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Lower-extremity revascularization common, but may be ineffective for nursing home residents with PAD
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A substantial number of elderly nursing home residents with peripheral artery disease underwent lower-extremity revascularization in the United States from 2005 to 2009, but most regained little or no ambulatory function and the mortality rate at 1 year was high.
Researchers identified 10,784 long-term nursing home residents with PAD aged older than 67 years who underwent lower-extremity revascularization during the study period. The ambulatory and functional status of all patients were assessed before and at 3, 6, 9 and 12 months after surgery.
Seventy-five percent of patients were unable to walk prior to surgery. The mean baseline Minimum Data Set for Nursing Homes activities of daily living score (MDS-ADL) was 14.5. The MDS-ADL rates self performance of seven daily activities on a 29-point scale, with 0 indicating total independence and 28 indicating total dependence. Forty-patients had experienced a decline in functional status prior to revascularization.
At 1 year after revascularization, 51% of patients had died, 28% were unable to walk and 32% had experienced functional decline.
Of the 1,672 patients able to walk prior to revascularization, 63% had died or were no longer ambulatory at 1 year after revascularization. Among those who were nonambulatory prior to revascularization, 89% had died or remained nonambulatory at 1 year.
Mean MDS-ADL score increased by 2.2 points from baseline to 1 year after revascularization, which represents a clinically significant decline in function, Lawrence Oresanya, MD, from the department of surgery at University of California, San Francisco, and colleagues wrote. This decline was most pronounced within the first 3 months after revascularization.
Multivariate analysis indicated independent associations between postsurgical death/nonambulatory status and preprocedure nonambulatory status (adjusted HR = 1.88; 95% CI, 1.78-1.99), age 80 years or older (adjusted HR = 1.28; 95% CI, 1.16-1.4), cognitive impairment (adjusted HR = 1.23; 95% CI, 1.18-1.29), decline in daily living activities prior to revascularization (adjusted HR = 1.23; 95% CI, 1.18-1.28), congestive HF (adjusted HR = 1.16; 95% CI, 1.11-1.22) and renal failure (adjusted HR = 1.09; 95% CI, 1.04-1.14).
“Our findings can inform conversations between physicians, patients and families about the risks and expected outcomes of surgery and whether the surgery is likely to be worthwhile,” Oresanya and colleagues concluded. “Ambulatory function, although clearly an important goal, may not be the primary objective of treatment and may be impossible to attain.”
In a related editorial, William J. Hall, MD, MACP, from the department of medicine at University of Rochester School of Medicine, Rochester, New York, noted that while this study was population based, it incorporated a “minimal” data set and did not include specific information on the indications for revascularization in each patient. However, he wrote, the results were “balanced and valuable,” and the study “point[s] the way to a more rational clinical approach to the care of frail elders with limited lifespan but with the prospect of constant pain and discomfort.
“The best care will be patient and family centered, interdisciplinary and characterized by communication and determining the goals of care,” Hall wrote. – by Adam Taliercio
For more information:
Hall, WJ. JAMA Intern Med. 2015;doi:10.1001/jamainternmed.2015.32.
Oresanya L, et al. JAMA Intern Med. 2015;doi:10.1001/jamainternmed.2015.0486.
Disclosures: The researchers and Hall report no relevant financial disclosures.