By Christina Frangou
Chicago—Determining whether an elderly patient has recently taken a fall can help surgeons to predict how well that patient will recover from a major operation, according to study findings.
The study showed that preoperative falls in older surgical patients are a powerful predictor of complications, prolonged hospital stays and higher rates of disability.
“It has been shown in previous studies that a history of falls predicts poor long-term outcomes, but we have never looked at immediate preoperative assessment related to postoperative outcomes,” said Teresa Jones, MD, lead study author and surgical resident at the University of Colorado in Denver.
“This is the first time that falls, as a stand-alone risk marker, have been used for predicting [surgical] outcomes in older adults.”
Forty-seven percent of hospital admissions of individuals aged 65 years and older are the result of fall-related injuries, according to the American College of Surgeons’ National Trauma Databank. The study was presented during the sixth Geriatric Surgical Forum at the 2012 Annual Clinical Congress of the American College of Surgeons.
Investigators studied 235 patients, with an average age of 74 years, who underwent colorectal or cardiac surgical procedures at the Denver Veterans Affairs Medical Center between 2005 and 2012. As part of their preoperative evaluation, Dr. Jones and her colleagues asked the patients if they had fallen in the six months before their scheduled operation. One-third of the patients reported falls.
Of those patients who reported falling more than once within that time frame, adverse outcomes occurred more frequently. Of the 81 patients who underwent colorectal procedures, 59% fell sometime before their operation and experienced more than one postoperative complication. In comparison, only 27% of those who did not fall experienced more than one postoperative complication. Complications included cardiac events; stroke; reoperation; and pulmonary, renal, thrombotic and infectious complications. The complication risk rose incrementally with the number of falls, but leveled off when a patient had fallen at least three times.
Among cardiac patients, 39% of those who sustained a fall preoperatively had two or more postoperative complications compared with 15.2% who did not.
Additionally, patients who reported a preoperative fall spent nearly three times as many days in the hospital as their fall-free counterparts. Furthermore, 59% of those who fell before surgery—compared with 4.2% of those who did not—needed institutional care following their operation.
Significant differences also were shown in patients undergoing cardiac surgical procedures. Session moderator Sandhya A. Lagoo-Deenadayalan, MD, PhD, associate professor of surgery at Duke University Medical Center, Durham, N.C., said that the study highlights an easy test that can be used to identify elderly patients who are at risk for complications.
“Elderly patients are able to do well after surgery, provided we are able to identify those who are frail and at high risk for postoperative complications. A simple marker that helps identify a high-risk elderly patient can also help in determining which patient needs additional interventions to prevent complications and improve outcomes following surgery.”
At Duke University, elderly patients with a history of falling are given a yellow bracelet on admission to alert the staff that this patient is at a higher risk for recurrent falls and requires more vigilant monitoring in the perioperative period.
Dr. Lagoo-Deenadayalan noted that 98% of the study participants were men, so future studies that have a more even gender distribution are needed.
Dr. Jones said that the research team hopes to assist with pre- and postoperative planning. “If it’s likely that a patient will need to enter a nursing home for several weeks after an operation, the patient and family can evaluate various facilities beforehand to see which one would best address their specific needs. It’s important for a patient to be at a place that they’ve been shown and know what to expect after surgery.”
More than one-third of all operations in the United States are now performed on people aged 65 years and older, and the fastest growing segment of the population undergoing various surgical procedures is adults in their 80s, the researchers said.
“This assessment is very novel in the sense that older adults have unique risk factors that we can look for that suggest they will do poorly after an operation, but these markers are not readily recognized by the wider surgical community,” said study co-author Thomas Robinson, MD, associate professor of surgery, University of Colorado, Denver.
The researchers said that their ultimate aim is to develop simple tests that will help surgeons to predict how their patients will do after surgery. “I think this study is going to improve care by changing how we counsel older adults prior to these major operations,” said Dr. Robinson. “We want to tailor the patient’s health care plan based on what will be the best possible outcome. We shouldn’t settle for putting people in institutional care facilities for the last six months of their life.”