The Impact of Dementia on Community-Dwelling Older Adults: Differences in Perioperative and Longer-Term Outcomes Following Emergency General Surgery
*Manuel Castillo-Angeles MD, MPH1, *Cheryl Zogg PhD1, *Rachel R. Adler ScD1, *Lingwei Xiang MPH1, Joaquim Havens MD1, *Joel Weissman PhD1, *Clancy J. Clark MD2
1Surgery, Brigham and Women's Hospital, Brookline, MA; 2Surgery, Wake Forest School of Medicine, Winston-Salem, NC
Background: As the US population ages, there is expected to be a parallel increase in the number of older adults requiring evaluation for surgical emergencies. Existing research conducted primarily among elective procedures over the short-term perioperative period suggests that older adults with Alzheimer’s Disease and Related Dementias (ADRD) are at particularly increased risk. However, little is known about the outcomes of patients with ADRD in emergency situations. The objective of this study was to examine the extent to which both short-term perioperative and longer-term post-discharge outcomes differ among older adults with and without ADRD undergoing common emergency general surgery (EGS) procedures.
Study Design: Community-dwelling older adults, ?65 years, hospitalized with an AAST-defined EGS condition who underwent 1-of-7 previously-described EGS procedures shown to represent >80% of the US’s operative EGS burden were identified using 2017 100% Medicare fee-for-service claims. Data from 12 months prior were used to identify dementia, comorbidities, and previous health-services utilization (including community-dwelling status). Patients were followed forward in time through 12 months after discharge. Risk-adjusted hierarchical models compared differences in 30/90/180/365-day mortality, readmission, and major morbidity. Differences in patients’ average number of healthy days at home (HDAH) and its constituent factors (e.g. time spent in skilled nursing facilities) within 365 days were also assessed. IPTW with propensity scores was used to account for potential confounding.
Results: A total of 186,806 community-dwelling older adults were included; 9.7% (n=18,114) had documented ADRD in the 12 months prior to surgery. Risk-adjusted differences in outcomes are presented in Table 1. Compared to older adults without ADRD, those with ADRD were more likely to be readmitted (365-day HR[95%CI]: 1.23[1.20-1.26]) and experience major morbidity (365-day HR[95%CI]: 1.54[1.49-1.60]). They were markedly more likely to die, a trend which increased in a step-wise fashion from 30 (HR[95%CI]: 2.78[2.54-3.05]) to 365 (3.19[3.08-3.31]) days. They spent an average of 70.7 (95%CI: 72.2-69.2) fewer HDAH, a reality primarily driven by increased new requirements for skilled nursing facility (mean difference [95%CI]: +22.3[21.9-22.8] days), hospice (+10.4[10.1-10.7]), and home health agency (+9.1[8.3-9.8] days) care.
Conclusions: As the US population ages, an increasing number of older adults will require urgent evaluation for emergency surgery. The results of this study suggest that among those with ADRD careful attention will need to be paid to when operative intervention is warranted given significantly increased risk of adverse outcomes, notably including 3-times higher mortality and an average of 2.5 additional months spent in decreased states of health compared to community-dwelling older adults without ADRD.
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