Incorporating Outcomes that Matter to Older Adults into Surgical Research

Approximately 4 million surgical procedures are performed annually in older adults aged 65 years and older. Older surgical patients are different from their younger counterparts due to baseline geriatric conditions such as frailty, cognitive impairment, and multimorbidity among others. Older adults also value different health outcomes than younger patients. Studies suggest that 70% of older adults would not choose treatments that would lead to loss of independence, functional decline, or cognitive impairment, even if the treatment would prolong life. Despite this fact, most surgical research in older adults is designed to evaluate traditional outcomes such as 1-year mortality or healthcare utilization rather than patient-centered outcomes. Data are lacking on how surgical interventions impact outcomes valued by older adults and on how baseline geriatric conditions such as frailty may influence these outcomes following surgery. The study by Thillainadesan et al in this issue addresses this knowledge gap for the burgeoning population of older adults undergoing vascular surgery. The authors had two objectives: (1) to evaluate the associations between frailty and multiple hospitalacquired geriatric syndromes and (2) to measure the utility of two validated frailty indices in predicting the hospitalacquired geriatric syndromes of delirium and functional decline. The authors conducted a prospective observational cohort study of 150 older adults (≥65 years) consecutively admitted to a vascular surgery service in 2019. Exclusion criteria included same-day procedures, surgery conducted while admitted to another service, or expected admission length of stay of less than 2 days. The study cohort underwent a variety of vascular surgery procedures ranging from endovascular to open revascularizations, amputations, and debridement. Important geriatric-focused baseline data points were collected and included two frailty indices (Clinical Frailty Scale and Rockwood Frailty Index) as the primary predictors, as well as multimorbidity, falls, functional status, and cognition. The primary outcome measures were hospital-acquired geriatric syndromes including delirium, functional decline at discharge, constipation, pressure injury, and falls. The secondary outcomes were more traditional measures such as mortality and readmissions but also polypharmacy and high-risk prescribing at discharge. The authors found that up to one-third of admitted older vascular surgery patients were frail, depending on the measure used. Of 150 patients enrolled, 65% experienced at least one hospital-acquired geriatric syndrome. Constipation was the most common (53%), followed by functional decline (19%) and delirium (10%). In multivariable logistic regression analysis, both the Rockwood Frailty Index (adjusted odds ratio (OR) = 5.64, 95% confidence interval (CI) = 1.47–21.7) and Clinical Frailty Scale (adjusted OR = 4.21, 95% CI = 1.14–15.5) were significantly associated with delirium. The authors also found that the Rockwood FI and CFS had acceptable discrimination when predicting for delirium. As the authors note, this study had some limitations, including a single hospital experience with a limited number of outcome events in a smaller cohort, which is reflected in wide confidence intervals for the primary outcomes. Despite these limitations, the authors demonstrate the feasibility of a prospective study designed to measure frailty and hospital-acquired geriatric syndromes in older surgical patients. In addition, the findings highlight the importance of measuring associations between baseline frailty and relevant geriatric-focused outcomes in hospitalized surgical patients. Prior large studies of older adults undergoing surgery have been designed to primarily measure traditional outcomes such as postoperative mortality. For example, a recent study of over 2.7 million surgical patients found that frailty was significantly associated with both 30-day and 180-day postoperative mortality. Surgical specialties were categorized from low to high intensity, and the relationship between frailty and mortality held even for low-intensity specialties such as plastic surgery. In vascular surgery, a high-intensity specialty, a designation of “very frail” as measured by the Risk Analysis Index was closely associated with 30-day mortality (adjusted OR = 12.66, 95% CI = 10.31–15.55). Similarly, another recent study retrospectively evaluated 1,341 older adults undergoing three types of major surgery from the Health and Retirement Study. The study objective was to evaluate the association between several geriatric conditions (functional dependence, DOI: 10.1111/jgs.17028