Frailty and Probable Dementia Risk Factors for Mortality After Major Surgery for Older Adults

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By Christopher Cheney

Among nearly 1,000 Medicare beneficiaries over age 65, the overall one-year mortality rate after major surgery was 13.4%, according to a new research article.

Earlier research has found that the five-year cumulative risk of major surgery for older U.S. adults is 13.8%, which amounts to nearly 5 million people. Given this relatively high number, major surgery for older adults is a consequential public health concern in the United States.

The new research article, which was published by JAMA Surgery, features data collected from 1,193 major surgeries involving 992 community-living older adults from 2011 to 2017. The data was drawn from Centers for Medicare & Medicaid Services fee-for-service Medicare claims and the National Health and Aging Trends Study. The definition of major surgery included any procedure performed in an operating room with general anesthesia.

The study includes several key data points:

  • The one-year mortality rate was highest for patients over the age of 90
  • The one-year mortality rate for elective surgeries was 7.4%, and the mortality rate for nonelective (unplanned) surgeries was 22.3%
  • Older adults who had elective surgery tended to have a more favorable risk profile than older adults who had nonelective surgery, including younger age, higher educational attainment, and lower incidence of frailty as well as possible or probable dementia
  • The one-year mortality rate for older adults who were not frail was 6.0% and 27.8% for older adults who were frail
  • The one-year mortality rate for older adults without dementia was 11.6% and 32.7% for older adults with probable dementia
  • The median time to death was 96 days for all major surgeries, 169 days for elective surgeries, and 62 days for nonelective surgeries

“In this study, the population-based estimate of one-year mortality after major surgery among community-living older adults in the U.S. was 13.4% but was three-fold higher for nonelective than elective procedures. Mortality was considerably elevated among older persons who were frail or who had probable dementia, highlighting the potential prognostic value of geriatric conditions after major surgery,” the research article’s co-authors wrote.

Interpreting the data

The data shows there are significant differences in one-year mortality after major surgery for older adults across subcategories, the study’s co-authors wrote.

“We found that nearly one of every seven community-living older U.S. adults died in the year after major surgery, including more than one of four who were frail and nearly one of three who had probable dementia. Mortality was three-fold higher for nonelective than elective surgery and was especially elevated for persons who were 90 years or older. Our findings suggest substantial differences in one-year mortality after major surgery across distinct subgroups of older persons and highlight the potential prognostic value of geriatric conditions such as frailty and dementia,” they wrote.

The data suggests there are ways to improve outcomes for older adults who undergo major surgery, the study’s co-authors wrote. “Our findings are notable because they define the scope and scale of mortality after major geriatric surgery in the U.S. and because they suggest a mix of surgical quality and safety among older persons. With improved preoperative optimization and recognition as well as enhanced perioperative management strategies, it is possible that mortality after major surgery could be reduced among older persons, especially those in high-risk subgroups.”

Christopher Cheney is the senior clinical care​ editor at HealthLeaders.