Functional Status Assessment in the Preoperative Evaluation of Older Adults

Abstract

MANY COMMON SURGICAL PROCEDURES SUCH AS spinal fusion, coronary artery bypass grafting, and arthroplasty are routinely performed on older adults. Although such procedures can enhance quality and duration of life, adverse events related to the procedure and postoperative period are key considerations. Important complications include delirium, infection, and cardiac events. Development of these and other complications are associated with increased length of stay, increased rate of discharge to chronic care facilities, and increased mortality. Although age has been considered a primary predictor of surgical outcomes, preoperative functional status is likely a better surrogate for postoperative risk. Delirium is a major concern for older patients. Although risk factors for postoperative delirium are well defined, relatively few patients receive targeted interventions for prevention. If preoperative evaluation helped identify patients with poor functional status (cognitive and physical impairment predicts delirium), these individuals might benefit from specific environmental and pharmacologic interventions. Although some institutions have addressed delirium prevention in a proactive, multidisciplinary manner, wide-scale implementation lags. Another important complication is surgical site infection (SSI). Besides increases in length of stay and health care costs associated with SSI, treatment can require additional surgical procedures and extended antimicrobial therapy. The resulting immobility often contributes to poor functional outcomes, thereby potentially reducing any palliative benefit of surgery. Even though age has been recognized as a risk factor for infection, the association has traditionally been attributed to immune senescence and patient comorbidities. Compelling evidence for a link between impaired functional status and SSI was recently demonstrated by Anderson et al, who reviewed 141 345 operative procedures, examining risk factors for the development of methicillin-resistant Staphylococcus aureus (MRSA) SSI. The need for assistance with 3 or more activities of daily living (ADLs) was independently associated with an increased risk of MRSA SSI, an association that persisted after stratifying patients by age. Despite increasing evidence suggesting that impaired functional status is associated with poor postoperative outcomes, the exact connection remains elusive. For instance, development of MRSA SSI is often preceded by MRSA colonization. Yet among older adults who develop SSI, it is unclear whether these patients are colonized with MRSA prior to their operation because of previous health care exposure or whether poor functional status results in increased length of stay and MRSA exposure postoperatively. Although decolonization strategies have been explored for SSI prevention, randomized studies have failed to show consistent benefit. As the number of older adults undergoing major operative procedures continues to increase, several critical changes must occur to address the care needs of this expanding population.