Skip to main content
Key Specialties
Cardiology Diabetology Endocrinology Gastroenterology Geriatrics and Gerontology Gynecology and Obstetrics Hematology Infectious Disease Internal Medicine Nephrology Neurology Oncology Pediatrics Respiratory Medicine Rheumatology Surgery
Congress Coverage
2024 ACC Congress 2023 ESMO Congress 2023 EASD Congress 2023 ERS Congress 2023 ESC Congress
Clinical Collections
Advances in Alzheimer’s

Keynote webinar | Spotlight on medication adherence

LIVE: Thursday 27th June 2024, 18:00-19:30 (CEST)
Join our expert panel to discover why you need to understand the drivers of non-adherence in your patients, and how you can optimize medication adherence in your clinics to drastically improve patient outcomes.
ADVANCED SEARCH
Log in
Top
BMC Medicine
Published in: BMC Medicine 1/2018

Open Access 01-12-2018 | Research article

Identifying older adults at risk of harm following elective surgery: a systematic review and meta-analysis

Authors: Jennifer Watt, Andrea C. Tricco, Catherine Talbot-Hamon, Ba’ Pham, Patricia Rios, Agnes Grudniewicz, Camilla Wong, Douglas Sinclair, Sharon E. Straus

Published in: BMC Medicine | Issue 1/2018

Login to get access

Abstract

Background

Elective surgeries can be associated with significant harm to older adults. The present study aimed to identify the prognostic factors associated with the development of postoperative complications among older adults undergoing elective surgery.

Methods

Medline, EMBASE, CINAHL, Cochrane Central Register of Controlled Trials, and AgeLine were searched for articles published between inception and April 21, 2016. Prospective studies reporting prognostic factors associated with postoperative complications (composite outcome of medical and surgical complications), functional decline, mortality, post-hospitalization discharge destination, and prolonged hospitalization among older adults undergoing elective surgery were included. Study characteristics and prognostic factors associated with the outcomes of interest were extracted independently by two reviewers. Random effects meta-analysis models were used to derive pooled effect estimates for prognostic factors and incidences of adverse outcomes.

Results

Of the 5692 titles and abstracts that were screened for inclusion, 44 studies (12,281 patients) reported on the following adverse postoperative outcomes: postoperative complications (n =28), postoperative mortality (n = 11), length of hospitalization (n = 21), functional decline (n = 6), and destination at discharge from hospital (n = 13). The pooled incidence of postoperative complications was 25.17% (95% confidence interval (CI) 18.03–33.98%, number needed to follow = 4). The geriatric syndromes of frailty (odds ratio (OR) 2.16, 95% CI 1.29–3.62) and cognitive impairment (OR 2.01, 95% CI 1.44–2.81) were associated with developing postoperative complications; however, there was no association with traditionally assessed prognostic factors such as age (OR 1.07, 95% CI 1.00–1.14) or American Society of Anesthesiologists status (OR 2.62, 95% CI 0.78–8.79). Besides frailty, other potentially modifiable prognostic factors, including depressive symptoms (OR 1.77, 95% CI 1.22–2.56) and smoking (OR 2.43, 95% CI 1.32–4.46), were also associated with developing postoperative complications.

Conclusion

Geriatric syndromes are important prognostic factors for postoperative complications. We identified potentially modifiable prognostic factors (e.g., frailty, depressive symptoms, and smoking) associated with developing postoperative complications that can be targeted preoperatively to optimize care.
Appendix
Available only for authorised users
Literature
1.
Audisio RA, Pope D, Gennari R, Maffezzini M, Hoekstra HJ, Mobarak D, et al. Shall we operate? Preoperative assessment in elderly cancer patients (PACE) can help. A SIOG surgical task force prospective study. Crit Rev Oncol Hematol. 2008;65:156–63.PubMedCrossRef
2.
Badgwell B, Stanley J, Chang GJ, Katz MHG, Lin HY, Ning J, et al. Comprehensive geriatric assessment of risk factors associated with adverse outcomes and resource utilization in cancer patients undergoing abdominal surgery. J Surg Oncol. 2013;108:182–6.PubMedCrossRef
3.
Sundermann SH, Dademasch A, Seifert B, Biefer HRC, Emmert MY, Walther T, et al. Frailty is a predictor of short- and mid-term mortality after elective cardiac surgery independently of age. Interact Cardiovasc Thorac Surg. 2014;18:580–5.PubMedCrossRef
4.
Bakker RC, Osse RJ, Tulen JHM, Kappetein AP, Bogers AJJC. Preoperative and operative predictors of delirium after cardiac surgery in elderly patients. Eur J Cardiothorac Surg. 2012;41:544–9.PubMedCrossRef
5.
Veliz-Reissmuller GT, Aguero Torres H, van der Linden J, Lindblom D, Eriksdotter Jonhagen M. Pre-operative mild cognitive dysfunction predicts risk for post-operative delirium after elective cardiac surgery. Aging Clin Exp Res. 2007;19:172–7.PubMedCrossRef
6.
Kristjansson SR, Jordhøy MS, Nesbakken A, Skovlund E, Bakka A, Johannessen H-O, et al. Which elements of a comprehensive geriatric assessment (CGA) predict post-operative complications and early mortality after colorectal cancer surgery? J Geriatr Oncol. 2010;1(2):57–65.CrossRef
7.
Dasgupta M, Rolfson DB, Stolee P, Borrie MJ, Speechley M. Frailty is associated with postoperative complications in older adults with medical problems. Arch Gerontol Geriatr. 2009;48:78–83.PubMedCrossRef
8.
Marcantonio ER, Goldman L, Mangione CM, Ludwig LE, Muraca B, Haslauer CM, et al. A clinical prediction rule for delirium after elective noncardiac surgery. JAMA. 1994;271(2):134–9.PubMedCrossRef
9.
Mohanty S, Rosenthal RA, Russell MM, Neuman MD, Ko CY, Esnaola NF. Optimal perioperative management of the geriatric patient: a best practices guideline from the American College of Surgeons NSQIP and the American Geriatrics Society. J Am Coll Surg. 2016;222(5):930–47.PubMedCrossRef
10.
Liberati A, Altman DG, Tetzlaff J, Mulrow C, Gotzsche PC, Ioannidis JP, et al. The PRISMA statement for reporting systematic reviews and meta-analyses of studies that evaluate health care interventions: explanation and elaboration. J Clin Epidemiol. 2009;62(10):e1–34.PubMedCrossRef
11.
Stroup DF, Berlin JA, Morton SC, Olkin I, Williamson GD, Rennie D, et al. Meta-analysis of observational studies in epidemiology: a proposal for reporting. Meta-analysis Of Observational Studies in Epidemiology (MOOSE) group. JAMA. 2000;283(15):2008–12.PubMedCrossRef
12.
13.
14.
Marcantonio ER, Flacker JM, Wright RJ, Resnick NM. Reducing delirium after hip fracture: a randomized trial. J Am Geriatr Soc. 2001;49(5):516–22.PubMedCrossRef
15.
Lenartowicz M, Parkovnick M, McFarlan A, Haas B, Straus SE, Nathens AB, et al. An evaluation of a proactive geriatric trauma consultation service. Ann Surg. 2012;256(6):1098–101.PubMedCrossRef
16.
Wells G, Shea B, O’Connell D, Peterson J, Welch V, Losos M, et al. The Newcastle-Ottawa Scale (NOS) for Assessing the Quality of Nonrandomised Studies in Meta-Analyses. Ottawa, Ontario: Ottawa Hospital Research Institute; 2008.
17.
Higgins JP, Altman DG, Gotzsche PC, Juni P, Moher D, Oxman AD, et al. The Cochrane Collaboration's tool for assessing risk of bias in randomised trials. BMJ. 2011;343:d5928.PubMedPubMedCentralCrossRef
18.
19.
Sanchez-Meca J, Marin-Martinez F, Chacon-Moscoso S. Effect-size indices for dichotomized outcomes in meta-analysis. Psychol Methods. 2003;8(4):448–67.PubMedCrossRef
20.
Mayer D. Essential Evidence-Based Medicine. 2nd ed. Cambridge: Cambridge University Press; 2009.
21.
22.
Viechtbauer W. Conducting meta-analyses in R with the metafor package. J Stat Softw. 2010;36(3):48.CrossRef
23.
Schwarzer G. meta: An R package for meta-analysis. R News. 2007;7(3):40–5.
24.
Clement ND, MacDonald D, Howie CR, Biant LC. The outcome of primary total hip and knee arthroplasty in patients aged 80 years or more. J Bone Joint Surg Br. 2011;93(9):1265–70.PubMedCrossRef
25.
Robinson TN, Wu DS, Pointer LF, Dunn CL, Moss M. Preoperative cognitive dysfunction is related to adverse postoperative outcomes in the elderly. J Am Coll Surg. 2012;215(1):12–7.PubMedPubMedCentralCrossRef
26.
Fukuse T, Satoda N, Hijiya K, Fujinaga T. Importance of a comprehensive geriatric assessment in prediction of complications following thoracic surgery in elderly patients. Chest. 2005;127:886–91.PubMedCrossRef
27.
Papaioannou A, Fraidakis O, Michaloudis D, Balalis C, Askitopoulou H. The impact of the type of anaesthesia on cognitive status and. Eur J Anaesthesiol. 2005;22:492–9.PubMedCrossRef
28.
Suh DH, Kim JW, Kim HS, Chung HH, Park NH, Song YS. Pre- and intra-operative variables associated with surgical complications in elderly patients with gynecologic cancer: the clinical value of comprehensive geriatric assessment. J Geriatr Oncol. 2014;5(3):315–22.PubMedCrossRef
29.
Makary MA, Segev DL, Pronovost PJ, Syin D, Bandeen-Roche K, Patel P, et al. Frailty as a predictor of surgical outcomes in older patients. J Am Coll Surg. 2010;210(6):901–8.PubMedCrossRef
30.
Gerude MF, Dias FL, de Farias TP, Albuquerque Sousa B, Thuler LC. Predictors of postoperative complications, prolonged length of hospital stay, and short-term mortality in elderly patients with malignant head and neck neoplasm. ORL J Otorhinolaryngol Relat Spec. 2014;76(3):153–64.PubMedCrossRef
31.
Huisman MG, Van Leeuwen BL, Ugolini G, Montroni I, Spiliotis J, Stabilini C, et al. ‘Timed Up & Go’: A screening tool for predicting 30-day morbidity in onco-geriatric surgical patients? A multicenter cohort study. PLoS One. 2014;9(1):e86863.PubMedCrossRef
32.
Javierre C, Ricart A, Manez R, Farrero E, Carrio ML, Rodriguez-Castro D, et al. Age and sex differences in perioperative myocardial infarction after cardiac surgery. Interact Cardiovasc Thorac Surg. 2012;15(1):28–32.PubMedPubMedCentralCrossRef
33.
Zhang L, Wang C, Sha SY, Kwauk S, Miller AR, Xie MS, et al. Mini-nutrition assessment, malnutrition, and postoperative complications in elderly Chinese patients with lung cancer. J BUON. 2012;17(2):323–6.PubMed
34.
Aykut K, Albayrak G, Guzeloglu M, Baysak A, Hazan E. Preoperative mild cognitive dysfunction predicts pulmonary complications after coronary artery bypass graft surgery. J Cardiothorac Vasc Anesth. 2013;27(6):1267–70.PubMedCrossRef
35.
Lasithiotakis K, Petrakis J, Venianaki M, Georgiades G, Koutsomanolis D, Andreou A, et al. Frailty predicts outcome of elective laparoscopic cholecystectomy in geriatric patients. Surg Endosc. 2013;27(4):1144–50.PubMedCrossRef
36.
Kenig J, Olszewska U, Zychiewicz B, Barczynski M, Mitus-Kenig M. Cumulative deficit model of geriatric assessment to predict the postoperative outcomes of older patients with solid abdominal cancer. J Geriatr Oncol. 2015;6:370–9.PubMedCrossRef
37.
Kim S, Marsh AP, Rustowicz L, Roach C, Leng XI, Kritchevsky SB, et al. Self-reported mobility in older patients predicts early postoperative outcomes after elective noncardiac surgery. Anesthesiology. 2016;124:815–25.PubMedPubMedCentralCrossRef
38.
Courtney-Brooks M, Tellawi AR, Scalici J, Duska LR, Jazaeri AA, Modesitt SC, et al. Frailty: an outcome predictor for elderly gynecologic oncology patients. Gynecol Oncol. 2012;126:20–4.PubMedCrossRef
39.
Green P, Woglom AE, Genereux P, Daneault B, Paradis JM, Schnell S, et al. The impact of frailty status on survival after transcatheter aortic valve replacement in older adults with severe aortic stenosis: a single-center experience. JACC Cardiovasc Interv. 2012;5:974–81.PubMedPubMedCentralCrossRef
40.
Kim S-W, Han H-S, Jung H-W, Kim K-I, Hwang DW, Kang S-B, et al. Multidimensional frailty score for the prediction of postoperative mortality risk. JAMA Surg. 2014;149:633–40.PubMedCrossRef
41.
Tan KY, Kawamura YJ, Tokomitsu A, Tang T. Assessment for frailty is useful for predicting morbidity in elderly patients undergoing colorectal cancer resection whose comorbidities are already optimized. Am J Surg. 2012;204:139–43.PubMedCrossRef
42.
Goto T, Baba T, Ito A, Maekawa K, Koshiji T. Gender differences in stroke risk among the elderly after coronary artery surgery. Anesth Analg. 2007;104(5):1016–22.PubMedCrossRef
43.
Dales RE, Dionne G, Leech JA, Lunau M, Schweitzer I. Preoperative prediction of pulmonary complications following thoracic surgery. Chest. 1993;104(1):155–9.PubMedCrossRef
44.
Gerson MC, Hurst JM, Hertzberg VS, Doogan PA, Cochran MB, Lim SP, et al. Cardiac prognosis in noncardiac geriatric surgery. Ann Intern Med. 1985;103(6 (Pt 1)):832–7.PubMedCrossRef
45.
Kothari A, Phillips S, Bretl T, Block K, Weigel T. Components of geriatric assessments predict thoracic surgery outcomes. J Surg Res. 2011;166(1):5–13.PubMedCrossRef
46.
van Venrooij LM, van Leeuwen PA, de Vos R, Borgmeijer-Hoelen MM, de Mol BA. Preoperative protein and energy intake and postoperative complications in well-nourished, non-hospitalized elderly cardiac surgery patients. Clin Nutr. 2009;28(2):117–21.PubMedCrossRef
47.
Fried LP, Tange CM, Walston J, Newman AB, Hirsch C, Gottdiener J, et al. Frailty in older adults: evidence for a phenotype. J Gerontol A Biol Sci Med Sci. 2001;56A(3):M146–56.CrossRef
48.
Rolfson DB, Majumdar SR, Tsuyuki RT, Tahir A, Rockwood K. Validity and reliability of the Edmonton Frail Scale. Age Ageing. 2006;35(5):526–9.PubMedCrossRef
49.
Yesavage JA, Brink TL, Rose TL, Lum O, Huang V, Adey M, et al. Development and validation of a geriatric depression screening scale: a preliminary report. J Psychiatr Res. 1982;17(1):37–49.PubMedCrossRef
50.
Goldman L, Caldera DL, Nussbaum SR, Southwick FS, Krogstad D, Murray B, et al. Multifactorial index of cardiac risk in noncardiac surgical procedures. N Engl J Med. 1977;297(16):845–50.PubMedCrossRef
51.
Kim K-I, Park K-H, Koo K-H, Han H-S, Kim C-H. Comprehensive geriatric assessment can predict postoperative morbidity and mortality in elderly patients undergoing elective surgery. Arch Gerontol Geriatr. 2013;56:507–12.PubMedCrossRef
52.
Hattler BG, Madia C, Johnson C, Armitage JM, Hardesty RL, Kormos RL, et al. Risk stratification using the Society of Thoracic Surgeons Program. Ann Thorac Surg. 1994;58(5):1348–52.PubMedCrossRef
53.
Williams JB, Alexander KP, Morin JF, Langlois Y, Noiseux N, Perrault LP, et al. Preoperative anxiety as a predictor of mortality and major morbidity in patients aged >70 years undergoing cardiac surgery. Am J Cardiol. 2013;111(1):137–42.PubMedPubMedCentralCrossRef
54.
Posner BM, Jette AM, Smith KW, Miller DR. Nutrition and health risks in the elderly: the nutrition screening initiative. Am J Public Health. 1993;83(7):972–8.PubMedPubMedCentralCrossRef
55.
Tamburino C, Capodanno D, Ramondo A, Petronio AS, Ettori F, Santoro G, et al. Incidence and predictors of early and late mortality after transcatheter aortic valve implantation in 663 patients with severe aortic stenosis. Circulation. 2011;123(3):299–308.PubMedCrossRef
56.
Wenaweser P, Pilgrim T, Roth N, Kadner A, Stortecky S, Kalesan B, et al. Clinical outcome and predictors for adverse events after transcatheter aortic valve implantation with the use of different devices and access routes. Am Heart J. 2011;161(6):1114–24.PubMedCrossRef
57.
Betomvuko P, Michaux I, Gabriel L, Bihin B, Gourdin M, De Saint Hubert M. Gait speed as predictor of outcomes of elective cardiac surgery in older patients. Eur Geriatric Med. 2015;6(1):S147.CrossRef
58.
Rogers MPL, Matthew H, Daltroy Lawren H, Eaton H, Peteet J, Wright E, Albert M. Delirium after elective orthopedic surgery: risk factors and natural history. Int J Psychiatry Med. 1989;19:109–21.PubMedCrossRef
59.
Reinöhl J, Kaier K, Gutmann A, Sorg S, von Zur MC, Siepe M, et al. In-hospital resource utilization in surgical and transcatheter aortic valve replacement. BMC Cardiovasc Disord. 2015;15:132.PubMedPubMedCentralCrossRef
60.
Schmidt M, Eckardt R, Scholtz K, Neuner B, Von Dossow-Hanfstingl V, Sehouli J, et al. Patient empowerment improved Perioperative quality of care in cancer patients aged > 65 Years - a randomized controlled trial. PLoS One. 2015;10(9):e0137824.PubMedPubMedCentralCrossRef
61.
Blakoe M, Greve H. Frailty – preoperative assessment and implications for nursing practice following heart surgery. Eur J Cardiovasc Nursing. 2015;14:S44.
62.
Kosar CM, Tabloski PA, Travison TG, Jones RN, Schmitt EM, Puelle MR, et al. Effect of preoperative pain and depressive symptoms on the risk of postoperative delirium: A prospective cohort study. Lancet Psychiatry. 2014;1:431–6.PubMedPubMedCentralCrossRef
63.
Lawrence VA, Hazuda HP, Cornell JE, Pederson T, Bradshaw PT, Mulrow CD, et al. Functional independence after major abdominal surgery in the elderly. J Am Coll Surg. 2004;199:762–72.PubMedCrossRef
64.
Amemiya T, Oda K, Ando M, Kitagawa Y, Shimada H, Kuroiwa K, et al. Activities of daily living and quality of life of elderly patients after elective surgery for gastric and colorectal cancers. Ann Surg. 2007;246:222–8.PubMedPubMedCentralCrossRef
65.
Min L, Mazzurco L, Gure TR, Cigolle CT, Lee P, Bloem C, et al. Longitudinal functional recovery after geriatric cardiac surgery. J Surg Res. 2015;194(1):25–33.PubMedCrossRef
66.
Legner VJ, Doerner D, Reilly DF, Mccormick WC. Risk factors for nursing home placement following major nonemergent surgery. Am J Med. 2004;117:82–6.PubMedCrossRef
67.
Otomo S, Maekawa K, Goto T, Baba T, Yoshitake A. Pre-existing cerebral infarcts as a risk factor for delirium after coronary artery bypass graft surgery. Interact Cardiovasc Thorac Surg. 2013;17(5):799–804.PubMedPubMedCentralCrossRef
68.
Pirracchio R, Resche-Rigon M, Bresson D, Basta B, Welschbillig S, Heyer L, et al. One-year outcome after neurosurgery for intracranial tumor in elderly patients. J Neurosurg Anesthesiol. 2010;22(4):342–6.PubMedCrossRef
69.
Hoogerduijn JG, de Rooij SE, Grobbee DE, Schuurmans MJ. Predicting functional decline in older patients undergoing cardiac surgery. Age Ageing. 2014;43(2):218–21.PubMedCrossRef
70.
Kwon S, Symons R, Yukawa M, Dasher N, Legner V, Flum DR. Evaluating the association of preoperative functional status and postoperative functional decline in older patients undergoing major surgery. Am Surg. 2012;78(12):1336–44.PubMedPubMedCentral
71.
72.
Clegg A, Young J, Iliffe S, Rikkert MO, Rockwood K. Frailty in elderly people. Lancet. 2013;381:752–62.PubMedCrossRef
73.
Fried LP, Tange CM, Walston J, Newman AB, Hirsch C, Gottdiener J, et al. Frailty in older adults: evidence for a phenotype. J Gerontol Med Sci. 2001;56A(3):M146–56.CrossRef
74.
Rockwood K, Song X, MacKnight C, Bergman H, Hogan DB, McDowell I, et al. A global clinical measure of fitness and frailty in elderly people. CMAJ. 2005;173(5):489–95.PubMedPubMedCentralCrossRef
75.
Oresanya LB, Lyons WL, Finlayson E. Preoperative assessment of the older patient: a narrative review. JAMA. 2014;311:2110–20.PubMedCrossRef
76.
Ng T, Feng L, Nyunt M, Feng L, Niti M, Tan B, et al. Nutritional, physical, cognitive, and combination interventions and frailty reversal among older adults: a randomized controlled trial. Am J Med. 2015;128(11):1225–36.PubMedCrossRef
77.
Thomsen T, Villebro N, Moller AM. Interventions for preoperative smoking cessation. Cochrane Database Syst Rev. 2014;3:CD002294.
78.
Moons KGM, Groot JAH, Bouwmeester W, Vergouwe Y, Mallett S, Altman DG, et al. Critical appraisal and data extraction for systematic reviews of prediction modelling studies: the CHARMS checklist. PLoS Med. 2014;11(10):e1001744.PubMedPubMedCentralCrossRef
Metadata
Title
Identifying older adults at risk of harm following elective surgery: a systematic review and meta-analysis
Authors
Jennifer Watt
Andrea C. Tricco
Catherine Talbot-Hamon
Ba’ Pham
Patricia Rios
Agnes Grudniewicz
Camilla Wong
Douglas Sinclair
Sharon E. Straus
Publication date
01-12-2018
Publisher
BioMed Central
Published in
BMC Medicine / Issue 1/2018
Electronic ISSN: 1741-7015
DOI
https://doi.org/10.1186/s12916-017-0986-2

Other articles of this Issue 1/2018

BMC Medicine 1/2018 Go to the issue

Correspondence

Updated cost-effectiveness and risk-benefit analysis of two infant rotavirus vaccination strategies in a high-income, low-endemic setting

Research article

Efficacy and safety of ascending doses of praziquantel against Schistosoma haematobium infection in preschool-aged and school-aged children: a single-blind randomised controlled trial

Research article

Near-death experiences, attacks by family members, and absence of health care in their home countries affect the quality of life of refugee women in Germany: a multi-region, cross-sectional, gender-sensitive study

Research article

External validation of the Scandinavian guidelines for management of minimal, mild and moderate head injuries in children

Research article

Modelling population-level impact to inform target product profiles for childhood malaria vaccines

Research article

Genotype-guided versus traditional clinical dosing of warfarin in patients of Asian ancestry: a randomized controlled trial