HHS Public Access Author manuscript Author Manuscript
J Am Geriatr Soc. Author manuscript; available in PMC 2017 October 01. Published in final edited form as: J Am Geriatr Soc. 2016 October ; 64(10): e102–e104. doi:10.1111/jgs.14349.
Low Mobility and Self-Reported Function Were Associated with Trends toward an Adverse Postoperative Course in Older Adult Surgical Patients
Author Manuscript
Alok Kapoor, MD, MSc, Nicholas S. Shaffer, MPH, Christine M. McDonough, PT, PhD, Daniel K. White, PT, ScD, MSc, Na Wang, Pamela Rosenkranz, RN, BSN, Med, Andrew Glantz, MD, David McAneny, MD, Gerard M. Doherty, MD, Howard J. Cabral, PhD, Jerry H. Gurwitz, MD, Roger A. Fielding, PhD, Alan M. Jette, PhD, and Rebecca A. Silliman, MD, PhD Department of Medicine, University of Massachusetts Medical School (AK, JHG); Meyers Primary Care Institute, Worcester Massachusetts (AK, JHG); Department of Medicine, Boston University School of Medicine (AK, NSS, RAS); Department of Health Law, Policy & Management, Boston University School of Public Health (CMM, AMJ); Department of Physical Therapy, University of Delaware (DKW); Data Coordinating Center, Boston University School of Public Health (N.W.); Department of Surgery, Boston University School of Medicine (PR, AG, DM, G.MD); Department of Biostatistics, Boston University School of Public Health (HJC); Nutrition, Exercise Physiology, and Sarcopenia Laboratory, Tufts University (R.A.F.)
To the Editor Author Manuscript
In some high risk populations of older adults even routine surgery can lead to an adverse postoperative course. Identifying these high risk older adults can be helpful in planning surgery. Prior assessment tools like the Revised Cardiac Risk Index1 focused on comorbidity predictors rather than mobility or function. Recently researchers started studying either mobility or functional status but few have directly compared mobility and self-reported function.
METHODS Population
Author Manuscript
Patients age 50 and older visiting the Pre-Procedure Clinic at Boston Medical Center prior to general, vascular, and urologic surgery; patients had to pass the MiniCog Assessment given limitations in measuring self-reported function in patients with impaired cognition.2
Correspondence to Alok Kapoor, MD, MSc, Division of Geriatric Medicine, University of Massachusetts Medical School, 365 Plantation Street, Suite 100, Worcester, MA 01605. P: (508) 334-1000. F: (617) 963-7482. [email protected]. Alternate correspondence to Nicholas Shaffer, MPH., P: (210) 836-8090 [email protected]. Conflict of Interest: None. Author Contributions: Design, manuscript writing/review: AK, NSS, CMM, DKW, PR, AG, DM, GMD, JHG, RAF, AMJ, RAS Analysis, manuscript review: NW, HJC Sponsor’s Role: None.
Kapoor et al.
Page 2
Outcomes
Author Manuscript
Adverse postoperative course including serious medical complication, discharge to nursing home, readmission, or death within 30 days of surgery following definitions of the American College of Surgeons (ACS).3 Follow-up We examined the first 30 days after surgery for our outcomes. In cases of follow-up less than 30 days, we used the last visit date. Independent variables
Author Manuscript
We measured gait speed over 4m following the protocol of Guralnick et al.4 We measured self-reported function with the computer adaptive testing (CAT) version of the late life function (LL-F) instrument.5 CAT decreases respondent burden while at the same time leveraging a 160 item function bank. Analysis We measured the association of gait speed and LL-F with an adverse postoperative course in clinically meaningful categories using chi-square testing. Because there were patients for whom we did not have complete 30 day follow-up, we also analyzed our data with a Cox proportional hazards model for each independent variable. Given limited sample size we did not adjust for other variables in our models.
RESULTS Author Manuscript
From pool of 456 eligible patients, 226 (49.6%) agreed to participate; 204 of these underwent surgery. Mean age was 62 years. Average gait speed was 1.06 ± 0.27 m/s. Average LL-F score was 58.6 ± 9.5. Eighteen patients had an adverse postoperative course. Examining gait speed and LL-F, we found a suggestion of a threshold value of 50 and 1.0 m/s, respectively for LL-F and gait speed in relation to adverse hospital course. (Table1) The effect of LL-F appeared less substantial. In Cox proportional hazards modeling, we found that gait speed ≤ 1.0 m/s was associated with a trend towards a 70% increased risk in an adverse postoperative outcome whereas LL-F ≤ 50 was associated with a trend towards a 32% increased risk.
DISCUSSION Author Manuscript
We found a trend linking mobility and self-reported function with an adverse postoperative course. Gait speed appeared to be more strongly associated with an adverse course, although our findings are limited by a low outcome rate. Prior studies reported variable effects of gait speed on adverse outcomes. Afilalo et al. studying cardiac surgery patients 70 years and older found that gait speed < 0.84 m/s predicted a more than a threefold increase in morbidity and mortality.6 By contrast, Kwon et al. did not find a relation between gait speed and the development of postoperative disability.7 The outcome instrument used by Kwon et al. has not been tested in surgical J Am Geriatr Soc. Author manuscript; available in PMC 2017 October 01.
Kapoor et al.
Page 3
Author Manuscript
populations, however, and therefore we cannot compare it directly with the adverse postoperative outcome we used. As for function, Rumsfeld et al. found a larger effect than we did – i.e. a 60% increase in risk of postoperative mortality for each 10 point reduction in the physical component score (PCS) summary statistic of the fixed form, short form-36.8 Similarly, working with the Veteran Rand-12 (close cousin to short form-12), we found that older male veterans undergoing total hip and knee replacement reporting lowest quartile of physical function (i.e. PCS values 39).9 We did not find as large an association in the current study given that our population was younger and reporting better function.
Author Manuscript
Findings from our pilot study hold promise for the inclusion of mobility and/or self-reported function in the preoperative assessment process for older adults. Each of these assessments requires only 2–3 minutes to administer, making them more feasible than recording Fried Frailty Criteria (which requires 15 minutes or more) as recommended by certain authorities.10 Scoring of frailty criteria (with 3 criteria required for classifying pre-frailty and 4 criteria for frailty) also limits our ability to risk stratify lower risk patients who might still be vulnerable. Future research should repeat our measurements in a larger sample and compare mobility and function against Fried Frailty across a wide spectrum of older adults.
Acknowledgments We acknowledge the sponsor of our research, the Boston Rehabilitation Outcomes Center Pilot Program and the parent NIH sponsor (5R24HD065688).
Author Manuscript
Funding Sources: Boston Rehabilitation Outcomes Center Pilot Program (5R24HD065688)
References
Author Manuscript
1. Lee TH, Marcantonio ER, Mangione CM, et al. Derivation and prospective validation of a simple index for prediction of cardiac risk of major noncardiac surgery. Circulation. 1999; 100:1043–9. [PubMed: 10477528] 2. Jette, AM., Kopits, IM., McDonough, CM., et al. Boston University Late-Life Function and Disability Instrument Version 1.04. (online). Boston Rehabilitation Outcomes Center; Available at: http://www.bu.edu/bostonroc/files/2012/04/LLFDI-CAT-Manual-Version-1.04.pdf [Accessed March 30, 2016] 3. ACS NSQIP Surgical Risk Calculator. [Accessed March 30, 2016] American College of Surgeons National Surgical Quality Improvement Program (online). Available at: http:// riskcalculator.facs.org/ 4. Guralnik JM, Simonsick EM, Ferrucci L, et al. A short physical performance battery assessing lower extremity function: association with self-reported disability and prediction of mortality and nursing home admission. J Gerontol. 1994; 49:M85–94. [PubMed: 8126356] 5. Jette, AM., Kopits, IM., McDonough, CM., et al. Boston University Late-Life Function and Disability Instrument Version 1.04. (online). Boston Rehabilitation Outcomes Center; Available at: http://www.bu.edu/bostonroc/files/2012/04/LLFDI-CAT-Manual-Version-1.04.pdf [Accessed March 30, 2016] 6. Afilalo J, Eisenberg MJ, Morin JF, et al. Gait speed as an incremental predictor of mortality and major morbidity in elderly patients undergoing cardiac surgery. J Am Coll Cardiol. 2010; 56:1668– 76. [PubMed: 21050978]
J Am Geriatr Soc. Author manuscript; available in PMC 2017 October 01.
Kapoor et al.
Page 4
Author Manuscript
7. 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; 78:1336–44. [PubMed: 23265122] 8. Rumsfeld JS, Mawhinney S, Mccarthy M, et al. Health-related quality of life as a predictor of mortality following coronary artery bypass graft surgery. Participants of the Department of Veterans Affairs Cooperative Study Group on Processes, Structures, and Outcomes of Care in Cardiac Surgery. JAMA. 1999; 281:1298–303. [PubMed: 10208145] 9. Kapoor A, Chew PW, Reisman JI, et al. Low Self-Reported Function Predicts Adverse Postoperative Course in Veterans Affairs Beneficiaries Undergoing Total Hip and Total Knee Replacement. J Am Geriatr Soc. In press. 10. Chow WB, Rosenthal RA, Merkow RP, et al. Optimal preoperative assessment of the geriatric surgical patient: a best practices guideline from the American College of Surgeons National Surgical Quality Improvement Program and the American Geriatrics Society. J Am Coll Surg. 2012; 215:453–66. [PubMed: 22917646]
Author Manuscript Author Manuscript Author Manuscript J Am Geriatr Soc. Author manuscript; available in PMC 2017 October 01.
Kapoor et al.
Page 5
Table 1
Author Manuscript
Adverse Postoperative Course and Length of Stay as a Function of Gait Speed and LL-F Assessment Tool Categories
Gait speed in m/s
LL-F
Categories
Adverse Postoperative course n/N (%)
Categories
Hazard Ratio for Adverse Postoperative Course (95% CI)
1.0
8/116 (6.9)
> 1.0
ref
0–50
5/48 (10.4)
≤ 50
1.32 (0.42–2.71))
50–60
6/70 (8.6) > 50
ref
>60
7/85 (8.2)
Abbreviations: LL-F = Late Life Function part of the Late Life Function and Disability Instrument
Author Manuscript Author Manuscript Author Manuscript J Am Geriatr Soc. Author manuscript; available in PMC 2017 October 01.
J Am Geriatr Soc. Author manuscript; available in PMC 2017 October 01. Published in final edited form as: J Am Geriatr Soc. 2016 October ; 64(10): e102–e104. doi:10.1111/jgs.14349.
Low Mobility and Self-Reported Function Were Associated with Trends toward an Adverse Postoperative Course in Older Adult Surgical Patients
Author Manuscript
Alok Kapoor, MD, MSc, Nicholas S. Shaffer, MPH, Christine M. McDonough, PT, PhD, Daniel K. White, PT, ScD, MSc, Na Wang, Pamela Rosenkranz, RN, BSN, Med, Andrew Glantz, MD, David McAneny, MD, Gerard M. Doherty, MD, Howard J. Cabral, PhD, Jerry H. Gurwitz, MD, Roger A. Fielding, PhD, Alan M. Jette, PhD, and Rebecca A. Silliman, MD, PhD Department of Medicine, University of Massachusetts Medical School (AK, JHG); Meyers Primary Care Institute, Worcester Massachusetts (AK, JHG); Department of Medicine, Boston University School of Medicine (AK, NSS, RAS); Department of Health Law, Policy & Management, Boston University School of Public Health (CMM, AMJ); Department of Physical Therapy, University of Delaware (DKW); Data Coordinating Center, Boston University School of Public Health (N.W.); Department of Surgery, Boston University School of Medicine (PR, AG, DM, G.MD); Department of Biostatistics, Boston University School of Public Health (HJC); Nutrition, Exercise Physiology, and Sarcopenia Laboratory, Tufts University (R.A.F.)
To the Editor Author Manuscript
In some high risk populations of older adults even routine surgery can lead to an adverse postoperative course. Identifying these high risk older adults can be helpful in planning surgery. Prior assessment tools like the Revised Cardiac Risk Index1 focused on comorbidity predictors rather than mobility or function. Recently researchers started studying either mobility or functional status but few have directly compared mobility and self-reported function.
METHODS Population
Author Manuscript
Patients age 50 and older visiting the Pre-Procedure Clinic at Boston Medical Center prior to general, vascular, and urologic surgery; patients had to pass the MiniCog Assessment given limitations in measuring self-reported function in patients with impaired cognition.2
Correspondence to Alok Kapoor, MD, MSc, Division of Geriatric Medicine, University of Massachusetts Medical School, 365 Plantation Street, Suite 100, Worcester, MA 01605. P: (508) 334-1000. F: (617) 963-7482. [email protected]. Alternate correspondence to Nicholas Shaffer, MPH., P: (210) 836-8090 [email protected]. Conflict of Interest: None. Author Contributions: Design, manuscript writing/review: AK, NSS, CMM, DKW, PR, AG, DM, GMD, JHG, RAF, AMJ, RAS Analysis, manuscript review: NW, HJC Sponsor’s Role: None.
Kapoor et al.
Page 2
Outcomes
Author Manuscript
Adverse postoperative course including serious medical complication, discharge to nursing home, readmission, or death within 30 days of surgery following definitions of the American College of Surgeons (ACS).3 Follow-up We examined the first 30 days after surgery for our outcomes. In cases of follow-up less than 30 days, we used the last visit date. Independent variables
Author Manuscript
We measured gait speed over 4m following the protocol of Guralnick et al.4 We measured self-reported function with the computer adaptive testing (CAT) version of the late life function (LL-F) instrument.5 CAT decreases respondent burden while at the same time leveraging a 160 item function bank. Analysis We measured the association of gait speed and LL-F with an adverse postoperative course in clinically meaningful categories using chi-square testing. Because there were patients for whom we did not have complete 30 day follow-up, we also analyzed our data with a Cox proportional hazards model for each independent variable. Given limited sample size we did not adjust for other variables in our models.
RESULTS Author Manuscript
From pool of 456 eligible patients, 226 (49.6%) agreed to participate; 204 of these underwent surgery. Mean age was 62 years. Average gait speed was 1.06 ± 0.27 m/s. Average LL-F score was 58.6 ± 9.5. Eighteen patients had an adverse postoperative course. Examining gait speed and LL-F, we found a suggestion of a threshold value of 50 and 1.0 m/s, respectively for LL-F and gait speed in relation to adverse hospital course. (Table1) The effect of LL-F appeared less substantial. In Cox proportional hazards modeling, we found that gait speed ≤ 1.0 m/s was associated with a trend towards a 70% increased risk in an adverse postoperative outcome whereas LL-F ≤ 50 was associated with a trend towards a 32% increased risk.
DISCUSSION Author Manuscript
We found a trend linking mobility and self-reported function with an adverse postoperative course. Gait speed appeared to be more strongly associated with an adverse course, although our findings are limited by a low outcome rate. Prior studies reported variable effects of gait speed on adverse outcomes. Afilalo et al. studying cardiac surgery patients 70 years and older found that gait speed < 0.84 m/s predicted a more than a threefold increase in morbidity and mortality.6 By contrast, Kwon et al. did not find a relation between gait speed and the development of postoperative disability.7 The outcome instrument used by Kwon et al. has not been tested in surgical J Am Geriatr Soc. Author manuscript; available in PMC 2017 October 01.
Kapoor et al.
Page 3
Author Manuscript
populations, however, and therefore we cannot compare it directly with the adverse postoperative outcome we used. As for function, Rumsfeld et al. found a larger effect than we did – i.e. a 60% increase in risk of postoperative mortality for each 10 point reduction in the physical component score (PCS) summary statistic of the fixed form, short form-36.8 Similarly, working with the Veteran Rand-12 (close cousin to short form-12), we found that older male veterans undergoing total hip and knee replacement reporting lowest quartile of physical function (i.e. PCS values 39).9 We did not find as large an association in the current study given that our population was younger and reporting better function.
Author Manuscript
Findings from our pilot study hold promise for the inclusion of mobility and/or self-reported function in the preoperative assessment process for older adults. Each of these assessments requires only 2–3 minutes to administer, making them more feasible than recording Fried Frailty Criteria (which requires 15 minutes or more) as recommended by certain authorities.10 Scoring of frailty criteria (with 3 criteria required for classifying pre-frailty and 4 criteria for frailty) also limits our ability to risk stratify lower risk patients who might still be vulnerable. Future research should repeat our measurements in a larger sample and compare mobility and function against Fried Frailty across a wide spectrum of older adults.
Acknowledgments We acknowledge the sponsor of our research, the Boston Rehabilitation Outcomes Center Pilot Program and the parent NIH sponsor (5R24HD065688).
Author Manuscript
Funding Sources: Boston Rehabilitation Outcomes Center Pilot Program (5R24HD065688)
References
Author Manuscript
1. Lee TH, Marcantonio ER, Mangione CM, et al. Derivation and prospective validation of a simple index for prediction of cardiac risk of major noncardiac surgery. Circulation. 1999; 100:1043–9. [PubMed: 10477528] 2. Jette, AM., Kopits, IM., McDonough, CM., et al. Boston University Late-Life Function and Disability Instrument Version 1.04. (online). Boston Rehabilitation Outcomes Center; Available at: http://www.bu.edu/bostonroc/files/2012/04/LLFDI-CAT-Manual-Version-1.04.pdf [Accessed March 30, 2016] 3. ACS NSQIP Surgical Risk Calculator. [Accessed March 30, 2016] American College of Surgeons National Surgical Quality Improvement Program (online). Available at: http:// riskcalculator.facs.org/ 4. Guralnik JM, Simonsick EM, Ferrucci L, et al. A short physical performance battery assessing lower extremity function: association with self-reported disability and prediction of mortality and nursing home admission. J Gerontol. 1994; 49:M85–94. [PubMed: 8126356] 5. Jette, AM., Kopits, IM., McDonough, CM., et al. Boston University Late-Life Function and Disability Instrument Version 1.04. (online). Boston Rehabilitation Outcomes Center; Available at: http://www.bu.edu/bostonroc/files/2012/04/LLFDI-CAT-Manual-Version-1.04.pdf [Accessed March 30, 2016] 6. Afilalo J, Eisenberg MJ, Morin JF, et al. Gait speed as an incremental predictor of mortality and major morbidity in elderly patients undergoing cardiac surgery. J Am Coll Cardiol. 2010; 56:1668– 76. [PubMed: 21050978]
J Am Geriatr Soc. Author manuscript; available in PMC 2017 October 01.
Kapoor et al.
Page 4
Author Manuscript
7. 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; 78:1336–44. [PubMed: 23265122] 8. Rumsfeld JS, Mawhinney S, Mccarthy M, et al. Health-related quality of life as a predictor of mortality following coronary artery bypass graft surgery. Participants of the Department of Veterans Affairs Cooperative Study Group on Processes, Structures, and Outcomes of Care in Cardiac Surgery. JAMA. 1999; 281:1298–303. [PubMed: 10208145] 9. Kapoor A, Chew PW, Reisman JI, et al. Low Self-Reported Function Predicts Adverse Postoperative Course in Veterans Affairs Beneficiaries Undergoing Total Hip and Total Knee Replacement. J Am Geriatr Soc. In press. 10. Chow WB, Rosenthal RA, Merkow RP, et al. Optimal preoperative assessment of the geriatric surgical patient: a best practices guideline from the American College of Surgeons National Surgical Quality Improvement Program and the American Geriatrics Society. J Am Coll Surg. 2012; 215:453–66. [PubMed: 22917646]
Author Manuscript Author Manuscript Author Manuscript J Am Geriatr Soc. Author manuscript; available in PMC 2017 October 01.
Kapoor et al.
Page 5
Table 1
Author Manuscript
Adverse Postoperative Course and Length of Stay as a Function of Gait Speed and LL-F Assessment Tool Categories
Gait speed in m/s
LL-F
Categories
Adverse Postoperative course n/N (%)
Categories
Hazard Ratio for Adverse Postoperative Course (95% CI)
1.0
8/116 (6.9)
> 1.0
ref
0–50
5/48 (10.4)
≤ 50
1.32 (0.42–2.71))
50–60
6/70 (8.6) > 50
ref
>60
7/85 (8.2)
Abbreviations: LL-F = Late Life Function part of the Late Life Function and Disability Instrument
Author Manuscript Author Manuscript Author Manuscript J Am Geriatr Soc. Author manuscript; available in PMC 2017 October 01.
