Page 81 - Risk quantification and modification in older patients with colorectal cancer

Geriatric risk score and poor surgical outcomes
decline, death, and high healthcare demand up to 3 months after hospitalization. The separate domains in that study did not satisfactorily predict the incidence of these adverse outcomes, as found in the current study for the risk for undernutrition.15 In addition, this adapted risk score of Heim, where patients aged 70–80 years are considered at risk when positive on three or more of the four VMS domains, appeared not useful for this study. Only 12 out of 356 patients (5%) under 80 years old in our study would be identified as at risk, missing important prognostic information for the majority of patients, most likely caused by differences between the populations of these two studies.
Similar to Heim et al. and in a similar population, Oud et al. found an incremental risk for 6-month mortality when more domains were impaired.16 The results of the current study confirm these results for patients admitted for elective colorectal cancer surgery and show a sustained mortality risk beyond the first year.
As stated above, we found no association between risk for undernutrition and survival and complications even though undernutrition is an acknowledged risk factor for complications in abdominal surgery.17-19 This may be related to the tools used to detect undernutrition. Multiple screening tools have been proposed by the European Society for Clinical Nutrition and Metabolism (ESPEN).20 However, all proposed tools differ in sensitivity and positive predictive value for adverse outcome, and the SNAQ and MUST screening tools show somewhat worse performance in this field compared with the more comprehensive NRS 2002.21 In addition, two categories of patients with high risk both for undernutrition and complications and death, were excluded from the present analysis: stage IV colorectal cancer patients and patients with acute or emergency indications for surgery. Of note, when undernutrition was omitted from the risk score, the HR for OS increased for survival, but the risk scores were no longer prognostic for any complication, possibly due to a modifying effect of undernutrition on the other domains.
For delirium, several preoperative risk factors have been reported, including advanced age, cognitive impairment, earlier delirium, and functional dependency.22 In this study, there was no objective assessment of cognitive function. Although the three- item delirium risk assessment has not yet been validated, it is promising that these three questions were also associated with postoperative delirium. When interested in cognitive function, other tools, such as an MMSE,23 would be appropriate.
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