Impact of institutionalization and anticholinergic medication on postoperative morbidity for major colorectal resections

Summary

Background

Institutionalized patients pose various surgical difficulties as many have conditions requiring psychiatric medications with the propensity for anticholinergic side effects. This study was initiated to determine the impact of institutionalization and anticholinergic medication on postoperative outcomes.

Methods

A total of 430 colorectal resection cases from 2006 to 2012 were studied. Among them, 19 were institutionalized patients and 17 were on long-term anticholinergic medications. Surgical outcomes were quantified by Clavien scoring, need for reoperations and postoperative deaths.

Results

Patients who were institutionalized or on anticholinergic medication were more likely to have increased postoperative morbidity requiring invasive interventions or worse (Clavien score ≥ 3; odds ratios 5.02 and 3.63, 95% confidence intervals 1.93–13.06 and 1.29–10.21 respectively). However, only institutionalization was found to be an independent risk factor.

Conclusion

This study identified institutionalized patients as a higher risk group associated with postoperative complications compared to patients from the community. Thus, they merit a more thorough preoperative optimization closer postoperative monitoring regime.

Keywords

colorectal resection; institutionalization; postoperative morbidity

1. Introduction

Institutionalization refers to the confinement of a person to a facility offering specialized care for social, medical, or psychiatric conditions. In the local setting, this includes individuals committed to a psychiatric facility, a nursing home for the elderly and infirmed, or a community hospital for rehabilitation over a long period. It was noted that many institutionalized individuals with psychiatric conditions were treated with medications that possess anticholinergic side effects—antipsychotics and tricyclic antidepressants—and thus it was hypothesized that the treatment modality could play a role in the development of postoperative complications. The anticholinergic effects of such medications could lead to decreased gut motility, increased duration of postoperative ileus or even causing paralytic ileus.¹ Studies have demonstrated an increased in the rate of water intoxication² and postoperative mortality^2 and 3 for patients on chronic antipsychotic medications.

However, there is limited literature available associating institutionalization and anticholinergic medication on postoperative morbidity and outcomes. This study was initiated to examine this issue in depth on patients who had undergone major colorectal resections in the Alexandra Health System (AHS) in Singapore. AHS presented an ideal setting for this study as it is the major referral center for patients from the Institute of Mental Health, a public psychiatric institution. AHS also has a significant number of nursing home referrals as they are within its catchment area.

2. Methods

All patients who had undergone major colorectal resections in AHS between December 2006 and November 2012 were reviewed. Among the 430 patients, 19 were institutionalized cases, 17 patients were on anticholinergic medication for psychiatric conditions and 10 patients fell into both categories. Data from our prospectively collected computer database were extracted and further clinical information was extracted from a review of the clinical notes. Individual comorbidities were recorded and quantified using the American Society of Anesthesiologist (ASA) system. Stage of malignant disease and urgency of operations performed were noted. Outcome measures of morbidity were quantified with the Clavien scoring system⁴ and this also included the need for reoperations and postoperative mortality. Analysis for factors correlating to the development of postoperative complications and mortality were performed using factors that were identified to be useful predictors by previous studies.

Bivariate analysis was performed using χ² test in SPSS for Windows (SPSS Inc., Chicago, IL, USA), version 20.0 on a personal computer. Results were expressed as odds ratios with 95% confidence intervals. Stepwise logistic regression analysis was used in multivariate analysis to identify parameters that independently had affected outcomes.

3. Results

The demographic and characteristics of institutionalized patients and those on anticholinergic medication are shown in Table 1. There was no statistically significant difference between institutionalized patients and those from the community in terms of age, sex, location of disease, stage of malignancy, urgency of operation, or ASA score. Patients who were on anticholinergic medication did not statistically differ from those who were not.

Table 1. Patient demographics and operation characteristics.

Variable	Institutionalized			Anticholinergic medication
	Yes	No	p	Yes	No	p
Age (y), mean (SD)	70.0 (12.30)	65.2 (12.65)	0.447	65.47 (11.65)	65.41 (12.71)	0.836
Male sex	47 (9/19)	57 (235/411)	0.399	53 (9/17)	57 (235/413)	0.747
Emergency operation	42 (8/19)	28 (116/411)	0.192	35 (6/17)	29 (118/413)	0.549
Rectal operation	37 (7/19)	43 (176/411)	0.606	29 (5/17)	43 (178/413)	0.263
Stage 3 disease and above	79 (11/14)	57 (197/344)	0.113	75.0 (12/16)	57.3 (196/342)	0.161
ASA Score 3 and above	53 (10/19)	33 (135/411)	0.075	53 (9/17)	33 (136/413)	0.087

Data are presented as % (n/N) unless otherwise indicated.

ASA = American Society of Anesthesiologist; SD = standard deviation.

Bivariate analysis showed that institutionalization and being on anticholinergic medication had increased risk of postoperative morbidity. The odds ratio for developing Clavien 3 complications and above was 5.02 [95% confidence interval (CI) 1.93–13.06] for institutionalized patients and 3.63 (95% CI 1.29–10.21) for those on anticholinergic medication (Table 2). The odds ratio for developing Clavien 2 complications and above was 3.43 (95% CI 1.28–9.22) for institutionalized patients and 2.87 (95% CI 1.04–7.91) for those on anticholinergic medication. Institutionalized patients were also found to have increased risk for reoperations (odds ratio 3.51, 95% CI 1.10–11.27). Notably, there was no statistically significant difference in the rate of hospitalization deaths for either group of patients.

Table 2. Odds ratio (OR) Clavien 2 and 3 complications, Reoperations and hospitalization death on bivariate analysis.

Factor	Clavien 2 complications OR (95% CI, p)	Clavien 3 complications OR (95% CI, p)	Reoperations OR (95% CI, p)	Hospitalization death OR (95% CI, p)
Male sex	1.19 (0.81–1.76, 0.382)	1.50 (0.85–2.64, 0.164)	1.58 (0.74–3.34, 0.231)	0.57 (0.19–1.67, 0.297)
Emergency operation	1.87 (1.22–2.85, 0.004)	2.50 (1.43–4.36, 0.001)	1.45 (0.69–3.05, 0.321)	6.72 (2.07–21.86. <0.001)
Rectal operation	0.59 (0.40–0.88, 0.009)	0.75 (0.43–1.32, 0.320)	0.88 (0.42–1.79, 0.702)	0.53 (0.16–1.71, 0.280)
ASA Score 3 and above	2.82 (1.87–4.26, <0.001)	2.22 (1.28–3.85, 0.004)	1.96 (0.96–3.99, 0.062)	3.71 (1.22–11.27, 0.014)
Institutionalized	3.43 (1.28–9.22, 0.010)	5.02 (1.93–13.06, <0.001)	3.51 (1.10–11.27, 0.025)	1.69 (0.21–13.62, 0.619)
Anticholinergic medication	2.87 (1.04–7.91, 0.034)	3.63 (1.29–10.21, 0.010)	2.74 (0.75–10.05, 0.115)	1.91 (0.24–15.50, 0.538)

ASA = American Society of Anesthesiologist; CI = confidence interval.

Multivariate analysis revealed institutionalization, urgency of operation, and ASA score to be independent predictors of morbidity (Clavien score ≥ 3; Table 3). Being on anticholinergic medication was not shown to be an independent predictor of morbidity.

Table 3. Multivariate analysis correlating to Clavien 3 score and above complications.

Factor	Odds ratio	95% CI	p
Male sex	1.61	0.89–2.91	0.119
Emergency operation	2.27	1.23–4.17	0.008
Rectal operation	1.07	0.57–1.98	0.843
ASA Score 3 and above	1.92	1.08–3.42	0.025
Institutionalized	3.70	1.08–12.72	0.038
Anticholinergic medication	1.48	0.37–5.89	0.577

ASA = American Society of Anesthesiologist; CI = confidence interval.

4. Discussion

Our study revealed both institutionalization and being on anticholinergic medication to be associated with an increased risk of postoperative complications, but only institutionalization was shown to be an independent predictor of increased morbidity.

While there is limited literature available on the postoperative outcomes of the institutionalized patients, a study reported that institutionalized patients who underwent intra-abdominal operations were at increased risk of postoperative morbidity and mortality.⁵ Cutler and Fink⁵ reported a postoperative complication rate of 26.5% among institutionalized patients who underwent intra-abdominal operations as opposed to 7.5% for the control group.

Notably, in this present study, the patient group differed from most other studies that generally involved institutionalized patients admitted to a psychiatric facility. In this study, although the psychiatric patients form a significant proportion of the institutionalized population, there were also a significant population of patients with both functional and cognitive impairment from nonpsychiatric medical conditions from nursing homes, facilities designed to provide basic nursing care and for daily needs. It was felt that these latter institutionalized patients were also generally associated as above-average risk for postoperative complications, regardless of the reasons for their confinement. Aoyanagi et al⁶ studied 86 psychiatric patients who had surgery for digestive malignancies and reported no increase in surgical risk for these patients. This result is in contrast to the limited body of evidence, which suggests that psychiatric patients tend to have stormier postoperative recoveries. A key difference in Aoyanagi et als⁶ study group was that only seven out of the 86 patients were institutionalized. Our findings support this, with institutionalization rather than anticholinergic medication (given for psychiatric conditions) being shown as an independent risk factor. Only 10 of the 17 psychiatric patients studied were institutionalized. This could partially explain why being on anticholinergic medication could be associated with an increased risk of Clavien score ≥ 3 complications on bivariate analysis but was not an independent risk factor. Institutionalization, rather than psychiatric condition, was shown to be the cause of increased postoperative risk for patients on anticholinergic medication.

Institutionalized patients were more likely to undergo emergency operations and presented with later stage of cancers, thus showing a higher ASA score although the difference was not statistically significant. This raised the question of whether institutionalization had led to later presentations, later stages of disease and consequently, increased risk of needing emergency operations. This scenario would, in part, have contributed to poorer outcomes. Later presentations with more advanced diseases requiring surgery have also been reported in the literature^7 and 8 and could be secondary to reduced pain perception^{8, 9 and 10} or the impaired ability to report symptoms or seek appropriate medical consultation. In particular, psychiatric patients were shown to be less likely to be picked up by mass screening for colorectal carcinoma, and this was attributed to their relative indifference to their own health.⁶ Even so, given that institutionalization was shown to be an independent predictor of increased morbidity, it was necessary to examine beyond emergency surgery and more advanced surgical diseases for the factors involved in increased postoperative morbidity.

Institutionalization has been shown to be associated with reduced albumin and malnutrition.¹¹ This in turn has been associated with poor wound healing and an increased rate of anastomotic leakage.¹² Increased risk of atelactasis and pneumonia was also reported for institutionalized psychiatric patient.⁵ This could be due to their impaired ability to cooperate with respiratory therapy or learn incentive spirometry postoperatively. Beyond these, there is room for further analysis into other factors that may contribute to increased postoperative morbidity. Areas that can be examined include attention by health care workers, compliance to treatment and an institutionalized individuals psychosocial health and sense of self-worth.

This study had identified institutionalized patients as a group at risk. They had increased risk of developing postoperative complications, and notably the odds ratio of developing Clavien score ≥ 3 complications was even greater for institutionalized patients then patients with a higher ASA score or who undergone emergency operations. The findings in this study merit greater awareness in the surgical community. When preparing an institutionalized patient, care should be taken to optimize conditions for postoperative recovery. Institutionalized patients should receive greater attention to preoperative optimization, especially in the elective setting. They would be likely to benefit from a lower threshold for close postoperative monitoring in the high dependency or intensive care unit. Closer monitoring of these higher risk individuals could lead to the earlier recognition and intervention of postoperative complications and contribute to improved outcomes.

A study by Finlayson et al¹³ on patients from nursing homes undergoing major surgery showed increased postoperative mortality and an increased need for invasive interventions after surgery. However, in the present study, the findings showed that institutionalized patients were more likely to develop significant postoperative complications and undergo reoperations or invasive intervention although they did not show increased risk of inpatient mortality. Ultimately, while increased morbidity may be seen, institutionalized patients should not be denied of colorectal resection, if indicated.

Regrettably, a lack of patients in this study limited the ability for the analysis of the type of complications developed by institutionalized patients. With more patients, it may be possible to identify the specific areas that contribute to the development of complications in institutionalization and allowing for directed interventions that mitigate their impact.

5. Conclusion

This study has shown that institutionalization is a significant independent risk factor for increased postoperative morbidity. Institutionalized patients represent a group of patients at risk and this should be an important consideration in approaching a colorectal resection for these patients.

References

1. 1 A. Kudoh, H. Ishihara, A. Matsuki; Pituitary-adrenal and parasympathetic function of chronic schizophrenic patients with postoperative ileus or hypotension; Neuropsychobiology, 39 (1999), pp. 125–130
2. 2 A. Matsuki, T. Oyama, S. Izai, E.K. Zsigmond; Excessive mortality in schizophrenic patients on chronic phenothiazine treatment; Agressologie, 13 (1972), pp. 407–418
3. 3 A. Kudoh, F. Kimura, T. Murakawa, H. Ishihara, A. Matsuki; Perioperative management of patients on long-term administration of psychotropic drugs; Masui., 42 (1993), pp. 1056–1064 [Article in Japanese]
4. 4 D. Dindo, N. Demartines, P.A. Clavien; Classification of surgical complications: A new proposal with evaluation in a cohort of 6336 patients and results of a Survey; Ann Surg, 240 (2004), pp. 205–213
5. 5 B.S. Cutler, M.P. Fink; Postoperative complications in patients with disabling psychiatric illnesses or intellectual handicaps: a case-controlled, retrospective analysis; Arch Surg, 125 (1990), pp. 1436–1440
6. 6 N. Aoyanagi, I. Iizuka, M. Watanabe; Surgery for digestive malignancies in patients with psychiatric disorders; World J Surg, 31 (2007), pp. 2323–2328
7. 7 L.A. Copeland, J.E. Zeber, M.J. Pugh, E.M. Mortensen, M.I. Restrepo, V.A. Lawrence; Postoperative complications in the seriously mentally ill: a systematic review of the literature; Ann Surg, 248 (2008), pp. 31–38
8. 8 M.I. Herz, S.R. Marder; Schizophrenia comprehensive treatment and management: diagnosis, course and outcome, and epidemiology; Am J Psychiatry, 160 (2003), pp. 808–809
9. 9 E. Katz, Y. Kluger, R. Ravinovici, D. Stein, Z. Gimmon; Acute surgical abdominal disease in chronic schizophrenic patients: a unique clinical problem; Isr J Med Sci, 26 (1990), pp. 275–277
10. 10 R.H. Dworkin, W.C. Clark, J.D. Lipsitz, et al.; Affective deficits and pain insensitivity in schizophrenia; Motivation Emotion, 17 (1993), pp. 245–276
11. 11 N. Hashimoto, N. Isaka, Y. Ishizawa, T. Mitsui, M. Sasaki; Surgical management of colorectal cancer in patients with psychiatric disorders; Surg Today., 39 (2009), pp. 393–398
12. 12 C.Y. Kang, W.J. Halabi, O.O. Chaudhry, et al.; Risk factors for anastomotic leakage after anterior resection for rectal cancer; JAMA Surg, 148 (2013), pp. 65–71
13. 13 E. Finlayson, L. Wang, C.S. Landefeld, R.A. Dudley; Major abdominal surgery in nursing home residents. A national study; Ann Surg, 254 (2011), pp. 921–926