Introduction

As stated in the 2019 World Population Ageing Report by the United Nations, the global population aged 65 and over was 703 million in 2019 and it is projected that this figure will double by 2050 [1–4]. Despite the absence of a universally accepted definition of frailty, it has been operationally linked to an increased risk of adverse clinical outcomes, including falls, surgical complications, nursing home admission, disability, and death [5]. Frailty significantly correlates with adverse clinical outcomes, ranging from increased healthcare utilisation to higher mortality rates [5].

Postoperative functional outcomes represent a major concern in older adults because surgery may accelerate functional decline and reduce independence [5]. Programmes that are designed to preserve or restore function, as opposed to merely extending survival, have demonstrated encouraging outcomes in enhancing postoperative quality of life [6]. The impact of surgical interventions on older adults can vary depending on various factors, including gender-related differences. The surgical outcomes for older adults are influenced by a multitude of biological and social factors. It is imperative to comprehend the influence of gender- and age-specific factors on surgical outcomes, as this knowledge can serve as a pivotal guide in the development of personalised interventions. Such interventions, in turn, have the potential to enhance the delivery of healthcare services [5, 6].

Recent studies have repeatedly demonstrated that gender has a significant impact on health outcomes among older adults. A body of research has indicated that older women report a lower subjective health status, higher levels of functional limitations, and a greater psychosocial burden when compared to men [7, 8]. These disparities demand comprehensive research into the interaction between gender and both functional and cognitive health. It is important to note that cognitive test results do not merely reflect brain health, but also lifelong experiences, educational history, and cultural or linguistic factors [9, 10]. It has been demonstrated that the quality of education, early-life experiences, and literacy levels have a significant impact on cognitive performance in later life. The variability in test results observed across different ethnic or cultural groups further underscores the importance of considering these factors when assessing cognitive health [7–11].

Therefore, the present exploratory cross-sectional study aimed to investigate the association between previous surgical history and balance performance, cognitive status, functional independence, and kinesio- phobia according to gender among community-dwelling older adults.

Material and methods

Design and participants

A cross-sectional study was conducted, employing a two-stage probability sampling design, which was stratified by time and space. Participants were selected from community settings using a stratified time-space sampling approach. Initially, arbitrary time-space blocks were selected from each stratum. In the second stage, participants within each selected block were chosen using systematic random sampling (for example, selecting every third eligible person from a randomly chosen starting point).

The study was conducted in community settings between March and September 2025. Individuals aged 65 years and over who resided within the designated study area were deemed eligible to participate. Participants were required to comply with the study procedures and assessments, have no severe hearing or vision impairments, and provide voluntary informed consent.

Prior to data collection, written informed consent was obtained from all participants.

Standardised assessment procedures were utilised to minimise the potential for bias. The knowledge bias was mitigated by the implementation of standardised and validated assessment tools, which were administered by trained physical therapists in accordance with a uniform protocol. The potential for interviewer bias was mitigated through the implementation of standardised instructions and assessments.

Sample size

An a priori power analysis was conducted using G*Power software to determine the required sample size. Based on a one-way analysis of variance including four groups, a total sample size of 231 participants was estimated to be sufficient to detect a medium effect size (f = 0.25) with a statistical power of 90% and a significance level of  = 0.05 [11]. The final sample of 271 participants included in the present study exceeded the minimum required sample size.

Data collection

Variables

The primary outcome measures comprised functional independence, balance performance, cognitive status, and kinesiophobia, which were assessed using the functional independence measure (FIM), the Berg balance scale (BBS), the standardised mini-mental state examination (SMMSE), and the Tampa scale of kinesiophobia (TAMPA), respectively. The primary exposure variables were gender and the previous surgical history (yes/no). Participants were divided into four groups based on the following exposure variables: women with a history of surgery, women without a history of surgery, men with a history of surgery, and men without a history of surgery. In the course of the analyses, the potential for confounding variables such as age and body mass index (BMI) was taken into consideration. Clinically relevant cut-off values were additionally used to classify balance-related fall risk, reduced functional independence, cognitive impairment, and high kinesiophobia.

Procedures

The study sample comprised 271 community-dwelling adults aged 65 years and over. The inclusion criteria were as follows: participants had to be 65 years of age or older and had to be residing in the designated study area. Participants deemed eligible were required to comply with the study procedures and assessments, to have no severe hearing or vision impairments, and to voluntarily agree to participate.

The data were collected through the implementation of structured face-to-face interviews, which were conducted in public community settings that are frequently visited by older adults. Such settings include parks, marketplaces, community centres, and tea houses. The administration of a standardised questionnaire, encompassing demographic characteristics, surgical history, and validated health-related assessment scales (FIM, BBS, SMMSE, and TAMPA), was conducted by trained interviewers. Anthropometric measurements, including height and weight, were taken to calculate BMI. Throughout the study period, all data were systematically recorded, with instances of non-response or refusal being meticulously documented.

The assessment of kinesiophobia was conducted utilising the Tampa scale of kinesiophobia, a 17-item questionnaire. The Tampa scale of kinesiophobia, a tool that has been validated for the measurement of fear of movement, yields scores ranging 17–68. As indicated in validity studies conducted in older adult populations, scores above 37 indicate a high level of kinesiophobia. The Tampa scale of kinesiophobia has undergone rigorous testing in patients with chronic pain and has demonstrated strong internal consistency, test-retest reliability, and both face and content validity [12, 13].

The functional independence measure is a tool used to assess functional independence in daily activities. It does this by analysing two aspects of disability: motor and cognitive functions. The functional independence measure is comprised of six distinct domains: personal care, bladder and bowel control, mobility, locomotion, communication, and social perception. The assessment of functional independence employs a seven- point scale, encompassing eighteen activities, with a maximum attainable score of 126. It is evident that elevated scores are indicative of augmented autonomy in activities of daily living. The functional independence measure is a widely utilised tool in the field of medical rehabilitation, serving as a crucial instrument for the assessment of functional independence [14].

The Berg balance scale, a widely utilised clinical assessment instrument, was originally developed to evaluate balance in older adults [15]. The 14-item test requires participants to perform static and dynamic daily tasks of varying difficulty levels. The items are scored on a scale of 0–4, and a maximum total score of 56 indicates excellent balance [16].

The standardised mini-mental state examination provides a comprehensive assessment of cognitive function. This assessment is straightforward to administer and provides information about the degree of cognitive impairment. The maximum score that can be attained on the test is 30, with higher scores denoting superior cognitive function. Scores below 23/24 indicate abnormal cognitive function in community-dwelling older adults. The revised SMMSE is administered to older adults with less than five years of education, while the modified SMMSE is administered to educated individuals. Scores ranging 24–30 are indicative of normal cognitive function, while scores of 20–23 denote mild cognitive impairment, and scores below 19 repre- sent moderate cognitive impairment [17].

Statistical analysis

Statistical analyses were performed using IBM SPSS Statistics for Windows (Version 26.0; IBM Corp., Armonk, NY, USA). Descriptive statistics are presented as mean ± standard deviation for continuous variables and as frequency and percentages for categorical variables. The normality of the data distribution was assessed using the Kolmogorov-Smirnov test and visual inspection of histograms.

A one-way analysis of variance was performed to examine differences among the four study groups defined by gender and surgical history (women with a surgical history, women without a surgical history, men with a surgical history, and men without a surgical history). Post hoc comparisons were conducted using Tukey’s test when appropriate.

Categorical comparisons between participants with and without a surgical history were performed using c² analysis. In addition, clinically relevant cut-off values were applied for balance performance, functional independence, cognitive status, and kinesiophobia in order to identify risk-related functional profiles.

Berg balance scale scores below 45 were accepted as indicating an increased balance-related fall risk, FIM scores below 125 as reduced functional independence, SMMSE scores below 24 as cognitive impairment, and TAMPA scores above 37 as high kinesiophobia. Statistical significance was set at p < 0.05.

Results

A total of 289 eligible older adults were contacted with a view to participating in the study. Eighteen individuals declined to participate, citing insufficient time or personal reasons. Consequently, 271 participants completed all assessments and were included in the analyses.

Table 1 presents the demographic characteristics of the participants. Of the total sample, 51.6% were female and 48.4% were male. Regarding surgical history, 60.1% of participants reported having undergone at least one surgical procedure, whereas 39.9% reported no surgical history. Among participants with a surgical history, 40.3% had undergone orthopaedic surgery, 12.5% general surgery, and 7.3% cardiovascular surgery. The mean age of the participants was 71.4 ±7.3 years, and the mean BMI was 29.2 ±7.9 kg/m².

Table 2 presents comparisons of functional, balance, cognitive, and kinesiophobia outcomes according to gender and surgical history. Male participants demonstrated significantly higher scores in cognitive status, balance performance, and functional independence compared with female participants (SMMSE, p < 0.001; BBS, p < 0.001; FIM, p = 0.007). In contrast, female participants reported significantly higher levels of kinesiophobia compared with males (p = 0.046). Older women with a surgical history demonstrated poorer balance performance and lower functional independence compared with the other groups.

Table 3 presents clinically relevant risk profiles according to surgical history. Participants with a surgical history more frequently demonstrated balance impairment associated with an increased fall risk (BBS < 45) compared with participants without a surgical history (38.7% vs. 24.8%, p = 0.023). Similarly, reduced functional independence (FIM < 125) was more prevalent among participants with a surgical history (25.6% vs. 13.8%, p = 0.027). No significant differences were observed between groups regarding cognitive impairment (SMMSE < 24) or high kinesiophobia (TAMPA > 37).

Discussion

This study presents findings on the relationship between surgical history, gender, balance, kinesiophobia, and functional independence in community-dwelling older adults. Our findings suggest that gender may influence the association between surgical history and functional status. Older adults with a history of surgery also showed a higher risk of balance-related falls and lower functional independence. The present findings should be interpreted as demonstrating an association rather than a causal relationship between the previous surgical history and current functional outcomes. Rather than evaluating the effects of specific surgical procedures, this study explored whether the presence of the previous surgical history may be associated with balance performance and functional independence among community-dwelling older adults [18].

Compared with the other groups, older women with a history of surgery had lower cognitive scores, lower functional independence, lower balance scores, and higher kinesiophobia levels. These findings are consistent with poorer functional outcomes in this population and are consistent with previous studies [18, 19].

Previous studies have shown that postoperative pain and kinesiophobia may contribute to functional limitations in older adults [12, 20, 21]. These factors should be considered when planning rehabilitation programs. Individualised assessments are important for evaluating functional status during the postoperative period [22]. Sayilan et al. [21] also reported that gender may influence mental and functional recovery after surgery. In the present study, older adults with a history of surgery had lower functional independence and a higher risk of balance-related falls. These findings suggest that previous surgical history may represent a clinically relevant characteristic during geriatric assessment in community-dwelling older adults.

Omaña et al. [23] reported that current balance tests alone may not reliably predict the fall risk in older adults. Beck Jepsen et al. [8] conducted an umbrella review and emphasised that standardised functional assessments in older adults remain inadequate, particularly with regard to balance and mobility. Routine balance and functional assessments may help physiotherapists, nurses, and community health professionals identify older adults at an increased risk of falls and functional decline. This approach has the potential to influence physical therapy and rehabilitation practices, with the aim of preventing adverse outcomes such as falls and frailty. The necessity for multifactorial assessments was emphasised by the same authors [23]. Therefore, evaluating balance, cognition, psychosocial factors, and surgical history together may provide a better understanding of functional status in older adults [18]. However, a review of the literature indicates that surgical history is frequently disregarded in studies conducted with older adults residing in the community. From a geriatric perspective, surgery may be associated with functional status, independence, and cognitive function in older adults [2, 18, 19]. Previous studies have reported associations between female gender, cognitive status, mobility, and a fall risk in older adults [1, 3, 24]. Suh et al. [1] reported in a study involving 10,073 community-dwelling older adults that 57.5% of women had a history of falls, which was associated with increased dependence in daily activities [3]. Kato et al. [24] reported in their study, which involved 2,017 older adults living in the community, that women exhibited more pronounced declines in physical function, including balance and lower extremity muscle strength, compared to men.

In the present study, older women showed lower balance performance and functional independence than men, with the lowest balance scores observed among women with a previous surgical history. Analyses based on established cut-off values also indicated a higher risk of balance-related falls and lower functional independence in participants with a previous surgical history. These findings suggest an association between previous surgical history and poorer functional outcomes in community-dwelling older adults, particularly among women. However, our results should not be interpreted as indicating that women have a poorer overall postoperative prognosis. Instead, they suggest that, within the outcomes evaluated in this study, older women may be more functionally vulnerable in terms of balance performance and functional independence.

Functional outcomes in older adults are influenced by many factors, including nutritional status, lifestyle, cultural background, and living conditions. Previous studies have highlighted the importance of considering these factors when interpreting functional assessments in community-dwelling older adults [2, 7, 25, 26]. In our study, BMI was comparable across all groups, making it less likely that differences in body composition substantially affected the results. In addition, all participants were recruited from the same country and from similar community settings, which may have reduced the influence of cultural and environmental differences on our findings [7, 26, 27].

The results of this study may be more applicable to community-dwelling older adults with similar social and cultural characteristics. Therefore, the findings should be interpreted carefully when considering older adults living in institutional settings or different healthcare systems [18, 19, 26, 27].

Limitations

This study has several limitations. First, its cross- sectional design precludes any causal interpretation of the observed associations. Second, information on frailty status, surgical type, anaesthesia-related factors, and time since surgery was not available and therefore could not be included in the analyses. These factors may have influenced the observed associations and should be considered in future studies. In addition, surgical history was based on self-report, which may have introduced recall bias. Despite these limitations, the findings provide preliminary evidence regarding the association between previous surgical history and balance performance, functional independence, cognitive status, and kinesiophobia in community-dwelling older adults. Accordingly, the findings should be interpreted with appropriate caution. Future prospective longitudinal studies incorporating frailty assessment and detailed perioperative characteristics are needed to further clarify these associations.

Conclusions

In conclusion, previous surgical history was associated with poorer balance performance and functional independence among community-dwelling older adults, particularly in women. These findings suggest that previous surgical history may represent a clinically relevant characteristic that warrants further functional assessment during geriatric evaluation. Future prospective longitudinal studies are required to investigate these associations while accounting for frailty status, surgical characteristics, and postoperative duration.

Disclosures

1. Institutional review board statement: This study was approved by the Ethics Committee of the Yalova University (approval decision no. 2024/202, dated 01.10.2024).

2. Assistance with the article: None.

3. Financial support and sponsorship: This study was supported by The Scientific and Technological Research Council of Türkiye (TÜBİTAK). Number: 1919B012406868.

4. Conflicts of interest: None.

References