Association of Functional, Cognitive, and Psychological Measures With 1-Year Mortality in Patients Undergoing Major Surgery | JAMA Surgery | JAMA Network
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    1 Comment for this article
    RE: Association of functional, cognitive, and psychological measures with 1-year mortality in patients undergoing major surgery
    Tomoyuki Kawada, MD | Nippon Medical School
    Tang et al. determined the association between measures of physical, cognitive, and psychological function and subsequent mortality in 1341 older adults after major surgery, including abdominal aortic aneurysm repair, coronary artery bypass graft, and colectomy (1). Adjusted hazard ratios (HRs) of >1 ADL dependence, >1 instrumental ADL dependence, the inability to walk several blocks, dementia and depression for 1-year mortality were 2.76, 1.32, 1.64, 1.91, and 1.72, respectively. In addition, the percentages of 1-year mortality with 0 to 2 risk factors were 10.0%, 16.2% and 27.8%, respectively. They concluded that poor function, impaired cognition, and the lack of psychological well-being were significantly associated with 1-year mortality. I have some concerns about their study with special reference to sex difference on the association.

    First, Meghji et al. conducted a retrospective cohort study to analyze preoperative characteristics and subsequent overall survival of 1127 women and 1379 men undergoing septal myectomy for obstructive hypertrophic cardiomyopathy (2). Adjusted HRs (95% confidence intervals [CIs]) of older age at surgery, greater NYHA class and presence of diabetes prior to surgery for mortality were 3.09 (2.12-4.52), 2.31 (1.03-5.15) and 1.57 (1.10-2.24), respectively. In contrast, there was no survival difference after septal myectomy by sex. They handled patients with mean age under 60 years, and combination effect of sex and age on mortality should be specified by further study.

    Second, Barbey et al. conducted a prospective study to evaluate the association of frailty/sex interactions on mortality in patients after elective abdominal aortic aneurysm repair (3). Adjusted HR (95% CI) of frailty for 1-year mortality in patients with endovascular abdominal aortic aneurysm repair (EVAR) treatment and open aneurysm repair (OAR) treatment were 1.32 (1.25-1.39) and 1.38 (1.28-1.48), respectively. Although there was no significant interaction between frailty and gender on the association with mortality, there was a survival disparity between sexes, presenting adjusted HR (95% CI) of females with EVAR treatment and with OAR treatment against males for 1-year mortality of 1.66 (1.10-2.52) and 1.43 (1.02-1.99), respectively. Reasons of increased risk in female patients might be partly explained by the following paper.

    Ramkumar et al. conducted a long-term prospective study to investigate a sex difference in all-cause mortality after abdominal aortic aneurysm repair owing to differences in repair type (4). Adjusted HRs (95% CIs) of women against men after EVAR repair treatment and after OAR repair treatment for mortality was 1.13 (1.03-1.24) and 0.94 (0.84-1.06), respectively. Although EVAR treatment affected the sex difference in mortality, there was no significant sex difference in OAR treatment. As risk ratio (95% CI) of women with OAR treatment against EVAR treatment was 1.65 (1.51-1.80), and application of repair type should be precisely explored.


    1. Tang VL, Jing B, Boscardin J, et al. JAMA Surg. 2020 Mar 11. doi: 10.1001/jamasurg.2020.0091

    2. Meghji Z, Nguyen A, Fatima B, et al. JAMA Cardiol. 2019;4(3):237-245. doi: 10.1001/jamacardio.2019.0084

    3. Barbey SM, Scali ST, Kubilis P, et al. J Vasc Surg. 2019;70(6):1831-1843. doi: 10.1016/j.jvs.2019.01.086

    4. Ramkumar N, Suckow BD, Arya S, et al. JAMA Netw Open. 2020;3(2):e1921240. doi: 10.1001/jamanetworkopen.2019.21240
    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. 2020;155(5):412-418. 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.


    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.