The impact of frailty in the elderly on the outcome of surgery in the aged

Understanding frailty: a qualitative study of older heart failure patients' frail experience and perceptions of healthcare professionals with frailty

BACKGROUND

Although frailty is highly prevalent in hospitalized older heart failure (HF) patients, its management is often delayed. Understanding the unique experiences of frail elderly HF patients and the perceptions of healthcare professionals (HPs) regarding frailty can facilitate the integration of frailty prevention and intervention into clinical practice. This study aimed to use a descriptive qualitative approach to obtain the experiences of frailty in older HF patients and the perceptions of HPs concerning frailty.

METHODS

Qualitative interviews were conducted with 16 frail elderly HF patients and 13 healthcare providers. Data were analyzed using thematic analysis.

RESULTS

The interviews yielded several themes with associated subthemes: "a state of predicament," "hope is gone and social isolation," "daily adjustment and attempts to do something," "thoughts on factors contributing to frailty," "the need for transformation of stakeholders' mindset regarding frailty," "management is imperative, but there is still a way to go".

CONCLUSIONS

Both elderly patients with HF and HPs described frailty as a state of predicament, involving being caught in life difficulties and falling into a treatment dilemma. Due to the overlap of symptoms and evaluating indicators between frailty and HF, it's essential to thoroughly understand modifiable risk factors that could worsen frailty and develop a specific frailty assessment tool for HF patients. Adequate social support, multidisciplinary collaboration, and a frailty education program for patients, caregivers, and HPs are essential to facilitate frailty management and improvement.

Frailty-aware care: giving value to frailty assessment across different healthcare settings

Healthcare systems need to adapt to better serve an aging population with complex presentations. Frailty assessments are a potential means to address this heterogeneity in aging to identify individuals at increased risk for adverse health outcomes. Furthermore, frailty assessments offer an opportunity to optimize patient care in various healthcare settings. While the vast number of frailty assessment tools available can be a source of confusion for clinicians, each tool has features adaptable to the constraints and goals of different healthcare settings. This review discusses and compares barriers, facilitators, and the application of frailty assessments in primary care, the emergency department/intensive care unit and surgical care to cover a breadth of settings with different frailty assessment considerations. The implementation of frailty-aware care across healthcare settings potentiates better healthcare outcomes for older adults.

Changes in frailty after parathyroid and thyroid surgery

BACKGROUND

Frailty tools assess symptoms and comorbidities that may coincide with those of primary hyperparathyroidism. To test the hypothesis that parathyroidectomy improves frailty, we conducted a prospective cohort comparison of frailty after parathyroid or thyroid surgery.

METHODS

The Risk Analysis Index measuring frailty was prospectively administered to patients undergoing curative parathyroid exploration or total thyroidectomy. Risk Analysis Index results at the preoperative, postoperative, and last follow-up visits were assessed longitudinally.

RESULTS

Compared to total thyroidectomy patients (n = 142), parathyroid exploration patients (n = 187) were older (P = .001), more often male (P = .05) and had longer surgical follow-up (P < .001). Mean preoperative Risk Analysis Index scores were higher in parathyroid exploration patients (24 ± 9 vs total thyroidectomy 17 ± 8, P < .001). Parathyroid exploration patients demonstrated a significant decrease in Risk Analysis Index score from preoperative to last follow-up (P < .01); total thyroidectomy patients did not (P = .44). Parathyroid exploration patients were also less likely to exhibit a 20% increase in Risk Analysis Index over time, suggesting that parathyroidectomy slowed progression of frailty (2% vs 19%, P = .003).

CONCLUSION

In this prospective study of frailty using a validated assessment tool, Risk Analysis Index scores decreased after parathyroid exploration surgery. When compared to total thyroidectomy patients, parathyroid exploration patients were also less likely to suffer a clinically meaningful ≥20% increase in Risk Analysis Index scores after surgery, suggesting that parathyroid exploration patients better maintained baseline health at final follow-up.

The impact of frailty on patient-reported outcomes after elective thoracolumbar degenerative spine surgery

OBJECTIVE

Frailty has been shown to be a risk factor of perioperative adverse events (AEs) in patients undergoing various types of spine surgery. However, the relationship between frailty and patient-reported outcomes (PROs) remains unclear. The primary objective of this study was to determine the impact of frailty on PROs of patients who underwent surgery for thoracolumbar degenerative conditions. The secondary objective was to determine the associations among frailty, baseline PROs, and perioperative AEs.

METHODS

This was a retrospective study of a prospective cohort of patients older than 55 years who underwent surgery between 2012 and 2018. Data and PROs (collected with EQ-5D, Physical Component Summary [PCS] and Mental Component Summary [MCS] of SF-12, Oswestry Disability Index [ODI], and numeric rating scales [NRS] for back pain and leg pain) of patients treated at a single academic center were extracted from the Canadian Spine Outcomes and Research Network registry. Frailty was calculated using the modified frailty index (mFI), and patients were classified as frail, prefrail, and nonfrail. A generalized estimating equation (GEE) regression model was used to assess the association between baseline frailty status and PRO measures at 3 and 12 months.

RESULTS

In total, 293 patients with a mean ± SD age of 67 ± 7 years were included. Of these, 22% (n = 65) were frail, 59% (n = 172) were prefrail, and 19% (n = 56) were nonfrail. At baseline, the three frailty groups had similar PROs, except PCS (p = 0.003) and ODI (p = 0.02) were worse in the frail group. A greater proportion of frail patients experienced major AEs than nonfrail patients (p < 0.0001). However, despite the increased incidence of AEs, there was no association between frailty and postoperative PROs (scores on EQ-5D, PCS and MCS, ODI, and back-pain and leg-pain NRS) at 3 and 12 months (p ≥ 0.05). In general, PROs improved at 3 and 12 months (with most patients reaching the minimum clinically important difference for all PROs).

CONCLUSIONS

Although frailty predicted postoperative AEs, mFI did not predict PROs of patients older than 55 years with degenerative thoracolumbar spine after spine surgery.

The Emergency Surgery Frailty Index (EmSFI): development and internal validation of a novel simple bedside risk score for elderly patients undergoing emergency surgery

BACKGROUND

Frailty assessment has acquired an increasing importance in recent years and it has been demonstrated that this vulnerable profile predisposes elderly patients to a worse outcome after surgery. Therefore, it becomes paramount to perform an accurate stratification of surgical risk in elderly undergoing emergency surgery.

STUDY DESIGN

1024 patients older than 65 years who required urgent surgical procedures were prospectively recruited from 38 Italian centers participating to the multicentric FRAILESEL (Frailty and Emergency Surgery in the Elderly) study, between December 2016 and May 2017. A univariate analysis was carried out, with the purpose of developing a frailty index in emergency surgery called "EmSFI". Receiver operating characteristic curve analysis was then performed to test the accuracy of our predictive score.

RESULTS

784 elderly patients were consecutively enrolled, constituting the development set and results were validated considering further 240 consecutive patients undergoing colorectal surgical procedures. A logistic regression analysis was performed identifying different EmSFI risk classes. The model exhibited good accuracy as regard to mortality for both the development set (AUC = 0.731 [95% CI 0.654-0.772]; HL test χ² = 6.780; p = 0.238) and the validation set (AUC = 0.762 [95% CI 0.682-0.842]; HL test χ² = 7.238; p = 0.299). As concern morbidity, our model showed a moderate accuracy in the development group, whereas a poor discrimination ability was observed in the validation cohort.

CONCLUSIONS

The validated EmSFI represents a reliable and time-sparing tool, despite its discriminative value decreased regarding complications. Thus, further studies are needed to investigate specifically surgical settings, validating the EmSFI prognostic role in assessing the procedure-related morbidity risk.

Low Psoas Lumbar Vertebral Index Is Associated with Mortality after Hip Fracture Surgery in Elderly Patients: A Retrospective Analysis

The psoas-to-lumbar index (PLVI) has been reported as a simple and easy way to measure central sarcopenia. However, only few studies have evaluated the association between PLVI and survival in surgical patients. This study evaluated the association between preoperative PLVI and mortality in elderly patients who underwent hip fracture surgery. We retrospectively analyzed 615 patients who underwent hip fracture surgery between January 2014 and December 2018. The median value of each PLVI was calculated according to sex, and the patients were categorized into two groups on the basis of the median value (low PLVI group vs. high PLVI group). Cox regression analysis was performed to evaluate the risk factors for 1 year and overall mortalities. The median values of PLVI were 0.62 and 0.50 in men and women, respectively. In the Cox regression analysis, low PLVI was significantly associated with higher 1 year (hazard ratio (HR): 1.87, 95% confidence interval (CI): 1.18–2.96, p = 0.008) and overall mortalities (HR: 1.51, 95% CI: 1.12–2.03, p = 0.006). Low PLVI was significantly associated with a higher mortality. Therefore, PLVI might be an independent predictor of mortality in elderly patients undergoing hip fracture surgery.

Point-of-care ultrasound measures of muscle and frailty measures

PURPOSE

Frailty is defined as a syndrome of increased vulnerability due to both age and disease that leads to an inability to cope with acute stressors. There has been growing interest in the surgical and emergency medicine literature in the potential use of Point-of-Care ultrasonic (PoCUS) measures of muscle mass to assess frailty in older adults. Our study examined the association between a simple ultrasonic measure of muscle thickness (MT, vastus medialis muscle thickness) and commonly used frailty measures (Cardiovascular Health Study, CHS; Rockwood Clinical Frailty Scale, RCFS) in older adults.

METHODS

Participants were recruited sequentially from ambulatory geriatric medicine clinics in an academic medical centre (Vancouver General Hospital, Vancouver, Canada). Each subject had MT measured by PoCUS, as well as the CHS index and Rockwood Clinical Frailty Scale.

RESULTS

150 older adults (age ≥ 65; mean age 80.0 ± 0.5 years, 66 women, 84 men) were recruited. In our final parsimonious models, MT showed a weak inverse association with the CHS index (Standardized β = - 0.180 ± 0.080, R² = 0.06, p = 0.027) and no association with the RCFS (p = 0.776). Within the CHS index, most of the association was due to grip strength in men (Standardized β = - 0.326 ± 0.099, R² = 0.26, p = 0.001).

CONCLUSION

Frailty is a multifactorial syndrome, and caution must be used in trying to screen for this condition with a single ultrasonic measure. Further work might indicate associations with a more restricted syndrome, such as sarcopenia.

Deep flexor sarcopenia as a predictor of poor functional outcome after anterior cervical discectomy in patients with myelopathy

BACKGROUND

Paraspinal muscle morphometry has been recognized to be a prognostic factor across various surgical conditions, but its utility in predicting disease-specific outcomes in spine surgery remains under-explored.

METHODS

A prospective cohort study was performed on 45 consecutive patients undergoing anterior cervical discectomy (ACD) for single-level, symptomatic cervical degenerative disc disease causing radiculomyelopathy or myelopathy. Previously described predictors of outcome such as age, gender, smoking, comorbidities, duration of symptoms, preoperative Nurick grade, extent of cord compression, and signal intensity change in the cord were recorded. Additionally, MRI-based morphometrics of the superficial and deep paraspinal muscles were recorded. Logistic regression (LR) analysis was performed using a purposeful variable selection process to identify variables that independently predicted Nurick grade improvement (NGI).

RESULTS

At a mean follow-up of 20.02 ± 8.63 months after ACD, 37 (82.22%) patients demonstrated NGI. LR analysis yielded three predictors of NGI of which two were related to the deep flexor muscles. While a worse preoperative Nurick grade negatively predicted NGI, a deep flexor area and deep flexor/deep extensor area ratio positively predicted NGI. The regression model demonstrated a good fit and was statistically significant (χ²(3) = 22.18, p < 0.0001). The model explained 64% of the variance in NGI and correctly classified 89% of cases.

CONCLUSIONS

This study has for the first time identified the utility of paraspinal morphometrics in predicting disease-specific functional outcome after cervical spine surgery. Our results indicate that in addition to preoperative Nurick grade, an already accepted outcome predictor, the deep flexor cross-sectional area, and the deep flexor/deep extensor ratio are strong predictors of NGI following ACD for single-level, symptomatic cervical degenerative disc disease with myelopathy. Deep muscle morphometrics could be included in future risk stratification algorithms for patients with cervical disc disease.

A multicenter observational study on the distribution of orthopaedic fracture types across 17 low- and middle-income countries

Objectives:

To describe the regional distribution of fractures sustained by women and health care system characteristics across 17 low- and middle-income countries (LMICs).

Methods:

The INternational ORthopaedic MUlticentre Study in fracture care (INORMUS) is an observational study collecting data on patients in LMICs who sustained a fracture or musculoskeletal injury. As a planned analysis for the INORMUS study, we explored differences in fracture locations and demographics reported among 9878 female patients who sustained a fracture within 17 LMICs in 5 regions (China, Africa, India, Other Asia, and Latin America).

Results:

Half of our study population (49.6%) was ≥60 years of age. Across all regions, 58.3% of patients possessed health insurance. Latin America possessed the highest proportion (88.8%) of health insurance, while in Africa, patients possessed the lowest (18.0%). Falls from standing were the most prevalent mechanism of injury (51.7%) followed by falls from height (12.8%) and motorcycle-related road traffic injuries (9.7%). The majority of the fractures (65.6%) occurred in patients aged 50 and older. Hip fractures were the most common fracture (26.8%), followed by tibia/fibula (12.6%) and spine fractures (9.7%). Open fractures accounted for 7.6% of fractures and were most commonly tibia/fibula fractures (35.1%). Despite these severe injuries, less than one-third (28.8%) of patients were transported for care after sustaining a fracture by ambulance. Regionally, a majority of female patients in Africa were working age and suffered tibia/fibula (21.6%) and femur fractures (14.0%). Patients in the regional category Other Asia, suffered the highest frequencies of open fractures (9.6% low grade, 7.1% high grade), and disproportionately from motorcycle road traffic injuries (29.9%).

Conclusion:

Across all regions, the most significant source of fracture burden was in the elderly, and included common fragility fractures, such as hip fractures. Notable regional deviations in fracture distributions were observed within Africa, and Other Asia. Across all studied LMICs, ambulance usage was low, and health insurance coverage was particularly low in Africa and India.

Surgical need among the ageing population of Uganda

BACKGROUND

Uganda's ageing population (age 50 years and older) will nearly double from 2015 to 2050. HIV/AIDS, diabetes, stroke among other disease processes have been studied in the elderly population. However, the burden of disease from surgically-treatable conditions is unknown.

OBJECTIVES

To determine the proportion of adults above 50 years with unmet surgical need and deaths attributable to probable surgically-treatable conditions.

METHODS

A cluster randomized sample representing the national population of Uganda was enumerated. The previously validated Surgeons Overseas assessment of surgical need instrument, a head-to-toe verbal interview, was used to determine any surgically-treatable conditions in two randomly-selected living household members. Deaths were detailed by heads of households. Weighted metrics are calculated taking sampling design into consideration and Taylor series linearization was used for sampling error estimation.

RESULTS

The study enumerated 425 individuals above age 50 years. The prevalence proportion of unmet surgical need was 27.8% (95%CI, 22.1-34.3). This extrapolates to 694,722 (95%CI, 552,279-857,157) individuals living with one or more surgically treatable conditions. The North sub-region was observed to have the highest prevalence proportion. Nearly two out of five household deaths (37.9%) were attributed to probable surgically treatable causes.

CONCLUSION

There is disproportionately high need for surgical care among the ageing population of Uganda with approximately 700,000 consultations needed.

The impact of frailty and sarcopenia on postoperative outcomes in adult spine surgery. A systematic review of the literature

STUDY DESIGN

Systematic review.

OBJECTIVES

To identify currently used measures of frailty and sarcopenia in the adult spine surgery literature. To assess their ability to predict postoperative outcomes including mortality, morbidity, in-hospital length of stay (LOS), and discharge disposition. To determine which is the best clinical measure of frailty and sarcopenia in predicting outcome after spine surgery.

SUMMARY OF BACKGROUND DATA

Frailty and sarcopenia have been identified as predictors of mortality and adverse-events (AEs) in numerous nonsurgical and nonspine populations. This topic is an emerging area of interest and study in patients undergoing spinal surgery.

METHODS

A systematic literature review using the PRISMA methodology of MEDLINE, PubMed, Ovid, EMBASE, and Cochrane databases was performed from January 1950 to August 2017. Included studies consisted of those that examined measures of frailty or sarcopenia in adult patients undergoing any spinal surgery. The literature was synthesized and recommendations are proposed based on the GRADE system.

RESULTS

The initial search yielded 210 results, 11 of which met our complete inclusion criteria. Seven reported on measures of frailty and four reported on measures of sarcopenia. Frailty, assessed using a variety of measurement tools, was a consistent predictor of mortality, major and minor morbidity, prolonged in-hospital LOS, and discharge to a center of higher care for adult patients undergoing spinal surgery. The relationship between sarcopenia and postoperative outcomes was inconsistent due to the lack of consensus regarding the definition, measurement tools, and wide variability in sarcopenia measured in the spinal population.

CONCLUSIONS

Frailty is predictive of AEs, mortality, in-hospital LOS, and discharge disposition in a number of distinct spinal surgery populations. The impact of sarcopenia on postoperative outcomes is equivocal given the current state of the literature. The relationship between spinal pathology, frailty, sarcopenia, and how they interact to yield outcome remains to be clarified. Frailty and sarcopenia are potentially useful tools for risk stratification of patients undergoing spinal surgery. This systematic review was registered with PROSPERO, registration number 85096.

Review of Current Evidence Regarding Surgery in Elderly Patients with Meningioma

The Japanese population features the highest rate of elderly individuals worldwide. Moreover, Japan has the highest number of computed tomography/magnetic resonance imaging devices in the world, which has led to an increase in the incidental detection of meningioma in healthy elderly patients. Many previous papers have discussed the risks and indications for surgery in this patient population, but available information remains insufficient, and the definition of “elderly” has not been standardized. This review tried to clarify the published evidence and challenges associated with elderly meningioma based on a search of the PubMed database using the terms “meningioma,” “elderly,” and “surgery” for English-language clinical studies and collected related papers published from 2000 to 2016. Twenty-four papers were reviewed and classified by definition of elderly age: over 60, 65, 70, and 80 years old. Six of seven papers that defined the elderly cutoff as over 65 years old were published after 2010, which suggested the consensus definition. Four preoperative grading scoring systems were described and associated with mortality. The 1-year and 5-year mortality rates ranged from 0% to 16.7% and from 7% to 27%, which were comparable with unselected cohorts. Review of risk factor analysis emphasized the importance of considering the preoperative status, presence of comorbidities, and optimum surgical timing during patient selection. Careful choice of patients can also lead to better quality of life. A prospective randomized study considering patient frailty should address the causes and prevention of complications.

Effectiveness of an intervention to prevent frailty in pre-frail community-dwelling older people consulting in primary care: a randomised controlled trial

Background

evidence on the effectiveness of interventions to prevent frailty is scarce.

Objective

to assess the effect of an intervention in preventing frailty progression in pre-frail older people.

Study design

a randomised, open label, controlled trial with two parallel arms.

Population

community-dwelling pre-frail older people (≥70 years) consulting in primary care.

Intervention

nutritional assessment (and derivation to a Nutritional Unit for usual care in the event of nutritional risk) and a physical activity programme including aerobic exercise and a set of mixed strengthening, balance and coordination exercises.

Control group

patients receiving the usual care.

Main outcome measure

prevalence of frailty (Fried criteria) at 12 months.

Secondary outcomes measures

functional capacity (Barthel index), falls and nutritional status (Short-Form Mini Nutritional Assessment) on follow-up at 12 months.

Results

one hundred and seventy-two participants were recruited and randomised (mean age: 78.3 years; mean number of Fried criteria: 1.45). Thirty-nine participants (22.6%) were dropped out during the study. At follow-up, 4.9% of the intervention group and 15.3% of the control group had evolved to frailty, for a crude odds ratio (OR) of 0.29 (95% confidence interval [CI]: 0.08-1.08; P = 0.052) and an adjusted (by age, gender and number of co-morbidities) OR of 0.19 (95% CI: 0.04-0.95; P = 0.044). Intervention group showed a higher outdoors walking hour per day (0.97 versus 0.73; P = 0.019) but no difference was observed in muscle strength, gait speed or other functional indicators.

Conclusion

an intervention focused on physical exercise and maintaining good nutritional status may be effective in preventing frailty in community-dwelling pre-frail older individuals.

ClinicalTrials.gov identifier

NCT02138968.

A Scoping Review of Frailty and Acute Care in Middle-Aged and Older Individuals with Recommendations for Future Research

There is general agreement that frailty is a state of heightened vulnerability to stressors arising from impairments in multiple systems leading to declines in homeostatic reserve and resiliency, but unresolved issues persist about its detection, underlying pathophysiology, and relationship with aging, disability, and multimorbidity. A particularly challenging area is the relationship between frailty and hospitalization. Based on the deliberations of a 2014 Canadian expert consultation meeting and a scoping review of the relevant literature between 2005 and 2015, this discussion paper presents a review of the current state of knowledge on frailty in the acute care setting, including its prevalence and ability to both predict the occurrence and outcomes of hospitalization. The examination of the available evidence highlighted a number of specific clinical and research topics requiring additional study. We conclude with a series of consensus recommendations regarding future research priorities in this important area.

Age and preexisting conditions as risk factors for severe adverse events and failure to rescue after injury

BACKGROUND

Failure to rescue (FTR: the conditional probability of death after complication) has been studied in trauma cohorts, but the impact of age and preexisting conditions (PECs) on risk of FTR is not well known. We assessed the relationship between age and PECs on the risk of experiencing serious adverse events (SAEs) subsequent FTR in trauma patients with the hypothesis that increased comorbidity burden and age would be associated with increased FTR.

MATERIALS AND METHODS

We performed a retrospective cohort analysis at an urban level 1 trauma center in Pennsylvania. All patients aged ≥16 y with minimum Abbreviated Injury Scale score ≥2 from 2009 to 2013 were included. Univariate logistic regression models for SAE and FTR were developed using age, PECs, demographics, and injury physiology. Variables found to be associated with the end point of interest (P ≤ 0.2) in univariate analysis were included in separate multivariable logistic regression models for each outcome.

RESULTS

SAE occurred in 1136 of 7533 (15.1 %) patients meeting inclusion criteria (median age 42 [interquartile range 26-59], 53% African-American, 72% male, 79% blunt, median ISS 10 [interquartile range 5-17]). Of those who experienced an SAE, 129 of 1136 patients subsequently died (FTR = 11.4%). Development of SAE and FTR was associated with age ≥ 70 y (odds ratio 1.58-1.78, 95% confidence interval 1.13-2.82). Renal disease was the only preexisting condition associated with both SAE and FTR.

CONCLUSIONS

Trauma patients with renal disease are mostly at increased risk for both SAE and FTR, but other PECs associated with SAE are not necessarily those associated with FTR. Future interventions designed to reduce FTR events should target this high-risk cohort.

What happens when we do not operate? Survival following conservative bowel cancer management

Introduction While surgery is the cornerstone of bowel cancer treatment, it comes with significant risks. Among patients aged over 80 years, 30-day mortality is 13%-15%, and additionally 12% will not return home and go on to live in supportive care. The question for patients and clinicians is whether operative surgery benefits elderly, frail patients. Methods Multidisciplinary team outcomes between October 2010 and April 2012 were searched to conduct a retrospective analysis of patients with known localised colorectal cancer who did not undergo surgery due to being deemed unfit. Results Twenty six patients survived for more than a few weeks following surgery, of whom 20% survived for at least 36 months. The average life expectancy following diagnosis was 1 year and 176 days, with a mean age at diagnosis of 87 years (range 77-93 years). One patient survived for 3 years and 240 days after diagnosis. Conclusions Although surgeons are naturally focused on surgical outcomes, non-operative outcomes are equally as important for patients. Elderly, frail patients benefit less from surgery for bowel cancer and have higher risks than younger cohorts, and this needs to be carefully discussed when jointly making the decision whether or not to operate.

Síndrome da fragilidade em idosos com diabetes mellitus tipo 2

Resumo Objetivo Conhecer a prevalência da síndrome da fragilidade em idosos com diabetes mellitus tipo 2. Métodos Estudo transversal que incluiu 30 idosos, de ambos os sexos, com idades entre 60 a 79 anos e diagnóstico de diabetes mellitus tipo 2. Os instrumentos de pesquisa foram validados para língua portuguesa e incluíram variáveis sociodemográficas, clínicas e critérios para síndrome da fragilidade. Os idosos foram divididos em frágil, pré-frágil e não frágil. Os dados foram analisados por estatística descritiva. Resultados A prevalência da fragilidade foi de 56,7%. Os fatores associados foram: sexo feminino (70,6%); viúvos (69,2%); cor branca (58,8%); não trabalhar (69,2%); e tempo de diagnóstico de 25 a 48 meses (47,1%). Conclusão Os fatores associados, tais como, sociodemográficos, econômicos e tempo de diagnóstico não interferiram na prevalência da síndrome da fragilidade em idosos com diabetes mellitus tipo 2.

Changing Epidemiology of Intestinal Obstruction in Ghana: Signs of Increasing Surgical Capacity and an Aging Population

INTRODUCTION

This study aimed to describe the epidemiology and outcomes of intestinal obstruction at a tertiary hospital in Ghana over time.

METHODS

Records of all patients admitted to a tertiary hospital from 2007 to 2011 with intestinal obstruction were identified using ICD-9 codes. Sociodemographic and clinical data were compared to a previously published series of intestinal obstructions from 1998 to 2003. Factors contributing to longer than expected hospital stays and death were further examined.

RESULTS

Of the 230 records reviewed, 108 patients (47%) had obstructions due to adhesions, 50 (21%) had volvulus, 22 (7%) had an ileus from perforation and 14 (6%) had intussusception. Hernia fell from the 1st to the 8th most common cause of obstruction. Patients with intestinal obstruction were older in 2007-2011 compared to those presenting between 1998 and 2003 (p < 0.001); conditions associated with older age (e.g., volvulus and neoplasia) were more frequently encountered (p < 0.001). Age over 50 years was strong factor of in-hospital death (adjusted OR 14.2, 95% CI 1.41-142.95).

CONCLUSION

Efforts to reduce hernia backlog and expand the surgical workforce may have had an effect on intestinal obstruction epidemiology in Ghana. Increasing aging-related pathology and a higher risk of death in elderly patients suggest that improvement in geriatric surgical care is urgently needed.

Geriatric emergency general surgery: Survival and outcomes in a low-middle income country

BACKGROUND

Geriatric patients remain largely unstudied in low-middle income health care settings. The purpose of this study was to compare the epidemiology and outcomes of older versus younger adults with emergency general surgical conditions in South Asia.

METHODS

Discharge data from March 2009 to April 2014 were obtained for all adult patients (≥16 years) with an International Classification of Diseases, 9th revision, Clinical Modification diagnosis codes consistent with an emergency general surgery condition as defined by the American Association for the Surgery of Trauma. Multivariable regression analyses compared patients >65 years of age with patients ≤65 years for differences in all-cause mortality, major complications, and duration of hospital stay. Models were adjusted for potential confounding owing to patient demographic and clinical case-mix data with propensity scores.

RESULTS

We included 13,893 patients; patients >65 years constituted 15% (n = 2,123) of the cohort. Relative to younger patients, older adults were more likely to present with a number of emergency general surgery conditions, including gastrointestinal bleeding (odds ratio OR [95% CI], 2.63[1.99-3.46]), resuscitation (2.17 [1.67-2.80]), and peptic ulcer disease (2.09 [1.40-3.10]). They had an 89% greater risk-adjusted odds (1.89 [1.55-2.29]) of complications and a 63% greater odds (1.63 [1.21-2.20]) of mortality. Restricted to patients undergoing operative interventions, older adults had 95% greater odds (1.95 [1.29-2.94]) of complications and 117% greater odds (2.17 [1.62-2.91]) of mortality.

CONCLUSION

Understanding unique needs of geriatric patients is critical to enhancing the management and prioritization of appropriate care in developing settings.

Surgical need in an aging population: A cluster-based household survey in Nepal

BACKGROUND

With an aging global population comes an obligate and substantial burden of noncommunicable disease, especially in low- and middle-income countries. An unknown proportion of this burden is treatable with surgical expertise. For health system planning, this study aimed to estimate the operative needs of individuals older than 50 of age years in Nepal.

METHODS

A 2-stage, cluster randomized, community-based survey was performed in Nepal using the validated Surgeons OverSeas Surgical Assessment Survey (SOSAS). SOSAS collects household demographics and selects household members randomly for verbal, head-to-toe examinations for surgical conditions; moreover, SOSAS also completes a verbal autopsy for deaths in the preceding year. Only respondents older than 50 years were included in the analysis.

RESULTS

The survey sampled 1,350 households, totaling 2,695 individuals (97% response rate). Of these, 273 surgical conditions were reported by 507 persons ages ≥ 50 years. Extrapolating, there are potentially 2.1 million people older than 50 years of age with surgically treatable conditions who need care in Nepal (95% confidence interval 1.8-2.4 million; 46,000-62,600 per 100,000 persons). One in 5 deaths was potentially treatable or palliated by surgical care. Although growths or masses (including hernias and goiters) were the surgical condition reported most commonly (25%), injuries and fractures also were common and associated with the greatest disability. Literacy and distance to secondary and tertiary health facilities were associated with lack of care for operative conditions (P < .05).

CONCLUSION

There is a large, unmet surgical need among the elderly in Nepal. Low literacy and distance from a capable health facility are the greatest barriers to care. As the global population ages, there is an increasing need to improve surgical services and strengthen health systems to care for this group.

Frailty and perioperative outcomes: a narrative review

BACKGROUND

Frailty has no single universally accepted definition or method for assessment. It is commonly defined from a physiological perspective as a disruption of homeostatic mechanisms ultimately leading to a vulnerable state. Numerous scoring indices and assessments exist to assist clinicians in determining the frailty status of a patient. The purpose of this review is to discuss the relationship between frailty and perioperative outcomes in surgical patients.

PRINCIPAL FINDINGS

We performed a review to determine the association of frailty with perioperative outcomes in patients undergoing a wide variety of surgical procedures. A scoping literature search was performed to capture studies from MEDLINE(®), EMBASE™, and CENTRAL (Cochrane), which resulted in locating 175 studies across the three electronic databases. After an article screening process, 19 studies were found that examined frailty and perioperative outcomes. The studies used a range of assessments to determine frailty status and included patients in a variety of surgical fields. Regardless of surgical population and method of frailty assessment, a relationship existed between adverse perioperative outcomes and frailty status. Frail patients undergoing surgical procedures had a higher likelihood than non-frail patients of experiencing mortality, morbidity, complications, increased hospital length of stay, and discharge to an institution.

CONCLUSIONS

Patients undergoing surgery who are deemed frail, regardless of the scoring assessment used, have a higher likelihood of experiencing adverse perioperative outcomes. With the lack of a unified definition for frailty, further research is needed to address which assessment method is most predictive of adverse postoperative outcomes.

Perioperative assessment of the cancer patient

The perioperative evaluation of patients with cancer differs from that of other patients in that the former may have received prior chemotherapy or radiation therapy. These cancer treatments have a wide range of side effects and complications that may affect patients' perioperative risks. The perioperative specialist who evaluates the cancer patient prior to surgery must be familiar with the effects of these treatments and their consequences for the major organ systems. The perioperative specialist must also be familiar with the natural history of cancer and have a basic understanding of how cancer affects the body. In this article, we review the perioperative concerns that are specific to the patient with cancer.

Evolving management of symptomatic chronic subdural hematoma: experience of a single institution and review of the literature

OBJECTIVE

Chronic subdural hematoma (cSDH) has an increasing incidence and results in high morbidity and mortality. We review here the 10-year experience of a single institution and the literature regarding the treatment and major associations of cSDH.

METHODS

We retrospectively reviewed all cSDHs surgically treated from 2000 to 2010 in the New York Harbor Health Care System to evaluate the duration from admission to treatment, type of treatment, length of stay (LOS) in critical care, LOS in the hospital, and recurrence. The literature was reviewed with regards to incidence, associations, and treatment of cSDH.

RESULTS

From 2000 to 2008, 44 patients were treated with burr holes (BHs). From 2008 to 2010, 29 patients were treated with twist-drill evacuation (subdural evacuating port system, SEPS). Four patients from each group were readmitted for reoperation (9% vs 14%; P = 0.53). The average time to intervention for SEPS (11.2 ± 15.3 hours) was faster than for BHs (40.3 ± 69.1 hours) (P = 0.02). The total hospital LOS was shorter for SEPS (9.3 ± 6.8 days) versus BHs (13.4 ± 10.2 days) (P = 0.04); both were significantly longer than for a brain tumor patient undergoing craniotomy (7.0 ± 0.5 days, n = 94, P < 0.01).

CONCLUSION

Despite decreasing LOSs as treatment for cSDH evolved from BHs to SEPS, the LOS for a cSDH is still longer than that of a patient undergoing craniotomy for brain tumor. We noted 11% recurrence in our series of patients, which included individuals who recurred as late as 3 years after initial diagnosis.

Psoas:lumbar vertebra index: central sarcopenia independently predicts morbidity in elderly trauma patients

Introduction

Central sarcopenia as a surrogate for frailty has recently been studied as a predictor of outcome in elderly medical patients, but less is known about how this metric relates to outcomes after trauma. We hypothesized that psoas:lumbar vertebral index (PLVI), a measure of central sarcopenia, is associated with increased morbidity and mortality in elderly trauma patients.

Methods

A query of our institutional trauma registry from 2005 to 2010 was performed. Data was collected prospectively for the Pennsylvania Trauma Outcomes Study (PTOS). Inclusion criteria: age >55 years, ISS >15, and ICU LOS >48 h. Using admission CT scans, psoas:vertebral index was computed as the ratio between the mean cross-sectional areas of the psoas muscles and the L4 vertebral body at the level of the L4 pedicles. The 50th percentile of the psoas:L4 vertebral index value was determined, and patients were grouped into high (>0.84) and low (≤0.83) categories based on their relation to the cohort median. Primary endpoints were mortality and morbidity (as a combined endpoint for PTOS-defined complications). Univariate logistic regression was used to test the association between patient factors and mortality. Factors found to be associated with mortality at p < 0.1 were entered into a multivariable model.

Results

A total of 180 patients met the study criteria. Median age was 74 years (IQR 63–82), median ISS was 24 (IQR 18–29). Patients were 58 % male and 66 % Caucasian. Mean PLVI was 0.86 (SD 0.25) and was higher in male patients than female patients (0.91 ± 0.26 vs. 0.77 ± 0.21, p < 0.001). PLVI was not associated with mortality in univariate or multivariable modeling. After controlling for comorbidities, ISS, and admission SBP, low PLVI was found to be strongly associated with morbidity (OR 4.91, 95 % CI 2.28–10.60).

Conclusions

Psoas:lumbar vertebral index is independently and negatively associated with posttraumatic morbidity but not mortality in elderly, severely injured trauma patients. PLVI can be calculated quickly and easily and may help identify patients at increased risk of complications.

Measures of frailty in population-based studies: an overview

Background

Although research productivity in the field of frailty has risen exponentially in recent years, there remains a lack of consensus regarding the measurement of this syndrome. This overview offers three services: first, we provide a comprehensive catalogue of current frailty measures; second, we evaluate their reliability and validity; third, we report on their popularity of use.

Methods

In order to identify relevant publications, we searched MEDLINE (from its inception in 1948 to May 2011); scrutinized the reference sections of the retrieved articles; and consulted our own files. An indicator of the frequency of use of each frailty instrument was based on the number of times it had been utilized by investigators other than the originators.

Results

Of the initially retrieved 2,166 papers, 27 original articles described separate frailty scales. The number (range: 1 to 38) and type of items (range of domains: physical functioning, disability, disease, sensory impairment, cognition, nutrition, mood, and social support) included in the frailty instruments varied widely. Reliability and validity had been examined in only 26% (7/27) of the instruments. The predictive validity of these scales for mortality varied: for instance, hazard ratios/odds ratios (95% confidence interval) for mortality risk for frail relative to non-frail people ranged from 1.21 (0.78; 1.87) to 6.03 (3.00; 12.08) for the Phenotype of Frailty and 1.57 (1.41; 1.74) to 10.53 (7.06; 15.70) for the Frailty Index. Among the 150 papers which we found to have used at least one of the 27 frailty instruments, 69% (n = 104) reported on the Phenotype of Frailty, 12% (n = 18) on the Frailty Index, and 19% (n = 28) on one of the remaining 25 instruments.

Conclusions

Although there are numerous frailty scales currently in use, reliability and validity have rarely been examined. The most evaluated and frequently used measure is the Phenotype of Frailty.

An update on delirium in the postoperative setting: prevention, diagnosis and management

Delirium is a serious and pervasive problem in the postoperative setting. Research to date has identified a number of key risk factors implicated in the development of delirium after surgical intervention, including advanced age, pre-existing cognitive impairment, lower pre-morbid functional status and history of psychiatric illness. Efforts to prevent postoperative delirium in the form of multi-component programs and prophylactic administration of medications have yielded some positive results. Studies investigating the effectiveness of various antipsychotics in the treatment of postoperative delirium have demonstrated somewhat mixed outcomes. Recent research has identified more sophisticated management of pain and sedation protocols as a way to prevent or mitigate delirium, with promising results. This chapter reviews the most recent literature pertaining to the prevention, diagnosis and management of postoperative delirium.

Frailty in primary care: a review of its conceptualization and implications for practice

Frail, older patients pose a challenge to the primary care physician who may often feel overwhelmed by their complex presentation and tenuous health status. At the same time, family physicians are ideally suited to incorporate the concept of frailty into their practice. They have the propensity and skill set that lends itself to patient-centred care, taking into account the individual subtleties of the patient's health within their social context. Tools to identify frailty in the primary care setting are still in the preliminary stages of development. Even so, some practical measures can be taken to recognize frailty in clinical practice and begin to address how its recognition may impact clinical care. This review seeks to address how frailty is recognised and managed, especially in the realm of primary care.

Assessment for frailty is useful for predicting morbidity in elderly patients undergoing colorectal cancer resection whose comorbidities are already optimized

BACKGROUND

The clinical syndrome of frailty identified through the assessment of weight loss, gait speed, grip strength, physical activity, and physical exhaustion has been used to identify patients with reduced reserves. We hypothesized that frailty is useful in predicting adverse outcomes in optimized elective elderly colorectal surgery patients.

METHODS

A prospective study was conducted at 2 centers (Singapore and Japan). All patients over 75 years of age undergoing colorectal resection were assessed for the presence of the syndrome of frailty. All these patients had already had their comorbidities optimized for surgery. The outcome measure was postoperative major complications (defined as Clavien-Dindo type II and above complications).

RESULTS

Eighty-three patients were studied from February 2008 to April 2010. The mean age was 81.5 years (range 75-93 years). The mean comorbidity index was 3.37 (range 0-11). Twenty-six (31.3%) patients were an American Society of Anesthesiologists (ASA) score of 3 and above. Chi-square analysis revealed that the odds ratio of postoperative major complications was 4.083 (95% confidence interval, 1.433-11.638) when the patient satisfied the criteria for frailty. Albumin <35, ASA >3, comorbidity index >5, and Physiologic and Operative Severity Score for the enUmeration of Mortality and Morbidity (POSSUM) scores were not predictive of postoperative major complications.

CONCLUSIONS

Preliminary findings show that frailty is a potent adjunctive tool of predicting postoperative morbidity. Frailty can be used to identify elderly patients needing further optimization before major surgery.