Frailty as a predictor of surgical outcomes in older patients

Early predictors for tissue healing deficit and leakage in geriatric critically ill patients receiving emergent abdominal surgery: a case control study

BACKGROUND

As our world ages and the elderly population grows. Surgery on the aged critically ill tend to result in additional morbidity and mortality. We sought to determine early predicting factors that were associated with postoperative leakage and tissue healing deficiency after emergent abdominal surgery in geriatric critically ill patients.

MATERIAL AND METHOD

Retrospectively, geriatric critically ill patients received anticipated, single-stage emergent abdominal surgery via emergency room were enrolled. Patients who received only one definitive surgery during their hospital course were labeled as group A, patients received anticipated one-stage surgery and eventually with postoperative leakage and tissue healing deficiency were labeled as group B. The demographics and parameters were obtained for comparison.

RESULT

There were 45 patients in group A, and 34 patients in group B. The mean age is 77.4 ± 6.1 years in Group A and 76.9 ± 8.5 years in Group B, the mean APACHE score was 20.3 ± 7.5 vs. 21.6 ± 7.7. There were no significances in age, gender, comorbidities, and physiological scores. There were significances in the persistent post-operative use of vasopressors and hypoalbuminemia. The 30-day mortality rate was 0% in group A and 38.2% in group B.

CONCLUSION

Persistent post operative vasopressor use and hypoalbuminemia are associated with higher rate of morbidity and mortality after emergent abdominal surgery in geriatric critically ill patients. Early recognition is essential for proper management. Further studies are required for a better understanding in identifying risk factors.

Patient frailty: the elephant in the operating room

For most surgeons and many anaesthetists, patient frailty is currently the 'elephant in the (operating) room': it is easy to spot, but is often ignored. In this paper, we discuss different approaches to the measurement of frailty and review the evidence regarding the effect of frailty on peri-operative outcomes. We explore the limitations of 'eyeballing' patients to quantify frailty, and consider why the frail older patient, challenged by seemingly minor insults in the postoperative period, may suffer falls or delirium. Frailty represents a state of increased vulnerability to stressors, and older inpatients are exposed to multiple stressors in the peri-operative setting. Quantifying frailty is likely to increase the precision of peri-operative risk assessment. The Frailty Index derived from Comprehensive Geriatric Assessment is a simple and robust way to quantify frailty, but is yet to be systematically investigated in the pre-operative setting. Furthermore, the optimal care for frail patients and the reversibility of frailty with prehabilitation are fertile areas for future research.

Effects of a modified Hospital Elder Life Program on frailty in individuals undergoing major elective abdominal surgery

OBJECTIVES

To test the effects of a modified Hospital Elder Life Program (mHELP) on frailty.

DESIGN

Matched and unmatched analyses of data from a before-and-after study.

SETTING

Hospital, inpatient.

PARTICIPANTS

Participants aged 65 and older (n = 189) undergoing major elective abdominal surgery at a medical center in Taiwan.

INTERVENTION

The mHELP included three nursing interventions: early mobilization, oral and nutritional assistance, and orienting communication.

MEASUREMENTS

Frailty rate and transitions between frailty states from hospital discharge to 3 months after discharge using Fried's phenotype criteria categorized as nonfrail (0 or 1 criteria present), prefrail (2 or 3 criteria present), and frail (4 or 5 criteria present).

RESULTS

In matched pairs, participants who received the mHELP interventions were significantly less likely to be frail at discharge (19.2%) than matched controls (65.4%) (adjusted odds ratio (AOR) = 0.10, 95% CI = 0.02-0.39). Transitions to states of greater frailty during hospitalization were more common for participants in the control group. Three months after discharge, participants who received the mHELP intervention during hospitalization were less likely to be frail (17.3%) than matched controls (23.1%) (AOR = 0.73, 95% CI = 0.21-2.56), although this difference did not achieve statistical significance.

CONCLUSION

The mHELP intervention is effective in reducing frailty by hospital discharge, but the benefit is diminished by 3 months after discharge. Thus, the mHELP provides a useful approach to manage in-hospital frailty for older adults undergoing major abdominal surgery.

A frailty index identifies patients at high risk of mortality after tracheostomy

OBJECTIVE

To evaluate the utility of a modified frailty index as an indicator of postoperative mortality in patients undergoing tracheostomy.

STUDY DESIGN

Case series with chart review.

SETTING

Tertiary care veterans hospital.

SUBJECTS AND METHODS

A chart review was conducted of consecutive tracheostomies performed between April 2007 and September 2012. A modified frailty index consisting of 11 items based on the Revised Minimum Data Set Mortality Rating Index (MMRI-R) was retrospectively applied using the patient's status immediately prior to tracheostomy. The resultant 6-month calculated mortality risk was compared with both the Veterans Health Administration Surgical Quality Improvement Program's (VASQIP) 30-day calculated mortality and actual mortality.

RESULTS

One hundred consecutive tracheostomies were analyzed. No patients were excluded. Sixty-nine patients died within the study period, with 1-, 6-, and 12-month mortality rates of 25%, 43%, and 59%, respectively. The average calculated 6-month mortality risk using the modified frailty index was 40.5% for nonsurvivors compared with 25.4% for survivors (P = .001). Both the VASQIP calculator and modified frailty index differentiated mortality risks between patients without head and neck cancer who survived less than 6 months versus those who survived longer than 6 months (P = .006 and .01). However, neither the VASQIP nor the modified frailty index differentiated mortality risks for head and neck cancer patients who survived less than 6 months versus greater than 6 months (P = .94 and .26).

CONCLUSION

A modified frailty index identifies patients without head and neck cancer at high risk of postoperative mortality after tracheostomy.

Lower skeletal muscle index and early complications in patients undergoing radical cystectomy for bladder cancer

BACKGROUND

Radical cystectomy (RC) is the standard treatment for patients with muscle-invasive bladder cancer (BC), and it is also a valid option for selected patients with high-risk non-muscle-invasive BC. The purpose of this study was to evaluate the effect on the lower skeletal muscle index (SMI) of short-term postoperative complications of radical cystectomy (RC) in patients with bladder cancer (BC).

METHODS

A total of 247 patients who received RC for BC and 204 age-matched healthy population-based controls were retrospectively assessed. SMI was measured by preoperative computed tomography scans at the L4 to L5 level. Early complications were graded by Clavien-Dindo classification; severity of grade III or greater was identified as a severe complication. Logistic regression was utilized to determine the relationships between covariables and severe complications.

RESULTS

A total of 125 (50.61%)/19 (7.69%) patients exhibited overall/severe complications during the early postoperative period. SMI was strongly associated with gender (P <0.01), but not age and body mass index (BMI), among patients with BC. Compared with the matched control group, BC patients exhibited lower SMI. The difference was statistically significant in the subgroup of male patients (P = 0.03). In the multivariate analysis, SMI was an independent predictor of developing severe complications. Each 1 cm²/m² increase in SMI was associated with a decrease in the odds of morbidity by 4.8%.

CONCLUSIONS

A lower SMI is frequently observed in bladder cancer patients undergoing RC and is shown to be strongly associated with early complications following surgery.

Sarcopenia as a predictor of complications and survival following radical cystectomy

PURPOSE

Patients undergoing radical cystectomy face substantial but highly variable risks of major complications. Risk stratification may be enhanced by objective measures such as sarcopenia. Sarcopenia (loss of skeletal muscle mass) has emerged as a novel biomarker associated with adverse outcomes in many clinical contexts relevant to cystectomy. Based on these data we hypothesized that sarcopenia would be associated with increased 30-day major complications and mortality after radical cystectomy for bladder cancer.

MATERIALS AND METHODS

We performed a retrospective study of patients treated with radical cystectomy at our institution from 2008 to 2011. Sarcopenia was assessed by measuring cross-sectional area of the psoas muscle (total psoas area) on preoperative computerized tomography. Cutoff points were developed and evaluated using ROC curves to determine predictive ability in men and women for outcomes of major complications and survival.

RESULTS

Of 224 patients with bladder cancer 200 underwent preoperative computerized tomography within 1 month of surgery. Total psoas area was calculated with a mean score of 712 and 571 cm2/m2 in men and women, respectively. A clear association was noted between major complications and lower total psoas area in women using a cutoff of 523 cm2/m2 to define sarcopenia (AUC 0.70). Sarcopenia was not significantly associated with complications in men. There was a nonsignificant trend of sarcopenia with worse 2-year survival.

CONCLUSIONS

Sarcopenia in women was a predictor of major complications after radical cystectomy. Further research confirming sarcopenia as a useful predictor of complications would support the development of targeted interventions to mitigate the untoward effects of sarcopenia before cancer surgery.

Radical cystectomy and the implications of comorbidity

Radical cystectomy (RC) with pelvic lymph node dissection constitutes the gold standard treatment for muscle-invasive urothelial carcinoma of the bladder and high-risk nonmuscle-invasive disease refractory to instillation therapy. Although RC is performed with curative intent, the overall 5-year survival has been reported to be as low as 62% in the current literature. Various clinicopathological parameters determine post-RC outcome, but besides these, the role of comorbidity has gained increasing attention. In the current clinical practice, comorbidity information is quantified using various evaluated comorbidity indices. In this paper, we discuss the most recent data on comorbidity and performance indices assessed in patients undergoing RC and highlight their clinical implications.

A prospective study examining the association between preoperative frailty and postoperative complications in patients undergoing minimally invasive surgery

BACKGROUND AND PURPOSE

Current surgical decision-making is overly subjective and often misjudges a patient's physiologic state. The concept of frailty has gained recent recognition and potentially represents a measureable phenotype, which can quantify a patient's physiologic reserve and risk of an adverse surgical outcome. We sought to investigate the relationship between preoperative markers of frailty and postoperative complications in patients undergoing minimally invasive surgery (MIS).

METHODS

Frailty, using the methodology described by Fried and coworkers, was prospectively measured in patients who presented to urology, general surgery, and surgical oncology clinics where major MIS (endoscopic, laparoscopic, or robotic) was planned. The relationship between preoperative markers of frailty and 30-day postoperative complications was our primary outcome measure.

RESULTS

Our cohort includes 80 patients. Mean age and body mass index were 60.0 (range 19-87) years and 29.2 (range 18.4-53.1) kg/m(2), respectively. The majority of patients were male (57.5%) and Caucasian (65.0%). Thirteen patients were deemed "intermediately frail" or "frail," and the remaining 67 were classified as "not frail." Thirteen (16.25%) patients experienced any postoperative complication. Five (38.5%) of the intermediately frail and frail patients experienced a complication, compared with eight (11.9%) of the not frail patients (odds ratio=5.914; 95% confidence interval=1.25-27.96; P=0.025).

CONCLUSION

The advent of MIS has potentially lured surgeons into thinking older and patients with comorbidities may more easily tolerate this surgical approach compared with traditional open techniques. Our data suggest, however, that intermediately frail or frail patients are at increased risk of experiencing postoperative complications compared with not frail patients.

Prevalence of frailty and its ability to predict in hospital delirium, falls, and 6-month mortality in hospitalized older patients

Background

The prevalence and significance of frailty are seldom studied in hospitalized patients. Aim of this study is to evaluate the prevalence of frailty and to determine the extent that frailty predicts delirium, falls and mortality in hospitalized older patients.

Methods

In a prospective study of 220 older patients, frailty was determined using the Cardiovascular Health Study (CHS) and the Study of Osteoporotic Fracture (SOF) frailty index. Patients were classified as nonfrail, prefrail, and frail, according to the specific criteria. Covariates included clinical and laboratory parameters. Outcome variables included in hospital delirium and falls, and 6-month mortality.

Results

The CHS frailty index was available in all 220 patients, of which 1.5% were classified as being nonfrail, 58.5% as prefrail, and 40% as frail. The SOF frailty index was available in 204 patients, of which 16% were classified as being nonfrail, 51.5% as prefrail, and 32.5% as frail. Frailty, as identified by the CHS and SOF indexes, was a significant risk factor for 6-month mortality. However, after adjustment for multiple risk factors, frailty remained a strong independent risk factor only for the model with the CHS index (OR 4.7, 95% CI 1.7-12.8). Frailty (identified by CHS and SOF indexes) was not found to be a risk factor for delirium or falls.

Conclusions

Frailty, as measured by the CHS index, is an independent risk factor for 6-month mortality. The CHS and the SOF indexes have limited value as risk assessment tools for specific geriatric syndromes (e.g., falls and delirium) in hospitalized older patients.

The feasibility of measuring frailty to predict disability and mortality in older medical intensive care unit survivors

PURPOSE

To determine whether frailty can be measured within 4 days prior to hospital discharge in older intensive care unit (ICU) survivors of respiratory failure and whether it is associated with post-discharge disability and mortality.

MATERIALS AND METHODS

We performed a single-center prospective cohort study of 22 medical ICU survivors age 65 years or older who had received noninvasive or invasive mechanical ventilation for at least 24 hours. Frailty was defined as a score of ≥3 using Fried's 5-point scale. We measured disability with the Katz Activities of Daily Living. We estimated unadjusted associations between Fried's frailty score and incident disability at 1-month and 6-month mortality using Cox proportional hazard models.

RESULTS

The mean (SD) age was 77 (9) years, mean Acute Physiology and Chronic Health Evaluation II score was 27 (9.7), mean frailty score was 3.4 (1.3), and 18 (82%) were frail. Nine subjects (41%) died within 6 months, and all were frail. Each 1-point increase in frailty score was associated with a 90% increased rate of incident disability at 1-month (rate ratio: 1.9, 95% CI 0.7-4.9) and a threefold increase in 6-month mortality (rate ratio: 3.0, 95% CI 1.4-6.3).

CONCLUSIONS

Frailty can be measured in older ICU survivors near hospital discharge and is associated with 6-month mortality in unadjusted analysis. Larger studies to determine if frailty independently predicts outcomes are warranted.

Risk stratification tools for predicting morbidity and mortality in adult patients undergoing major surgery: qualitative systematic review

Risk stratification is essential for both clinical risk prediction and comparative audit. There are a variety of risk stratification tools available for use in major noncardiac surgery, but their discrimination and calibration have not previously been systematically reviewed in heterogeneous patient cohorts.Embase, MEDLINE, and Web of Science were searched for studies published between January 1, 1980 and August 6, 2011 in adult patients undergoing major noncardiac, nonneurological surgery. Twenty-seven studies evaluating 34 risk stratification tools were identified which met inclusion criteria. The Portsmouth-Physiology and Operative Severity Score for the enUmeration of Mortality and the Surgical Risk Scale were demonstrated to be the most consistently accurate tools that have been validated in multiple studies; however, both have limitations. Future work should focus on further evaluation of these and other parsimonious risk predictors, including validation in international cohorts. There is also a need for studies examining the impact that the use of these tools has on clinical decision making and patient outcome.

Implementing frailty into clinical practice: a cautionary tale

BACKGROUND

Little is known about the contribution of frailty in improving patient-level prediction beyond readily available clinical information. The objective of this study is to compare the predictive ability of 129 combinations of seven frailty markers (cognition, energy, mobility, mood, nutrition, physical activity, and strength) and quantify their contribution to predictive accuracy beyond age, sex, and number of chronic diseases.

METHODS

Two cohorts from the Established Populations for Epidemiologic Studies of the Elderly were used. The model with the best predictive fit in predicting 6-year incidence of disability was determined using the Akaike Information Criterion. Predictive accuracy was measured by the C statistic.

RESULTS

Incident disability was 23% in one cohort and 20% in the other cohort. The "best model" in each cohort was found to be a model including between five and seven frailty markers including cognition, mobility, nutrition, physical activity, and strength. Predictive accuracy of the 129 models ranged from 0.73 to 0.77 across both cohorts. Adding frailty markers to age, sex, and chronic disease increased predictive accuracy by up to 3% in both cohorts (p < .001). The contribution of frailty increased up to 9% in the oldest age group.

CONCLUSIONS

Adding frailty markers provided a modest increase in patient-level prediction of disability. Such a modest increase may still be worthwhile because while age, sex, and the number of chronic diseases are not modifiable, frailty may be. Further studies examining the contribution of frailty in improving prediction are needed before adopting frailty as a prognostic tool.

Impact of sarcopenia on outcomes following intra-arterial therapy of hepatic malignancies

BACKGROUND

Assessment of patient performance status is often subjective. Sarcopenia--measurement of muscle wasting--may be a more objective means to assess performance status and therefore mortality risk following intra-arterial therapy (IAT).

METHODS

Total psoas area (TPA) was measured on cross-sectional imaging in 216 patients undergoing IAT of hepatic malignancies between 2002 and 2012. Sarcopenia was defined as TPA in the lowest sex-specific quartile. Impact of sarcopenia was assessed relative to other clinicopathological factors.

RESULTS

Indications for IAT included hepatocellular carcinoma (51 %), intrahepatic cholangiocarcinoma (13 %), colorectal liver metastasis (7 %), or other metastatic disease (30 %). Median TPA among men (568 mm(2)/m(2)) was greater than women (413 mm(2)/m(2)). IAT involved conventional chemoembolization (54 %), drug-eluting beads (40 %), or yttrium-90 (6 %). Median tumor size was 5.8 cm; most patients had multiple lesions (74 %). Ninety-day mortality was 9.3 %; 3-year survival was 39 %. Factors associated with risk of death were tumor size (HR = 1.84) and Child's score (HR = 2.15) (all P < 0.05). On multivariate analysis, sarcopenia remained independently associated with increased risk of death (lowest vs. highest TPA quartile, HR = 1.84; P = 0.04). Sarcopenic patients had a 3-year survival of 28 vs. 44 % for non-sarcopenic patients.

CONCLUSIONS

Sarcopenia was an independent predictor of mortality following IAT with sarcopenic patients having a twofold increased risk of death. Sarcopenia is an objective measure of frailty that can help clinical decision-making regarding IAT for hepatic malignancies.

Association between sarcopenia and the risk of serious infection among adults undergoing liver transplantation

Although sarcopenia (muscle loss) is associated with increased mortality after liver transplantation, its influence on other complications is less well understood. We examined the association between sarcopenia and the risk of severe posttransplant infections among adult liver transplant recipients. By calculating the total psoas area (TPA) on preoperative computed tomography scans, we assessed sarcopenia among 207 liver transplant recipients. The presence or absence of a severe posttransplant infection was determined by a review of the medical chart. The influence of posttransplant infections on overall survival was also assessed. We identified 196 episodes of severe infections among 111 patients. Fifty-six patients had more than 1 infection. The median time to the development of an infection was 27 days (interquartile range = 13-62 days). When the patients were grouped by TPA tertiles, patients in the lowest tertile had a greater than 4-fold higher chance of developing a severe infection in comparison with patients in the highest tertile (odds ratio = 4.6, 95% confidence interval =  2.25-9.53). In a multivariate analysis, recipient age (hazard ratio = 1.04, P = 0.02), pretransplant TPA (hazard ratio = 0.38, P < 0.01), and pretransplant total bilirubin level (hazard ratio = 1.05, P = 0.02) were independently associated with the risk of developing severe infections. Patients with severe posttransplant infections had worse 1-year survival than patients without infections (76% versus 92%, P = 0.003). In conclusion, among patients undergoing liver transplantation, a lower TPA was associated with a heightened risk for posttransplant infectious complications and mortality. Future efforts should focus on approaches for assessing and mitigating vulnerability in patients undergoing transplantation.

Association between frailty and short- and long-term outcomes among critically ill patients: a multicentre prospective cohort study

BACKGROUND

Frailty is a multidimensional syndrome characterized by loss of physiologic and cognitive reserves that confers vulnerability to adverse outcomes. We determined the prevalence, correlates and outcomes associated with frailty among adults admitted to intensive care.

METHODS

We prospectively enrolled 421 critically ill adults aged 50 or more at 6 hospitals across the province of Alberta. The primary exposure was frailty, defined by a score greater than 4 on the Clinical Frailty Scale. The primary outcome measure was in-hospital mortality. Secondary outcome measures included adverse events, 1-year mortality and quality of life.

RESULTS

The prevalence of frailty was 32.8% (95% confidence interval [CI] 28.3%-37.5%). Frail patients were older, were more likely to be female, and had more comorbidities and greater functional dependence than those who were not frail. In-hospital mortality was higher among frail patients than among non-frail patients (32% v. 16%; adjusted odds ratio [OR] 1.81, 95% CI 1.09-3.01) and remained higher at 1 year (48% v. 25%; adjusted hazard ratio 1.82, 95% CI 1.28-2.60). Major adverse events were more common among frail patients (39% v. 29%; OR 1.54, 95% CI 1.01-2.37). Compared with nonfrail survivors, frail survivors were more likely to become functionally dependent (71% v. 52%; OR 2.25, 95% CI 1.03-4.89), had significantly lower quality of life and were more often readmitted to hospital (56% v. 39%; OR 1.98, 95% CI 1.22-3.23) in the 12 months following enrolment.

INTERPRETATION

Frailty was common among critically ill adults aged 50 and older and identified a population at increased risk of adverse events, morbidity and mortality. Diagnosis of frailty could improve prognostication and identify a vulnerable population that might benefit from follow-up and intervention.

Peri-operative management of older people undergoing surgery

Increasing numbers of older people are undergoing both emergency and elective surgery. However, they remain at increased risk of adverse outcome in comparison with younger patients. This may relate to the association of ageing with physiological deterioration, multi-morbidity and geriatric syndromes such as frailty, all of which are independent predictors of adverse post-operative outcome. Although there is an emerging evidence base for the identification and management of these predictors, this has not yet translated into routine clinical practice. Older patients undergoing surgery often receive sub-optimal care and surgical pathways are not well suited to complex older patients with multi-pathology. Evidence is emerging for alternative models of care that incorporate the evolving evidence base for optimal peri-operative management of the older surgical patient, including risk assessment and optimization. This article aims to provide a practical overview of the literature to all disciplines working in this field.

Defining "the elderly" undergoing major gastrointestinal resections: receiver operating characteristic analysis of a large ACS-NSQIP cohort

OBJECTIVE

"The elderly" is an often used but poorly defined descriptor of surgical patients. Investigators have used varying subjectively determined age cutoffs to report outcomes in the elderly. We set out to use objective outcomes data to determine the "at-risk" elderly population.

METHODS

PATIENTS

129,331 patients identified from the ACS-NSQIP database (2005-2010) undergoing major gastrointestinal resections.

OUTCOME

Mortality.

STATISTICAL METHODS

Locally weighted regression was used to fit the trend line of mortality over age. Receiver operating characteristic analysis was used to identify the "predictive age" for mortality.

RESULTS

Mortality steadily increases with age. On receiver operating characteristic analysis, there is a nonlinear transition zone (50-75 years of age) flanked by 2 linear zones on either end. The younger linear zone showed a low mortality increase (0.5% per decade). Larger mortality increase with age (5.3% per decade) was observed at the older age end. Similar patterns were observed for large-volume surgical subtypes, with clustering of a "critical age" beyond which mortality increases dramatically at 75 ± 2 years. Receiver operating characteristic analysis identified the "optimum age" for mortality being 68.5 years (area under the curve = 0.72, sensitivity = 66.6%, and specificity = 65.5%).

CONCLUSIONS

Mortality risk for major gastrointestinal surgical resections starts increasing at 50 years of age, and at 75 years of age, it starts increasing very rapidly. The optimum age of 68.5 years predicts mortality with the best combination of sensitivity and specificity. These ages should be used to standardize outcome data and focus perioperative resources to improve outcomes.

Frailty and risk in proximal aortic surgery

OBJECTIVES

Although frailty has recently been examined in various populations as a predictor of morbidity and mortality, its effect on thoracic aortic surgery outcomes has not been studied. The objective of the present study was to evaluate the role of frailty in predicting postoperative morbidity and mortality in patients undergoing proximal aortic replacement surgery.

METHODS

A retrospective analysis of a prospectively maintained database was performed for all patients undergoing elective and nonelective proximal aortic operations (root, ascending aorta, and/or arch) at a single-referral institution from June 2005 to December 2012. A total of 581 patients underwent proximal aortic surgery, of whom 574 (98.8%) were included in the present analysis; 7 were excluded because of incomplete data. Frailty was evaluated using an index consisting of age >70 years, body mass index <18.5 kg/m(2), anemia, history of stroke, hypoalbuminemia, and total psoas volume in the bottom quartile of the population. One point was given for each criterion met to determine a frailty score of 0 to 6. Frailty was defined as a score of ≥2. Risk models for length of stay >14 days, discharge to other than home, 30-day composite major morbidity, 30-day composite major morbidity/mortality, and 30-day and 1-year mortality were calculated using multivariate regression modeling.

RESULTS

Of the 574 patients, 148 (25.7%) were defined as frail (frailty score ≥2). The unadjusted 30-day/in-hospital and long-term outcomes were significantly worse for the frail versus nonfrail patients in all but 1 of the outcomes analyzed; no difference was found in the 30-day readmission rates between the 2 groups. In the multivariate model, a frailty score of ≥2 was associated with discharge to other than home and 30-day and 1-year mortality.

CONCLUSIONS

Frailty, as defined using a 6-component frailty index, can serve as an independent predictor of discharge disposition and early and late mortality risk in patients undergoing proximal aortic surgery. These frailty markers, all of which are easily assessed preoperatively, could provide valuable information for patient counseling and risk stratification before proximal aortic replacement.

Personalizing and targeting therapy for COPD: the role of molecular and clinical biomarkers

Chronic obstructive pulmonary disease (COPD) is a heterogeneous disease characterized by persistent airflow limitation. It is the third leading cause of death worldwide, and there are currently no curative strategies for this disease. Many factors contribute to COPD susceptibility, progression and exacerbations. These include cigarette smoking, environmental and occupational pollutants, respiratory infections and comorbidities. As the clinical phenotypes of COPD are so variable, it has been difficult to devise an individualized treatment plan for patients with this complex chronic disease. This review will highlight how potential clinical, inflammatory, genomic and epigenomic biomarkers for COPD could be used to personalize treatment, leading to improved disease management and prevention for our patients.

Association between body composition and frailty among prevalent hemodialysis patients: a US Renal Data System special study

Studies of frailty among patients on hemodialysis have relied on definitions that substitute self-reported functioning for measures of physical performance and omit weight loss or substitute alternate criteria. We examined the association between body composition and a definition of frailty that includes measured physical performance and weight loss in a cross-sectional analysis of 638 adult patients receiving maintenance hemodialysis at 14 centers. Frailty was defined as having three of following characteristics: weight loss, weakness, exhaustion, low physical activity, and slow gait speed. We performed logistic regression with body mass index (BMI) and bioelectrical impedance spectroscopy (BIS)-derived estimates of intracellular water (ICW), fat mass, and extracellular water (ECW) as the main predictors, and age, sex, race, and comorbidity as covariates. Overall, 30% of participants were frail. Older age (odds ratio [OR], 1.31 per 10 years; 95% confidence interval [95% CI], 1.14 to 1.50), diabetes (OR, 1.65; 95% CI, 1.13 to 2.40), higher fat mass (OR, 1.18; 95% CI, 1.02 to 1.37), and higher ECW (OR, 1.33; 95% CI, 1.20 to 1.47) associated with higher odds of frailty. Higher ICW associated with lower odds of frailty (OR, 0.80 per kg; 95% CI, 0.73 to 0.87). The addition of BMI data did not change the area under the receiver operating characteristics curve (AUC; AUC=0.66 versus 0.66; P=0.71), but the addition of BIS data did change the AUC (AUC=0.72; P<0.001). Thus, individual components of body composition but not BMI associate strongly with frailty in this cohort of patients receiving hemodialysis.

Pancreatic surgery in the very old: face to face with a challenge of the near future

BACKGROUND

The proportion of octogenarians requiring surgery for pancreatic disease is rapidly growing. This trend will be continued during the next decades, posing a challenge to surgeons and the health care system worldwide. This study aimed to analyze the results of pancreatic surgery in octogenarians in terms of safety and survival based on a cohort of patients at a European high-volume center.

METHODS

During a 7-year period, 1,705 operations were performed, 76 in patients ≥ 80 years of age. Data on the octogenarians were retrospectively reviewed and compared to those of the whole collective and to contemporary data from the literature. Primary endpoints were mortality, morbidity, and survival.

RESULTS

Overall, 80 % had a malignant disease, and resections were performed in 50 % of all cases. Mortality was 11.8 % and morbidity 72.4 %. There were significantly more medical than surgical complications: 56.6 versus 34.2 %. Pancreatic fistula occurred in 5.3 %, postoperative bleeding in 3.9 %, and delayed gastric emptying in 19.7 %. The median hospital stay was 15 days and the intensive care unit stay 2 days. Mean survival was 28.2 months and in patients with cancer 22.6 months. The 1-, 3-, and 5-year survival rates were 61.4, 31.3, and 18.8 %, respectively.

CONCLUSIONS

Despite high mortality and morbidity rates, surgery remains the only chance for cure in most octogenarians with pancreatic disease. Careful patient selection is the key to success and improved long-term survival in this group, which will represent a substantial fraction of the population in the near future.

Improving mortality following emergent surgery in older patients requires focus on complication rescue

OBJECTIVE

To determine whether a hospital's ability to rescue patients from major complications underlies variation in outcomes for elderly patients undergoing emergent surgery.

BACKGROUND

Perioperative mortality rates in elderly patients undergoing emergent general/vascular operations are high and vary widely across Michigan hospitals.

METHODS

We identified 23,224 patients undergoing emergent general/vascular surgical procedures at 41 hospitals within the Michigan Surgical Quality Collaborative between 2006 and 2011. Hospitals were ranked by risk- and reliability-adjusted 30-day mortality rates and grouped into tertiles. We stratified patients by age (<75 and ≥75 years). Risk-adjusted major complication and failure-to-rescue (ie, mortality after major complication) rates were determined for each tertile of hospital mortality.

RESULTS

Risk-adjusted mortality rates in elderly patients varied 2-fold across all hospitals. Complication rates correlated poorly with mortality. Failure-to-rescue rates, however, were markedly higher in high-mortality hospitals (29% lowest tertile vs 41% highest tertile; P < 0.01). When compared with younger patients, overall failure-to-rescue rates were almost 2-fold greater in the elderly (36.1% ≥75 vs 18.7% <75; P < 0.01).

CONCLUSIONS

A hospital's failure to rescue patients from major complications seems to underlie the variation in mortality rates across Michigan hospitals after emergent surgery. Although higher failure-to-rescue rates in the elderly may signify their diminished physiological reserve for surviving critical illness, the wide variation across hospitals also highlights the importance of systems aimed at the early recognition and effective management of major complications in this vulnerable population.

Slower walking speed forecasts increased postoperative morbidity and 1-year mortality across surgical specialties

OBJECTIVE

The purpose of this study was to determine the relationship between the Timed Up and Go test and postoperative morbidity and 1-year mortality, and to compare the Timed Up and Go to the standard-of-care surgical risk calculators for prediction of postoperative complications.

METHODS

In this prospective cohort study, patients 65 years and older undergoing elective colorectal and cardiac operations with a minimum of 1-year follow-up were included. The Timed Up and Go test was performed preoperatively. This timed test starts with the subject standing from a chair, walking 10 feet, returning to the chair, and ends after the subject sits. Timed Up and Go results were grouped as fast ≤ 10 seconds, intermediate = 11-14 seconds, and slow ≥ 15 seconds. Receiver operating characteristic curves were used to compare the 3 Timed Up and Go groups to current standard-of-care surgical risk calculators at forecasting postoperative complications.

RESULTS

This study included 272 subjects (mean age of 74 ± 6 years). Slower Timed Up and Go was associated with increased postoperative complications after colorectal (fast 13%, intermediate 29%, and slow 77%; P < 0.001) and cardiac (fast 11%, intermediate 26%, and slow 52%; P < 0.001) operations. Slower Timed Up and Go was associated with increased 1-year mortality following both colorectal (fast 3%, intermediate 10%, and slow 31%; P = 0.006) and cardiac (fast 2%, intermediate 3%, and slow 12%; P = 0.039) operations. Receiver operating characteristic area under curve of the Timed Up and Go and the risk calculators for the colorectal group was 0.775 (95% CI: 0.670-0.880) and 0.554 (95% CI: 0.499-0.609), and for the cardiac group was 0.684 (95% CI: 0.603-0.766) and 0.552 (95% CI: 0.477-0.626).

CONCLUSIONS

Slower Timed Up and Go forecasted increased postoperative complications and 1-year mortality across surgical specialties. Regardless of operation performed, the Timed Up and Go compared favorably to the more complex risk calculators at forecasting postoperative complications.

Sarcopenia as a predictor of prognosis in patients following hepatectomy for hepatocellular carcinoma

BACKGROUND

Sarcopenia was identified recently as a poor prognostic factor in patients with cancer. The present study investigated the effect of sarcopenia on short- and long-term outcomes following partial hepatectomy for hepatocellular carcinoma (HCC), and aimed to identify prognostic factors.

METHODS

Data were collected retrospectively for all consecutive patients who underwent hepatectomy for HCC with curative intent between January 2004 and December 2009. Patients were assigned to one of two groups according to the presence or absence of sarcopenia, assessed by computed tomographic measurement of muscle mass at the level of the third lumbar vertebra. Clinicopathological, surgical outcome and long-term survival data were analysed.

RESULTS

Sarcopenia was present in 75 (40·3 per cent) of 186 patients, and was significantly correlated with female sex, lower body mass index and liver dysfunction, as indicated by abnormal serum albumin levels and indocyanine green retention test at 15 min values. In patients with, and without sarcopenia, the 5-year overall survival rate was 71 and 83·7 per cent respectively, and the 5-year recurrence-free survival rate was 13 and 33·2 per cent respectively. Multivariable analysis revealed that reduced skeletal muscle mass was predictive of an unfavourable prognosis.

CONCLUSION

Sarcopenia was predictive of worse overall survival even when adjusted for other known predictors in patients with HCC after partial hepatectomy.

Identification of quality of care deficiencies in elderly surgical patients by measuring adherence to process-based quality indicators

BACKGROUND

The ability to measure surgical quality of care is important and can lead to improvements in patient safety. As such, processes should be carried out in an identical fashion for all patients, regardless of how vulnerable or complex they are. Our objectives were to assess quality of surgical care delivered to elderly patients and to determine the association between patient characteristics and quality of care.

STUDY DESIGN

This is a retrospective pilot cohort study, conducted in a single university-affiliated hospital. Using the institution's National Surgical Quality Improvement Program (NSQIP) database (2009 to 2010), 143 consecutive patients 65 years or older, undergoing elective major abdominal surgery, were selected. Adherence to 15 process-based quality indicators (QIs) was measured, and a pass rate was calculated for each individual QI. The association between patient characteristics (age, sex, Charlson Comorbidity Index, functional status, wound class) and patient quality score was assessed using multiple linear regression.

RESULTS

Quality indicators with the lowest pass rates included postoperative delirium screening (0%), level of care documentation (0.7%), cognition and functional assessment at discharge (4.9%), oral intake documentation (12.6%), and pressure ulcer risk assessment (35.0%). The mean patient quality score was 46.8% ± 10.7% (range 16.7% to 75.0%). No association was found between patient characteristics and patient quality score.

CONCLUSIONS

Quality of care delivered to elderly patients undergoing major surgery at our institution was generally poor and independent of patient characteristics. Although quality appears to be uniform across different patients, these results provide targets for quality improvement initiatives.

Comprehensive geriatric assessment of risk factors associated with adverse outcomes and resource utilization in cancer patients undergoing abdominal surgery

BACKGROUND

The purpose of this prospective study was to identify risk factors for adverse outcomes or increased resource utilization after abdominal cancer surgery in geriatric patients.

METHODS

Baseline clinical and geriatric assessment variables including functional status, nutritional status, comorbidity index, mental status, depression scale score, fatigue inventory scale, and polypharmacy scale were prospectively recorded for patients age ≥65 undergoing intra-abdominal oncologic surgery. Outcome variables included morbidity, mortality, discharge to nursing facility, prolonged hospital stay, and readmission.

RESULTS

Of 111 patients, surgery type was colorectal in 40%, hepatopancreatobiliary in 30%, and gastric/duodenal in 14%. Variables associated with discharge to a nursing facility on multivariate analysis included weight loss ≥10% (OR 6.52 [95% CI: 1.43-29.76], P = 0.02), ASA score ≥2 (OR 5.08 [1.13-22.77], P = 0.03), and ECOG score ≥2 (OR 4.51 [1.03-19.71], P = 0.04). Variables independently associated with prolonged hospital stay included weight loss ≥10% (OR 4.03 [1.13-14.43], P = 0.03), the presence of polypharmacy (OR 2.45 [1.09-5.48], P = 0.03), and distant disease (OR 0.37 [0.15-0.91], P = 0.03). No variables were associated with morbidity or readmission.

CONCLUSIONS

Pre-operative clinical and geriatric assessment tools can help predict the need for discharge to a nursing facility or increased length of stay. Future studies will be required to identify patients suitable for interventions to decrease hospital and post-discharge resource utilization.

Frailty indicators and functional status in older patients after colorectal cancer surgery

OBJECTIVES

The number of older survivors from colorectal cancer is increasing, but little is known regarding long-term consequences of cancer treatment in this patient group. Physical function is an important outcome for older patients, affecting both autonomy and quality of life. We aimed to investigate physical function in older patients with colorectal cancer before and after surgery, and to examine the role of individual frailty indicators as predictors of functional decline.

MATERIAL AND METHODS

We present 16-28 months follow-up data of older patients after elective surgery for colorectal cancer. During a home-visit, physical function was evaluated by activities of daily living (ADL), instrumental activities of daily living (IADL), the timed up-and-go (TUG) test, and grip strength. Measurements were compared with those obtained preoperatively using the Wilcoxon signed rank test. Frailty indicators were dichotomized and implemented in logistic regression models to explore their associations to a decline in the physical function scores.

RESULTS

Eighty-four patients were included and the median age was 82 years. There was a significant decrease in ADL (p = 0.04) and IADL scores (p ≤ 0.001) at follow-up. We found no associations between frailty indicators and the risk of decline in physical functioning.

CONCLUSION

In our population of older patients with surgically treated colorectal cancer, there was a significant decline in ADL- and IADL-scores at follow-up. No change was found in TUG or grip strength, and frailty indicators did not predict decline in physical function.

Operationalization of frailty using eight commonly used scales and comparison of their ability to predict all-cause mortality

OBJECTIVES

To operationalize frailty using eight scales and to compare their content validity, feasibility, prevalence estimates of frailty, and ability to predict all-cause mortality.

DESIGN

Secondary analysis of the Survey of Health, Ageing and Retirement in Europe (SHARE).

SETTING

Eleven European countries.

PARTICIPANTS

Individuals aged 50 to 104 (mean age 65.3 ± 10.5, 54.8% female, N = 27,527).

MEASUREMENTS

Frailty was operationalized using SHARE data based on the Groningen Frailty Indicator, the Tilburg Frailty Indicator, a 70-item Frailty Index (FI), a 44-item FI based on a Comprehensive Geriatric Assessment (FI-CGA), the Clinical Frailty Scale, frailty phenotype (weighted and unweighted versions), the Edmonton Frail Scale, and the FRAIL scale.

RESULTS

All scales had fewer than 6% of cases with at least one missing item, except the SHARE-frailty phenotype (11.1%) and the SHARE-Tilburg (12.2%). In the SHARE-Groningen, SHARE-Tilburg, SHARE-frailty phenotype, and SHARE-FRAIL scales, death rates were 3 to 5 times as high in excluded cases as in included ones. Frailty prevalence estimates ranged from 6% (SHARE-FRAIL) to 44% (SHARE-Groningen). All scales categorized 2.4% of participants as frail. Of unweighted scales, the SHARE-FI and SHARE-Edmonton scales most accurately predicted mortality at 2 (SHARE-FI area under the receiver operating characteristic curve (AUC) = 0.77, 95% confidence interval (CI) = 0.75-0.79); SHARE-Edmonton AUC = 0.76, 95% CI = 0.74-0.79) and 5 (both AUC = 0.75, 95% CI = 0.74-0.77) years. The continuous score of the weighted SHARE-frailty phenotype (AUC = 0.77, 95% CI = 0.75-0.78) predicted 5-year mortality better than the unweighted SHARE-frailty phenotype (AUC = 0.70, 95% CI = 0.68-0.71), but the categorical score of the weighted SHARE-frailty phenotype did not (AUC = 0.70, 95% CI = 0.68-0.72).

CONCLUSION

Substantive differences exist between scales in their content validity, feasibility, and ability to predict all-cause mortality. These frailty scales capture related but distinct groups. Weighting items in frailty scales can improve their predictive ability, but the trade-off between specificity, predictive power, and generalizability requires additional evaluation.

Frailty and early hospital readmission after kidney transplantation

Early hospital readmission (EHR) after kidney transplantation (KT) is associated with increased morbidity and higher costs. Registry-based recipient, transplant and center-level predictors of EHR are limited, and novel predictors are needed. We hypothesized that frailty, a measure of physiologic reserve initially described and validated in geriatrics and recently associated with early KT outcomes, might serve as a novel, independent predictor of EHR in KT recipients of all ages. We measured frailty in 383 KT recipients at Johns Hopkins Hospital. EHR was ascertained from medical records as ≥1 hospitalization within 30 days of initial post-KT discharge. Frail KT recipients were much more likely to experience EHR (45.8% vs. 28.0%, p = 0.005), regardless of age. After adjusting for previously described registry-based risk factors, frailty independently predicted 61% higher risk of EHR (adjusted RR = 1.61, 95% CI: 1.18-2.19, p = 0.002). In addition, frailty improved EHR risk prediction by improving the area under the receiver operating characteristic curve (p = 0.01) as well as the net reclassification index (p = 0.04). Identifying frail KT recipients for targeted outpatient monitoring and intervention may reduce EHR rates.

Assessment of morbidity and mortality after esophagectomy using a modified frailty index

BACKGROUND

Esophagectomy is associated with significant morbidity and mortality. This retrospective study examined use of a modified frailty index as a potential predictor of morbidity and mortality in esophagectomy patients.

METHODS

National Surgical Quality Improvement Program Participant Use Files were reviewed for 2005 through 2010. Patients undergoing esophagectomy were selected based on CPT codes. A modified frailty index with 11 variables was used to determine correlation between frailty and postesophagectomy morbidity and mortality. Data were analyzed using χ(2) test and logistic regression.

RESULTS

A total of 2,095 patients were included in the analysis. Higher frailty scores were associated with a statistically significant increase in morbidity and mortality. A frailty score of 0, 1, 2, 3, 4, and 5 had associated morbidity rates of 17.9% (142 of 795 patients), 25.1% (178 of 710 patients), 31.4% (126 of 401 patients), 34.4% (48 of 140 patients), 44.4% (16 of 36 patients), and 61.5% (8 of 13 patients), respectively. A frailty score of 0, 1, 2, 3, 4, and 5 had associated mortality rates of 1.8% (14 of 795 patients), 3.8% (27 of 710 patients), 4% (16 of 401 patients), 7.1% (10 of 140 patients), 8.3% (3 of 36 patients), and 23.1% (3 of 13 patients), respectively. When using multivariate logistic regression for mortality comparing age, functional status, prealbumin, emergency surgery, wound class, American Society of Anesthesiologists score, and sex, only age and frailty were statistically significant. The odds ratio was 31.84 for frailty (p = 0.015) and 1.05 (p = 0.001) for age.

CONCLUSIONS

Using a large national database, a modified frailty index was shown to correlate with postesophagectomy morbidity and mortality. Such an index may be used to aid in improving risk assessment and patient selection for esophagectomy.

Simple frailty score predicts postoperative complications across surgical specialties

BACKGROUND

Our purpose was to determine the relationship between preoperative frailty and the occurrence of postoperative complications after colorectal and cardiac operations.

METHODS

Patients 65 years or older undergoing elective colorectal or cardiac surgery were enrolled. Seven baseline frailty traits were measured preoperatively: Katz score less than or equal to 5, Timed Up and Go test greater than or equal to 15 seconds, Charlson Index greater than or equal to 3, anemia less than 35%, Mini-Cog score less than or equal to 3, albumin less than 3.4 g/dL, and 1 or more falls within 6 months. Patients were categorized by the number of positive traits as follows: nonfrail: 0 to 1 traits, prefrail: 2 to 3 traits, and frail: 4 or more traits.

RESULTS

Two hundred one subjects (age 74 ± 6 years) were studied. Preoperative frailty was associated with increased postoperative complications after colorectal (nonfrail: 21%, prefrail: 40%, frail: 58%; P = .016) and cardiac operations (nonfrail: 17%, prefrail: 28%, frail: 56%; P < .001). This finding in both groups was independent of advancing age. Frail individuals in both groups had longer hospital stays and higher 30-day readmission rates. Receiver operating characteristic curves examining frailty's ability to forecast complications were colorectal (.702, P = .004) and cardiac (.711, P < .001).

CONCLUSIONS

A simple preoperative frailty score defines older adults at higher risk for postoperative complications across surgical specialties.

Analytic morphometric assessment of patients undergoing colectomy for colon cancer

BACKGROUND

Analytic morphometrics provides objective data that may better stratify risk. We investigated morphometrics and outcome among colon cancer patients.

METHODS

An IRB-approved review identified 302 patients undergoing colectomy who had CT scans. These were processed to measure psoas area (PA), density (PD), subcutaneous fat (SFD), visceral fat (VF), and total body fat (TBF). Correlation with complications, recurrence, and survival were obtained by t-tests and linear regression models after adjusting for age and Charlson index.

RESULTS

The best predictor of surgical complications was PD. PMH, Charlson, BMI, and age were not significant when PD was considered. SF area was the single best predictor of a wound infection. While all measures of obesity correlated with outcome, TBF was most predictive. Final multivariate Cox models for survival included age, Charlson score, nodal positivity, and TBF.

CONCLUSIONS

Analytic morphometric analysis provided objective data that stratified complications and outcome better than age, BMI, or co-morbidities.

A prognostic model for 6-month mortality in elderly survivors of critical illness

BACKGROUND

Although 1.4 million elderly Americans survive hospitalization involving intensive care annually, many are at risk for early mortality following discharge. No models that predict the likelihood of death after discharge exist explicitly for this population. Therefore, we derived and externally validated a 6-month postdischarge mortality prediction model for elderly ICU survivors.

METHODS

We derived the model from medical record and claims data for 1,526 consecutive patients aged ≥ 65 years who had their first medical ICU admission in 2006 to 2009 at a tertiary-care hospital and survived to discharge (excluding those patients discharged to hospice). We then validated the model in 1,010 patients from a different tertiary-care hospital.

RESULTS

Six-month mortality was 27.3% and 30.2% in the derivation and validation cohorts, respectively. Independent predictors of mortality (in descending order of contribution to the model's predictive power) were a do-not-resuscitate order, older age, burden of comorbidity, admission from or discharge to a skilled-care facility, hospital length of stay, principal diagnoses of sepsis and hematologic malignancy, and male sex. For the derivation and external validation cohorts, the area under the receiver operating characteristic curve was 0.80 (SE, 0.01) and 0.71 (SE, 0.02), respectively, with good calibration for both (P = 0.31 and 0.43).

CONCLUSIONS

Clinical variables available at hospital discharge can help predict 6-month mortality for elderly ICU survivors. Variables that capture elements of frailty, disability, the burden of comorbidity, and patient preferences regarding resuscitation during the hospitalization contribute most to this model's predictive power. The model could aid providers in counseling elderly ICU survivors at high risk of death and their families.

Optimizing perioperative management of geriatric patients with head and neck cancer

Given emerging demographic trends, many more elderly patients are being diagnosed with head and neck cancers. The surgical care paradigm for this cohort of patients must take into account specific challenges inherent to geriatric perioperative management. This article attempts to summarize the existing body of literature relevant to the geriatric head and neck cancer population, and to extrapolate relevant data from geriatric perioperative medicine in order to better understand and guide management decisions. The involvement of geriatricians and of patients' primary care providers may be invaluable in assisting in complex perioperative decision-making and in participating in longitudinal management. Preoperative risk stratification and assessment of medical, social, and functional variables are critical for appropriate decision-making in this challenging patient population.