术前有 118 例（7%）患者报告认知障碍，388 例（23%）患者使用助行器，82 例（5%）患者部分或完全依赖他人。344 例（20.5%）患者出院时发生 LOI，且 LOI 与 LOS 延长（发病率比[IRR] 1.44，95%CI 1.30 至 1.59）和主要并发症（比值比[OR] 1.86，95%CI 1.36 至 2.53）独立相关。出院时 LOI 的预测因素包括年龄增长、认知障碍、使用助行器和术后谵妄。80 岁以上的患者中，有 93 例（18%）在 30 天时 LOI。30 天时 LOI 的预测因素包括术前使用助行器、术后谵妄和需要新的助行器。
每 5 名接受结直肠癌手术的老年患者中就有 1 名发生 LOI，其风险因素包括认知和活动能力下降。未来的研究应评估长期 LOI 的风险，并探索优化该患者群体的干预措施。
