Comparison Between Charlson Comorbidity Index (CCI) and The American Society of Anesthesiologists Physical Status Classification (ASA) in Predicting Mortality in Geriatric Patients Undergoing Anesthesia at Dr Sardjito Hospital Yogyakarta
Abstract
Background: Geriatric patients tend to have more comorbidities accompanied by a decline in physiological and cognitive function, which impacts perioperative outcomes. The combination of physiological dysfunction, especially changes in pharmacodynamics and pharmacokinetics of drugs, leads to several challenges in administering anesthesia. The Charlson Comorbidity Index (CCI) has been used to predict mortality based on comorbidity assessment. The American Society of Anesthesiologists (ASA) categorizes physiological status to estimate patient health based on anesthesia expert assessment. Increased CCI and ASA scores are known to have significant correlation to increased mortality in geriatric patients undergoing surgery.
Objective: To compare the Charlson Comorbidity Index (CCI) and the American Society of Anesthesiologists (ASA) Physical Status Classification in predicting mortality in geriatric patients undergoing anesthesia at Dr. Sardjito Hospital, Yogyakarta
Methods: A retrospective observational study was conducted on all geriatric patients undergoing anesthesia procedures in the operating room of Dr. Sardjito Hospital, Yogyakarta, during the period of February-April 2021. Normality tests were performed using Kolmogorov-Smirnov. Bivariate analysis was conducted using the Chi-square test. A p-value of <0.05 was considered statistically significant. The predictive validity of CCI and ASA scores, as well as the optimal cutoff point for CCI scores, were evaluated using multivariate logistic regression analysis based on discrimination testing by observing the Area Under Curve (AUC) and the Hosmer-Lemeshow calibration test.
Results: There was a significant association between CCI scores and mortality (OR 4.589; 95% CI 1.257-16.747; p=0.021). Meanwhile, no significant association was found between ASA and mortality in geriatric patients undergoing anesthesia
References
Setiati S. Geriatric Medicine, Sarcopenia, Frailty and Geriatric Quality of Life: Future Challenge in Education, Research and Medical Service in Indonesia. eJournal Kedokteran Indonesia. 2013;1(3):234–42. doi:10.23886/ejki.1.3008.
Orimo H, Ito H, Suzuki T, Araki A, Hosoi T, Sawabe M. Reviewing the definition of “elderly.” Geriatr Gerontol Int. 2006;6(3):149–158. doi:10.1111/j.1447 0594.2006.00341.x.
Subdirektorat Statistik Pendidikan dan Kesejahteraan Sosial, Badan Pusat Statistik. Statistik Penduduk Lanjut Usia 2020. Badan Pusat Statistik; 2020. 1–289. Available from: https://www.bps.go.id/publication/2020/12/21/0fc023221965624a644c1111/statistik-penduduk-lanjut usia 2020.html.
United Nations Department of Economic and Social Affairs, Population Division. World Population Ageing 2020 Highlights: Living arrangements of older persons. New York: United Nations; 2020. doi:10.18356/9789210051934
Chambers DJ. Anaesthesia in the elderly. Anaesth Intensive Care Med. 2019;20(12):705–9. doi:10.1016/j.mpaic.2019.10.001.
Joyce MF, Reich JA. Critical Care Issues of the Geriatric Patient. Anesthesiol Clin. 2015;33(3):551–61. doi:10.1016/j.anclin.2015.05.009
Ibitoye S, Braude P. Geriatric perioperative care. Med (United Kingdom). 2021;49(1):51–5. doi:10.1016/j.mpmed.2020.10.004.
Riley C, Andrzejowski J. Inadvertent perioperative hypothermia. BJA Educ. 2018;18(8):227–33. doi:10.1016/j.bjae.2018.05.003
Doyle DJ, Hendrix JM, Garmon EH. American Society of Anesthesiologists Classification. In: StatPearls [Internet]. Treasure Island (FL): StatPearls. 2022. Available from: https://www.ncbi.nlm.nih.gov/books/NBK441940/.
Kastanis G, Topalidou A, Alpantaki K, Rosiadis M, Balalis K. Is the ASA Score in Geriatric Hip Fractures a Predictive Factor for Complications and Readmission?. Scientifica (Cairo). 2016;2016:7096245. doi:10.1155/2016/7096245.
Neuhaus V, King J, Hageman MG, Ring DC. Charlson comorbidity indices and in hospital deaths in patients with hip fractures. Clin Orthop Relat Res. [Internet]. 2013;471(5):1712 19. doi:10.1007/s11999 012 2705 9.
Lau TW, Fang C, Leung F. Assessment of postoperative short term and long term mortality risk in Chinese geriatric patients for hip fracture using the Charlson comorbidity score. Hong Kong Med J. [Internet]. 2016;22(1):16 22. Doi:10.12809/hkmj154451.
Quach LH, Jayamaha S, Whitehouse SL, Crawford R, Pulle CR, Bell JJ. Comparison of the Charlson Comorbidity Index with the ASA score for predicting 12-month mortality in acute hip fracture. Injury. 2020;51(4):1004-10. Doi: 10.1016/j.injury.2020.02.074
Haugan K, Klaksvik J, Foss OA. 30-day mortality in patients after hip fracture surgery: a comparison of the Charlson Comorbidity Index score and ASA score used in two prediction models. Injury [Internet]. 2021;52(8):2379-83. Available from: https://linkinghub.elsevier.com/retrieve/pii/S0020138321001029
Beaupre LA, Khong H, Smith C, Kang S, Evens L, Jaiswal PK, et al. The impact of time to surgery after hip fracture on mortality at 30- and 90-days: does a single benchmark apply to all?. Injury. [Internet]. 2019 ;50(4):950-5. Available from: https://linkinghub.elsevier.com/retrieve/pii/S0020138319301317
Matsue Y, Kamiya K, Saito H, Saito K, Ogasahara Y, Maekawa E, et al. Prevalence and prognostic impact of the coexistence of multiple frailty domains in elderly patients with heart failure: the FRAGILE-HF cohort study. Eur J Heart Fail. [Internet]. 2020;22(11):2112-9. Available from: https://onlinelibrary.wiley.com/doi/10.1002/ejhf.1926
Fukuda T, Imai S, Shimoda S, Maruo K, Nakadera M, Horiguchi H. Aspiration pneumonia and anesthesia techniques in hip fracture surgery in elderly patients: A retrospective cohort study using administrative data. J Orthop Surg. [Internet]. 2022;30(1):1 11. Available from: http://journals.sagepub.com/doi/10.1177/10225536221078622
Kadambi S, Loh KP, Dunne R, Magnuson A, Maggiore R, Zittel J, et al. Older adults with cancer and their caregivers — current landscape and future directions for clinical care. Nat Rev Clin Oncol. [Internet]. 2020;17(12):742 55. Doi:10.1038/s41571 020 0421 z
Alan O, Gursel O, Unsal M, Altin S, Kilciksiz S. Oncologic approach in geriatric patients. Med J Okmeydani Train Res Hosp. 2014;29(Suppl 2):94-8. Doi: 10.5222/otd.supp2.2013.094
Cinar D, Tas D. Cancer in the elderly. North Clin Istanb. 2015;2(1):73-80. Doi: 10.14744/nci.2015.72691
Assouan D, Paillaud E, Caillet P, Broussier A, Kempf E, Frelaut M, et al. Cancer mortality and competing causes of death in older adults with cancer: a prospective, multicentre cohort study (ELCAPA-19). Cancer Med. [Internet]. 2023;12(22):20940-52. Available from: https://onlinelibrary.wiley.com/doi/10.1002/cam4.6639
Milanesi A, Weinreb JE. Diabetes in the elderly. In: Endotext. [Internet]. South Dartmouth (MA): MDText.com, Inc.; 2020. Available from: http://www.ncbi.nlm.nih.gov/pubmed/26348752
Kılınç G, Karakuş Ö, Gürer B. The role of ASA score and Charlson comorbidity index in predicting in-hospital mortality in geriatric hip fracture patients. Eur Rev Med Pharmacol Sci. 2023;27(15):7065-72. Doi: 10.26355/eurrev_202308_33279
Karres J, Kieviet N, Eerenberg JP, Vrouenraets BC. Predicting early mortality after hip fracture surgery: the Hip Fracture Estimator of Mortality Amsterdam. J Orthop Trauma. [Internet]. 2018 Jan;32(1):27-33. Available from: https://journals.lww.com/00005131-201801000-00006
Sugiarto A, Pryambodho I, Imelda M, Aditianingsih D. Charlson comorbidity index to predict 28-day mortality in critically ill COVID-19 patients. Med J Indones. [Internet]. 2023;32(1):19-24. Available from: https://mji.ui.ac.id/journal/index.php/mji/article/view/6070
Shu J, Santulli G. Update on peripheral artery disease: epidemiology and evidence-based facts. Atherosclerosis. [Internet]. 2018;275:379-81. Available from: https://linkinghub.elsevier.com/retrieve/pii/S0021915018302764
Gul F, Janzer SF. Peripheral vascular disease. In: StatPearls. [Internet]. Treasure Island (FL): StatPearls Publishing; 2024. Available from: http://www.ncbi.nlm.nih.gov/pubmed/21873417
Aronow W. Peripheral arterial disease in the elderly. Clin Interv Aging. [Internet]. 2008;2:645-54. Available from: https://www.dovepress.com/peripheral-arterial-disease-in-the-elderly-peer-reviewed-article-CIA
Duron JJ, Duron E, Dugue T, Pujol J, Muscari F, Collet D, et al. Risk factors for mortality in major digestive surgery in the elderly. Ann Surg. [Internet]. 2011;254(2):375-82. Available from: https://journals.lww.com/00000658-201108000-00028
Arenal JJ, Bengoechea-Beeby M. Mortality associated with emergency abdominal surgery in the elderly. Can J Surg. [Internet]. 2003;46(2):111-6. Available from: http://www.ncbi.nlm.nih.gov/pubmed/12691347
Chu CC, Weng SF, Chen KT, Chien CC, Shieh JP, Chen JY, et al. Propensity score–matched comparison of postoperative adverse outcomes between geriatric patients given a general or a neuraxial anesthetic for hip surgery. Anesthesiology. [Internet]. 2015;123(1):136-47. Available from: https://pubs.asahq.org/anesthesiology/article/123/1/136/12458
Neuman MD, Silber JH, Elkassabany NM, Ludwig JM, Fleisher LA. Comparative effectiveness of regional versus general anesthesia for hip fracture surgery in adults. Anesthesiology. [Internet]. 2012;117(1):72-92. Available from: https://pubs.asahq.org/anesthesiology/article/117/1/72/11283
Radcliff TA, Henderson WG, Stoner TJ, Khuri SF, Dohm M, Hutt E. Patient risk factors, operative care, and outcomes among older community-dwelling male veterans with hip fracture. J Bone Joint Surg Am. [Internet]. 2008;90(1):34-42. Available from: http://journals.lww.com/00004623-200801000-00006
Kunutsor SK, Hamal PB, Tomassini S, Yeung J, Whitehouse MR, Matharu GS. Clinical effectiveness and safety of spinal anaesthesia compared with general anaesthesia in patients undergoing hip fracture surgery using a consensus-based core outcome set and patient-and public-informed outcomes: a systematic review and meta-analysis. Br J Anaesth. [Internet]. 2022;129(5):788-800. Available from: https://linkinghub.elsevier.com/retrieve/pii/S0007091222004275
Van Waesberghe J, Stevanovic A, Rossaint R, Coburn M. General vs. neuraxial anaesthesia in hip fracture patients: a systematic review and meta-analysis. BMC Anesthesiol. [Internet]. 2017;17(1):1-25. Available from: http://bmcanesthesiol.biomedcentral.com/articles/10.1186/s12871-017-0380-9
Zhao B, Chen X, Chen Q, Li G, Chen Z, Yang Z, et al. Intraoperative hypotension and related risk factors for postoperative mortality after noncardiac surgery in elderly patients: a retrospective analysis report. Clin Interv Aging. [Internet]. 2021;16:1757-67. Available from: https://www.dovepress.com/intraoperative-hypotension-and-related-risk-factors-for-postoperative--peer-reviewed-fulltext-article-CIA
An R, Pang QY, Liu H. Association of intra-operative hypotension with acute kidney injury, myocardial injury and mortality in non-cardiac surgery: a meta-analysis. Int J Clin Pract. [Internet]. 2019;73(10):e13394. Available from: https://onlinelibrary.wiley.com/doi/10.1111/ijcp.13394
Monk TG, Bronsert MR, Henderson WG, Mangione MP, Sum-Ping STJ, Bentt DR, et al. Association between intraoperative hypotension and hypertension and 30-day postoperative mortality in noncardiac surgery. Anesthesiology. [Internet]. 2015;123(2):307-19. Available from: https://pubs.asahq.org/anesthesiology/article/123/2/307/13989
Barash PG, Cullen BF, Stoelting RK, Stock MC. Clinical Anesthesia. 7th ed. Philadelphia: Lippincott Williams & Wilkins. 2009, 230.
Cai J, Zhang Y, Bai X, Li S, Chen J, Chen R, et al. Postoperative hemorrhage in an elderly patient with a glioblastoma multiform and a calcified chronic subdural hematoma. World J Surg Oncol. [Internet]. 2014;12(1):110. Available from: https://wjso.biomedcentral.com/articles/10.1186/1477-7819-12-110
Taylor FB, Toh CH, Hoots WK, Wada H, Levi M; Scientific Subcommittee on Disseminated Intravascular Coagulation (DIC) of the International Society on Thrombosis and Haemostasis (ISTH). Towards definition, clinical and laboratory criteria, and a scoring system for disseminated intravascular coagulation. Thromb Haemost. [Internet]. 2001;86(5):1327-30. Available from: http://www.ncbi.nlm.nih.gov/pubmed/11816725
Sheikh HQ, Hossain FS, Aqil A, Akinbamijo B, Mushtaq V, Kapoor H. A comprehensive analysis of the causes and predictors of 30-day mortality following hip fracture surgery. Clin Orthop Surg. [Internet]. 2017;9(1):10-17. Available from: https://ecios.org/DOIx.php?id=10.4055/cios.2017.9.1.10
Fabbian F, De Giorgi A, Ferro S, Lacavalla D, Andreotti D, Ascanelli S, et al. Post-operative all-cause mortality in elderly patients undergoing abdominal emergency surgery: role of Charlson comorbidity index. Healthcare (Basel). [Internet]. 2021;9(7):805. Available from: https://www.mdpi.com/2227-9032/9/7/805
Lau T, Fang C, Leung F. Assessment of postoperative short-term and long-term mortality risk in Chinese geriatric patients for hip fracture using the Charlson comorbidity score. Hong Kong Med J. [Internet]. 2016;22(1):16-22. Available from: http://www.hkmj.org/abstracts/v22n1/16.htm
Smith T, Pelpola K, Ball M, Ong A, Myint PK. Pre-operative indicators for mortality following hip fracture surgery: a systematic review and meta-analysis. Age Ageing [Internet]. 2014;43(4):464-71. Available from: https://academic.oup.com/ageing/article/43/4/464/2812257
Cher EWL, Allen JC, Howe TS, Koh JSB. Comorbidity as the dominant predictor of mortality after hip fracture surgeries. Osteoporos Int. [Internet]. 2019;30(12):2477-83. Available from: http://link.springer.com/10.1007/s00198-019-05139-8
Yeoh CJC, Fazal MA. ASA grade and elderly patients with femoral neck fracture. Geriatr Orthop Surg Rehabil. [Internet]. 2014;5(4):195-9. Available from: http://journals.sagepub.com/doi/10.1177/2151458514560471
Nkanang B, Parker M, Parker E, Griffiths R. Perioperative mortality for patients with a hip fracture. Injury. [Internet]. 2017;48(10):2180-3. Available from: https://linkinghub.elsevier.com/retrieve/pii/S0020138317304266
Ek S, Meyer AC, Hedström M, Modig K. Comorbidity and the association with 1-year mortality in hip fracture patients: can the ASA score and the Charlson Comorbidity Index be used interchangeably?. Aging Clin Exp Res. [Internet]. 2022;34(1):129-36. Available from: https://link.springer.com/article/10.1007/s40520-021-01896-x
Delahoy MJ, Whitaker M, O’Halloran A, Chai SJ, Kirley PD, Alden N, et al. Characteristics and maternal and birth outcomes of hospitalized pregnant women with laboratory-confirmed COVID-19 — COVID-NET, 13 states, March 1–August 22, 2020. MMWR Morb Mortal Wkly Rep. [Internet]. 2020;69(38):1347-54. Available from: http://www.cdc.gov/mmwr/volumes/69/wr/mm6938e1.htm
Adeyemi OJ, Meltzer-Bruhn A, Esper G, DiMaggio C, Grudzen C, Chodosh J, et al. Crosswalk between Charlson Comorbidity Index and the American Society of Anesthesiologists physical status score for geriatric trauma assessment. Healthcare (Basel). [Internet]. 2023;11(8):1137. Available from: https://www.mdpi.com/2227-9032/11/8/1137
Copyright (c) 2026 Ragil Catur Nugroho
This work is licensed under a Creative Commons Attribution-ShareAlike 4.0 International License.
The Contributor and the company/institution agree that all copies of the Final Published
Version or any part thereof distributed or posted by them in print or electronic format as permitted herein will include the notice of copyright as stipulated in the Journal and a full citation to the Journal.
