Tuesday, December 28, 2010

Outcomes of Surgery in Older Persons: How Could We Know So Little?

About half of all operations performed in the United States are performed on persons over the age of 65. So you would think that there would be tons of research to help us guide patients as they ask us questions about how their health will be impacted by an operation. But we know very little. As far as evidence-based medicine is concerned, surgery in the elderly is an evidence-based wasteland.

How will an 85 year old with severe knee arthritis do after a joint replacement? One reason that this question is so hard to answer is that 85 year olds are so different. This question can not be answered generically. Some are highly active, while others (even if they had good knees) are disabled physically and/or cognitively. We suspect functional factors like these are likely to have huge impacts on surgical outcomes, but there is almost no data to guide us.

And we even lack the most basic evidence to address the older patient's "How will I do after surgery" question. Most of the information we have is on rates of death and surgical complications such as post-operative pneumonia. Of course these are important, but when the older patient asks, "how will I do" often what they are really asking is "How long will it be before I get back to normal?" "How long will I have trouble taking care of myself and be dependent on family caregivers?" "How long will my thinking be abnormal after surgery?" "How long before I can climb up the flight of stairs to my home?" "I know death is a rare complication, but how often will I suffer a permament loss in my ability to function independently?"

The honest answer to these questions: "WE DON'T KNOW."

In the New Old Age blog, Paula Span reports on an important study that breaks useful ground in starting to address these important questions. Led by Dr. Martin Makary, a surgeon at Johns Hopkins Hospital, the study proves that easy to measure markers of the patient's functional status strongly predict outcomes after surgery in older patients.

Markary used a 5 item frailty score (Weight loss, poor grip strength, exhaustion, low physical activity, decreased walking speed). The number of these measures on which a patient was frail strongly predicted outcomes after surgery. In fact, the frailty score seemed to be a better measure of surgical risk than the age of the patient or standard measures of surgical risk. The frailty score strongly predicted the risk of post-operative complications, or the need for nursing home care after surgery.

This study is a very useful advance in our understanding of surgical outcomes in older persons, but there is a need for much more research. Further studies need to better refine which measures of patient functioning best predict surgical outcomes. For example, this study did not measure cognitive functioning, which is undoubtedly a very important determinant of outcomes.

More importantly, while this study showed that it is important to assess functional ability before surgery, we need to know more about what happens to functional ability after surgery. This study advanced our understanding of commonly used surgical outcomes, but did not look at functional status outcomes. (ie, how long will my caregiver need to help with basic activities of daily living? How long before my walking is back to normal?)

We need studies in older persons that really provide an answer when the patient asks, "How will I do after surgery?"

Hopefully this study is the first of many from this team that begin to address these vital questions.

by: [Ken Covinsky]

1 comment:

Tim Cousounis said...

It's been my experience (professionally and personally) that much more is known than communicated (to patients and/or families).
It's been the slow rate of adoption of evidence-based practices, coupled with poor clinician-patient communications, which need to be improved.