Most of us have come across an elderly relative or friend who is subjected to surgery after a fall to fix a broken bone. We then hear that they did not make it through surgery or they died soon after. We immediately assume that the medical care was substandard.

A new research from USA suggests that taking both physical frailty and cognitive impairment into account before surgery may yield a better estimate than either factor taken alone of the odds an older person will survive after major surgery.

Although the patients who were operated were much younger (average age 58) and most of them were operated for cancer (removing a kidney, prostate or part of the bladder), we can surmise that the same rule can be applied for the older patient who sustains a hip fracture and who may not make it through surgery.

The study was done at a single academic medical centre in Georgia, and most patients were white and undergoing elective surgery. In the study reported in the Journal of the American College of Surgeons, researchers examined data on 330 adults who had major surgery, including 168 who were considered “robust” because they didn’t appear to have any cognitive problems or issues with physical frailty. Over four years of follow-up, 53 patients died.

Assessment for cognitive skills was done by asking patients to draw clocks. These tests rely on executive function and visual and spatial planning skills rather than on education or language ability. Assessment of frailty was done through data from tests of walking speed, activity levels, weakness and exhaustion.

Among patients who were robust or only cognitively impaired, around 12 percent died. Among those who were physically frail but not cognitively impaired, mortality was 25 percent. But with both frailty and cognitive problems, deaths rose to 42 percent.

Dr. Viraj Master of Emory University in Atlanta who is the senior author said “Cognitive impairment in frail surgical patients is a strong predictor of worsening survival”.
Dr Master indicated that while the study didn’t examine why the combination of cognitive impairment and physical frailty might hasten death, it was possible that people with only one of these problems were better able to compensate for deficits from the other condition.

Dr. Master said that “The decreased physiological and cognitive reserves of patients undergoing major surgery make it difficult for patients to not only physically heal and recover after a surgery, but mentally understand how to care for their needs and use mental judgment to make decisions about their care,”
In the robust group of patients who didn’t have cognitive impairment or frailty, 20 of 168 died within four years. In the group that was both frail and cognitively impaired, 11 of 26 patients died.

Dr. Bellal Joseph of the University of Arizona in Tucson who was not involved in the study said the findings suggest that assessing cognitive and physical abilities before surgery might help identify patients who are more likely to die or have complications. He also mentioned that “This study highlights that the patients who suffer from both frailty and cognitive impairments have more stressors going into surgery,” “The other group that is always worrisome is the ‘prefrail,’ those that are on the verge of frailty, because surgery could push them over the edge into frailty.”

When doctors identify high-risk patients in advance, they may be able to offer people rehabilitation or recommend changes in nutrition, exercise or drug regimens that might make them more robust heading into surgery, Joseph said.