Association for Academic SurgeryComponents of Geriatric Assessments Predict Thoracic Surgery Outcomes
Introduction
Surgical intervention is the initial and preferred therapeutic approach for most thoracic malignancies, and the incidence of most thoracic malignancies increases with age [1]. It has been estimated that by 2030 over 60% of the population will be over the age of 60, and as a result thoracic surgeons will more frequently be required to gauge the impact of surgery on older patients [2]. Of major concern to older patients is maintaining quality of life without acquiring chronic morbidity or dependency after surgery [3]. The decision to operate on older thoracic surgery patients and provide them true informed consent requires consideration of both benefit and risk [4].
Currently, assessing the total impact of major thoracic surgery in geriatric patients is difficult. As an independent variable, patient age alone does not accurately predict surgical risk for thoracic cancers 5, 6, 7. Using methodologies such as noncomprehensive performance status evaluations or subjective judgment can often lead to denial of treatment to “risky” patients [8]. Recent studies have demonstrated certain co-morbidities may increase the likelihood of having adverse postoperative events, but are not validated predictive screening tools [9].
Taken together, these factors indicate a need to develop a concise yet accurate predictive tool, which can estimate how surgery will affect quality of life of individual patients who meet physiologic criteria and have been scheduled for surgery. In general internal medicine and family practice clinics, comprehensive geriatric assessments are used to predict a range of patient outcomes from cancer mortality to chemotherapy tolerance 10, 11. These assessments include validated screening tools for common geriatric syndromes such as the geriatric depression scale (GDS), nutrition screening initiative nutritional health checklist (NSI NHC), activities of daily living (ADLs), and instrumental activities of daily living (IADLs) to consider mood, nutrition, and functional status in older patients 12, 13, 14, 15. However, they are lengthy, making them impractical in a high volume surgical practice.
The first major study to compare the results of comprehensive geriatric assessment to surgical outcomes was conducted in 2009 by Kristjansson and colleagues [16]. The group used activities of daily living, personal activities of daily living, instrumental activities of daily living, Nottingham extended activities of daily living scale, cumulative illness rating scale, mini nutritional assessment, mini mental state examination, and the geriatric depression scale to classify patients as “fit,” “intermediate,” or “frail” [17]. These classifications were then compared with the incidence of severe complications in patients undergoing elective surgery for all stages of colon cancer. The authors found that patients classified as intermediate or frail were more likely to have severe complications than those who were fit. However, they identified the long length of time for administration as a potential limitation for application to surgical practice [16].
The GDS is a 15 question survey in its short-form version and a 30 question survey in its complete form [14]. The short form of the GDS has been found to be just as valid diagnostically as the long form [12]. When given by a qualified individual during a preoperative visit, the GDS short form takes about 5 min to administer. The National Health Initiative NHC is a 10 item checklist that takes between 4 and 6 min to administer. There are a total of 6 ADLs and 8 IADLs that are assessed, and each takes about 5 min.
A goal of our prospective study was to determine if individual questions from the GDS and NSI NHC, and individual ADLs and IADLs could successfully estimate surgical risk in geriatric patients presenting with thoracic neoplasms of the lung, esophagus, pleura, and thymus who were already scheduled for surgery. We hypothesized that a single or combination of individual questions extracted from the GDS, NSI NHC, ADLs, or IADLs would have predictive value for major complications, discharge destination (home or non-home), and length of hospital stay. The objective was to determine if a concise, rapid, preoperative geriatric assessment could be developed from components of existing screening tools to successfully estimate surgical risk.
Section snippets
Methods
Patient recruitment into the study was conducted on all patients ≥70 y old scheduled for a thoracic oncology surgery. Eligible participants were ≥70 y old with lung, esophageal, pleural. or thymic neoplasms, and deemed an acceptable surgical candidate by current routine preoperative physiologic studies. Residents of nursing homes and assisted living facilities were eligible for this study if they were otherwise thought to be appropriate surgical candidates; other institutionalized patients were
Results
A total of 60 patients were analyzed and accrual goal for this phase of study was met (18 with primary esophageal, 34 with primary lung, five with lung metastases, one with tracheal, and two with other metastatic lesions). Esophagectomy was performed in 18 patients, lobectomy in 28 patients, wedge resection in eight patients, pneumonectomy in four patients, segmentectomy in one patient, and chest wall resection in one patient. Of patients entered into the study, 30 d and overall in-hospital
Discussion
Our study suggests that the results of geriatric screening tools can predict outcomes in geriatric patients undergoing major thoracic cancer surgeries. More importantly, single questions from these screens were able to accurately predict measured outcomes. The IADL “shopping” and questions 2 and 12 of the GDS (Have you dropped many of your activities and interests? and Do you feel pretty worthless the way you are now?) were able to predict for the incidence of major complications and location
References (23)
- et al.
Cancer epidemiology in the elderly
Crit Rev Oncol
(2001) - et al.
Thoracic surgery in the elderly
J Am Coll Surg
(2004) - et al.
Outcomes of cardiac surgery in patients age ≥80 years: Results from the national cardiovascular network
J Am Coll Cardiol
(2000) - et al.
Comprehensive geriatric assessment predicts tolerance to chemotherapy and survival in elderly patients with advanced ovarian carcinoma: A GINECO study
Ann Oncol
(2005) - et al.
Development and validation of a geriatric depression screening scale: A preliminary report
J Psychiatr Res
(1983) - et al.
The abbreviated comprehensive geriatric assessment (aCGA) for use in the older cancer patient as a prescreen: Scoring and interpretation
Crit Rev Oncol
(2006) - et al.
Relationship of nutritional status to length of stay, hospital costs, and discharge status of patients hospitalized in the medicine service
J Am Diet Assoc
(1997) - et al.
Long-term trends in life expectancy and active life expectancy in the united states
Population Develop Rev
(2006) - et al.
Geriatric surgery is about disease, not age
J R Soc Med
(2008) - et al.
Outcomes of anesthesia and surgery in people 100 years of age and older
J Am Geriatr Soc
(1998)