Frailty index and all-cause and cause-specific mortality in Chinese adults: a prospective cohort study

BACKGROUND

The fraily index is a useful proxy measure of accelerated biological ageing and in estimating all-cause and cause-specific mortality in older individuals in European and US populations. However, the predictive value of the frailty index in other populations outside of Europe and the USA and in adults younger than 50 years is unknown. We aimed to examine the association between the frailty index and mortality in a population of Chinese adults.

METHODS

In this prospective cohort study, we used data from the China Kadoorie Biobank. We included adults aged 30-79 years from ten areas (five urban areas and five rural areas) of China who had no missing values for the items that made up the frailty index. We did not exclude participants on the basis of baseline morbidity status. We calculated the follow-up person-years from the baseline date to either the date of death, loss to follow-up, or Dec 31, 2017, whichever came first, through linkage with the registries of China's Disease Surveillance Points system and local residential records. Active follow-up visits to local communities were done annually for participants who were not linked to any established registries. Causes of death from official death certificates were supplemented, if necessary, by reviewing medical records or doing standard verbal autopsy procedures. The frailty index was calculated using 28 baseline variables, all of which were health status deficits measured by use of questionnaires and physical examination. We defined three categories of frailty status: robust (frailty index ≤0·10), prefrail (frailty index >0·10 to <0·25), and frail (frailty index ≥0·25). The primary outcomes were all-cause mortality and cause-specific mortality in Chinese adults aged 30-79 years. We used a Cox proportional hazards model to estimate the associations between the frailty index and all-cause and cause-specific mortality, adjusting for chronological age, education, and lifestyle factors.

FINDINGS

512 723 participants, recruited between June 25, 2004, and July 15, 2008, were followed up for a median of 10·8 years (IQR 10·2-13·1; total follow-up 5 551 974 person-years). 291 954 (56·9%) people were categorised as robust, 205 075 (40·0%) people were categorised as prefrail, and 15 694 (3·1%) people were categorised as frail. Women aged between 45 years and 79 years had a higher mean frailty index and a higher prevalence of frailty than did men. During follow-up, 49 371 deaths were recorded. After adjustment for established and potential risk factors for death, each 0·1 increment in the frailty index was associated with a higher risk of all-cause mortality (hazard ratio [HR] 1·68, 95% CI 1·66-1·71). Such associations were stronger among younger adults than among older adults (pinteraction<0·0001), with HRs per 0·1 increment of the frailty index of 1·95 (95% CI 1·87-2·03) for those younger than 50 years, 1·80 (1·76-1·83) for those aged 50-64 years, and 1·56 (1·53-1·59) for those 65 years and older. After adjustments, there was no difference between the sexes in the association between the frailty index and all-cause mortality (pinteraction=0·75). For each 0·1 increment of the frailty index, the corresponding HRs for risk of death were 1·89 (95% CI 1·83-1·94) from ischaemic heart disease, 1·84 (1·79-1·89) from cerebrovascular disease, 1·19 (1·16-1·22) from cancer, 2·54 (2·45-2·63) from respiratory disease, 1·78 (1·59-2·00) from infection, and 1·78 (1·73-1·83) from all other causes.

INTERPRETATION

The frailty index is associated with all-cause and cause-specific mortality independent of chronological age in younger and older Chinese adults. The identification of younger adults with accelerated ageing by use of surrogate measures could be useful for the prevention of premature death and the extension of healthy active life expectancy.

FUNDING

The National Natural Science Foundation of China, the National Key R&D Program of China, the Chinese Ministry of Science and Technology, the Kadoorie Charitable Foundation, and the Wellcome Trust.

Instruments for the detection of frailty syndrome in older adults: A systematic review

Frailty is a dynamic process in which there is a reduction in the physical, psychological and/or social function associated with aging. The aim of this study was to identify instruments for the detection of frailty in older adults, characterizing their components, application scenarios, ability to identify pre-frailty and clinimetric properties evaluated. The study was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA), under registration number CRD42017039318. A total of 14 electronic sources were searched to identify studies that investigated instruments for the detection of frailty or that presented the construction and/or clinimetric evaluation of the instrument, according to criteria established by the COnsensus-based Standards for the selection of health Measurement INstruments (COSMIN). 96 studies were included in the qualitative synthesis: 51 instruments for the detection of frailty were identified, with predominantly physical domains; 40 were constructed and/or validated for use in the older adult community population, 28 only highlighted the distinction between frail and non-frail individuals and 23 presented three or more levels of frailty. The FRAGIRE, FRAIL Scale, Edmonton Frail Scale and IVCF-20 instruments were the most frequently analyzed in relation to clinimetric properties. It was concluded that: (I) there is a large number of instruments for measuring the same construct, which makes it difficult for researchers and clinicians to choose the most appropriate; (II) the FRAGIRE and CFAI stand out due to their multidimensional aspects, including an environmental assessment; however, (III) the need for standardization of the scales was identified, since the use of different instruments in clinical trials may prevent the comparability of the results in systematic reviews and; (IV) considering the different instruments identified in this review, the choice of researchers/clinicians should be guided by the issues related to the translation and validation for their location and the suitability for their context.

Longitudinal trajectories, correlations and mortality associations of nine biological ages across 20-years follow-up

Biological age measurements (BAs) assess aging-related physiological change and predict health risks among individuals of the same chronological age (CA). Multiple BAs have been proposed and are well studied individually but not jointly. We included 845 individuals and 3973 repeated measurements from a Swedish population-based cohort and examined longitudinal trajectories, correlations, and mortality associations of nine BAs across 20 years follow-up. We found the longitudinal growth of functional BAs accelerated around age 70; average levels of BA curves differed by sex across the age span (50-90 years). All BAs were correlated to varying degrees; correlations were mostly explained by CA. Individually, all BAs except for telomere length were associated with mortality risk independently of CA. The largest effects were seen for methylation age estimators (GrimAge) and the frailty index (FI). In joint models, two methylation age estimators (Horvath and GrimAge) and FI remained predictive, suggesting they are complementary in predicting mortality.

Vitamin D Supplementation Associated to Better Survival in Hospitalized Frail Elderly COVID-19 Patients: The GERIA-COVID Quasi-Experimental Study

BACKGROUND

The objective of this quasi-experimental study was to determine whether bolus vitamin D supplementation taken either regularly over the preceding year or after the diagnosis of COVID-19 was effective in improving survival among hospitalized frail elderly COVID-19 patients.

METHODS

Seventy-seven patients consecutively hospitalized for COVID-19 in a geriatric unit were included. Intervention groups were participants regularly supplemented with vitamin D over the preceding year (Group 1), and those supplemented with vitamin D after COVID-19 diagnosis (Group 2). The comparator group involved participants having received no vitamin D supplements (Group 3). Outcomes were 14-day mortality and highest (worst) score on the ordinal scale for clinical improvement (OSCI) measured during COVID-19 acute phase. Potential confounders were age, gender, functional abilities, undernutrition, cancer, hypertension, cardiomyopathy, glycated hemoglobin, number of acute health issues at admission, hospital use of antibiotics, corticosteroids, and pharmacological treatments of respiratory disorders.

RESULTS

The three groups (n = 77; mean ± SD, 88 ± 5years; 49% women) were similar at baseline (except for woman proportion, p = 0.02), as were the treatments used for COVID-19. In Group 1 (n = 29), 93.1% of COVID-19 participants survived at day 14, compared to 81.2% survivors in Group 2 (n = 16) (p = 0.33) and 68.7% survivors in Group 3 (n = 32) (p = 0.02). While considering Group 3 as reference (hazard ratio (HR) = 1), the fully-adjusted HR for 14-day mortality was HR = 0.07 (p = 0.017) for Group 1 and HR = 0.37 (p = 0.28) for Group 2. Group 1 had longer survival time than Group 3 (log-rank p = 0.015), although there was no difference between Groups 2 and 3 (log-rank p = 0.32). Group 1, but not Group 2 (p = 0.40), was associated with lower risk of OSCI score ≥5 compared to Group 3 (odds ratio = 0.08, p= 0.03).

CONCLUSIONS

Regular bolus vitamin D supplementation was associated with less severe COVID-19 and better survival in frail elderly.

Frailty status at admission to hospital predicts multiple adverse outcomes

Aims

frailty is proposed as a summative measure of health status and marker of individual vulnerability. We aimed to investigate the discriminative capacity of a frailty index (FI) derived from interRAI Comprehensive Geriatric Assessment for Acute Care (AC) in relation to multiple adverse inpatient outcomes.

Methods

in this prospective cohort study, an FI was derived for 1,418 patients ≥70 years across 11 hospitals in Australia. The interRAI-AC was administered at admission and discharge by trained nurses, who also screened patients daily for geriatric syndromes.

Results

in adjusted logistic regression models an increase of 0.1 in FI was significantly associated with increased likelihood of length of stay >28 days (odds ratio [OR]: 1.29 [1.10-1.52]), new discharge to residential aged care (OR: 1.31 [1.10-1.57]), in-hospital falls (OR: 1.29 [1.10-1.50]), delirium (OR: 2.34 [2.08-2.63]), pressure ulcer incidence (OR: 1.51 [1.23-1.87]) and inpatient mortality (OR: 2.01 [1.66-2.42]). For each of these adverse outcomes, the cut-point at which optimal sensitivity and specificity occurred was for an FI > 0.40. Specificity was higher than sensitivity with positive predictive values of 7-52% and negative predictive values of 88-98%. FI-AC was not significantly associated with readmissions to hospital.

Conclusions

the interRAI-AC can be used to derive a single score that predicts multiple adverse outcomes in older inpatients. A score of ≤0.40 can well discriminate patients who are unlikely to die or experience a geriatric syndrome. Whether the FI-AC can result in management decisions that improve outcomes requires further study.

Frailty Associated With Waitlist Mortality Independent of Ascites and Hepatic Encephalopathy in a Multicenter Study

BACKGROUND & AIMS

Frailty is associated with mortality in patients with cirrhosis. We measured frailty using 3 simple tests and calculated Liver Frailty Index (LFI) scores for patients at multiple ambulatory centers. We investigated associations between LFI scores, ascites, and hepatic encephalopathy (HE) and mortality.

METHODS

Adults without hepatocellular carcinoma who were on the liver transplantation waitlist at 9 centers in the United States (N = 1044) were evaluated using the LFI; LFI scores of at least 4.5 indicated that patients were frail. We performed logistic regression analyses to assess associations between frailty and ascites or HE and competing risk regression analyses (with liver transplantation as the competing risk) to estimate sub-hazard ratios (sHRs) of waitlist mortality (death or removal from the waitlist).

RESULTS

Of study subjects, 36% had ascites, 41% had HE, and 25% were frail. The odds of frailty were higher for patients with ascites (adjusted odd ratio 1.56, 95% confidence interval [CI] 1.15-2.14) or HE (odd ratio 2.45, 95% CI 1.80-3.33) than for those without these features. Larger proportions of frail patients with ascites (29%) or HE (30%) died while on the waitlist compared with patients who were not frail (17% of patients with ascites and 20% with HE). In univariable analysis, ascites (sHR 1.52, 95% CI 1.14-2.05), HE (sHR 1.84, 95% CI 1.38-2.45), and frailty (sHR 2.38, 95% CI 1.77-3.20) were associated with waitlist mortality. In adjusted models, only frailty remained significantly associated with waitlist mortality (sHR 1.82, 95% CI 1.31-2.52); ascites and HE were not.

CONCLUSIONS

Frailty is a prevalent complication of cirrhosis that is observed more frequently in patients with ascites or HE and independently associated with waitlist mortality. LFI scores can be used to objectively quantify risk of death related to frailty-in excess of liver disease severity-in patients with cirrhosis.

Longitudinal associations between body composition, sarcopenic obesity and outcomes of frailty, disability, institutionalisation and mortality in community-dwelling older men: The Concord Health and Ageing in Men Project

Background

to explore the longitudinal associations between body composition measures, sarcopenic obesity and outcomes of frailty, activities of daily living (ADL) and instrumental ADL (IADL) disability, institutionalisation and mortality.

Methods

men aged ≥ 70 years (2005-07) from the Concord Health and Ageing in Men Project were assessed at baseline (n = 1,705), 2 (n = 1,366) and 5 years (n = 954). The main outcome measures were frailty (adapted Fried criteria), ADL, including personal care and mobility and IADL disability (ability to perform tasks for independent living), institutionalisation and mortality. The Foundation for the National Institutes of Health cut-points were used for low muscle mass: appendicular lean mass (ALM):Body Mass Index (BMI) ratio (ALMBMI) <0.789 and obesity was defined as >30% fat. Generalised estimating equations were used to examine the longitudinal associations between the independent variables (obesity alone, low muscle mass and sarcopenic obesity) and frailty, ADL and IADL disability.

Results

in unadjusted, age adjusted and fully adjusted analysis, men with low muscle mass showed increased risk of frailty and IADL disability. In fully adjusted analysis, men with sarcopenic obesity had an increased risk of frailty (odds ratio (OR): 2.00 (95% confidence of interval (CI): 1.42, 2.82)) ADL disability (OR: 1.58 (95% CI: 1.12, 2.24)) and IADL disability (OR: 1.36 (95% CI: 1.05, 1.76)). Obesity alone was protective for institutionalisation (OR: 0.51 (95% CI: 0.31, 0.84)) but was not associated with any other outcomes.

Conclusions

low muscle mass and sarcopenic obesity were associated with poor functional outcomes, independent of confounders. This would suggest that future trials on frailty and disability prevention should be designed to intervene on both muscle mass and fat mass.

Social Frailty Is Associated with Physical Functioning, Cognition, and Depression, and Predicts Mortality

OBJECTIVES

Social frailty is related to adverse health-related outcomes. However, the measurement thereof is controversial and research into the relationship between social frailty and physical functioning remains limited. This study aimed to determine social frailty status via developing a simple self-reported screening tool, termed the HALFT scale, and to examine the association between social frailty and physical functioning, cognition, depression, and mortality among community-dwelling older adults.

DESIGN

Prospective cohort study.

SETTING

Community.

PARTICIPANTS

1697 community-dwelling adults aged ≥60 years from Beijing Longitudinal Study of Aging were included.

MEASUREMENTS

The HALFT scale was developed based on 5 items: unhelpful to others, limited social participation, loneliness, financial difficulty, and not having anyone to talk to. Socioeconomic and demographic data were collected, and physical functioning, frailty index, cognition, and depression were assessed.

RESULTS

The prevalence of social frailty was 7.7% (weighted, 4.5%). Participants with physical frailty, low levels of physical activity, and poor physical functioning had a higher prevalence of social frailty. Social frailty was associated with dementia, subjective memory decline, depression, cognitive impairment, and having experienced a recent significant life event. After adjusting for age and sex, the 8-year mortality hazard ratios were 2.5-4.3 and 1.6-2.3, respectively, for those with social frailty or pre-social frailty. Each component of the HALFT scale predicted 8-year mortality.

CONCLUSIONS

Social frailty is associated with physical functioning, cognition, and depression, and predicts mortality. The HALFT scale could be a useful screening tool for determining social frailty in older adults. Interventions aimed at preventing or delaying social frailty are warranted.

The Association of Frailty With Post-ICU Disability, Nursing Home Admission, and Mortality: A Longitudinal Study

BACKGROUND

Frailty is a strong indicator of vulnerability among older persons, but its association with ICU outcomes has not been evaluated prospectively (ie, with objective measurements obtained prior to ICU admission). Our objective was to prospectively evaluate the relationship between frailty and post-ICU disability, incident nursing home admission, and death.

METHODS

The parent cohort included 754 adults aged ≥ 70 years, who were evaluated monthly for disability in 13 functional activities and every 18 months for frailty (1998-2014). Frailty was assessed using the Fried index, where frailty, prefrailty, and nonfrailty were defined, respectively, as at least three, one or two, and zero criteria (of five). The analytic sample included 391 ICU admissions.

RESULTS

The mean age was 84.0 years. Frailty and prefrailty were present prior to 213 (54.5%) and 140 (35.8%) of the 391 admissions, respectively. Relative to nonfrailty, frailty was associated with 41% greater disability over the 6 months following a critical illness (adjusted risk ratio, 1.41; 95% CI, 1.12-1.78); prefrailty conferred 28% greater disability (adjusted risk ratio, 1.28; 95% CI, 1.01-1.63). Frailty (odds ratio, 3.52; 95% CI, 1.23-10.08), but not prefrailty (odds ratio, 2.01; 95% CI, 0.77-5.24), was associated with increased nursing home admission. Each one-point increase in frailty count (range, 0-5) was associated with double the likelihood of death (hazard ratio, 2.00; 95% CI, 1.33-3.00) through 6 months of follow-up.

CONCLUSIONS

Pre-ICU frailty status was associated with increased post-ICU disability and new nursing home admission among ICU survivors, and death among all admissions. Pre-ICU frailty status may provide prognostic information about outcomes after a critical illness.

Factors Associated with Frailty and Its Trajectory among Patients on Hemodialysis

BACKGROUND AND OBJECTIVES

Frailty is common among patients on hemodialysis and associated with adverse outcomes. However, little is known about changes in frailty over time and the factors associated with those changes.

DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS

To address these questions, we examined 762 participants in the A Cohort to Investigate the Value of Exercise/Analyses Designed to Investigate the Paradox of Obesity and Survival in ESRD cohort study, among whom frailty was assessed at baseline and 12 and 24 months. We used ordinal generalized estimating equations analyses and modeled frailty (on a scale from zero to five possible components) and death during follow-up.

RESULTS

The mean frailty score at baseline was 1.9, and the distribution of frailty scores was similar at each evaluation. However, most participants' scores changed, with patients improving almost as often as worsening (overall change, 0.2 points per year; 95% confidence interval, 0.1 to 0.3). Hispanic ethnicity (0.6 points per year; 95% confidence interval, 0.0 to 1.1) and diabetes (0.7 points per year; 95% confidence interval, 0.3 to 1.0) were associated with higher frailty scores and higher serum albumin concentration with lower frailty scores (-1.1 points per g/dl; 95% confidence interval, -1.5 to -0.7). In addition, patients whose serum albumin increased over time were less likely to become frail, with each 1-g/dl increase in albumin associated with a 0.4-point reduction in frailty score (95% confidence interval, -0.80 to -0.05). To examine the underpinnings of the association between serum albumin and frailty, we included serum IL-6, normalized protein catabolic rate, and patient self-report of hospitalization within the last year in a second model. Higher IL-6 and hospitalization were statistically significantly associated with worse frailty at any point and worsening frailty over time, whereas normalized protein catabolic rate was not independently associated with frailty.

CONCLUSIONS

There was substantial year to year variability in frailty scores, with approximately equal numbers of patients improving and worsening. Markers of inflammation and hospitalization were independently associated with worsening frailty. Studies should examine whether interventions to address inflammation or posthospitalization rehabilitation can improve the trajectory of frailty.

Association of Frailty and Malnutrition With Long-term Functional and Mortality Outcomes Among Community-Dwelling Older Adults: Results From the Singapore Longitudinal Aging Study 1

IMPORTANCE

Physical frailty and malnutrition are prevalent among older adults and may be associated with functional and mortality outcomes.

OBJECTIVE

To assess the health outcomes associated with physical frailty and malnutrition singly and in combination among older adults.

DESIGN, SETTING, AND PARTICIPANTS

Population-based cohort study (Singapore Longitudinal Aging Study 1). Included were 2804 community-dwelling adults in Singapore aged 55 years or older at baseline (September 1, 2003, to December 23, 2005), with 2 follow-ups at 2- to 3-year intervals (from March 7, 2005, to September 10, 2007, and from November 13, 2007, to December 12, 2009) and a 12-year mortality follow-up to March 31, 2017. Data analysis was from July 1 to September 28, 2017.

MAIN OUTCOMES AND MEASURES

Baseline physical frailty (Fried criteria) with participants categorized according to the total score as frail (3-5 points), prefrail (1-2 points), or robust (0 point), and nutritional status (Nutrition Screening Initiative DETERMINE Your Nutritional Health Checklist and Mini Nutritional Assessment Short-Form [MNA-SF]). Baseline (prevalent) and follow-up (incident) instrumental/basic activities of daily living (IADL/ADL) disability, poor quality of life (QOL), and mortality were measured. Estimates of association were by odds ratios (ORs) and hazard ratios (HRs) and their 95% CIs.

RESULTS

The participants (mean [SD] age, 66.0 [7.7] years; 1033 [36.8%] male; 2611 [93.1%] Chinese) included 1021 (37.6%) categorized as robust with MNA-SF normal nutrition (R-NN), 330 (12.2%) robust with MNA-SF at risk/malnourished (R-ARM), 734 (27.0%) prefrail/frail with MNA-SF normal nutrition (PFF-NN), and 631 (23.2%) prefrail/frail with MNA-SF at risk/malnourished (PFF-ARM). Among these 2804 participants, 44 had missing frailty status, and 78 had missing MNA-SF nutritional status; therefore, 88 participants in total had missing frailty-nutritional status. In cross-sectional analyses, the prevalence of IADL/ADL disability was lowest among the R-NN group (169 [16.9%]) and increased substantially only among the PFF-ARM group (249 [40.2%]) (OR, 1.88; 95% CI, 1.40-2.53). Poor QOL prevalence was lowest among the R-NN group (142 [14.1%]), and the increase in other frailty and nutritional status groups was highest in the PFF-ARM group (255 [41.3%]) (OR, 2.61; 95% CI, 1.96-3.49). In longitudinal analyses, significant association with only incident poor QOL across frailty and nutritional status groups was highest in the PFF-ARM group (89 [34.8%]) compared with the R-NN group (132 [19.2%]) (OR, 1.70; 95% CI, 1.17-2.48). The mortality rate was lowest in the R-NN group (0.54 per 100 person-years) and highest in the PFF-ARM group (3.04 per 100 person-years) (HR, 1.72; 95% CI, 1.01-2.92). The results based on the Nutrition Screening Initiative measure of nutritional status were similar.

CONCLUSIONS AND RELEVANCE

Reported adverse health outcomes attributed to poor nutrition often appear more likely to be associated with physical frailty. Prefrail/frail older persons with poor nutrition might be targeted for interventions to prevent or delay adverse functional and mortality outcomes.

Changes in frailty are associated with waitlist mortality in patients with cirrhosis

BACKGROUND & AIMS

To date, studies evaluating the association between frailty and mortality in patients with cirrhosis have been limited to assessments of frailty at a single time point. We aimed to evaluate changes in frailty over time and their association with death/delisting in patients too sick for liver transplantation.

METHODS

Adults with cirrhosis, listed for liver transplantation at 8 US centers, underwent ambulatory longitudinal frailty testing using the liver frailty index (LFI). We used multilevel linear mixed-effects regression to model and predict changes in LFI (ΔLFI) per 3 months, based on age, gender, model for end-stage liver disease (MELD)-Na, ascites, and hepatic encephalopathy, categorizing patients by frailty trajectories. Competing risk regression evaluated the subhazard ratio (sHR) of baseline LFI and predicted ΔLFI on death/delisting, with transplantation as the competing risk.

RESULTS

We analyzed 2,851 visits from 1,093 outpatients with cirrhosis. Patients with severe worsening of frailty had worse baseline LFI and were more likely to have non-alcoholic fatty liver disease, diabetes, or dialysis-dependence. After a median follow-up of 11 months, 223 (20%) of the overall cohort died/were delisted because of sickness. The cumulative incidence of death/delisting increased by worsening ΔLFI group. In competing risk regression adjusted for baseline LFI, age, height, MELD-Na, and albumin, a 0.1 unit change in ΔLFI per 3 months was associated with a 2.04-fold increased risk of death/delisting (95% CI 1.35-3.09).

CONCLUSION

Worsening frailty was significantly associated with death/delisting independent of baseline frailty and MELD-Na. Notably, patients who experienced improvements in frailty had a lower risk of death/delisting. Our data support the longitudinal measurement of frailty, using the LFI, in patients with cirrhosis and lay the foundation for interventional work aimed at reversing frailty.

LAY SUMMARY

Frailty, as measured at a single time point, is predictive of death in patients with cirrhosis, but whether changes in frailty over time are associated with death is unknown. In a study of over 1,000 patients with cirrhosis who underwent frailty testing, we demonstrate that worsening frailty is strongly linked with mortality, regardless of baseline frailty and liver disease severity. Notably, patients who experienced improvements in frailty over time had a lower risk of death/delisting. Our data support the longitudinal measurement of frailty in patients with cirrhosis and lay the foundation for interventional work aimed at reversing frailty.

Treatment of Proximal Femoral Fragility Fractures in Patients with COVID-19 During the SARS-CoV-2 Outbreak in Northern Italy

BACKGROUND

From February 20 to April 2020, the coronavirus SARS (severe acute respiratory syndrome)-CoV-2 spread in northern Italy, drastically challenging the care capacities of the national health care system. Unprepared for this emergency, hospitals have quickly reformulated paths of assistance in an effort to guarantee treatment for infected patients. Orthopaedic departments have been focused on elderly traumatology, especially the treatment of femoral neck fractures in patients with coronavirus disease-2019 (COVID-19). The purpose of the present study was to evaluate the orthopaedic management strategy for femoral fragility fractures in COVID-19-positive patients with the hypothesis that operative treatment may contribute to the overall stability of the patient.

METHODS

Sixteen patients affected by proximal femoral fracture and a recent history of fever, shortness of breath, and desaturation were admitted to the emergency room. Thoracic computed tomography (CT) and oropharyngeal swabs confirmed that they were positive for COVID-19, requiring hospitalization and prophylaxis with low-molecular-weight heparin.

RESULTS

Three patients died before surgery because of severe respiratory insufficiency and multiple-organ-failure syndrome. Ten patients underwent surgery on the day after admission, whereas 3 patients had suspended their use of direct thrombin inhibitors and needed surgery to be delayed until the third day after admission. In all patients except 1, we noted an improvement in terms of O2 saturation and assisted respiration. In 9 patients, hemodynamic and respiratory stability was observed at an average of 7 days postoperatively. Four patients who underwent surgical treatment died of respiratory failure on the first day after surgery (1 patient), the third day after surgery (2 patients), or the seventh day after surgery (1 patient).

CONCLUSIONS

We noted a stabilization of respiratory parameters in 12 COVID-19-positive patients who underwent surgery treatment of proximal femoral fractures. We believe that in elderly patients with COVID-19 who have proximal femoral fractures, surgery may contribute to the overall stability of the patient, seated mobilization, improvement in physiological ventilation, and general patient comfort in bed.

LEVEL OF EVIDENCE

Prognostic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Frailty Factors and Outcomes in Vascular Surgery Patients: A Systematic Review and Meta-analysis

OBJECTIVE

To describe and critique tools used to assess frailty in vascular surgery patients, and investigate its associations with patient factors and outcomes.

BACKGROUND

Increasing evidence shows negative impacts of frailty on outcomes in surgical patients, but little investigation of its associations with patient factors has been undertaken.

METHODS

Systematic review and meta-analysis of studies reporting frailty in vascular surgery patients (PROSPERO registration: CRD42018116253) searching Medline, Embase, CINAHL, PsycINFO, and Scopus. Quality of studies was assessed using Newcastle-Ottawa scores (NOS) and quality of evidence using Grading of Recommendations Assessment, Development, and Evaluation criteria. Associations of frailty with patient factors were investigated by difference in means (MD) or expressed as risk ratios (RRs), and associations with outcomes expressed as odds ratios (ORs) or hazard ratios (HRs). Data were pooled using random-effects models.

RESULTS

Fifty-three studies were included in the review and only 8 (15%) were both good quality (NOS ≥ 7) and used a well-validated frailty measure. Eighteen studies (62,976 patients) provided data for the meta-analysis. Frailty was associated with increased age [MD 4.05 years; 95% confidence interval (CI) 3.35, 4.75], female sex (RR 1.32; 95% CI 1.14, 1.54), and lower body mass index (MD -1.81; 95% CI -2.94, -0.68). Frailty was associated with 30-day mortality [adjusted OR (AOR) 2.77; 95% CI 2.01-3.81), postoperative complications (AOR 2.16; 95% CI 1.55, 3.02), and long-term mortality (HR 1.85; 95% CI 1.31, 2.62). Sarcopenia was not associated with any outcomes.

CONCLUSION

Frailty, but not sarcopenia, is associated with worse outcomes in vascular surgery patients. Well-validated frailty assessment tools should be preferred clinically, and in future research.

Development and Evaluation of a New Frailty Index for Older Surgical Patients With Cancer

IMPORTANCE

Frailty based on the modified Frailty Index is associated with poor postoperative outcomes. However, the index requires high levels of personnel time and effort and often has missing data.

OBJECTIVE

To evaluate the association of the Memorial Sloan Kettering-Frailty Index (MSK-FI) with established geriatric assessment (GA) and surgical outcomes.

DESIGN, SETTING, AND PARTICIPANTS

This cohort study included prospectively evaluated patients with cancer 75 years and older who were referred to MSK Geriatrics Service clinics for preoperative evaluation before undergoing surgery requiring hospitalization between February 2015 and September 2017. Patients were comanaged by the Geriatrics Service and Surgery Service in the postoperative period.

EXPOSURES

Impairments identified by GA and comorbid conditions retrieved from submitted International Classification of Diseases, Ninth Revision (ICD-9) and ICD-10 codes within the first 48 hours of hospitalization.

MAIN OUTCOMES AND MEASURES

The association of MSK-FI score (which included ICD-9 and ICD-10 codes) with GA impairments (based on clinical interview and examination as well as patient reports) was examined. The associations of MSK-FI score with short-term surgical outcomes (ie, frequency of complications, length of stay, 30-day surgical complications, 30-day intensive care unit admissions, and 30-day readmissions) and 1-year survival, estimated by Kaplan-Meier methods, were determined.

RESULTS

In total, 1137 patients (median [interquartile range] age, 80 [77-84] years; 583 [51.2%] women) were included in the study. A higher MSK-FI score was associated with the number of GA impairments (ρ = 0.52; bootstrapped 95% CI, 0.47-0.56). Each 1-point increase in MSK-FI score was associated with longer length of stay (0.58 d; 95% CI, 0.22-0.95; P = .002) and higher odds of intensive care unit admission (odds ratio, 1.28; 95% CI, 1.04-1.58; P = .02). Median (interquartile range) follow-up among survivors was 12.1 (5.6-19.1) months. The MSK-FI score was associated with overall mortality; 12-month risk of death was 5% for a score of 0 and approximately 20% for scores of 4 and higher (nonlinear association, P = .005).

CONCLUSIONS AND RELEVANCE

In this study, the MSK-FI was associated with the previously validated GA and postoperative outcomes in older patients with cancer and may be a feasible tool for perioperative assessment of older surgical patients with cancer. Future studies should assess the association of MSK-FI score with postoperative care and outcomes of older, frail patients with cancer.

Frailty and Clinical Outcomes in Heart Failure: A Systematic Review and Meta-analysis

OBJECTIVE

Frailty is a known risk factor for adverse outcomes after cardiac interventions. However, the extent to which it increases the likelihood of adverse outcomes in heart failure (HF) patients remains unexplored. Therefore, we conducted this systematic review and meta-analysis to quantify the impact of frailty on prognosis in this patient population.

DESIGN

Meta-analysis.

SETTING AND PARTICIPANTS

PubMed and Embase were searched for studies that investigated the relationship between frailty and outcomes in patients with HF. The search period was from the beginning of the databases through to December 3, 2017.

MEASURES

A total of 342 and 919 entries were retrieved from PubMed and Embase, respectively. Of these, 20 met our inclusion criteria and were therefore included.

RESULTS

Frailty significantly increased the risk of all-cause mortality [hazard ratio (HR) = 1.59, 95% confidence interval (CI) = 1.39-1.82, P < .0001, I2 = 55%] and hospitalizations (HR = 1.31, 95% CI = 1.21-1.42, P < .0001, I2 = 0%). Moreover, it was predictive of all-cause mortality after ventricular assist device implantation for advanced HF (HR = 1.62, 95% CI = 1.35-1.94, P < .0001, I2 = 2%).

CONCLUSIONS/IMPLICATIONS

Frailty is a significant predictor of all-cause mortality and hospital readmissions in HF. Assessment and close monitoring of frailty status of heart failure patients can potentially better guide clinical management of this population.

Aging, frailty and complex networks

When people age their mortality rate increases exponentially, following Gompertz's law. Even so, individuals do not die from old age. Instead, they accumulate age-related illnesses and conditions and so become increasingly vulnerable to death from various external and internal stressors. As a measure of such vulnerability, frailty can be quantified using the frailty index (FI). Larger values of the FI are strongly associated with mortality and other adverse health outcomes. This association, and the insensitivity of the FI to the particular health variables that are included in its construction, makes it a powerful, convenient, and increasingly popular integrative health measure. Still, little is known about why the FI works so well. Our group has recently developed a theoretical network model of health deficits to better understand how changes in health are captured by the FI. In our model, health-related variables are represented by the nodes of a complex network. The network has a scale-free shape or "topology": a few nodes have many connections with other nodes, whereas most nodes have few connections. These nodes can be in two states, either damaged or undamaged. Transitions between damaged and non-damaged states are governed by the stochastic environment of individual nodes. Changes in the degree of damage of connected nodes change the local environment and make further damage more likely. Our model shows how age-dependent acceleration of the FI and of mortality emerges, even without specifying an age-damage relationship or any other time-dependent parameter. We have also used our model to assess how informative individual deficits are with respect to mortality. We find that the information is larger for nodes that are well connected than for nodes that are not. The model supports the idea that aging occurs as an emergent phenomenon, and not as a result of age-specific programming. Instead, aging reflects how damage propagates through a complex network of interconnected elements.

The frailty syndrome is associated with adverse health outcomes in very old patients with stable heart failure: A prospective study in six Spanish hospitals

BACKGROUND

Most studies on the association between the frailty syndrome and adverse health outcomes in patients with heart failure (HF) have used non-standard definitions of frailty. This study examined the association of frailty, diagnosed by well-accepted criteria, with mortality, readmission and functional decline in very old ambulatory patients with HF.

METHODS

Prospective study with 497 patients in six Spanish hospitals and followed up during one year. Mean (SD) age was 85.2 (7.3) years, and 79.3% had LVEF >45%. Frailty was diagnosed as having ≥3 of the 5 Fried criteria. Readmission was defined as a new episode of hospitalisation lasting >24h, and functional decline as an incident limitation in any activity of daily living at the 1-year visit. Statistical analyses were performed with Cox and logistic regression, as appropriate, and adjusted for the main prognostic factors at baseline.

RESULTS

At baseline, 57.5% of patients were frail. The adjusted hazard ratio (95% confidence interval) for mortality among frail versus non-frail patients was 1.93 (1.20-3.27). Mortality was higher among patients with low physical activity [1.64 (1.10-2.45)] or exhaustion [1.83 (1.21-2.77)]. Frailty was linked to increased risk of readmission [1.66 (1.17-2.36)] and functional decline [odds ratio 1.67 (1.01-2.79)]. Slow gait speed was related to functional decline [odds ratio 3.59 (1.75-7.34)]. A higher number of frailty criteria was associated with a higher risk of the three study outcomes (P trend<0.01 in each outcome).

CONCLUSIONS

Frailty was associated with increased risk of 1-year mortality, hospital readmission and functional decline among older ambulatory patients with HF.

Disability, quality of life and all-cause mortality in older Mexican adults: association with multimorbidity and frailty

BACKGROUND

Multimorbidity and frailty are relevant conditions among older adult population. There is growing evidence about their association with poor health outcomes like disability, worst quality of life, and death. Nonetheless, the independent associations of both conditions have been studied, and few evidence exists about an interaction between them. Our aims were to assess the association of frailty and multimorbidity with the disability, quality of life and all-cause mortality as well as to analyze a potential interaction between these conditions.

METHODS

Analytical samples included 1410 respondents for disability and quality of life, and 1792 for mortality. We performed a longitudinal analysis with older Mexican adults aged 50, using data collected from the WHO's Study on global AGEing and Adult Health Waves 1 and 2. Disability was measured using the World Health Organization Disability Assessment Schedule (WHODAS 2.0), and quality of life using the WHOQOL (WHO Quality of Life) instrument. All-cause mortality was determined by reviewing death certificates. Associations of frailty and multimorbidity with disability, quality of life and mortality were estimated using linear regression and Cox proportional hazards models.

RESULTS

Multimorbidity assessed through three patterns (cardiopulmonary, vascular-metabolic, and mental-musculoskeletal) was associated with the three outcomes in this study. Cardiopulmonary and mental-musculoskeletal patterns increased the WHODAS mean score (β = 5.05; p < 0.01 and β = 5.10; p < 0.01, respectively) and decreased WHOQOL score (β = - 1.81; p < 0.01 and β = - 2.99; p < 0.01, respectively). Vascular-metabolic was associated with mortality (HR = 1.47; p = 0.04), disability (β = 3.27; p < 0.01) and quality of life (β = - 1.30; p = 0.02). Frailty was associated with mortality (pre-frail: HR = 1.48; p = 0.02 and frail: HR = 1.68; p = 0.03), disability (pre-frail: β = 5.02; p < 0.01; frail: β = 13.29; p < 0.01) and quality of life (pre-frail: β = - 2.23; p < 0.01; frail: β = - 4.38; p < 0.01). Interaction terms of frailty and multimorbidity were not statistically significant.

CONCLUSIONS

Multimorbidity and frailty are important predictors of poor health outcomes. These results highlight the importance of carrying out health promotion and prevention actions as well as specific interventions aimed at older adults who suffer from multimorbidity and frailty, in such a way that deleterious effects on health can be avoided.

Association of frailty with outcomes in individuals with COVID-19: A living review and meta-analysis

BACKGROUND AND OBJECTIVES

Frailty leaves older adults vulnerable to adverse health outcomes. Frailty assessment is recommended by multiple COVID-19 guidelines to inform care and resource allocation. We aimed to identify, describe, and synthesize studies reporting the association of frailty with outcomes (informed by the Institute for Healthcare Improvement's Triple Aim [health, resource use, and experience]) in individuals with COVID-19.

DESIGN

Systematic review and meta-analysis.

SETTING

Studies reporting associations between frailty and outcomes in the setting of COVID-19 diagnosis.

PARTICIPANTS

Adults with COVID-19.

MEASUREMENTS

Following review of titles, abstracts and full text, we included 52 studies that contained 118,373 participants with COVID-19. Risk of bias was assessed using the Quality in Prognostic studies tool. Our primary outcome was mortality, secondary outcomes included delirium, intensive care unit admission, need for ventilation and discharge location. Where appropriate, random-effects meta-analysis was used to pool adjusted and unadjusted effect measures by frailty instrument.

RESULTS

The Clinical Frailty Scale (CFS) was the most used frailty instrument. Mortality was reported in 37 studies. After confounder adjustment, frailty identified using the CFS was significantly associated with mortality in COVID-19 positive patients (odds ratio 1.79, 95% confidence interval [CI] 1.49-2.14; hazard ratio 1.87, 95% CI 1.33-2.61). On an unadjusted basis, frailty identified using the CFS was significantly associated with increased odds of delirium and reduced odds of intensive care unit admission. Results were generally consistent using other frailty instruments. Patient-reported, cost and experience outcomes were rarely reported.

CONCLUSION

Frailty is associated with a substantial increase in mortality risk in COVID-19 patients, even after adjustment. Delirium risk is also increased. Frailty assessment may help to guide prognosis and individualized care planning, but data relating frailty status to patient-reported outcomes are urgently needed to provide a more comprehensive overview of outcomes relevant to older adults.

Intrinsic capacity and its associations with incident dependence and mortality in 10/66 Dementia Research Group studies in Latin America, India, and China: A population-based cohort study

BACKGROUND

The World Health Organization (WHO) has reframed health and healthcare for older people around achieving the goal of healthy ageing. The recent WHO Integrated Care for Older People (ICOPE) guidelines focus on maintaining intrinsic capacity, i.e., addressing declines in neuromusculoskeletal, vitality, sensory, cognitive, psychological, and continence domains, aiming to prevent or delay the onset of dependence. The target group with 1 or more declines in intrinsic capacity (DICs) is broad, and implementation may be challenging in less-resourced settings. We aimed to inform planning by assessing intrinsic capacity prevalence, by characterising the target group, and by validating the general approach-testing hypotheses that DIC was consistently associated with higher risks of incident dependence and death.

METHODS AND FINDINGS

We conducted population-based cohort studies (baseline, 2003-2007) in urban sites in Cuba, Dominican Republic, Puerto Rico, and Venezuela, and rural and urban sites in Peru, Mexico, India, and China. Door-knocking identified eligible participants, aged 65 years and over and normally resident in each geographically defined catchment area. Sociodemographic, behaviour and lifestyle, health, and healthcare utilisation and cost questionnaires, and physical assessments were administered to all participants, with incident dependence and mortality ascertained 3 to 5 years later (2008-2010). In 12 sites in 8 countries, 17,031 participants were surveyed at baseline. Overall mean age was 74.2 years, range of means by site 71.3-76.3 years; 62.4% were female, range 53.4%-67.3%. At baseline, only 30% retained full capacity across all domains. The proportion retaining capacity fell sharply with increasing age, and declines affecting multiple domains were more common. Poverty, morbidity (particularly dementia, depression, and stroke), and disability were concentrated among those with DIC, although only 10% were frail, and a further 9% had needs for care. Hypertension and lifestyle risk factors for chronic disease, and healthcare utilisation and costs, were more evenly distributed in the population. In total, 15,901 participants were included in the mortality cohort (2,602 deaths/53,911 person-years of follow-up), and 12,939 participants in the dependence cohort (1,896 incident cases/38,320 person-years). One or more DICs strongly and independently predicted incident dependence (pooled adjusted subhazard ratio 1.91, 95% CI 1.69-2.17) and death (pooled adjusted hazard ratio 1.66, 95% CI 1.49-1.85). Relative risks were higher for those who were frail, but were also substantially elevated for the much larger sub-groups yet to become frail. Mortality was mainly concentrated in the frail and dependent sub-groups. The main limitations were potential for DIC exposure misclassification and attrition bias.

CONCLUSIONS

In this study we observed a high prevalence of DICs, particularly in older age groups. Those affected had substantially increased risks of dependence and death. Most needs for care arose in those with DIC yet to become frail. Our findings provide some support for the strategy of optimising intrinsic capacity in pursuit of healthy ageing. Implementation at scale requires community-based screening and assessment, and a stepped-care intervention approach, with redefined roles for community healthcare workers and efforts to engage, train, and support them in these tasks. ICOPE might be usefully integrated into community programmes for detecting and case managing chronic diseases including hypertension and diabetes.

Scoping review of frailty in vascular surgery

OBJECTIVE

This review sought to describe the current state of knowledge of the impact of frailty on perioperative clinical outcomes in patients undergoing vascular interventions.

METHODS

A scoping review of the literature from both PubMed and Ovid Embase databases was conducted to identify relevant English- and French-language articles published from inception to May 31, 2018. Patients undergoing vascular surgery interventions were included.

RESULTS

Twenty-three studies have addressed the prevalence or prognostic impact of frailty in patients undergoing vascular surgery procedures. The prevalence of frailty ranged from 20% to 60%, and notably 14 different frailty assessments were used in these studies. Frailty was associated with increased comorbid status, prolonged length of stay, discharge to assisted living facility, loss of independence, postoperative morbidity, and all-cause mortality.

CONCLUSIONS

There are a variety of heterogeneous tools to measure frailty in patients undergoing vascular surgery interventions. The prevalence of frailty varies by the scale used to measure it, as does its predictive value. Clinicians and surgeons should be sensitized to the importance of assessing frailty preoperatively in older adults undergoing vascular surgery and using it to assist in the decision-making process and allocation of surgical resources.

Frailty and Mortality Outcomes After Percutaneous Coronary Intervention: A Systematic Review and Meta-Analysis

BACKGROUND

Frailty has been identified as a risk factor for mortality. However, whether frailty increases mortality risk in patients undergoing percutaneous coronary intervention (PCI) has been controversial. Therefore, we conducted a systematic review and meta-analysis of the frailty measures and mortality outcomes in this setting.

METHODS

PubMed and EMBASE were searched until July 23, 2017 for studies evaluating the association between frailty measures and mortality in individuals who have undergone PCI.

RESULTS

A total of 141 entries were retrieved from our search strategy. A total of 8 studies involving 2332 patients were included in the final meta-analysis (mean age: 69 years; 68% male, follow-up duration was 30 ± 28 months). Frailty was a significant predictor of all-cause mortality after PCI, with a hazard ratio (HR) of 2.97 [95% confidence interval (CI) 1.56-5.66, P = .001]. This was substantial heterogeneity present (I2: 79%). Subgroup analysis using the Fried score reduced I2 to 68% without altering the pooled HR (2.78, 95% CI 1.02-7.76; P < .05). Using the Canadian Study of Health and Aging Clinical Frailty Scale reduced I2 to 0% while preserving the pooled HR (5.99, 95% CI 2.77-12.95, P < .001).

CONCLUSIONS

Frailty leads to significantly higher mortality rates in patients who have undergone PCI. Both the Fried score and Canadian Study of Health and Aging Clinical Frailty Scale are powerful predictors of mortality. These findings may support the notion that an alternative to invasive strategy should be considered in frail patients who are indicated for revascularization.

Sarcopenia of the Psoas Muscles Is Associated With Poor Outcomes Following Lung Transplantation

BACKGROUND

Sarcopenia, a known component of frailty, defined by diminished cross-sectional area of the psoas muscles, is associated with poor outcomes after a range of surgical procedures. However, little is known of the relationship between sarcopenia of the psoas muscles (SPM) and long-term survival, decline in pulmonary function, and graft failure after lung transplantation.

METHODS

We reviewed patients who underwent primary lung transplantation at our institution from 2011 to 2014. Cross-sectional areas of the psoas muscles at the L4 vertebral level were measured using preoperative computed tomography. Gender-based cutoff values for sarcopenia were generated and validated. The primary outcomes were 1-, 2-, and 3-year all-cause mortality, forced expiratory volume in 1 second values, and graft function. Adjusted logistic regression and survival analysis was used to analyze outcomes.

RESULTS

Ninety-five patients were included in this study; 39 (41.1%) patients were considered sarcopenic. SPM was significantly associated with short-term and midterm mortality on multivariate analysis (1 year: odds ratio [OR], 8.7, p = 0.017; 2 years: OR, 12.7, p < 0.01; 3 years: OR, 13.4, p < 0.01). Survival analysis showed significantly decreased survival in sarcopenic patients at 3 years (35.9% versus 76.8%; p < 0.01). SPM is also associated with decreased forced expiratory volume in 1 second (coefficient, -17.3; p = 0.03). Adjusted Cox analysis showed an increased hazard for all-cause mortality (hazard ratio, 5.8, p < 0.01) and graft failure (hazard ratio, 14.7, p < 0.01) in sarcopenic patients.

CONCLUSIONS

This study demonstrates a significant association between SPM and death, pulmonary function, and graft failure in patients receiving a lung transplant. Determining SPM preoperatively may be a useful component of frailty assessment and a predictor of survival in this patient population.

Population-Based Estimates of 1-Year Mortality After Major Surgery Among Community-Living Older US Adults

Importance

Despite their importance to guiding public health decision-making and policies and to establishing programs aimed at improving surgical care, contemporary nationally representative mortality data for geriatric surgery are lacking.

Objective

To calculate population-based estimates of mortality after major surgery in community-living older US adults and to determine how these estimates differ according to key demographic, surgical, and geriatric characteristics.

Design, Setting, and Participants

Prospective longitudinal cohort study with 1 year of follow-up in the continental US from 2011 to 2018. Participants included 5590 community-living fee-for-service Medicare beneficiaries, aged 65 years or older, from the National Health and Aging Trends Study (NHATS). Data analysis was conducted from February 22, 2021, to March 16, 2022.

Main Outcomes and Measures

Major surgeries and mortality over 1 year were identified through linkages with data from the Centers for Medicare & Medicaid Services. Data on frailty and dementia were obtained from the annual NHATS assessments.

Results

From 2011 to 2017, of the 1193 major surgeries (from 992 community-living participants), the mean (SD) age was 79.2 (7.1) years; 665 were women (55.7%), and 30 were Hispanic (2.5%), 198 non-Hispanic Black (16.6%), and 915 non-Hispanic White (76.7%). Over the 1-year follow-up period, there were 206 deaths representing 872 096 survey-weighted deaths and 13.4% (95% CI, 10.9%-15.9%) mortality. Mortality rates were 7.4% (95% CI, 4.9%-9.9%) for elective surgeries and 22.3% (95% CI, 17.4%-27.1%) for nonelective surgeries. For geriatric subgroups, 1-year mortality was 6.0% (95% CI, 2.6%-9.4%) for persons who were nonfrail, 27.8% (95% CI, 21.2%-34.3%) for those who were frail, 11.6% (95% CI, 8.8%-14.4%) for persons without dementia, and 32.7% (95% CI, 24.3%-41.0%) for those with probable dementia. The age- and sex-adjusted hazard ratios for 1-year mortality were 4.41 (95% CI, 2.53-7.69) for frailty with a reduction in restricted mean survival time of 48.8 days and 2.18 (95% CI, 1.40-3.40) for probable dementia with a reduction in restricted mean survival time of 44.9 days.

Conclusions and Relevance

In this study, the population-based estimate of 1-year mortality after major surgery among community-living older adults in the US was 13.4% but was 3-fold higher for nonelective than elective procedures. Mortality was considerably elevated among older persons who were frail or who had probable dementia, highlighting the potential prognostic value of geriatric conditions after major surgery.