Many nursing home residents die or cannot walk after lower extremity revascularisation

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Many nursing home residents who underwent lower extremity revascularization died, did not walk or had functional decline following the procedure, which is commonly used to treat leg pain caused by peripheral arterial disease, wounds that will not heal or worsening gangrene, according to an article published online by JAMA Internal Medicine.

Lower extremity revascularisation is often performed so patients with peripheral arterial disease can maintain the ability to walk, which is a key component of functional independence. But outcomes among patients with high levels of functional dependence, such as nursing home residents, are poorly understood, according to background in the study.

Emily Finlayson, of the University of California, San Francisco, USA, and co-authors used Medicare claims data for 2005 to 2009 to identify nursing home residents who underwent lower extremity revascularisation.

The authors identified 10,784 long-term nursing home residents (37% were men, average age 82) who underwent the procedure, which was performed electively in 67% of the cases.

Before surgery, 75% of the nursing home residents were not walking and 40% had experienced functional decline. At one year after surgery, 51% of the patients had died, 28% were not walking and 32% had sustained functional decline, according to the results.

Patients who were walking before surgery did not fare well after the procedure: among 1,672 nursing home residents who were ambulatory before surgery, 63% died or were nonambulatory at one year. Among the 7,188 patients who were nonambulatory before surgery, 89% had died or were nonambulatory at one year, according to the results.

Among nursing home residents who were alive one year after surgery, 34% who were ambulatory before surgery became nonambulatory and 24% who were nonambulatory at baseline became ambulatory, results indicate.

Analyses by the authors showed that dying or being nonambulatory was associated with factors such as being 80 years or older, cognitive impairment, congestive heart failure, renal failure, emergency surgery, not walking before surgery and a decline in activities of daily living before surgery.

“We found that a substantial number of nursing home residents in the USA undergo lower extremity revascularisation, and many gain little, if any, function. The mortality rate, however, is high, with half of residents dying within a year of surgery…Ambulatory function, although clearly an important goal, may not be the primary objective of treatment and may be impossible to attain. Nonambulatory patients with refractory ischaemic rest pain, wounds that do not heal despite months of nursing care, or worsening gangrene seek palliation for the relief of symptoms…Thus, our findings should be interpreted cautiously; successful relief of pain, healing of wounds and avoidance of major amputation may benefit some of the patients who underwent lower extremity revascularisation,” the authors concludes.

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