Association for Academic Surgery
Components of Geriatric Assessments Predict Thoracic Surgery Outcomes

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Background

No tool currently exists to rapidly allow surgeons to objectively quantify surgical risk in geriatric patients. The goal of our prospective study was to determine if individual questions extracted from validated screens for common geriatric syndromes would have predictive value for surgical risk in geriatric patients with thoracic neoplasms.

Methods

Patients ≥ 70 y old were recruited to participate in a prospective, IRB-approved study involving the preoperative administration of validated screening tests. Patients were given the geriatric depression scale (GDS), nutrition screening initiative nutritional health checklist (NSI NHC), mini mental status exam (MMSE), brief fatigue inventory (BFI), and assessed for activities of daily living (ADLs) and instrumental activities of daily living (IADLs). All patients enrolled in this study were scheduled for thoracic surgery.

Results

Patients who responded to having a dependency in the IADL “shopping” were more likely to have major complications and to be discharged to a non-home location than those without a dependency (P = 0.011, 0.003). Patients who answered “yes” to questions 1, 9, and 10 of the NSI NHC had a longer mean length of stay compared with patients who answered “no” (P = 0.039, 0.010, 0.031). Answering “yes” to GDS question 2 correlated with the incidence of major complications (r = 0.270 P = 0.037). Answering “yes” to GDS question 12 increased the likelihood of being discharged to a non-home location postoperatively (odds ratio = 11.64, 95% CI, 0.68–202.86, P = 0.047).

Conclusions

Our data indicate that an abbreviated, rapid presurgical assessment can be developed for estimating operative risk, length of stay, and discharge destination in geriatric patients with thoracic malignancies using individual questions from previously validated screening tools.

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

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      Some studies used the Barthel index of ADL [1,5] whereas others used Katz index of ADL [3,7–9]. Cognitive status was most often measured using the Folstein mini-mental status examination [1,3,5,6,9]. There was a range of differences in who conducted the preoperative interviews; some interviews were conducted by student doctors, research assistants, trained nurse practitioners, and medical doctors with or without training in geriatrics. [1,6,7,9].

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