A New Risk Stratification Tool for Nonagenarian and Centenarian Surgical Patients
Advancing Surgical Decision-Making for the Oldest Patients
The number of nonagenarians (90–99 years) and centenarians (100+ years) undergoing surgical procedures has grown exponentially in recent years. With this trend comes a pressing need for precise risk stratification tools tailored to this unique patient population. Traditional models like the Age-Adjusted Charlson Comorbidity Index (ACCI), while widely used, often fall short in accounting for the complex interplay of age, comorbidities, and surgical risks seen in the oldest cohorts.
A study led by Weinberg et al., published in Annals of Surgery Open1, introduces the GERIATRIC risk stratification tool, a model specifically designed for patients over 90 years of age. By integrating a comprehensive array of clinical and surgical variables, this tool provides clinicians with an accurate framework for predicting complications and mortality, offering critical insights to guide decision-making in this vulnerable group.
Challenges of Surgery in Nonagenarians and Centenarians
The physiological vulnerabilities of nonagenarians and centenarians—combined with their higher rates of comorbidities such as heart failure, anemia, and electrolyte imbalances—pose unique challenges in the perioperative setting. Traditional scoring systems like the ACCI, which heavily weigh chronological age, often overestimate risks and recommend overly conservative approaches.
As a result, clinicians have faced significant uncertainty when determining whether to recommend surgical intervention for these patients, particularly when balancing potential benefits against the risk of severe complications or mortality.
"The ACCI disproportionately elevates risk scores for nonagenarians, placing excessive weight on age rather than comorbidities," the study notes, emphasizing the need for a more nuanced tool.
The Development of the GERIATRIC Tool
The GERIATRIC tool was developed using data from over 3,000 nonagenarians and centenarians who underwent surgery at a major Australian teaching hospital. The study incorporated a range of clinical and laboratory variables, including hemoglobin levels, electrolyte imbalances, surgery type (emergency vs. elective), and preoperative ICU care, in addition to ACCI components.
The tool was validated using robust statistical methods, demonstrating superior predictive accuracy compared to the ACCI. Its ability to stratify patients into high- or low-risk groups for complications and mortality was particularly noteworthy.
Key findings include:
Postoperative complications: The GERIATRIC tool achieved an AUROC of 0.857, reflecting excellent discrimination ability.
Severe complications: It demonstrated an AUROC of 0.833 for predicting major complications requiring intensive care.
In-hospital mortality: The model’s AUROC was 0.780, indicating fair accuracy for predicting mortality during the index hospital stay.
Clinical Applications and Benefits
The GERIATRIC tool equips surgeons and perioperative teams with actionable insights to guide surgical decision-making, particularly for complex cases involving high-risk procedures. By focusing on clinically meaningful parameters, the model offers a balanced view of the risks associated with surgery in elderly patients.
“The GERIATRIC tool facilitates shared decision-making, providing clinicians and families with clear, evidence-based predictions of outcomes,” the authors state.
The tool’s web-based calculator, freely accessible to clinicians, further enhances its utility, enabling real-time risk assessment in both elective and emergency settings.
Future Directions and Limitations
While the GERIATRIC tool represents a significant step forward, further validation across diverse healthcare systems and patient populations is essential. Expanding the model to include functional status and frailty measures could improve its accuracy, particularly for predicting long-term outcomes.
The study’s retrospective design and single-center data source also highlight the need for prospective, multicenter trials to confirm its generalizability. Additionally, more granular analysis of surgery-specific risks could refine its applications across various specialties.
"With continued development and validation, the GERIATRIC tool has the potential to set a new standard in surgical care for the oldest patients," the study concludes.
Related Research and References
Kim, T. I., et al. (2020). "Surgery for the very old: Are nonagenarians different?" American Surgeon.
DOI: 10.1177/0003134820982572Ogawa, T., et al. (2021). "Age and clinical outcomes after hip fracture surgery: Do nonagenarian classifications matter?" Age and Ageing.
DOI: 10.1093/ageing/afab121Kitridis, D., et al. (2022). "Mortality and complication rates in nonagenarians undergoing total hip and knee arthroplasty." European Geriatric Medicine.
DOI: 10.1007/s41999-022-00630-1Fariña-Castro, R., et al. (2017). "Five-year survival after surgery in nonagenarian patients." Geriatrics and Gerontology International.
DOI: 10.1111/ggi.13119
Weinberg, L., Lee, D. K., Fletcher, L., Ou Yang, B., Karp, J., Koshy, A. N., Guha, R., Slifirski, H., D’Silva, M. R., Bellomo, R., & Churilov, L. (2024). The perioperative NonaGEnaRIan And cenTenarian suRgICal (GERIATRIC) risk stratification tool. Annals of Surgery Open: Perspectives of Surgical History, Education, and Clinical Approaches, 5(4), e524. https://doi.org/10.1097/as9.0000000000000524