It is projected that the number of Americans aged 65 or older will double from 46 to 98 million between 2014 and 2060. A study by Yale researchers identified the chief risk factors associated with loss of independence in older patients after a major surgery.

This study, published Feb. 24 in the Journal of the American Geriatrics Society, was led by professor of geriatrics and of epidemiology Thomas Gill. As a geriatrician, Gill’s clinical work primarily involves older people. He found that what older patients rated as most important, “time and time again,” was their independence. Post-surgery, the ability to manage one’s own personal care needs and not depend on family for day-to-day affairs was a crucial outcome for patients. This study had two goals: to identify subgroups that are at high risk for poor functional outcomes and to identify factors that could serve as the basis for an intervention in the spirit of a co-management model, or the enlistment of geriatricians to assist surgeons in the care of older patients.

“Independence is very important to older individuals,” Professor of Geriatrics Leo Cooney MED ’69 said. “The ability to take care of yourself allows you to stay in your own home, stay connected to your family and friends, continue to be a part of your community and stay who you are throughout your late life.”

The researchers followed 754 individuals in south-central Connecticut aged 70 or older. From March 1997 to December 2017, 247 people underwent 327 major surgeries. The team identified ten factors associated with disability over six months after major surgery.

These factors included age 85 years or older, female sex, Black race or Hispanic ethnicity, neighborhood disadvantage, multimorbidity, frailty, one or more disabilities, low functional self-efficacy, smoking and obesity. The study measured the risk posed by each factor with regards to burden of disability: Women had a 15 percent greater burden, persons with frailty had 19 percent greater burden and being aged 85 or older posed a 30 percent greater burden.

“Women are more susceptible to having more poor functional outcomes after almost any illness,” Gill said. “And there are probably different explanations for that. One is that women tend to have lower mortality than men so they have more opportunities to have worse functional outcomes because they haven’t died.”

Gill explained that non-elective surgeries, by definition, are surgeries that “you don’t know [are] going to happen.” These urgent medical procedures warrant interventions post-surgery. However, for elective surgeries, which are procedures scheduled in advance, interventions may be implemented before the surgery and attempt to improve the person’s physical capacity to endure the surgery and recovery process.

In evaluating the risk posed by low socioeconomic status, Gill emphasized that Medicaid-eligible patients and more generally, people with fewer economic resources, may not be able to afford co-payments and other requirements for post-hospital care, including rehabilitation. The co-payments that insurance does not cover are often the responsibility of the patient and their family. Gill speculated that co-payments could serve as an impediment to receiving the care that is recommended or required post-surgery.

“After major surgery, persons often need to have rehabilitation in order to regain some of the functions that they have lost,” Gill said. 

A subset of these ten identified factors could be addressed by interventions –– notably, the factors of frailty, low functional self-efficacy, smoking and obesity. Preoperative screening for frailty and cognitive impairment after major elective surgery could trigger a referral to a geriatrician for further evaluation of vulnerability to disability after major surgery.

According to Gill, major surgery and hospitalization often lead to considerable decline in function. The team was interested in trying to diminish those declines by developing interventions that could accelerate recovery after a major disabling event, such as surgery. This study will provide evidence in support of co-management models that could improve outcomes after surgery.

“Many programs across the country have gone to this co-management model,” Gill said. “Geriatricians are enlisted to assist in the care of older patients who are having major surgery because the surgeons either aren’t trained in that type of management, or they don’t have time because they are busy in the operating room. But there’s not yet much evidence whether this co-management model is effective or not, so that’s one of the reasons why we conducted this research study.”

Assistant professor of geriatrics Marcia Mecca referenced a study by professor of geriatrics and Section Chief of Geriatric Medicine Terri Fried that was published 20 years ago, outlining the prominent role that the risk of functional dependence plays in the decision making of older adults. Fried found that in the case of seriously ill patients who would die without treatment, over 70 percent of older persons would decline treatment that causes severe functional disability even if their survival was assured.

In the preoperative setting, she declared it vital for older adults to understand both the anticipated benefit of a surgery and the risks. Mecca urged health care providers to emphasize potential effects on older patients’ independence post-surgery when explaining health outcomes during discussion of treatment options.

“Dr. Gill and his colleagues have made an important contribution to our knowledge by identifying those factors connected to this new disability,” Cooney said. “This information will help healthcare institutions implement interventions designed to maintain independence. This is a crucial step in ensuring the quality of life of older persons.”

Gill is the director of the Program on Aging and Pepper Older Americans Independence Centers, as well as director of the Center on Disability and Disabling Disorders.