Significant new disability after major non-cardiac surgery in older adults aged 65 years and older in Canada: a multicentre prospective cohort study.

BACKGROUND

Older adults aged 65 years and older considering major surgery often prioritise functional and cognitive outcomes over survival. Therefore, we conducted a prospective cohort study that aimed to characterise the incidence, effect, and predictors of new postoperative disability in older adults.

METHODS

The Functional Improvement Trajectories After Surgery multicentre prospective cohort study enrolled older adults (ie, those aged ≥65 years) undergoing major elective non-cardiac surgery at 17 hospitals across Canada. Endovascular, joint replacement, intra-cranial, and palliative procedures were excluded. The WHO Disability Assessment Schedule was used to assess disability preoperatively and at 1, 3, 6, 9, and 12 months postoperatively. The primary outcome was 6-month significant new disability or death. The secondary outcome was this composite outcome at 12 months. Multivariable logistic regression models were used to estimate associations of baseline characteristics with outcomes.

FINDINGS: Between Dec 16, 2019, and April 26, 2023, we enrolled 2007 patients (median age 72 years [IQR 68-76]; 853 [42·5%] were female), of whom 1988 (99·1%) lived at home and 868 (43·3%) lived with frailty. By 6 months after surgery, 16·5% patients had significant new disability and death, increasing to 20·7% by 1 year. Patients with new disability at 6 months had higher risks of concurrent depression (risk difference 36·7%, 95% CI 31·9-41·6) and decisional regret (9·9%, 5·1-14·7). At 12 months, the higher risks of depression (33·6%, 28·2-39·0) and decisional regret (12·9%, 7·9-17·8) persisted. Multivariable modelling identified baseline frailty, cognitive impairment, mobility aids, open surgery, smoking, and possibly unmet social supports as associated with increased risks of postoperative new disability or death.

INTERPRETATION: One in six older adults in this cohort experienced new disability or death at 6 months following major surgery, increasing to one in five patients by 1 year. Preoperative assessment of frailty, cognitive status, and social supports could enhance shared decision making, care planning, and functional recovery.

FUNDING: Canadian Institutes of Health Research, PSI Foundation, Ontario Ministry of Health Innovation Fund, and the Elizabeth A and Richard J Currie, OC Chair in Translational Anesthesia Research at St Michael's Hospital and the University of Toronto.