A Descriptive Survey Study on the Effect of Age on Quality of Life Following Stoma Surgery

Abstract

  The number of operative procedures involving the creation of an intestinal stoma is likely to increase as the population ages. Understanding the role of age on postoperative outcomes such as quality of life (QoL) and self-efficacy is critical to developing appropriate supportive strategies. A descriptive survey study was conducted among 18 patients (11 men seven women, age range 47 to 90 years) who had an intestinal ostomy created during a 3-year period at the University of Alberta Hospital in Edmonton, Alberta, Canada.

The Stoma Quality of Life Survey and a self-efficacy survey examining self-care, activities of daily living, and instrumental activities of daily living were administered. Patient records were obtained through a retrospective chart review; of the 57 patients identified, 18 were still alive, had not undergone stoma reversal, were cognitively competent, and agreed to participate. Seven patients were <65 years old and 11 were ≥65 years old. Of those, four patients had their stoma since 2009, four patients since 2010, and 10 patients since 2011. Although older patients had more comorbidities and higher mortality following the surgery (46.1% for patients >65 versus 26.1%, for patients <65 years old), no statistically significant difference was found between the two groups for stoma-associated QoL and self-efficacy scores. In patients who had stoma surgery in 2011, older patients on average had higher QoL scores (65.21 versus 61.87, maximum score 100, P = 0.56), but lower self-efficacy scores (32.50 versus 35.25, maximum score 40, P = 0.50). These findings are similar to previously reported study results. However, the small study sample size limits analysis of the variables that may affect QoL in stoma patients. This study supports the need for additional prospective studies to help clinicians develop effective support strategies.

 Potential Conflicts of Interest: This study was funded by the M.S.I. Foundation and the Canadian Institute of Health Research Health Professional Summer Student Award.

Introduction

  The growing number of North America’s elderly, combined with increasing life expectancy, has led to a greater number of older patients undergoing gastrointestinal (GI) surgery. These abdominal surgeries can require intestinal resections leading to a discontinuity of the GI tract. In many instances, this necessitates the creation of an intestinal stoma. Common indications for stomas include malignancy, infection, obstruction, and perforation. Receiving an ostomy is a life-changing experience that has both mental and physical long-term effects. According to multiple retrospective and prospective studies, patients with ostomies have to cope not only with daily maintenance of the stoma, but also with the associated changes in body image,^1-4 sexual function,^5-7 social activities,⁸ and sleep.

  Regardless of age, the challenges faced by ostomy patients can affect many aspects of well-being. Likely, older patients strive to enjoy active lives, have anxieties regarding the effects of having a stoma, and perceive quality of life (QoL) to be extremely important, similar to their younger counterparts. Although studies have examined the psychological and physical effects of having a stoma, few have explored the effect of age on QoL and ability to manage the stoma. The relatively few retrospective studies^12,13 that have examined the relationship between age and stomas suggest that while older age alone should not be reason to deny patients ostomy surgery, older patients are affected differently than younger patients following stoma surgery.

  Compared to their younger counterparts, the geriatric population is unique due to several additional factors that impact health. Elderly patients may be frail, have comorbid conditions, present as emergency cases,¹⁴ and have cognitive and/or physical impairments.¹⁵ In several retrospective studies^14,16 focusing on outcomes following colorectal surgery, older patients tended to have longer lengths of stay, more frequent postoperative complications, and a significant reduction of overall survival in comparison to the younger population. Therefore, elderly patients are considered high-risk surgical populations and are more likely to undergo intestinal diversion through an ostomy, as opposed to primary anastamosis, following a resection.¹⁷

  Understanding how age affects QoL following stoma surgery is important to help healthcare workers acknowledge and competently address the needs of older patients. To determine whether older patients (≥65 years) are more likely to have lower perceived QoL and decreased self-efficacy compared to their younger (<65 years) counterparts following stoma surgery, a retrospective review of patient records was conducted, and the effect of age on patient QoL, self-efficacy, and management after stoma surgery (financial and need for assistance with stoma care) was assessed prospectively using The Stoma Quality of Life Survey and a self-efficacy survey.

Methods

  Study design. This study consisted of two components: 1) a retrospective chart review and 2) administration of QoL and self-efficacy surveys to living patients identified from the chart review. A local institutional infection control surveillance database consisting of all clean-contaminated colon surgery cases was used to identify cases for retrospective review. All patients requiring the creation of an ostomy at the University of Alberta Hospital, in Edmonton, Alberta, Canada between January 2009 and December 2011 were identified and a retrospective chart review conducted.

  Inclusion criteria were all patients over the age of 18 years undergoing the creation of an ileostomy or colostomy for all diagnoses. Elective and urgent cases were included. Only clean-contaminated cases were included in the institutional surveillance database, and as such, were the only case classification included for study. The Centers for Disease Control and Prevention (CDC) guidelines were used for the definition of clean-contaminated cases, which are defined as operative wounds in which the respiratory, alimentary, genital, or urinary tract is entered under controlled conditions and without unusual contamination.

  Following the chart review, the following exclusion criteria were applied to identify participants for the surveys: ostomy reversal at the time of the study, cognitive impairment at the time of follow-up, and death at time of the study. Ostomy reversal was an exclusion for survey participation to eliminate recall bias in assessing stoma-related outcomes. Living patients were contacted by telephone. Information about the study was provided and oral consent was obtained from the patients. Ethics approval was granted by the Human Research Ethics Board (HREB) at the University of Alberta.

  Procedure. Background characteristics of all patients who met study criteria were obtained from the detailed chart review. This retrospective data collection included patient demographics and clinical characteristics at the time of ostomy creation (age, American Society of Anesthesiologists [ASA] score, comorbidities), and operative characteristics (type of ostomy, operative diagnosis, urgency, reversal, and year of surgery/time since surgery). The ASA score ranging from 1 to 6 (where 1 = a healthy patient and 6 = a declared brain-dead patient whose organs are being retrieved for donor purposes) was used to grade the physical status of patients at the time of the operation. Additional perioperative data were collected on postoperative outcomes, such as overall mortality. All demographic data were de-identified following chart review.

  A mini mental test (the four-item Abbreviated Mental Test, AMT4)¹⁹ was used to screen willing participants to ensure their capacity to complete the surveys. Subsequently, the questionnaires were administered over the telephone by a medical student during the same encounter to those who were willing and cognitively competent.

  Three questionnaires were administered. First, patients were asked general questions regarding demographics as well as living arrangement (Are you currently living with anyone?), stoma-related finances (How much money do you spend on your stoma monthly? <$50, $50 to 100, or >$100), and assistance with stoma care (Do you get help taking care of your stoma? Always, sometimes, or never). Second, participants completed the Stoma-QoL,⁸ a validated questionnaire developed by Prieto et al, which focuses on four domains: sleep, sexual activity, relations to family/close friends, and relations to those other than family/close friends. The Stoma-QoL consists of 20 statements (eg, I become anxious when the pouch is full), each scored from 1 to 4 (where 1 = always and 4 = not at all) for a total raw score out of 80, and then converted to a global score between 0 and 100. The Stoma-QoL was administered in English. Because activities of daily living are an integral aspect of postoperative outcomes, a third survey examining self-efficacy was developed to directly address patient ostomy management.

  The self-efficacy questions were formulated by the researchers to focus on the subcategories self-care, basic activities of daily living (BADL), and instrumental activities of daily living (IADL). BADL focuses on fundamental self-care, such as feeding and personal hygiene; IADL emphasizes activities needed for independent community functioning, such as housework and shopping. The survey consisted of 10 questions, each scored from 1 to 4 (maximum score = 40) based on how confident the patient was in performing a specific task (for example, preventing leakages or keeping the stoma site clean, where 1 = not confident and 4 = extremely confident) (see Figure 1). The self-efficacy questionnaire was an instrument designed by the researchers and was not tested for validity or reliability. For both the self-efficacy and Stoma-QoL surveys, higher scores represented higher self-efficacy and QoL, respectively.

Results

  Patient demographics. Two hundred, forty-one (241) clean-contaminated colon surgeries, performed between 2009 and 2011, were identified using the institutional infection control database. Of these, 57 patients (age range 26 to 91 years old) underwent the creation of an intestinal ostomy. Of these, 35 living patients were eligible to participate in the QoL and self-efficacy surveys; three were excluded because of ostomy reversal. The remaining 32 patients were contacted: one refused participation, one lacked the mental capacity to participate, and 12 were lost to follow-up. Mortality rate since time of surgery was higher in the older versus younger age group (47.1% versus 26.1%, P = 0.17). Ultimately, 18 patients (length of time since ostomy ranging from 6 months to 3 years) completed the surveys. Patient demographics are presented in Table 1.

  Older patients had more comorbidities at the time of surgery than younger patients, particularly diabetes (17.6% versus 4.3%, P = 0.22), coronary artery disease (32.4% versus 13.0%, P = 0.12), hypertension (50.0% versus 30.4%, P = 0.17), chronic obstructive pulmonary disease (20.6% versus 4.3%, P = 0.13), and renal failure (8.8% versus 4.3%, P = 0.64). Obesity (body mass index [BMI] ≥30) was more prevalent in the younger group (43.5% versus 26.5%, P = 0.25). More older patients than younger patients had an ASA score >2 (82.4% versus 65.2%, P = 0.21). Higher ASA scores represent more severe comorbid disease and lower functional physical status.

  Surgical characteristics (see Table 2). Colostomies were more common than ileostomies in both age groups (64.7% versus 78.3%, older versus younger patients, respectively; P = 0.38). Older patients were more likely to have the stoma created during an emergency surgery than younger patients (50.0% versus 21.7%, P = 0.052). Cancer was the most common indication for surgery in both older and younger patients (73.5% versus 43.5%, respectively) (see Figure 2). Other indications for surgery included immobility/incontinence, colostomy prolapse, diverticular disease, sigmoid volvulus, rectal prolapse, and colonic polyps. Older patients had significantly lower rates of sacral decubitus ulcers (2.9% versus 21.7%, P = 0.006) and a trend toward lower rates of inflammatory bowel disease (0% versus 8.7%, P = 0.06). Three patients, all in the >65 years of age group, underwent ostomy reversal surgery.

  Self-efficacy and QoL. No statistically significant differences were found in self-efficacy scores between older and younger patients (older versus younger patients, 32.57 [range 21–40] versus 32.45 [range 15–40] out of a maximum score of 40, P = 0.98). For the Stoma-QoL, average scores were higher in older than in younger patients, although the difference was not statistically significant (63.94 versus 56.18 out of a maximum score of 100, P = 0.14) (see Figure 3).

  To exclude the effect of length of time that patients had ostomies, the 2011 cohort of patients (N = 10) was analyzed as a subgroup. The 2011 group was the largest subset of patients from the 3-year period, and these patients had ostomies for the shortest period of time. The 2011 cohort also was divided into two age groups (age <65 and ≥65 years) and examined for the effect of age on self-efficacy and QoL. In the 2011 subset, older patients had lower self-efficacy (average 32.50 versus 35.25, P = 0.50) but higher QoL scores (average 65.21 versus 61.87, P = 0.56) than their younger counterparts.

  The majority of both older and younger patients never required assistance with daily stoma care (63.6% of older and 57.1% of younger patients). Among patients who required assistance, older patients were more likely to always need help (36.4% versus 14.3%) as opposed to younger patients who tended to report needing only occasional help (28.5%) (see Figure 4). After taking health insurance coverage into consideration, younger patients were more likely than older patients to spend more than $50 per month on ostomy supplies (57.1% versus 27.3%, P = 0.21).

Discussion

  The objective of this retrospective chart review and descriptive survey study was to assess the effect of age on self-efficacy and QoL following ostomy surgery. Elderly patients are considered to be at a higher operative risk primarily due to their lower physiologic reserve and higher incidence of comorbidities.²⁰ This is an important problem to address due to the rapidly aging demographics of the Western world.

  As expected, the older group of patients (age ≥65) had a higher number of comorbidities than the younger patients (age <65). Although this finding was not statistically significant, a trend toward higher incidence of comorbidities in the older age group was noted, with rates of diabetes and chronic obstructive pulmonary disease almost four times higher in the older age group. The overall health differences between groups also are reflected in the higher mortality rate in the older age group (47.1% versus 26.1%). This is corroborated by numerous studies that show older age groups have significantly higher mortality following colorectal surgery due to comorbidities.^16,21,22 A retrospective study by Grosso et al²³ found that patients >65 years of age not only presented with more comorbidities than younger patients, but they also subsequently had a higher incidence of postoperative complications and lower 3- and 5-year survival rates.

  It might be expected that the elderly group of patients would have lower QoL and self-efficacy, but in this study, no differences were found. In fact, QoL scores in older patients following stoma surgery may be equal to, if not higher than, those of younger patients. These findings are consistent with a retrospective study done by Stryker et al¹⁵ comparing the QoL of older versus younger patients with conventional ileostomies. They found that in all categories of QoL assessment, older patients scored as well or higher than the younger patients. Although greater difficulty in daily management was found to be more prevalent among the older age group members, they did not experience more occupational or activity restrictions. A retrospective study by Scarpa et al²⁴ involving 34 patients with ileostomies following colorectal cancer showed that QoL scores were consistent in three age groups (<50, 50 to 70, >70 years of age), but older patients required additional assistance taking care of their stomas. These findings underscore the observation that although older patients require more assistance with the care of their stomas (for example, changing appliances), this does not necessarily translate to a lower QoL.

  The self-efficacy questionnaire designed for this study measured three key domains: self-care, BADL, and IADL. Most questions were targeted at measuring patients’ confidence in their ability to care for their stoma (for example, change appliances, prevent leakage, take baths/showers, and be physically active). In this study’s subset of patients who underwent stoma surgery in 2011, the older population had lower self-efficacy scores. This finding may be expected as a result of the deterioration in visual acuity, skin integrity, gastrointestinal health, and joint mobility issues that arise with age.¹⁵ Wu et al’s²⁵ cross-sectional correlation study of 96 stoma patients (mean duration of having a stoma 26.2 months) recruited from two acute care hospitals in Hong Kong similarly found that older patients tend to have lower self-efficacy than younger age groups. However, despite older patients scoring similar to or lower than their younger counterparts on the self-efficacy survey, their QoL was not correspondingly decreased. These results suggest that in stoma patients, QoL may be affected by more factors than stoma care self-efficacy alone. Marquis et al²⁶ found that patients who were satisfied with the care they received and who perceived their stoma care nurses as having a genuine interest in them had the highest QoL index postoperatively.

  This study was designed primarily to compare older and younger patients in terms of overall self-efficacy and QoL and did not measure other physiologic and psychosocial domains that likely also account for differences in QoL that are not explained by self-efficacy alone. For example, Bekkers et al⁵ prospectively studied psychosocial adaptation following stoma surgery and found that age is a significant characteristic that affects psychosocial rehabilitation. Following ostomy formation, older patients had more problems adapting in the sexuality domain and experienced more social environmental problems (such as leisure time activities and holidays).

  Research also has shown that changes in QoL over time differ between older and younger patients. A prospective pilot study by Ma et al²⁷ followed changes in QoL of 49 patients aged 23 to 86 years old over a 12-month period. Participants completed a QoL questionnaire preoperatively and at 6 and 12 months postoperatively. In the context of physical and mental functioning, older patients showed less improvement in QoL over a 12-month period than the younger patients and also showed no further improvement after 6 months. A prospective study examining impact of age on QoL of 519 rectal cancer patients by Schmidt et al²⁸ similarly has shown that the QoL of older patients does not return to baseline even 2 years after the stoma procedure, suggesting physical functioning of older patient is more permanently affected by the surgery.

  There are several possible explanations for the current findings that older patients fare equally as well or potentially better than younger patients after stoma surgery. Because stoma surgery is such a drastic, body-altering procedure, body image is one of the most significant and common patient concerns.^1-4,29 Furthermore, body image is strongly linked to an individual’s sense of sexual attractiveness1 and comfort with social interactions.² Consequently, ostomy surgery can impact partner interactions³⁰ and sexual functioning.³¹ In the current patient population, older patients reported greater comfort with their bodies, less concern regarding their sexual adequacy, and positive relationships with their spouse/family/friends. This corresponds to Orsini’s¹³ long-term cancer survivorship study, which demonstrated that sexual functioning and enjoyment were significantly lower in younger patients compared to the normative population and not significantly different in older patients. Comfort with body image may contribute to the higher QoL in the current older age group. Older patients also may be more likely to have established relationships and an occupation or be retired.

  Nichols and Riemer³² examined the effect of stabilizing forces on postsurgical recovery and found that patients with occupational stability where ostomy surgery did not lead to a change in work habit reported higher life satisfaction scores. In addition, a stable spouse/partner relationship (patients who were married before surgery and remained married after surgery) also predicted higher life satisfaction scores, as did having a stable and supportive family. Because family is often a significant source of support and positive interactions for patients, a family or spouse’s ability to adapt and demonstrate a positive emotional response plays a significant role in improving an ostomate’s self-esteem and ability to adapt to the effects of the surgery.^33,34 Altschuler et al’s³⁵ descriptive study, branching from a parent study measuring QoL in cancer survivors with ostomies, found that withdrawal of husbands’ or partners’ support has a significant impact on psychosocial adjustment following ostomy surgery. In the majority of cases (17 out of 22), women with high or low health-related QoL scores corresponded to a positive or negative description regarding husband/partner support respectively. These variables were not measured in the current study.

Limitations

  Bias may have been introduced due to the small sample size and the retrospective nature of the study. Only 18 of the 57 patients identified from the surgical database could be surveyed. In addition, the older age group was predominantly male, which may limit generalizability to the overall patient population. Ideally, the study would prospectively identify patients undergoing stoma creation and have standardized follow-up periods. By doing so, the effect of age alone on QoL could be better isolated and distinguished from any changes in QoL that result from patients having had more time to adapt to their stoma. The self-efficacy survey measure used in this study was not validated, further limiting generalizability.

  Finally, bias could be introduced by the variable time interval between ostomy creation and survey administration. The largest cohort of patients (2011 subset) had ostomies for the shortest period of time. Subgroup analysis did not show differences in the observed trends in self-efficacy and QoL; however, time can potentially affect these outcomes. A prospective study design would help to negate these limits but requires a large sample size due to anticipated drop-outs. Because 47% of the older population and only 26% of the younger age group died before the time the survey was conducted, survivorship bias may have caused higher self-efficacy and QoL scores in the older age group.

Conclusion

  This retrospective review and descriptive survey study provides data supporting the need for a larger prospective study examining how age affects postoperative stoma-associated outcomes, including self-efficacy and QoL. Although older patients seem to score lower in terms of self-efficacy within 1 year after surgery, results from this study suggest their QoL is equal to, if not higher than, that of younger patients. Because older patients are physiologically and psychologically unique from their younger counterparts, understanding the effect of an ostomy on their QoL is crucial to addressing their needs. This knowledge is essential for the effective allocation of healthcare resources, understanding which patient populations would most benefit from pre- and postoperative support, and determining the most useful types of support.

Acknowledgment

  The authors are grateful to the University of Alberta’s Acute Care and Emergency Surgery (ACES) group and Ms. Yvonne Tul for their support in this research. ACES Group members include Ronald Brisebois, MD, FRCSC; Klaus Buttenschoen, MD; Kamran Fathimani MD, FRCSC; Stewart M. Hamilton, MD, MSc, FRCSC; Rachel G. Khadaroo, MD, PhD, FRCSC; Gordon M. Lees, MD, FRCSC; Todd McMullen, MD, PhD, FRCSC; William Patton, MD, CCFP(EM), FCFP; Mary Van Wijngaarden-Stephens, MD, FRCSC; J. Drew Sutherland, MD, FRCSC; Sandy Widder, MD, MHA, FRCSC; and David C. Williams, MD, MSc, FRCSC. The authors also thank enterostomal therapy nurses, Sandra Allen, RN, ET; Sandra Bressmer, RN, ET, BScN; and Sharon Goodhelpsen, RN, ET for the excellent care they provide for their patients.

 Ms. Wong is a medical student, Faculty of Medicine and Dentistry; Dr. Young is a surgical resident, Division of General Surgery, Department of Surgery; Drs. Widder and Khadaroo are General Surgeons, Division of General Surgery, Department of Surgery, University of Alberta, Edmonton, Alberta, Canada. Please address correspondence to: Dr. Rachel G. Khadaroo, Department of Surgery, 2D Walter C. Mackenzie Centre, 8440-112 St NW, Edmonton, AB T6G 2B7 Canada; email: khadaroo@ualberta.ca.

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