Functional independence after major abdominal surgery in the elderly - 24/08/11

Doi : 10.1016/j.jamcollsurg.2004.05.280

Valerie A. Lawrence, MD, MSc *^†,⁎, Helen P. Hazuda, PhD ^‡, John E. Cornell, PhD *, ^†, Thomas Pederson, MSc *, Patrick T. Bradshaw, MSc ^§, Cynthia D. Mulrow, MD, MSc *, ^†, Carey P. Page, MD ^∥
^* Veterans Evidence-based Research Dissemination and Implementation Center (VERDICT), a Veterans Affairs Health Services Research and Development Center of Excellence, South Texas Veterans Health Care System, The University of Texas Health Science Center at San Antonio, TX.
^† Division of General Medicine, The University of Texas Health Science Center at San Antonio, TX.
^‡ Division of Clinical Epidemiology, The University of Texas Health Science Center at San Antonio, TX.
^§ Center for Epidemiology and Biostatistics, The University of Texas Health Science Center at San Antonio, TX.
^∥ Department of Surgery, The University of Texas Health Science Center at San Antonio, TX.

^*Correspondence address: Valerie A Lawrence, MD, Ambulatory Care 11C-6, Audie L Murphy Division, South Texas Veterans Health Care System, 7400 Merton Minter Blvd, San Antonio, TX.

Résumé

Background

Elders undergo approximately 40% of more than 1 million major abdominal operations annually. Yet evidence about recovery to preoperative levels of functional independence is limited. This study details course and predictors of functional recovery after elective major abdominal operations in the elderly.

Study design

This was a prospective cohort of 372 consecutive patients, 60 years old or more, enrolled from surgeons in private practice and two university-affiliated hospitals, assessed preoperatively and postoperatively at 1, 3, and 6 weeks, 3 and 6 months, using self-report and performance-based measures (Activities of Daily Living [ADL], Instrumental Activities of Daily Living [IADL], Medical Outcomes Study Short Form-36 Physical Component and Mental Component Scales [PCS, MCS], Geriatric Depression Scale [GDS], Folstein Mini-Mental State Exam [MMSE], timed walk, functional reach, hand grip strength).

Results

Mean age was 69 ± 6 years with 56% men, 47% nonHispanic Caucasian, and 42% Mexican American; hospital distribution was 49% private, 51% university-affiliated.

Maximum functional declines (95% CI) occurred 1 week postoperatively: ADL, 2.8 points (2.4 to 3.2); IADL, 7.6 points (7 to 8.3); SF-36 PCS, 6.5 points (5.4 to 7.6); Mini-Mental State Exam, 0.5 points (0.2 to 0.7); timed walk, 6.8 seconds (5.2 to 8.4); functional reach, 1.7 inches (1.2 to 2.2); grip strength, 2 kilograms (1.3 to 2.7) (p < 0.001 for all). SF-36 mental component scale and Geriatric Depression Scale scores did not worsen.

Mean recovery times were: Mini-Mental State Exam, 3 weeks; timed walk, 6 weeks; ADL, SF-36 PCS, and functional reach, 3 months; and IADL, 6 months. Mean grip strength did not return to preoperative status by 6 months. The incidence of persistent disability at 6 months, compared with preoperative status, was: ADL, 9%; IADL, 19%; PCS, 16%; mental component scale, 17%; timed walk, 39%; functional reach, 58%; and grip strength, 52%.

Potentially modifiable independent predictors of ADL and IADL recovery were preoperative physical conditioning and depression plus serious postoperative complications.

Conclusions

The clinical course of functional recovery varied across different measures. Protracted disability at 6 months after operation was substantial. Several potentially modifiable factors consistently predicted recovery.

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Abbreviations and acronyms : ADL, GDS, IADL, MCS, MMSE, PCS, SF-36

Plan

Study cohort and followup

Baseline characteristics

Mortality and morbidity

Course of recovery

Protracted postoperative recovery

Predictors of recovery

Discussion

Author contributions

No competing interests declared.
Supported by The National Institute on Aging: NIA RO1 AG14304; P20 AG12044; NIA RO1 AG10444; NIA RO1 AG16518 and Veterans Evidence-based Research Dissemination and Implementation Center (VERDICT), a Veterans Affairs Health Services Research and Development Center of Excellence.