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Original Investigation
March 11, 2020

Association of Functional, Cognitive, and Psychological Measures With 1-Year Mortality in Patients Undergoing Major Surgery

Author Affiliations
  • 1Division of Geriatrics, Department of Medicine, University of California, San Francisco, San Francisco
  • 2Division of Geriatrics, Veterans Affairs Medical Center, San Francisco, California
  • 3Northern California Institute for Research and Education, San Francisco
  • 4Department of Surgery, University of California, San Francisco
  • 5Phillip R. Lee Institute of Health Policy Studies, University of California, San Francisco
JAMA Surg. Published online March 11, 2020. doi:10.1001/jamasurg.2020.0091
Key Points

Question  Are functional, cognitive, and psychological measures that are grounded in geriatric assessment associated with 1-year mortality in older adults after major surgery?

Findings  In this cohort study, 17% of participants who underwent major surgery died within 1 year. Functional, cognitive, and psychological measures were significantly associated with mortality.

Meaning  Specific measures, such as preoperative function, cognition, and psychological well-being, may need to be incorporated into the preoperative assessment to enhance surgical decision-making and patient counseling.

Abstract

Importance  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.

Objective  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.

Exposures  Major surgery, including abdominal aortic aneurysm repair, coronary artery bypass graft, and colectomy.

Main Outcomes and Measures  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.

Results  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%).

Conclusions and Relevance  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.

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