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Roughly one in seven community-living older adults in the U.S. died in the year after a major surgery, and the risk was far higher for those with frailty or probable dementia, according to a national population-based estimate.

Based on findings from nearly 1,000 community-living Medicare beneficiaries who underwent a major surgery from 2011 to 2017, the population estimate for mortality within 1 year of surgery was 13.4%, reported Thomas Gill, MD, of the Yale School of Medicine in New Haven, Connecticut, and colleagues.

Mortality at 1 year grew to 27.8% among the individuals with frailty (adjusted hazard ratio [aHR] 2.18, 95% CI 1.40-3.40) and 32.7% for those with probable dementia (aHR 4.41, 95% CI 2.53-7.69), the authors wrote in .

Major surgery is common in this population, Gill's group explained, with a 5-year cumulative risk of 13.8% that represents nearly 5 million people. Individuals with frailty comprise 12.1% of this population, while those with probable dementia comprise 12.4%.

"These values, combined with the mortality estimates reported in the current study, highlight the public health relevance of major surgery in an aging society, and suggest that policies, resources, interventions, and programs aimed at optimizing the care and outcomes of older U.S. adults undergoing major surgery may have utility," wrote Gill and colleagues.

In an , Jennifer Perone, MD, and Daniel Anaya, MD, both of the H. Lee Moffitt Cancer Center and Research Institute in Tampa, Florida, noted that the mortality rates in the frail and dementia populations "suggest that there is a break in the system where goals of surgery are often not accomplished following surgery."

"These findings are likely to have an even more drastic effect on patients in the assisted-living setting, with clear unmet needs for those most vulnerable," they continued. "The cumulative mortality extending along the first year suggests that death is not associated with surgery alone but also with chronic conditions (and changes derived from surgery) and the overall life expectancy of the population."

For their study, Gill and colleagues examined data on 1,193 major surgeries from 992 community-living older adults enrolled in the National Health and Aging Trends Study (), including 661 elective and 532 non-elective surgeries. All patients were fee-for-service Medicare beneficiaries, and major surgeries and mortality were identified by linking to data from the Centers for Medicare & Medicaid Services. Information on dementia and frailty came from NHATS assessments.

Mean patient age was 79 years, and 56% were women. Over three-quarters were white and 16.6% were Black. The mean number of chronic conditions was 2.8, which included frailty in a fourth of patients, pre-frailty in about half, possible dementia in 10.6%, and probable dementia in 12.5%. The most common surgeries were musculoskeletal (40%), followed by abdominal (18%) and vascular (12%) surgeries.

Those who underwent elective surgery tended to be younger and have better education compared to those undergoing non-elective surgery, and were also less likely to be eligible for Medicaid, frail, or have possible or probable dementia.

At 1 year of follow-up, 206 patients died, representing 872,097 survey-weighted deaths. Median time to death was 96 days for all major surgeries (169 days for elective and 62 days for non-elective surgeries).

Non-elective surgery was associated with a nearly threefold higher mortality risk compared with elective or planned surgery (22.3% vs 7.4%, respectively; aHR 2.75, 95% CI 1.85-4.08). Additionally, Black race was associated with a higher mortality risk compared with white race (aHR 1.73, 95% CI 1.06-2.80) as was male sex (aHR 1.51, 95% CI 1.08-2.13).

Not surprisingly, risk of 1-year cumulative mortality increased with age and was significantly higher in the three oldest age groups (compared to patients ages 65-69):

• Age 80-84: aHR 2.50 (95% CI 1.34-4.66)
• Age 85-89: aHR 3.03 (95% CI 1.48-6.19)
• Age ≥90 and up: aHR 6.56 (95% CI 3.19-13.5)

"Large mortality differences were readily apparent within the first month after major surgery for the two oldest age groups and for persons who had frailty and probable dementia," the study authors noted. "These differences, which were comparable to that observed between elective and nonelective surgery, persisted over the following 11 months, suggesting the potential short-term and long-term prognostic value of these factors."

Among the limitations were that data were unavailable for individuals with Medicare Advantage, a growing population where enrollment rates are expected to increase from the 25% in the current analysis to 42% by 2028.

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