Older individuals contemplating surgery often express concerns regarding potential complications, returning home, and the anticipated improvement in their quality of life. Notably, the avoidance of new or worsening disability becomes a paramount consideration with advancing age. To better guide patients, clinicians must not only discuss surgical success rates but also apprise them of the likelihood of developing new or worsening disability after surgery.
In a recent single-center analysis encompassing 2,176 patients aged 70 and older who received surgery, 12% of patients had passed away, 23% experienced significant disability, and 42% faced death or disability at the six-month mark.
The occurrence of new or worsening disability after surgery is a common concern. Research and reporting and important components of preventing this from occurring. The 12-item World Health Organization Disability Assessment Schedule version 2.0 (WHODAS) has been validated for this purpose, offering operational definitions for clinically significant disability, worsening disability, and disability-free survival. Recognizing the need for comprehensive risk assessment, the primary objective of WHODAS 2.0 was to define risk factors for postoperative disability. Risk factors contributing to postoperative disability include greater patient age, frailty, severe systemic disease, and poor functional status. The type of surgery may also play a role, with higher rates of new disability reported in thoracic, orthopedic, and neurosurgery. Utilizing a purpose-built hospital registry, the researchers sought to develop and validate a model predicting death or disability in older surgical patients.
The WHODAS 2.0 has emerged as a clinically acceptable, valid, reliable, and responsive instrument for measuring disability after surgery in diverse populations. By focusing on limitations in major life domains such as cognition, mobility, self-care, interpersonal relationships, work, household roles, and participation in society, WHODAS 2.0 can provide meaningful outcome data for clinicians and patients alike.
While traditional surgical metrics emphasize mortality and complications, patients, especially older ones, prioritize quality of life. One study aimed to bridge this gap by evaluating factors influencing functional recovery after major surgery. The focus on postoperative disability was underscored by the recognition that more than 70% of older individuals would not opt for a treatment causing severe functional disability, even with assured survival. Another study delved into potential predictors of functional recovery after major surgery in older patients. Factors such as being non-frail, undergoing elective surgery, absence of hearing impairment, and fewer years of education were positively associated with functional recovery. Conversely, certain comorbidities were linked to a higher risk of protracted disability after surgery.
In conclusion, postoperative disability is a common risk of surgery, especially in older surgical patients. Clinicians must counsel patients regarding these risks and employ validated tools to help predict disability. By employing the WHODAS 2.0 as a comprehensive measure, clinicians can provide patients with valuable insights into risk factors, recovery predictors, and the long-term impact of major surgery on functional status. As research continues, interventions targeting modifiable risk factors hold promise for improving outcomes and enhancing the post-surgical experience for older individuals.
References
1. Mark A. Shulman, Sophie Wallace, Annie Gilbert, Jennifer R. Reilly, Jessica Kasza, Paul S. Myles; Predicting Death or Disability after Surgery in the Older Adult. Anesthesiology 2023; 139:420–431 doi: https://doi.org/10.1097/ALN.0000000000004683
2. Mark A. Shulman, Paul S. Myles, Matthew T. V. Chan, David R. McIlroy, Sophie Wallace, Jennie Ponsford; Measurement of Disability-free Survival after Surgery. Anesthesiology 2015; 122:524–536 doi: https://doi.org/10.1097/ALN.0000000000000586
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7. WHO Disability Assessment Schedule (WHODAS) 2.0. Accessed Nov 27, 2023. https://www.who.int/standards/classifications/international-classification-of-functioning-disability-and-health/who-disability-assessment-schedule