Frail patients are at increased risk for mortality and prolonged institutional care after cardiac surgery

Functional Outcomes of Frail Patients After Cardiac Surgery: An Observational Study

BACKGROUND

Although frailty has been associated with major morbidity/mortality and increased length of stay after cardiac surgery, few studies have examined functional outcomes. We hypothesized that frailty would be independently associated with decreased functional status, increased discharge to a nonhome location, and longer duration of hospitalization after cardiac surgery, and that delirium would modify these associations.

METHODS

This was an observational study nested in 2 trials, each of which was conducted by the same research team with identical measurement of exposures and outcomes. The Fried frailty scale was measured at baseline. The primary outcome (defined before data collection) was functional decline, defined as ≥2-point decline from baseline in Instrumental Activities of Daily Living (IADL) score at 1 month after surgery. Secondary outcomes were absolute decline in IADL score, discharge to a new nonhome location, and duration of hospitalization. Associations were analyzed using linear, logistic, and Poisson regression models with adjustments for variables considered before analysis (age, gender, race, and logistic European Score for Cardiac Operative Risk Evaluation [EuroSCORE]) and in a propensity score analysis.

RESULTS

Data were available from 133 patients (83 from first trial and 50 from the second trial). The prevalence of frailty was 33% (44 of 133). In adjusted models, frail patients had increased odds of functional decline (primary outcome; odds ratio [OR], 2.41 [95% confidence interval {CI}, 1.03-5.63]; P = .04) and greater decline at 1 month in the secondary outcome of absolute IADL score (-1.48 [95% CI, -2.77 to -0.30]; P = .019), compared to nonfrail patients. Delirium significantly modified the association of frailty and change in absolute IADL score at 1 month. In adjusted hypothesis-generating models using secondary outcomes, frail patients had increased discharge to a new nonhome location (OR, 3.25 [95% CI, 1.37-7.69]; P = .007) and increased duration of hospitalization (1.35 days [95% CI, 1.19-1.52]; P < .0001) compared to nonfrail patients. The increased duration of hospitalization, but no change in functional status or discharge location, was partially mediated by increased complications in frail patients.

CONCLUSIONS

Frailty may identify patients at risk of functional decline at 1 month after cardiac surgery. Perioperative strategies to optimize frail cardiac surgery patients are needed.

Association of frailty with all-cause mortality and bleeding among elderly patients with acute myocardial infarction: a systematic review and meta-analysis

Background

Frailty is a multidimensional syndrome that reflects the physiological reserve of elderly. It is related to unfavorable outcomes in various cardiovascular conditions. We conducted a systematic review and meta-analysis of the association of frailty with all-cause mortality and bleeding after acute myocardial infarction (AMI) in the elderly.

Methods

We comprehensively searched the databases of MEDLINE and EMBASE from inception to March 2019. The studies that reported mortality and bleeding in AMI patients who were evaluated and classified by frailty status were included. Data from each study were combined using the random-effects, generic inverse variance method of DerSimonian and Laird to calculate hazard ratio (HR), and 95% confidence interval (CI).

Results

Twenty-one studies from 2011 to 2019 were included in this meta-analysis involving 143,301 subjects (mean age 75.33-year-old, 60.0% male). Frailty status was evaluated using different methods such as Fried Frailty Index. Frailty was statistically associated with increased early mortality in nine studies (pooled HR = 2.07, 95% CI: 1.67–2.56, P < 0.001, I² = 41.2%) and late mortality in 11 studies (pooled HR = 2.30, 95% CI: 1.70–3.11, P < 0.001, I² = 65.8%). Moreover, frailty was also statistically associated with higher bleeding in 7 studies (pooled HR = 1.34, 95% CI: 1.12–1.59, P < 0.001, I² = 4.7%).

Conclusion

Frailty is strongly and independently associated with bleeding, early and late mortality in elderly with AMI. Frailty assessment should be considered as an additional risk factor and used to guide toward personalized treatment strategies.

Surgery for the Very Old: Are Nonagenarians Different?

Octogenarians and nonagenarians are considered the “very old” and are often viewed as one group. Americans are aging, with the proportion of the very old expected to increase from 1.9 per cent of the population to 4.3 per cent in 2050. This study aimed to underscore the differences in surgical trends, demographics, and outcomes between octogenarians and nonagenarians. The ACS-NSQIP database (2007–2012) was used to derive the type of surgeries, demographics, and outcomes of octogenarian and nonagenarians undergoing nonemergent vascular, orthopedic, and general surgery procedures. Between 2007 and 2012, nonagenarians accounted for an increasing percentage of surgeries (85 to 121 per 10,000 surgeries, relative risk = 1.42; 95% CI: 1.30–1.54) across surgical specialties, including vascular, general, and orthopedic surgery, whereas the percentage of octogenarians undergoing surgery remained unchanged. Nonagenarians had a higher 30-day perioperative mortality and a longer hospital stay than octogenarians after vascular, orthopedic, and general surgery procedures. Nonagenarians are a rapidly growing group of surgical patients with significantly higher perioperative mortality and longer postoperative hospital stay. The impact of surgery on the quality of life of nonagenarians needs to be studied to justify the increasing healthcare costs.

Age, Not Sex, Modifies the Effect of Frailty on Long-term Outcomes After Cardiac Surgery

OBJECTIVE

To examine the prevalence of frailty in surgical patients and determine whether age and sex modify the relationship between frailty and long-term mortality.

BACKGROUND

Frailty is a complex and prevalent clinical syndrome. The cardiac surgery literature consists mostly of small, single-center studies, and the epidemiology of frailty remains to be fully elucidated in a real-world surgical population.

METHODS

This retrospective cohort study included patients who underwent coronary artery bypass grafting, and/or aortic, mitral or tricuspid valve surgery in Ontario, Canada, between 2008 and 2016. The primary outcome was all-cause mortality. Survival probabilities were calculated using the Kaplan-Meier method, and the association of covariates with the hazard of death was assessed using multivariable Cox proportional hazard models. Frailty was assessed using the Johns Hopkins Adjusted Clinical Groups frailty-defining diagnoses indicator.

RESULTS

Of 72,824 patients, 11,685 (16%) were frail. At median 5 ± 2 years of follow-up, 2921 (25.0%) frail patients and 8637 (14.1%) non-frail patients had died [adjusted hazard ratio 1.60; 95% confidence interval (CI), 1.53-1.68]. The adjusted hazard ratio was highest in patients who underwent isolated mitral (2.18; 95% CI, 1.71-2.77) and mitral + aortic valve surgery (1.85; 95% CI, 1.33-2.58) and lowest after coronary artery bypass grafting + mitral valve surgery (1.38; 95% CI, 1.11-1.70). Age, but not sex, modified the effect of frailty on mortality; such that the rate of death decreased linearly with increasing patient age.

CONCLUSIONS

We observed a high prevalence of frailty in patients undergoing cardiac surgery, and a statistically significant association between frailty and long-term mortality after cardiac procedures. Importantly, the rate of death was inversely proportional to age, such that frailty had a stronger adverse impact on younger patients. Our findings highlight the need to incorporate frailty into the preoperative risk stratification and investigate strategies to support younger patients who are frail.

Comprehensive Geriatric Assessment in the Management of Older Patients With Cardiovascular Disease

Cardiovascular disease (CVD) disproportionately affects older adults. It is expected that by 2030, one in five people in the United States will be older than 65 years. Individuals with CVD now live longer due, in part, to current prevention and treatment approaches. Addressing the needs of older individuals requires inclusion and assessment of frailty, multimorbidity, depression, quality of life, and cognition. Despite the conceptual relevance and prognostic importance of these factors, they are seldom formally evaluated in clinical practice. Further, although these constructs coexist with traditional cardiovascular risk factors, their exact prevalence and prognostic impact remain largely unknown. Development of the right decision tools, which include these variables, can facilitate patient-centered care for older adults. These gaps in knowledge hinder optimal care use and underscore the need to rigorously evaluate the optimal constructs for providing care to older adults. In this review, we describe available tools to examine the prognostic role of age-related factors in patients with CVD.

Translation of the Frailty Paradigm from Older Adults to Children with Cardiac Disease

Children and adolescents with cardiac disease (CCD) have significant morbidity and lower quality of life. However, there are no broadly applicable tools similar to the frailty score as described in the elderly, to define functional phenotype in terms of physical capability and psychosocial wellbeing in CCD. The purpose of this study is to investigate the domains of the frailty in CCD. We prospectively recruited CCD (8-17.5 years old, 70% single ventricle, 27% heart failure, 12% pulmonary hypertension; NYHA classes I, II and III) and age and gender matched healthy controls (total n = 56; CCD n = 34, controls n = 22; age 12.6 ± 2.6 years; 39.3% female). We measured the five domains of frailty: slowness, weakness, exhaustion, body composition and physical activity using developmentally appropriate methods. Age and gender-based population norms were used to obtain Z scores and percentiles for each measurement. Two-tailed t-tests were used to compare the two groups. The CCD group performed significantly worse in all five domains of frailty compared to healthy controls. Slowness: 6-min walk test with Z score -3.9 ± 1.3 vs -1.4 ± 1.3, p < 0.001; weakness: handgrip strength percentile 18.9 ± 20.9 vs 57.9 ± 26.0, p < 0.001; exhaustion: multidimensional fatigue scale percentile 63.7 ± 13.5 vs 83.3 ± 14.4, p < 0.001; body composition: height percentile 43.4 ± 29.5 vs 71.4 ± 25.2, p < 0.001, weight percentile 46.0 ± 36.0 vs 70.9 ± 24.3, p = 0.006, BMI percentile 48.4 ± 35.5 vs 66.9 ± 24.2, p = 0.04, triceps skinfold thickness 41.0 ± 24.0 vs 54.4 ± 22.1, p = 0.04; physical activity: pediatric activity questionnaire score 2 ± 0.6 vs 2.7 ± 0.6, p < 0.001. The domains of frailty can be quantified in children using developmentally appropriate methods. CCD differ significantly from controls in all five domains, supporting the concept of quantifying the domains of frailty. Larger longitudinal studies are needed to study frailty in CCD and examine if it predicts adverse health outcomes.Clinical Trial Registration: The ClinicalTrials.gov identification number is NCT02999438. https://clinicaltrials.gov/ct2/show/NCT02999438.

The impact of frailty on acute care general surgery patients: A systematic review

BACKGROUND

Frailty may predict negative health outcomes more accurately than chronological age alone. This review examines evidence for the impact of frailty on adverse outcomes in patients admitted with an acute care general surgery (ACS) diagnosis.

METHODS

A systematic literature search for studies reporting frailty and outcomes after admission with an ACS diagnosis was performed. We searched PubMed and SCOPUS from inception until September 2017.

RESULTS

A total of 8,668 records were screened, of which seven studies examined the relationship between frailty and outcomes in ACS patients. Frailty was associated with higher 30-day mortality patients (odds ratio, 3.04; 95% confidence interval, 2.67-3.46; p < 0.01), postoperative complications, length of stay, institutional discharge, and critical care admission.

CONCLUSIONS

There is emerging evidence that frailty is associated with worse outcomes in patients with an unplanned admission due to an ACS diagnosis. Further investigation is warranted with regard to how frailty may impact patients with an acute illness more severely.

LEVEL OF EVIDENCE

Systematic review, level III.

Changes in Functional Status and Health-Related Quality of Life in Older Adults After Surgical, Interventional, or Medical Management of Acute Myocardial Infarction

Functional status and health-related quality of life (HRQoL) are important outcomes, particularly among older patients. However, data on such patient-centered outcomes after cardiac surgery are limited. We evaluated the incidence and predictors of decline in functional status and HRQoL among older patients hospitalized for acute myocardial infarction (AMI). Participants were age 75 years or older hospitalized for AMI at 94 US sites. We examined decline in functional status (defined as decline in 1 or more activities of daily living, ADLs), as well as mental (MCS) and physical component scales (PCS) of the SF-12 to assess HRQoL (5-point decline or greater in each scale) between 1 month prior to the hospitalization and 6 months after. Multivariable model compared the risk of decline after coronary artery bypass graft (CABG), percutaneous coronary intervention (PCI) and medical management. Among 3041 patients (1708 PCI, 362 CABG, and 971 medical management), 1525 (50.2%) experienced decline in 1 or more domain: 633 (20.8%) declined in ADLs, 786 (25.9%) declined in the MCS, and 1078 (35.5%) declined in the PCS. The unadjusted incidence of ADL decline was the lowest among patients who underwent CABG (n = 50, 13.8%) compared with PCI (n = 271, 15.9%) or medical management (n = 312, 32.1%). Patients who underwent CABG and PCI had lower adjusted risk of decline in functional and HRQoL compared with those who received medical therapy. The risks after CABG and PCI were not significantly different. Over half of older patients significantly declined in function or HRQoL after AMI. Compared with medical management, risk of decline was lower in those who underwent revascularization.

The FRAIL-FIT study: Frailty's relationship with adverse-event incidence in the longer term, at one year following intensive care unit treatment - A retrospective observational cohort study

INTRODUCTION

Frailty is a syndrome of decreased reserve and heightened vulnerability. Frailty scoring has potential to facilitate more informed decisions in the intensive care unit. To validate this, its relationship with outcomes must be tested extensively. This study aimed to investigate frailty's impact on adverse outcomes after intensive care unit admission, primarily one-year mortality.

METHODS

This single-centre retrospective observational cohort study examined prospectively collected data from 400 intensive care unit patients. Frailty was assessed using the Clinical Frailty Scale and defined as Clinical Frailty Scale ≥ 5. Unadjusted and adjusted analyses tested the relationships of frailty, covariates and outcomes.

RESULTS

Of 400 eligible patients, 111 (27.8%) were frail and 289 (72.3%) were non-frail. Compared to non-frail patients, frail patients were older (62 vs. 56, p < 0.001) and had higher Acute Physiology and Chronic Health Evaluation II scores (22 vs. 19, p < 0.001). Females were more likely to be frail than males (34.1% vs. 22.9% frail, p = 0.018). Frail patients were less likely to survive the intensive care unit (p = 0.03), hospital (p = 0.003) or to one year (p < 0.001). Frailty significantly increased one-year mortality hazards in unadjusted analyses (hazard ratio 1.96; 95% confidence interval 1.41-2.72; p < 0.001) and covariate adjusted analyses (hazard ratio 1.41; 95% confidence interval 1.00-1.98; p = 0.0497). Frail patients had more hospital admissions (p = 0.014) and longer hospital stays within both one year before (p = 0.002) and one year after intensive care unit admission (p = 0.012).

CONCLUSIONS

Frailty was common and associated with greater age, female gender, higher sickness severity and more healthcare use. Frailty was significantly associated with greater risks of mortality in both unadjusted and adjusted analyses. Frailty scoring is a promising tool which could improve decision making in intensive care.

Anaesthesia geriatric evaluation to guide patient selection for preoperative multidisciplinary team care in cardiac surgery

BACKGROUND

A multidisciplinary approach to improve postoperative outcomes in frail elderly patients is gaining interest. Multidisciplinary team care should be targeted at complex patients at high risk for adverse postoperative outcome to limit the strain on available resources and to prevent an unnecessary increase in patient burden. This study aimed to improve patient selection for multidisciplinary care by identifying risk factors for disability after cardiac surgery in elderly patients.

METHODS

This was a two-centre prospective cohort study of 537 patients aged ≥70 yr undergoing elective cardiac surgery. Before surgery, 11 frailty characteristics were investigated. Outcome was disability at 3 months defined as World Health Organization Disability Assessment Schedule 2.0 ≥25%. Multivariable modelling using logistic regression, concordance statistic (c-statistic), and net reclassification index was used to identify factors contributing to patient selection.

RESULTS

Disability occurred in 91 (17%) patients. Ten out of 11 frailty characteristics were associated with disability. A multivariable model, including the European System for Cardiac Operative Risk Evaluation II and preoperative haemoglobin, yielded a c-statistic of 0.71 (95% confidence interval [CI]: 0.66-0.77). After adding pre-specified frailty characteristics (polypharmacy, gait speed, physical disability, preoperative health-related quality of life, and living alone) to this model, the c-statistic improved to 0.78 (95% CI: 0.73-0.83). The net reclassification index was 0.32 (P<0.001), showing improved discrimination for patients at risk for disability at 3 months.

CONCLUSIONS

The addition of preoperative frailty characteristics to a multivariable model improved discrimination between elderly patients with and without disability at 3 months after cardiac surgery, and can be used to guide patient selection for preoperative multidisciplinary team care.

CLINICAL TRIAL REGISTRATION

NCT02535728.

Recommendations for Preoperative Assessment and Shared Decision-Making in Cardiac Surgery

Purpose of review

Recommendations about shared decision-making and guidelines on preoperative evaluation of patients undergoing non-cardiac surgery are abundant, but respective recommendations for cardiac surgery are sparse. We provide an overview of available evidence.

Recent findings

While there currently is no consensus statement on the preoperative anesthetic evaluation and shared decision-making for the adult patient undergoing cardiac surgery, evidence pertaining to specific organ systems is available.

Summary

We provide a comprehensive review of available evidence pertaining to preoperative assessment and shared decision-making for patients undergoing cardiac surgery and recommend a thorough preoperative workup in this vulnerable population.

Transesophageal echocardiography complications associated with interventional cardiology procedures

BACKGROUND

Although there have been several reports documenting complications related with transesophageal echocardiography (TEE) manipulation following cardiac surgery, there is a paucity of data regarding the safety of TEE used to guide catheter-based interventions. The aim of this study was to determine the prevalence, types and risk factors of complications associated with procedures requiring active TEE guidance.

METHODS

This study included 1249 consecutive patients undergoing either transcatheter aortic valve implantation (TAVI), Mitraclip, left atrial appendage occlusion (LAAO) or paravalvular leak closure (PVLC). Patients were divided into 2 cohorts based on the degree of probe manipulation required to guide the procedure and the risk of developing a TEE-related complication: low-risk (TAVI, n = 1037) and high-risk (Mitraclip, LAAO and PVLC, n = 212). Patients were further analyzed according to the occurrence of major and minor TEE-related complications.

RESULTS

The overall incidence of TEE-related complications was 0.9% in the TAVI group and 6.1% in the rest of the cohort (P < .001). Patients in the high-risk cohort had also a higher incidence of major-complications (2.8% vs 0.6%, P = .008), and factors associated with an increased risk were being underweight, having a prior history of gastrointestinal bleeding and the use of chronic steroids/immunosuppressive medications. Procedural time under TEE-manipulation was longer in patients exhibiting complications and was an independent predictor of major complications (OR = 1.13, 95% CI 1.01-1.25, for each 10 minutes increments in imaging time). Patients with major complications undergoing Mitraclip had the longest median time under TEE-manipulation (297 minutes) and a risk of developing a major-complication that was 10.64 times higher than the rest of the cohort (95% CI 3.30-34.29, P < .001).

CONCLUSION

The prevalence of TEE-related complications associated with interventional procedures is higher than previously reported. Undergoing a prolonged procedure, particularly in the setting of Mitraclip, was the main factor linked to TEE-related complications.

Comprehensive Geriatric Assessment in Cardiovascular Disease

Frailty and cardiovascular disease (CVD) are both highly prevalent in older adults. Cardiovascular disease has been identified as the most frequent cause of death, while frailty has been identified as one of geriatric giants characterized by decreased physiological reserves and increased vulnerability. However, the exact pathobiological links between the two conditions have not been fully elucidated. Consequently, we observe a relevant difficulty not only in accurately defining cardiovascular risk in vulnerable elderly patients (and the other way around), but also a lack of consensus regarding CVD management in the very old. Nowadays, considering the enormous technical innovation, many elderly patients, if appropriately selected, could be eligible even for the most complex treatments, including invasive cardiological procedures. Identification of frail patients at risk of negative outcomes can allow the customization of therapeutic interventions in elderly patients with CVD, allowing the elderly who can benefit from them to undergo even invasive procedures and avoiding futile or dangerous treatments for the most vulnerable patients. A large number of tools and definitions for assessing frailty have been proposed; different scales and assessment tools can be useful for different purposes, but at present there is no clear indication for their use in CVD. In this chapter, we will describe the main geriatric approach to ascertain frailty, the assessment tools used in patients with cardiovascular diseases, and propose an operational strategy to evaluate frailty and identify patients eligible for pharmacologic or surgical interventions.

Frailty, disability and comorbidity: different domains lead to different effects after surgical aortic valve replacement in elderly patients

OBJECTIVES

Frailty syndrome predicts adverse outcomes after surgical aortic valve replacement. However, disability or comorbidity is frequently associated with preoperative frailty evaluation. The effects of these domains on early and late outcomes were analysed.

METHODS

A prospective study including patients aged ≥75 years with symptomatic severe aortic stenosis who received aortic valve replacement with or without coronary artery bypass grafting was conducted. We used the Cardiovascular Health Study Frailty Phenotype to assess frailty, the Lawton-Brody index to define disability and the Charlson comorbidity index (CCI) to evaluate comorbidity.

RESULTS

Frailty was identified in 57 (31%), dependence in 18 (9.9%) and advanced comorbidity (CCI ≥ 4) in 67 (36.6%) of the 183 enrolled patients. Operative mortality (1.6%), transfusion rate and duration of stay increased in patients with CCI ≥4 (P < 0.005). There was a non-significant trend for these adverse outcomes among the frail patients. Follow-up was achieved in all patients (median/interquartile range 869/699-1099 days). Kaplan-Meier univariable analysis showed a reduced survival rate for frail and dependent patients and for those with multiple comorbidities (P < 0.05). According to multivariable analysis, frailty and comorbidity were independent risk factors for 1-year mortality, while disability and comorbidity, but not frailty, were risk factors for 3-year mortality (P < 0.05).

CONCLUSIONS

Surgical aortic valve replacement in patients aged ≥75 years is a safe procedure with low mortality rates. Operative outcomes are mainly affected by comorbidities. The main influence of survival occurs throughout the first year, and an improved functional status prevents any progression towards disabilities, which could potentially benefit long-term outcomes.

CLINICAL TRIAL REGISTRATION NUMBER

NCT02745314.

Trunk Muscle Cross-Sectional Area as a Predictive Factor for Length of Postoperative Hospitalization after Surgical Aortic Valve Replacement

Purpose: We investigated the utility of trunk muscle cross-sectional area to predict length of hospitalization after surgical aortic valve replacement (AVR) for aortic stenosis (AS).

Methods: Adult AS patients who underwent isolated AVR at a single institution were studied. The cross-sectional area of the erector spinae muscles (ESM) at the first and second lumbar vertebrae and that of the psoas muscle (PM) at the third and fourth lumbar vertebrae were measured on preoperative computed tomography (CT). Each was indexed to body surface area. Risk factors for prolonged postoperative hospitalization (>3 weeks) were assessed using multivariate regression analyses.

Results: Of 56 patients (mean age 76 ± 9 years; 25 men), 20 (35.7%) patients required prolonged hospitalization. A smaller indexed ESM cross-sectional area at the first lumbar vertebra (per 1 cm/m², odds ratio [OR] = 0.71, 95% confidence interval [CI] = 0.57–0.88, P <0.01) and lower preoperative serum albumin level (per 0.1 g/dL, OR = 0.83, 95% CI = 0.70–0.99, P <0.05) were shown as independent predictors. Indexed PM cross- sectional area was not statistically significant.

Conclusion: The cross-sectional area of the trunk muscles can be used to identify patients at risk for prolonged hospitalization after AVR for adult AS.

Modified frailty index is predictive of wound complications in obese patients undergoing gynecologic surgery via a midline vertical incision

OBJECTIVES

There are limited methods to identify which obese patients will experience wound complications after undergoing gynecologic surgery. We sought to determine the association between frailty and postoperative wound complications and to develop a prediction model for wound complications in this patient population.

METHODS

We reviewed prospectively collected data of obese patients undergoing laparotomy though midline vertical incisions from 7/2013-3/2016. Modified frailty index (mFI) was calculated using 11 comorbidities previously validated. The primary outcome was the composite rate of postoperative wound complication. Data was analyzed using Fisher exact test or Chi-square and t-tests or Kruskal-Wallis tests. Poisson regression models were used to generate relative risks. Prediction models were created with receiver-operator characteristic curve analysis.

RESULTS

Of 163 patients included, 56 (34%) were considered frail. Wound complications occurred in 52 patients (31.9%): 28 (50%) frail and 24 (22.4%) non-frail patients (RR 2.23, 95%CI 1.29-3.85). Frail patients had significantly greater frequencies of wound breakdown (37.5% vs 15%, RR 2.51, 95%CI 1.31-4.81). After controlling for BMI, tobacco use, and maximum postoperative glucose, frailty remained an independent predictor of wound complication (aRR 1.88, 95%CI 1.04-3.40). The area under the curve for the predictive model incorporating frailty was 0.73 for wound complications.

CONCLUSION

Frailty is associated with wound complications in obese patients undergoing gynecologic surgery via a midline vertical incision and is a useful tool in identifying the most high risk patients. Further prospective research is necessary to incorporate mFI into preoperative planning and counseling.

Preoperative immunonutrition in frail patients with colorectal cancer: an intervention to improve postoperative outcomes

PURPOSE

The aim of this study is to evaluate whether preoperative immunonutrition can shorten length of stay and improve postoperative outcomes in frail patients who are candidates for major oncologic colorectal surgery.

METHODS

A single center retrospective analysis of a prospectively collected database of frail patients, who underwent surgery with curative intent for colorectal cancer between January 2014 and December 2017, was performed. From March 2016, frail oncological patients undergoing major surgery were recommended to receive preoperative immunonutrition; their postoperative outcomes were compared to those of patients not treated with any preoperative nutritional support. Propensity score matching in a 1:1 ratio was used to balance patient characteristics.

RESULTS

Overall, 175 patients were included in the study. Of 74 patients receiving immunonutrition, 65 were matched with the group not treated with immunonutrition (n = 101). Baseline characteristics were comparable after matching. Although differences in postoperative length of stay were nonsignificant (p = 0.38), patients who received immunonutrition showed a shorter gastrointestinal (GI) recovery time (3.00 [2.00-4.00] versus 4.00 [2.00-5.00], p = 0.04), a lower rate of situs site infections complications (0.31 [0.10, 0.94], p = 0.04) and less need of antibiotic treatment (0.19 [0.06, 0.64], p = 0.01).

CONCLUSION

Preoperative immunonutrition was found to reduce both postoperative situs site infections and need of antibiotic treatment during the postoperative course. This study encourages the use of preoperative immune-enhancing nutrition as a part of multimodal prehabilitation programs in the management of frail colorectal cancer patients.

Role of Frailty on Risk Stratification in Cardiac Surgery and Procedures

The number of older people candidates for interventional cardiology, such as PCI but especially for transcatheter aortic valve implantation (TAVI) , would increase in the future. Generically, the surgical risk, the amount of complications in the perioperative period, mortality and severe disability remain significantly higher in the elderly than in younger. For this reason it's important to determine the indication for surgical intervention, using tools able to predict not only the classics outcome (length of stay, mortality), but also those more specifically geriatrics, correlate to frailty: delirium, cognitive deterioration, risk of institutionalization and decline in functional status. The majority of the most used surgical risks scores are often specialist-oriented and many variables are not considered. The need of a multidimensional diagnostic process, focused on detect frailty, in order to program a coordinated and integrated plan for treatment and long term follow up, led to the development of a specific geriatric tool: the Comprehensive Geriatric Assessment (CGA). The CGA has the aim to improve the prognostic ability of the current risk scores to capture short long term mortality and disability, and helping to resolve a crucial issue providing solid clinical indications to help physician in the definition of on interventional approach as futile. This tool will likely optimize the selection of TAVI older candidates could have the maximal benefit from the procedure.

Association Between Number of Teeth, Denture Use and Frailty: Findings from the West China Health and Aging Trend Study

OBJECTIVE

Frailty and poor oral health are both common age-related conditions. However, the association between oral health and frailty has not been explored thoroughly among older Chinese adults. We aimed to investigate the associations between number of teeth, denture use, and frailty among older adults in western China.

DESIGN

Cross-sectional study.

SETTING

Community-based.

PARTICIPANTS

Participants were 4037 community-dwelling individuals aged 60 and older from the West China Health and Aging Trend (WCHAT) study.

MEASUREMENTS

Frailty was assessed using the physical frailty phenotype (PFP) and categorized as non-frail, prefrail and frail. In addition, number of teeth and denture use were examined by calibrated dentists. Multinomial logistic regression models were performed to examine the association between number of teeth, denture use, and frailty.

RESULTS

The overall prevalence of frailty was 6.7% among 4037 participants aged 60 and older in western China. Participants with no more than 20 teeth were associated with higher odds of being prefrail or frail whether wearing dentures or not. Denture using could not help lower the odds of being prefrail or frail for older adults with fewer teeth.

CONCLUSIONS

This study suggested that frailty was associated with having fewer teeth (≤20 teeth) among older Chinese adults. Future research involving targeted interventions addressing number of teeth may help provide information to establish effective strategies for frailty prevention in older adults.

Oxidative Stress, Frailty and Cardiovascular Diseases: Current Evidence

The aim of this chapter is to review the results of recent studies analyzing the role of oxidative stress and systemic inflammation as potential contributors to frailty and CVD, and to explain a possible pathogenic relationship between the latter two conditions. Available evidence suggests that frail patients have elevated levels of oxidative stress biomarkers and proinflammatory cytokines, as well as with reduced concentrations of endogenous antioxidants. This implies that oxidative stress and systemic inflammation might play a role in the pathogenesis of frailty, but an underlying mechanism of this relationship is still mostly hypothetical. Oxidative stress and systemic inflammation are also involved in the pathogenesis of CVD. Cardiovascular conditions are established risk factor for frailty and in turn, presence of frailty constitutes an unfavorable prognostic factor in cardiac patients. Finally, some cardiovascular risk factors, such as lack of physical activity, smoking, obesity and inappropriate diet, are also involved in the etiology of oxidative stress, chronic inflammation and frailty. This complex interplay between intrinsic and extrinsic elements should be considered during holistic management of older persons with frailty and/or cardiovascular conditions.

Asymptomatic aortic stenosis in a geriatric population. The role of frailty and comorbidity in mortality

INTRODUCTION AND OBJECTIVES

The prognosis of asymptomatic severe aortic stenosis (AS) has not been widely documented in elderly patients who are frequently frail and have comorbidities. We sought to analyze the factors that influence early mortality in geriatric patients with asymptomatic severe AS.

METHODS

This ambispective cohort study included 104 patients aged 70 years or older with asymptomatic severe AS. Epidemiological, geriatric, clinical and echocardiographic variables were collected and compared between frail and nonfrail patients. During follow-up, the time from diagnosis to mortality and the causes of death were recorded.

RESULTS

Overall, 59.6% of the patients were frail. During follow-up, 69.4% of the frail patients died, with a median time to mortality of 2.52 years (95%CI, 1.36-3.69). The overall 1-year survival rate in frail patients was 76%. On multivariate analysis, age (HR, 2.47; 95%CI, 1.00-6.12), a Charlson comorbidity index ≥ 5 (HR, 3.75; 95%CI, 1.47-9.52) and frailty (HR, 6.67; 95%CI, 1.43-9.52) were independently related to mortality. In total, 8.7% of the patients had a Charlson comorbidity index ≥ 5, and all these patients died during follow-up, with a median survival of 1.01 years (95%CI, 0.36-1.67). The area under the receiver operating characteristic curve of the Charlson index was 0.739 (95%CI, 0.646-0.832). In this population, values ≥ 5 showed high specificity (100%) but low sensitivity.

CONCLUSIONS

A high prevalence of frailty was present in geriatric patients with asymptomatic severe AS. Age, a Charlson index ≥ 5 and frailty were independent factors for mortality, conferring an unfavorable short-term prognosis.

Frailty in Older Patients with Acute Coronary Syndrome in Vietnam

Background

There has been limited evidence about frailty in older patients with acute coronary syndrome (ACS) in Vietnam.

Aim

(1) To investigate the prevalence of frailty in older patients hospitalised with ACS and its associated factors; (2) To investigate the impact of frailty on percutaneous coronary intervention (PCI) and adverse outcomes in this population.

Methods

Patients aged ≥60 with ACS admitted to two teaching hospitals in Vietnam were recruited from 9/2017 to 4/2018. Frailty was defined by the Reported Edmonton Frail Scale. Multivariate logistic regression was applied to investigate the associated factors of frailty and the impact of frailty on PCI and adverse outcomes.

Results

There were 324 participants, mean age 73.5±8.3, 39.2% female. The prevalence of frailty was 48.1%. Advanced age, female gender, history of hypertension, heart failure, stroke and chronic kidney disease were significantly associated with a frailty status. Overall, 50.3% of the participants received PCI (58.3% in the non-frail vs 41.7% in the frail, p=0.003). However, frailty did not have an independent impact on PCI (adjusted OR 0.66, 95% CI 0.41–1.08). Frailty was significantly associated with increased risk of having arrhythmia during hospitalisation (adjusted OR 2.24, 95% CI 1.32–3.80), hospital-acquired pneumonia (adjusted OR 2.27, 95% CI 1.24–4.17), in-hospital mortality (adjusted OR 3.02, 95% CI 1.35–6.75), 30-day mortality (adjusted OR 3.28, 95% CI 1.59–6.76), and 30-day readmission (adjusted OR 2.53, 95% CI 1.38–4.63).

Conclusion

In this study, frailty was present in nearly half of older patients with ACS and was associated with increased adverse outcomes. These findings suggest that frailty screening should be performed in older patients with ACS in Vietnam.

Routine frailty assessment predicts postoperative complications in elderly patients across surgical disciplines - a retrospective observational study

BACKGROUND

Frailty is a frequent and underdiagnosed functional syndrome involving reduced physiological reserves and an increased vulnerability against stressors, with severe individual and socioeconomic consequences. A routine frailty assessment was implemented at our preoperative anaesthesia clinic to identify patients at risk.

OBJECTIVE

This study examines the relationship between frailty status and the incidence of in-hospital postoperative complications in elderly surgical patients across several surgical disciplines.

DESIGN

Retrospective observational analysis.

SETTING

Single center, major tertiary care university hospital. Data collection took place between June 2016 and March 2017.

PATIENTS

Patients 65 years old or older were evaluated for frailty using Fried's 5-point frailty assessment prior to elective non-cardiac surgery. Patients were classified into non-frail (0 criteria, reference group), pre-frail (1-2 positive criteria) and frail (3-5 positive criteria) groups.

MAIN OUTCOME MEASURES

The incidence of postoperative complications was assessed until discharge from the hospital, using the roster from the National VA Surgical Quality Improvement Program. Propensity score matching and logistic regression analysis were performed.

RESULTS

From 1186 elderly patients, 46.9% were classified as pre-frail (n = 556), and 11.4% as frail (n = 135). The rate of complications were significantly higher in the pre-frail (34.7%) and frail groups (47.4%), as compared to the non-frail group (27.5%). Similarly, length of stay (non-frail: 5.0 [3.0;7.0], pre-frail: 7.0 [3.0;9.0], frail 8.0 [4.5;12.0]; p < 0.001) and discharges to care facilities (non-frail:1.6%, pre-frail: 7.4%, frail: 17.8%); p < 0.001) were significantly associated with frailty status. After propensity score matching and logistic regression analysis, the risk for developing postoperative complications was approximately two-fold for pre-frail (OR 1.78; 95% CI 1.04-3.05) and frail (OR 2.08; 95% CI 1.21-3.60) patients.

CONCLUSIONS

The preoperative frailty assessment of elderly patients identified pre-frail and frail subgroups to have the highest rate of postoperative complications, regardless of age, surgical discipline, and surgical risk. Significantly increased length of hospitalisation and discharges to care facilities were also observed. Implementation of routine frailty assessments appear to be an effective tool in identifying patients with increased risk. Now future studies are needed to investigate whether patients benefit from optimization of patient counselling, process planning, and risk reduction protocols based on the application of risk stratification.

Acute kidney injury is independently associated with mortality and resource use after emergency general surgery operations

INTRODUCTION

The incidence of severe perioperative renal dysfunction in high-acuity patients has not been well-explored at the national level. The present study aimed to evaluate the trends in the incidence of perioperative acute kidney injury and renal replacement therapy as well as associated mortality among patients undergoing an emergency general surgery operation.

METHODS

This was a retrospective cohort study using the National Inpatient Sample to identify all adult patients (>18 y) without chronic kidney disease who underwent an emergency general surgery procedure from 2008 to 2016. The study cohort was stratified based on presence of acute kidney injury and need for renal replacement therapy postoperatively. A multivariable logistic regression model was developed to predict the odds of mortality and composite morbidity. Nonparametric trend analyses of acute kidney injury and renal replacement therapy incidence and associated mortality were performed.

RESULTS

Of an estimated 5,862,657 patients who underwent an emergency general surgery procedure during the study period, 7.4% patients developed an acute kidney injury and 0.48% patients required renal replacement therapy. Overall, the incidence of acute kidney injury (5.3%-19.4%) and renal replacement therapy (0.43%-0.93%) increased (P < .0001) over the study period. Even without need for renal replacement therapy, acute kidney injury was associated with greater odds of mortality and composite morbidity (adjusted odds ratio 5.2, 95% confidence interval [CI] 5.1-5.3) and mortality (adjusted odds ratio = 2.20, 95% CI 2.3-2.4), as well as greater costs of hospitalization and duration of stay.

CONCLUSION

In this national study, we found that the incidence of acute kidney injury and renal replacement therapy after an emergency general surgery operation has increased. Both acute renal failure and hemodialysis were associated with much greater odds of morbidity and mortality. The apparent increase in the rate of acute kidney injury and renal replacement therapy warrant further investigation of mechanisms for monitoring and limiting the impact of organ malperfusion associated with emergency general surgery operations.

Ischemia and reperfusion injury following cardioplegic arrest is attenuated by age and testosterone deficiency in male but not female mice

BACKGROUND

Cardiovascular disease increases with age in both sexes. Treatment can require cardiac surgery, where the hearts are pre-treated with protective cardioplegic solution before ischemia and reperfusion (I/R). While endogenous estrogen is beneficial in I/R, whether testosterone is involved is uncertain and whether age modifies responses to I/R is unclear. We investigated sex- and age-specific differences in I/R injury in the hearts pre-treated with clinically relevant cardioplegic solution.

METHODS

The hearts were isolated from young (6-9 months) and old (20-28 months) mice of both sexes and perfused (Langendorff) with Krebs-Henseleit buffer (15 min, 37 °C), followed by St. Thomas' two cardioplegia (6 min, 6-7 °C), global ischemia (90 min, 23-24 °C), and reperfusion (30 min, 37 °C). The hearts were perfused with triphenyltetrazolium chloride to quantify infarct area. Testosterone's role was investigated in gonadectomized (GDX, 6-9 months) male mice; serum testosterone and estradiol were measured with ELISA assays.

RESULTS

Left ventricular developed pressure (LVDP) recovered to 67.3 ± 7.4% in the old compared to 21.8 ± 9.2% in the young male hearts (p < 0.05). Similar results were seen for rates of pressure development (+dP/dt) and decay (-dP/dt). Infarct areas were smaller in the old male hearts (16.6 ± 1.6%) than in the younger hearts (55.8 ± 1.2%, p < 0.05). By contrast, the hearts from young and old females exhibited a similar post-ischemic functional recovery and no age-dependent difference in infarcts. There was a sex difference in the young group, where ventricular function (LVDP, +dP/dt, -dP/dt) recovered better and infarcts were smaller in females than males. Estradiol levels were highest in young females. Testosterone was high in young males but low in females and old males, which suggested beneficial effects of low testosterone. Indeed, the hearts from GDX males exhibited much better recovery of LVDP in reperfusion than that from intact males (values were 64.4 ± 7.5 % vs. 21.8 ± 9.2%; p < 0.05). The GDX hearts also had smaller infarcts than the hearts from intact males (p < 0.05).

CONCLUSIONS

Although age had no effect on susceptibility to I/R injury after cardioplegic arrest in females, it actually protected against injury in older males. Our findings indicate that low testosterone may be protective against I/R injury following cardioplegic arrest in older males.

Frailty Phenotypes and Relations With Surgical Outcomes: A Latent Class Analysis

BACKGROUND

Frailty is an important concept in the care of older adults although controversy remains regarding its defining features and clinical utility. Both the Fried phenotype and the Rockwood deficit accumulation approaches cast frailty as a "burden" without exploring the relative salience of its cardinal markers and their relevance to the patient. New multifactorial perspectives require a reliable assessment of frailty that can validly predict postoperative health outcomes.

METHODS

In a retrospective study of 2828 unselected surgical patients, we used item response theory to examine the ability of 32 heterogeneous markers capturing limitations in physical, functional, emotional, and social activity domains to indicate severity of frailty as a latent continuum. Eighteen markers efficiently indicated frailty severity and were then subject to latent class analysis to derive discrete phenotypes. Next, we validated the obtained frailty phenotypes against patient-reported 30-day postoperative outcomes using multivariable logistic regression. Models were adjusted for demographics, comorbidity, type and duration of surgery, and cigarette and alcohol consumption.

RESULTS

The 18 markers provided psychometric evidence of a single reliable continuum of frailty severity. Latent class analyses produced 3 distinct subtypes, based on patients' endorsement probabilities of the frailty indicators: not frail (49.7%), moderately frail (33.5%), and severely frail (16.7%). Unlike the moderate class, severely frail endorsed emotional health problems in addition to physical burdens and functional limitations. Models adjusting for age, sex, type of anesthesia, and intraoperative factors indicated that severely frail (odds ratio, 1.89; 95% confidence interval, 1.42-2.50) and moderately frail patients (odds ratio, 1.31; 95% confidence interval, 1.03-1.67) both had higher odds of experiencing postoperative complications compared to not frail patients. In a 3-way comparison, a higher proportion of severely frail patients (10.7%) reported poorer quality of life after surgery compared to moderately frail (9.2%) and not frail (8.3%) patients (P < .001). There was no significant difference among these groups in proportions reporting hospital readmission (5.6%, 5.1%, and 3.8%, respectively; P = .067).

CONCLUSIONS

Self-report frailty items can accurately discern 3 distinct phenotypes differing in composition and their relations with surgical outcomes. Systematically assessing a wider set of domains including limitations in functional, emotional, and social activities can inform clinicians on what precipitates loss of physiological reserve and profoundly influences patients' lives. This information can help guide the current discussion on frailty and add meaningful clinical tools to the surgical practice.

Outcomes and Predictors of Mortality in Hospitalized Frail Patients Undergoing Percutaneous Coronary Intervention

Objective To study the impact of frailty on inpatient outcomes among patients undergoing percutaneous coronary intervention (PCI). Methods The National Inpatient Sample data of all PCI-related hospitalizations throughout the United States (US) from 2010 through 2014 was utilized. Patients were divided into two groups: frailty and no-frailty. International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) codes were used to stratify groups and outcomes. In order to address the substantial difference in the total number of valid observations between the two groups, a propensity-matched analysis was performed at a 1:1 ratio and caliper width of 0.01. Results A total of 2,612,661 PCI-related hospitalizations throughout the US from 2010 through 2014 were identified, out of which 16,517 admissions (0.6%) had coexisting frailty. Only 1:1 propensity-matched data was utilized for the study. Propensity-matched frailty group (n=14,717) as compared to no-frailty (n=14,755) was frequently older, white, and Medicare enrollee (p<0.05). The frailty group had significantly higher rates of comorbidities and complications (p<0.05). All-cause in-hospital mortality was higher in the no-frailty group (p<0.05). Age, white race, non-elective admission, urban hospitals, and comorbidities predicted in-hospital mortality in frailty group (p<0.05). Rheumatoid arthritis, depression, hypertension, obesity, dyslipidemia, and history of previous PCI decreased odds of in-hospital mortality in frailty group (p<0.05). Frailty group had prolonged hospital stay and higher hospital charges (p<0.05). Conclusions Frailty has a significant effect on PCI-related outcomes. We present a previously unknown protective effect of cardiovascular disease risk factors and other health risk factors on frail patients undergoing PCI. Frailty's inclusion in risk stratification will help in predicting the post-procedure complications and improve resource utilization.

30-day mortality in frail patients undergoing cardiac surgery: the results of the frailty in cardiac surgery (FICS) copenhagen study

Objectives. Typically, patients referred to cardiac surgery are aged. Because EuroSCORE tend to overestimate and STS tend to underestimate the risk of mortality after cardiac surgery, frailty has become interesting as a potential predictor for mortality after cardiac surgery. Therefore, we conducted a study to identify the number of frail patients undergoing cardiac surgery and describe the risk of short-term complications and mortality. Design. In a prospective observational study, we have compared the surgical outcome in frail versus non-frail patients. Patients aged > 65 years and undergoing non-acute cardiac surgery were included. Frailty was assessed using the comprehensive assessment of frailty (CAF) score. The CAF evaluates the patient's physical condition through performing physical tests. Results. 604 patients included, 477 were men and the median age was 73 years (range, 65-90). Twenty-five percent were deemed frail. Frail patients had a four times higher 30-day mortality. Furthermore, frail patients had higher postoperative complication rates of atrial fibrillation, prolonged ventilation, re-operations, renal failure, transfusion requirements, and increased length of stay. Patients who died within 30 days had a significantly higher CAF score than those who survived (p = .039). Based on ROC curves, the area under the curve (AUC) for CAF score was 0.700, EuroSCORE 0.664 and STS score 0.748. Conclusion. Frailty is common in patients undergoing cardiac surgery and carries increased risk of 30-day mortality and postoperative complications. The AUC indicates similar prediction of mortality for CAF score compared to the existing risk scores. Clinical Trials Registration ID: NCT02992587.

Effects of β-hydroxy-β-methylbutyrate (HMB) supplementation in addition to multicomponent exercise in adults older than 70 years living in nursing homes, a cluster randomized placebo-controlled trial: the HEAL study protocol

Background

Evidence supports the fact that multicomponent exercise and HMB supplementation are, separately, effective in improving older adult’s health and palliate functional metabolic diseases in older people. However, the true effect of HMB supplementation combined with a tailored exercise program in frail older adults is still unknown. Thus, the aim of the HEAL (HMB + Exercise = Adults Living longer) study is to assess the effects of the combination of a daily multicomponent exercise and resistance training (VIVIFRAIL program) intervention in addition to HMB supplementation on older adults’ health.

Methods/design

A 24-week cluster randomized, double-blind, placebo-controlled study will be conducted on 104 adults ≥70 years. Nursing homes will be randomized to either of four groups: Ex-HMB (exercise intervention with HMB), Ex-Plac (exercise intervention with placebo), NoEx-HMB (no exercise intervention with HMB), and Controls (No exercise and no HMB). Intervention groups which include exercise will complete the individualized multicomponent (strength, balance and cardiovascular exercises) training program VIVIFRAIL. Intervention groups which include HMB supplementation will receive a 3 g/daily dose of free acid HMB in powder form. The primary outcome measure is the functional capacity. Secondary outcome measures are muscle strength and power, frailty and fall risk, body composition, biochemical analyses and cardiometabolic risk factor, disability and comorbidity, cognitive function and depression.

Discussion

The findings of the HEAL study will help professionals from public health systems to identify cost-effective and innovative actions to improve older people’s health and quality of life, and endorse exercise practice in older adults and people living in nursing homes.

Trial registration

NCT03827499; Date of registration: 01/02/2019.

Rehospitalization and resource use after inpatient admission for extracorporeal life support in the United States

BACKGROUND

With increasing dissemination and improved survival after extracorporeal life support, also called extracorporeal membrane oxygenation, the decrease in readmissions after hospitalization involving extracorporeal life support is an emerging priority. The present study aimed to identify predictors of early readmission after extracorporeal life support at a national level.

METHODS

This was a retrospective cohort study using the Nationwide Readmissions Database. All patients ≥18 years who underwent extracorporeal life support from 2010 to 2015 were identified. Patients were stratified into the following categories of extracorporeal life support: postcardiotomy, primary cardiogenic shock, cardiopulmonary failure, respiratory failure, transplantation, and miscellaneous. The primary outcome of the study was the rate of 90-day rehospitalization after extracorporeal life support admission. A multivariable logistic regression model was developed to predict the odds of unplanned 90-day readmission. Kaplan-Meier analyses were also performed.

RESULTS

An estimated 18,748 patients received extracorporeal life support with overall mortality of 50.2%. Of the patients who survived hospitalization, 30.2% were discharged to a skilled nursing facility, and 21.1% were readmitted within 90 days after discharge. After adjusting for patient and hospital characteristics, cardiogenic shock was associated with the greatest odds of mortality (adjusted odds ratio 1.6; 95% confidence interval, 1.09-1.46; C-statistic, 0.64). The cohort with respiratory failure had decreased odds of readmission (adjusted odds ratio 0.76; 95% confidence interval, 0.58-0.99). Discharge to skilled nursing facility (adjusted odds ratio 1.64; 95% confidence interval, 1.36-1.97) was independently associated with readmission. Cardiac and respiratory-related readmissions comprised the majority of unplanned 90-day rehospitalizations.

CONCLUSION

In this large analysis of readmissions after extracorporeal life support in adults, 21% of extracorporeal life support survivors were rehospitalized within 90 days of discharge. Disposition to a skilled nursing facility, but not advanced age nor female sex, was associated with readmission.

Activities of daily living among elderly persons with severe aortic stenosis

PURPOSE

To determine the level of limitations in activities of daily living (ADL) and instrumental ADL, and identify related factors to instrumental ADL among elderly persons with severe aortic stenosis (AS).

MATERIALS AND METHODS

We prospectively enrolled 112 consecutive elderly persons (mean age, 84.6 ± 4.4 y) with severe AS. We assessed ADL and instrumental ADL using the Barthel index (BI) and the Frenchay activities index (FAI), respectively. Cardiac, physical, cognitive and kidney functions, nutritional status, medical histories, and comorbidities were assessed. A multiple logistic analysis was developed to explore related factors to the FAI.

RESULTS

The medians (ranges) of BI and FAI were 100 (15-100) and 21 (0-38), respectively. The multiple logistic analysis revealed that a history of heart failure (sβ = -0.189), a history of cerebrovascular disease (sβ = -0.233), the short physical performance battery score ≤ 8 (sβ = -0.272), the mini-mental state examination score ≤ 23 (sβ = -0.168) were significantly related to the FAI (p < 0.05).

CONCLUSIONS

Physical frailty, a history of heart failure, cerebrovascular disease, and cognitive decline were independently related to declined instrumental ADL. IMPLICATIONS FOR REHABILIATION Activities of daily living was well-preserved among elderly persons with severe aortic stenosis. Instrumental activities of daily living varied among patients with aortic stenosis and was sometimes impaired. Physical frailty, a history of heart failure, and a history of cerebrovascular disease were independently associated with instrumental activities of daily living in elderly persons with severe aortic stenosis.

Survival of elderly outpatients: effects of frailty, multimorbidity and disability

This study aims to analyze the impact of frailty, multimorbidity and disability on the survival of elderly people attended in a geriatric outpatient facility, and identify the clinical risk factors associated with death. It is a longitudinal study, with 133 elderly people initially evaluated in relation to frailty, multimorbidity (simultaneous presence of three or more chronic diseases) and disability in Daily Life Activities. The Kaplan Meier method was used to analyze survival time, and the Cox regression was used for association of the clinical factors with death. In follow-up over six years, 21.2% of the participants died, survival being lowest among those who were fragile (p < 0.05). The variables frailty (HR = 2.26; CI95%: 1.03-4.93) and Chronic Renal Insufficiency (HR = 3.00; CI95%: 1.20-7.47) were the factors of highest risk for death in the multivariate analysis. Frailty had a negative effect on the survival of these patients, but no statistically significant association was found in relation to multimorbidity or disability. Tracking of vulnerabilities in the outpatient geriatric service is important, due to the significant number of elderly people with geriatric syndromes that use this type of service, and the taking of decisions on directions for care of these individuals.

Frailty Syndrome and the Use of Frailty Indices as a Preoperative Risk Stratification Tool in Spine Surgery: A Review

This comprehensive narrative literature review aims to extract studies related to frailty indices and their use in elective spine procedures, as limited studies regarding frailty exist in the spine literature. Most studies are retrospective analyses of prospectively collected databases. Evidence suggests a positive correlation between frailty level and mortality rate, postoperative complication rate, length of stay, and the possibility of discharge to a skilled nursing facility; these correlations have been illustrated across various spine procedures. The leading index is the modified frailty index, which measures 11 deficits. The development of more comprehensive frailty indices, such as the Adult Spinal Deformity Frailty Index, are promising and have high predictive value regarding postoperative complication rate in patients with spinal deformity. However, a frailty index that combines clinical, radiographic, and laboratory measures awaits development. Perhaps, the use of a frailty index in preoperative risk stratification for elective spine procedures could serve multiple purposes, including screening for high-risk patients, enhancement of operative decision making, approximation of complication rate for informed decision making, and refinement of perioperative care. Further prospective studies are warranted to determine clinically meaningful interventions in frail individuals.

Association of Preoperative Frailty With Intraoperative Hemodynamic Instability and Postoperative Mortality

BACKGROUND

Frailty, a state of decreased physiological reserve, is strongly associated with perioperative mortality in older adults. However, the mechanism by which frailty is associated with mortality is not yet understood. Autonomic dysfunction in the form of decreased intraoperative hemodynamic variability has been shown to be associated with increased mortality. We aimed to see whether frail patients have less hemodynamic variability under anesthesia and whether variability mediates the relationship between frailty and 30-day mortality.

METHODS

We performed a single-center retrospective study of 1223 patients ≥65 years of age undergoing surgery between July 2008 and December 2012. We used markers of frailty: age >70, preoperative body mass index <18.5, hematocrit <35%, albumin <3.4 g/dL, and creatinine >2.0 mg/dL. We modeled the outcome of 30-day mortality with number of frailty conditions adjusting for gender, length of surgery, American Society of Anesthesiologists class, and need for transfusion. Intraoperative hemodynamic variability was defined as the count of episodes of absolute change >15% in fractional mean arterial pressure (MAP) between consecutive 5-minute intervals. We evaluated the role of intraoperative hemodynamic variability as a mediator (modifier) of the relationship between frailty and mortality, checking for 3 conditions: (1) frailty must affect episodes of absolute change >15% in fractional MAP; (2) episodes of absolute change >15% in fractional MAP must affect 30-day mortality; and (3) mediation effect is significant. We used the product method, in which the mediation effect was estimated as the product of the first 2 relationships. Then we applied the percentile bootstrap method to obtain the 95% CI for the estimate of mediation effect.

RESULTS

Number of frailty conditions and episodes of absolute change >15% in fractional MAP were inversely proportional. Presence of ≥4 frailty conditions was associated with >40% reduction of the number of episodes of absolute change >15% in fractional MAP. Regarding mortality, episodes of absolute change >15% in fractional MAP were protective. The addition of absolute change >15% in fractional MAP in the mortality model resulted in a decrease in the frailty odds ratio from 10.6 to 9.1 (4+ conditions), suggesting that episodes of absolute change >15% in fractional MAP are indeed a mediator. The mediation effect was modest; 5 episodes of absolute change >15% in fractional MAP was 5.2%, 6.4%, 6.9%, and 9.0% for frailty conditions from 1 to 4+, respectively.

CONCLUSIONS

Frailty is associated with less intraoperative blood pressure variation, and the relationship of frailty with 30-day mortality is partially mediated by episodes of absolute change >15% in fractional MAP. This suggests that autonomic dysregulation may be a modest part of the mechanism behind the association between frailty and perioperative mortality. Our finding is consistent with recent literature, suggesting that an intact autonomic nervous system confers lower perioperative mortality.

Impact of frailty on outcomes after discharge in older surgical patients: a prospective cohort study

BACKGROUND

Frailty is a state of vulnerability to diverse stressors. We assessed the impact of frailty on outcomes after discharge in older surgical patients.

METHODS

We prospectively followed patients 65 years of age or older who underwent emergency abdominal surgery at either of 2 tertiary care centres and who needed assistance with fewer than 3 activities of daily living. Preadmission frailty was defined according to the Canadian Study of Health and Aging Clinical Frailty Scale as "well" (score 1 or 2), "vulnerable" (score 3 or 4) or "frail" (score 5 or 6). We assessed composite end points of 30-day and 6-month all-cause readmission or death by multivariable logistic regression.

RESULTS

Of 308 patients (median age 75 [range 65-94] yr, median Clinical Frailty Score 3 [range 1-6]), 168 (54.5%) were classified as vulnerable and 68 (22.1%) as frail. Ten (4.2%) of those classified as vulnerable or frail received a geriatric consultation. At 30 days after discharge, the proportions of patients who were readmitted or had died were greater among vulnerable patients (n = 27 [16.1%]; adjusted odds ratio [OR] 4.60, 95% confidence interval [CI] 1.29-16.45) and frail patients (n = 12 [17.6%]; adjusted OR 4.51, 95% CI 1.13-17.94) than among patients who were well (n = 3 [4.2%]). By 6 months, the degree of frailty independently and dose-dependently predicted readmission or death: 56 (33.3%) of the vulnerable patients (adjusted OR 2.15, 95% CI 1.01-4.55) and 37 (54.4%) of the frail patients (adjusted OR 3.27, 95% CI 1.32-8.12) were readmitted or had died, compared with 11 (15.3%) of the patients who were well.

INTERPRETATION

Vulnerability and frailty were prevalent in older patients undergoing surgery and unlikely to trigger specialized geriatric assessment, yet remained independently associated with greater risk of readmission for as long as 6 months after discharge. Therefore, the degree of frailty has important prognostic value for readmission.

TRIAL REGISTRATION FOR PRIMARY STUDY

ClinicalTrials.gov, no. NCT02233153.