Long-term Functional Decline After High-Risk Elective Colorectal Surgery in Older Adults

BACKGROUND: Although most surgical outcomes research focuses on clinical end points and complications, older adult patients may value functional outcomes more. However, little is known about the risk of long-term functional disability after colorectal procedures.

OBJECTIVE: The purpose of this research was to understand the incidence and likelihood of functional decline after high-risk (ie, ≥1% inpatient mortality) colorectal operations both without and with complications.

DESIGN: This was a retrospective matched cohort study.

SETTINGS: The Health and Retirement Study, a nationally representative, longitudinal survey of adults >50 years of age, collects data on functional status, cognition, and demographics, among other topics. The survey was linked with Medicare claims and National Death Index data from 1992 to 2012.

PATIENTS: Patients ≥65 years of age who underwent elective high-risk colorectal surgery with functional status measured before and after surgery were included. These patients were matched 1:3 to survey respondents who did not undergo major surgery, based on propensity scores.

MAIN OUTCOME MEASURES: Functional decline, the primary outcome, was defined as an increase in the number of activities of daily living and instrumental activities of daily living requiring assistance before and after surgery. Using logistic regression, we examined whether surgery without or with complications was associated with functional decline. RESULTS: We identified 289 patients who underwent high-risk colorectal surgery and 867 matched control subjects. Of the surgery patients, 90 (31%) experienced a complication. Compared with the control subjects, surgery patients experienced greater likelihood of functional decline (without complications: OR = 1.82 (95% CI, 1.22-2.71), and with complications: OR = 2.96 (95% CI, 1.70-5.14)). Increasing age also predicted greater odds of functional decline (OR = 2.09, per decade (95% CI, 1.57-2.80)). LIMITATIONS: The functional measures were self-reported by survey participants.

CONCLUSIONS: High-risk colorectal surgery, without or with complications, is associated with increased likelihood of functional decline in older adults. Patient-centered decision-making should include discussion of expected functional outcomes and long-term disability.