Surgery survival for elderly tied to frailty and cognitive skills
Taking both physical frailty and cognitive impairment into account may yield a better estimate than either factor alone of the odds an older person will survive after major surgery, a U.S. study suggests.
Researchers examined data on 330 older adults who had major surgery, including 168 who were considered “robust” because they didn’t appear to have any cognitive problems or issues with physical frailty. Over four years of follow-up, 53 patients died.
Among patients who were robust or only cognitively impaired, around 12 percent died. Among those who were physically frail but not cognitively impaired, mortality was 25 percent. But with both frailty and cognitive problems, deaths rose to 42 percent, researchers report in the Journal of the American College of Surgeons.
“Cognitive impairment in frail surgical patients is a strong predictor of worsening survival,” said senior study author Dr. Viraj Master of Emory University in Atlanta.
While the study didn’t examine why the combination of cognitive impairment and physical frailty might hasten death, it’s possible that people with only one of these problems are better able to compensate for deficits from the other condition, Master said by email.
“The decreased physiological and cognitive reserves of patients undergoing major surgery make it difficult for patients to not only physically heal and recover after a surgery, but mentally understand how to care for their needs and use mental judgment to make decisions about their care,” Master said.
For the study, researchers examined data from cognitive skills assessments done by asking patients to draw clocks. These tests rely on executive function and visual and spatial planning skills rather than on education or language ability.
In addition, researchers analyzed data from tests of walking speed, activity levels, weakness and exhaustion to determine which patients were physically frail.
In the robust group of patients who didn’t have cognitive impairment or frailty, 20 of 168 died within four years.
In the group that was both frail and cognitively impaired, 11 of 26 patients died.
Compared to robust patients, those with frailty and cognitive impairment were four times more likely to die.
Patients were 58 years old on average, and they most often were having surgery to remove a kidney, prostate or part of the bladder. More than half of them had operations for cancer.
One limitation of the study is that there isn’t one universally used clock-drawing test, so it’s possible the results researchers got in this study might be different if the experiment were done with a different test, the researchers note.
The study was also done at a single academic medical center in Georgia, and most patients were white and undergoing elective surgery, making it possible that results would be different in other groups of people or at other hospitals in other parts of the country.
Even so, the findings suggest that assessing cognitive and physical abilities before surgery might help identify patients who are more likely to die or have complications, said Dr. Bellal Joseph of the University of Arizona in Tucson.
“This study highlights that the patients that suffer from both frailty and cognitive impairments have more stressors going into surgery,” Joseph, who wasn’t involved in the study, said by email. “The other group that is always worrisome is the ‘prefrail,’ those that are on the verge of frailty, because surgery could push them over the edge into frailty.”
When doctors identify high-risk patients in advance, they may be able to offer people rehabilitation or recommend changes in nutrition, exercise or drug regimens that might make them more robust heading into surgery, Joseph said.
“The good news is that we believe that we can improve frail patients with prehabilitation,” Joseph added.
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