Short-Term Functional Trajectories After Surgery in Older Adults: National Patterns of Loss and Recovery in 436,471 Patients

Objective: To characterize short-term functional trajectories and identify risk factors for loss and recovery of independence among older surgical patients at a national level. Background: As the surgical population ages, frailty increasingly influences outcomes beyond mortality. Short-term postoperative functional independence is a key patient-centered outcome with long-term implications, yet national data across surgical specialties remain limited. Methods: We conducted a retrospective cohort study using the 2022–2024 American College of Surgeons National Surgical Quality Improvement Program database, including all patients aged ≥75 years. Patients were categorized by functional trajectory from admission to 30 days postdischarge: maintenance of independence, loss of independence (LOI), maintenance of dependence, or gain of independence (GOI). Multivariable logistic regression identified independent factors associated with LOI among baseline-independent patients, and with GOI among baseline-dependent patients. Prespecified subgroup analyses assessed effect modification by dementia, age, frailty (mFI-5 score), surgical specialty, surgical approach, urgency, and setting. Results: Among 436,471 patients, 28.2% of baseline-independent adults experienced LOI, while 5.6% of baseline-dependent patients experienced GOI. LOI rates increased stepwise with age and frailty and were strongly associated with frailty, recent falls, preoperative sepsis, higher American Society of Anesthesiologists class, urgent/emergent surgery, inpatient setting, and open surgical approaches. LOI was associated with markedly higher postoperative mortality, prolonged hospitalization, delirium, sepsis, ventilator dependence, and nonhome discharge. Dementia was independently associated with LOI risk and inversely with GOI risk across nearly all subgroups. Conclusions: Short-term LOI is common among adults aged ≥75 years and represents a powerful marker of adverse postoperative complications. Dementia and perioperative acuity are dominant associated factors of short-term functional trajectory, while short-term recovery of independence is rare. Findings suggest that short-term functional outcomes should be incorporated into preoperative risk stratification, shared decision-making, and perioperative care pathways for older adults.