Assessment of predictive validity and feasibility of Edmonton Frail Scale in identifying postoperative complications among elderly patients: a prospective observational study

The Haemato-Oncology Frailty (HOF) score to assess frailty in lymphoma

Morbidity and mortality during chemotherapy in older adults with haematological malignancy can be unpredictable. The Haemato-Oncology Frailty (HOF) score was previously found to predict outcomes in a cohort of patients with plasma cell myeloma. In this study, we assess its utility in assessing frailty in patients with lymphoma, and compare its performance to that of two other frailty scores. The HOF score was able to predict progression-free survival in this population, and was also shown to have potential in assessing the dynamism of frailty during chemotherapy. It performed well when compared to the Charlson Comorbidity Index (CCI) score and the Haematopoietic Cell Transplantation-Specific Comorbidity Index (HCTCI), although the study was not powered to assess for non-inferiority. The HOF score is a new score with the potential for application in different haematological malignancies.

A systematic review of frailty assessment tools used in vascular surgery research

OBJECTIVE

Frailty is common in vascular patients and is recognized for its prognostic value. In the absence of consensus, a multitude of frailty assessment tools exist. This systematic review aimed to quantify the variety in these tools and describe their content and application to inform future research and clinical practice.

METHODS

Multiple cross-disciplinary electronic literature databases were searched from inception to August 2022. Studies describing frailty assessment in a vascular surgical population were eligible. Data extraction to a validated template included patient demographics, tool content, and analysis methods. A secondary systematic search for papers describing the psychometric properties of commonly used frailty tools was then performed.

RESULTS

Screening 5358 records identified 111 eligible studies, with an aggregate population of 5,418,236 patients. Forty-three differing frailty assessment tools were identified. One-third of these failed to assess frailty as a multidomain deficit and there was a reliance on assessing function and presence of comorbidity. Substantial methodological variability in data analysis and lack of methodological description was also identified. Published psychometric assessment was available for only 4 of the 10 most commonly used frailty tools. The Clinical Frailty Scale was the most studied and demonstrates good psychometric properties within a surgical population.

CONCLUSIONS

Substantial heterogeneity in frailty assessment is demonstrated, precluding meaningful comparisons of services and data pooling. A uniform approach to assessment is required to guide future frailty research. Based on the literature, we make the following recommendations: frailty should be considered a continuous construct and the reporting of frailty tools' application needs standardized. In the absence of consensus, the Clinical Frailty Scale is a validated tool with good psychometric properties that demonstrates usefulness in vascular surgery.

The construct validity of an abridged version of the general self-efficacy scale for adults with attention-deficit/hyperactivity disorder

Objectives

The General Self-Efficacy (GSE) scale is a validated self-rated questionnaire increasingly used in mental health research. However, despite several psychometric advantages of the GSE scale, its validity in those diagnosed with attention-deficit/hyperactivity disorder (ADHD) has not yet been examined. Moreover, a shorter version of the GSE scale would contribute to a more rational use of resources in extensive multivariate studies. Therefore, as self-rated scales to measure self-efficacy in this population are lacking, the current study aims to develop a condensed version of the GSE for adults with ADHD.

Methods

A group of patient collaborators (user representatives) from an ADHD organization and health professionals shortened the original 10-item GSE scale to six items and evaluated the content validity of the revised scale. Second, 525 potential participants were invited to participate in a cross-sectional study conducted in 2021 (between January 19th and February 7th). Of them, 403 filled out the GSE-6 for ADHD and two scales measuring psychological well-being and mental health (the five-item World Health Organization Well-Being Index, WHO-5, and the four-item Patient Health Questionnaire, PHQ-4). The psychometric properties of the new scale were examined, testing a priori formulated hypotheses.

Results

The brief GSE-6 for ADHD displayed good internal consistency with a Cronbach's α of 0.907. No floor or ceiling effect was detected. Exploratory and confirmatory factor analyses supported a one-factor structure. The GSE-6 also showed a moderate positive correlation with the WHO-5 (rs = 0.578) and a moderate negative correlation with the depression and anxiety rating scale PHQ-4 (rs = -0.595).

Conclusion

The 6-item GSE for ADHD was evaluated to have good content validity. The scale demonstrated good psychometric properties. The results indicate that the GSE-6 may help assess self-efficacy in adults with ADHD.

A systematic review of predictive accuracy via c-statistic of preoperative frailty tests for extended length of stay, post-operative complications, and mortality

Frailty, as an age-related syndrome of reduced physiological reserve, contributes significantly to post-operative outcomes. With the aging population, frailty poses a significant threat to patients and health systems. Since 2012, preoperative frailty assessment has been recommended, yet its implementation has been inhibited by the vast number of frailty tests and lack of consensus. Since the anesthesiologist is the best placed for perioperative care, an anesthesia-tailored preoperative frailty test must be simple, quick, universally applicable to all surgeries, accurate, and ideally available in an app or online form. This systematic review attempted to rank frailty tests by predictive accuracy using the c-statistic in the outcomes of extended length of stay, 3-month post-operative complications, and 3-month mortality, as well as feasibility outcomes including time to completion, equipment and training requirements, cost, and database compatibility. Presenting findings of all frailty tests as a future reference for anesthesiologists, Clinical Frailty Scale was found to have the best combination of accuracy and feasibility for mortality with speed of completion and phone app availability; Edmonton Frailty Scale had the best accuracy for post-operative complications with opportunity for self-reporting. Finally, extended length of stay had too little data for recommendation of a frailty test. This review also demonstrated the need for changing research emphasis from odds ratios to metrics that measure the accuracy of a test itself, such as the c-statistic.

The Impact of Radiotherapy on Frailty in Patients Aged 65 and Over

Introduction and objective Frailty is characterized by the body's increased susceptibility to stressors due to aging and a concurrent decline in its resilience. A dominant hypothesis suggests that oncological interventions may amplify this vulnerability. Consequently, elderly individuals with cancer may pose challenges for conventional treatments. This research sought to assess the effects of radiotherapy (RT) on the frailty of elderly cancer patients by utilizing the Edmonton Frail Scale (EFS). Methods This research was designed as a prospective observational study. Patients aged 65 and older, receiving treatment at the radiation oncology clinic, were asked to complete the EFS form both before and at the end of their RT course. The scores achieved before and after the RT were obtained, and the medical histories of the patients were recorded. The difference between the pre- and post-RT scores was calculated by subtracting the post-RT score from the pre-RT score to determine any increase or decrease in the score. For the statistical evaluations, a suite of tests (including the Shapiro-Wilk test, Kolmogorov-Smirnov test, paired sample t-test, independent t-tests, analysis of variance {ANOVA}, and Pearson correlation) were implemented. All analyses were conducted using the Statistical Package for Social Sciences (SPSS) software (version 29.0) (IBM SPSS Statistics, Armonk, NY). Results From April 2021 to August 2023, a total of 121 patients participated in the study. Out of these, 81 underwent assessments both pre- and post-RT. The median age was 73; the median follow-up period was five months. The predominant diagnoses included prostate cancer, breast cancer, and gynecological malignancies. A significant proportion of patients was diagnosed with stage IV cancer and underwent palliative RT. Post-RT evaluations revealed a decline in scores for some patients, while an increase was observed for others. Certain score variations were statistically significant. Moreover, an inverse correlation was discerned between the RT dose and fraction number and the post-RT EFS score. Conclusion Our research confirmed that a substantial number of patients either experienced a decrease or maintained stability in their EFS scores after RT. This observation suggests that RT might not exacerbate frailty in the elderly in the short term. Nevertheless, to elucidate the long-term impact of RT on frailty, there is a pressing need for a comprehensive assessment correlating EFS scores with survival rates.

Domains of Frailty Predict Loss of Independence in Older Adults After Noncardiac Surgery

IMPORTANCE

Preoperative frailty has been consistently associated with death, severe complications, and loss of independence (LOI) after surgery. LOI is an important patient-centered outcome, but it is unclear which domains of frailty are most strongly associated with LOI. Such information would be important to target individual geriatric domains for optimization.

OBJECTIVE

To assess whether impairment in individual domains of the Edmonton Frail Scale (EFS) can predict LOI in older adults after noncardiac surgery.

DESIGN

Retrospective Cohort Study.

SETTING

One Academic Hospital.

PARTICIPANTS

Patients aged 65 or older who were living independently and evaluated with the EFS during a preoperative visit to the Center for Preoperative Optimization at the Johns Hopkins Hospital between June 2018 and January 2020.

MAIN OUTCOME

LOI defined as discharge to increased level of care outside of the home with new mobility deficit or functional dependence. New mobility deficit and functional dependence were extracted from chart review of the standardized occupational therapy and physical therapy assessment performed before discharge.

RESULTS

A total of 3497 patients were analyzed. Age (mean±SD) was 73.4±6.2 years, and 1579 (45.2%) were female. The median total EFS score was 3 (range 0-16), and 725/3497 (27%) were considered frail (EFS≥6). The frequencies of impairment in each EFS domain were functional performance (33.5% moderately impaired, 11% severely impaired), history of hospital readmission (42%), poor self-described health status (37%), and abnormal cognition (17.1% moderately impaired, 13.8% severely impaired). Overall, 235/3497 (6.7%) patients experienced LOI. Total EFS score was associated with LOI (odds ratio: 1.37, 95% CI, 1.30-1.45, P <0.001) in a model adjusted for age, sex, body mass index, American Society of Anesthesiologists rating, congestive heart failure, valvular heart disease, hypertension diagnosis, chronic lung disease, diabetes, renal failure, liver disease, weight loss, anemia, and depression. Using a nested log likelihood approach, the domains of functional performance, functional dependence, social support, health status, and urinary incontinence improved the base multivariable model. In cross-validation, total EFS improved the prediction of LOI with the final model achieving an area under the curve of 0.840. Functional performance was the single domain that most improved outcome prediction, but together with functional dependence, social support, and urinary incontinence, the model resulted in an area under the curve of 0.838.

CONCLUSION AND RELEVANCE

Among domains measured by the EFS before a wide range of noncardiac surgeries in older adults, functional performance, functional dependence, social support, and urinary incontinence were independently associated with and improved the prediction of LOI. Clinical initiatives to mitigate LOI may consider screening with the EFS and targeting abnormalities within these domains.

Frailty and Pre-Frailty in the Setting of Total Joint Arthroplasty: A Narrative Review

Background

Total joint arthroplasties are among the most common surgical procedures performed in the United States. Although numerous safeguards are in place to optimize patient health and safety pre-, intra-, and postoperatively, patient frailty is often incompletely assessed or not assessed at all. Frailty has been shown to increase rates of adverse events and length of stay. We discuss the impact of frailty on patient outcomes and healthcare economics as well as provide widely accepted models to assess frailty and their optimal usage.

Methods

Several databases were searched using the keywords "frailty," "TJA," "THA," "frailty index," "frailty assessment," and "frailty risk." A total of 45 articles were used in this literature review.

Results

It is estimated that nearly half of patients over the age of 85 meet criteria for frailty. Frailty in surgical patients has been shown to increase total costs as well as length of stay. Additionally, increased rates of numerous adverse events are associated with increased frailty.

Conclusions

The literature demonstrates that frailty poses increased risk of adverse events, increased length of stay, and increased cost. There are several models that accurately assess frailty and can feasibly be implemented into preoperative screening.

Does ASA classification effectively risk stratify patients undergoing bariatric surgery: a MBSAQIP retrospective cohort of 138,612 of patients

INTRODUCTION

It is important to appropriately risk stratify bariatric surgery patients, as these patients often have obesity-related comorbidities which can increase postoperative complication risk but also benefit the most from bariatric surgery. We aimed to evaluate the utility of risk stratification using ASA class for bariatric surgery patients and assessed predictive factors of postoperative complications.

METHODS

The 2020 MBSAQIP database was analyzed, and an ASA-deemed high-risk cohort (class IV) and normal-risk (ASA class II and III) cohort were compared. Univariate analysis was performed to characterize differences between cohorts and to compare complication rates. Multivariate logistic regression analysis was performed to determine factors associated with increased odds of postoperative complications.

RESULTS

We evaluated 138 612 patients with 5380 (3.9%) considered high-risk and 133 232 (96.1%) normal-risk. High-risk patients were more likely to be older (46.2 ± 12.0vs.43.4 ± 11.9, p < 0.001), male (30.9%vs.18.4%, p < 0.001), have higher BMI (51.4 ± 10.2vs.44.9 ± 7.4, p < 0.001), and have more comorbidities. High-risk patients were more likely to have increased 30-day serious complications (4.5%vs.2.8%, p < 0.001) and death (0.2%vs.0.1%, p = 0.001) but not anastomotic leak (0.2%vs.0.2%, p = 0.983). Multivariate models showed ASA class IV patients were at higher odds for any serious complication by 30 days (aOR 1.36, 95%CI 1.18-1.56, p < 0.001) but not for death (aOR 1.04, 95%CI 0.49-2.21, p = 0.921). The factor independently associated with the highest odds of complication in both models was functional status preoperatively (partially dependent aOR 2.06, 95%CI 1.56-2.72, p < 0.001; fully dependent aOR 3.19, 95%CI 1.10-9.28, p = 0.033 for any serious complication; partially dependent aOR 5.08, 95%CI 2.16-12.00, p < 0.001 for death).

CONCLUSIONS

While elevated ASA class correlates with increased serious complications, pre-operative functional status appears to have a much greater contribution to odds of serious complications and mortality. These findings question the utility of using ASA to risk stratify patients peri-operatively and provides evidence for using a simpler and more practical functional status approach.

Transforming the perioperative medicine care model: The Singapore experience

More than 300 million surgeries are performed worldwide annually. Established perioperative centres in the UK, USA and Australia have demonstrated the impact of improving perioperative care in reducing costs, increasing patient satisfaction and improving population health. Likewise, the surgical burden of care in Asia is increasing, but with sociocultural, economic and epigenetic differences compared to the west. As Singapore's largest hospital, the Singapore General Hospital pre-admission perioperative clinic sees about 20,000 patients annually. We aim to illustrate Singapore General Hospital's perioperative model of care to contribute to the paucity of literature describing perioperative programme implementation within Asia, and to encourage the cross-sharing of perioperative practices internationally. Our perioperative framework navigates risk assessment, risk counselling, and mitigation of health, medical and functional risks to better patients' perioperative outcomes and population health. We have implemented evidence-based pathways for common conditions such as anaemia and malnutrition, including a multidisciplinary programme for the elderly to tackle frailty and reduce length of stay. We describe how we have enhanced local risk profiling with the Combined Assessment of Risk Encountered in Surgery surgical risk calculator derived locally using a gradient boosting machine learning model. Finally, we report clinical outcomes of these interventions and discuss further challenges and new initiatives at each tier of our perioperative model. Our perioperative care model provides a framework that other centres can adopt to promote value-driven care, while catering for differences in the Asian population, thereby promoting evidence-based improvements in the area of perioperative medicine.

The effectiveness of a group-based Otago exercise program on physical function, frailty and health status in older nursing home residents: A systematic review and meta-analysis

OBJECTIVES

To explore the effects of a group-based Otago exercise program (OEP) on physical function (mobility, balance, lower limb strength), frailty and health status in older nursing home residents to determine the optimal scheme and format.

METHODS

This systematic review and meta-analysis was conducted to estimate group-based OEP effects. Subgroup analysis was performed to identify the influences of the participant and intervention characteristics on the effects.

RESULTS

Twelve studies met the eligibility criteria and were included in this meta-analysis, and the overall quality was relatively high. The results showed that the group-based OEP significantly improved physical function, including mobility [SMD=-0.64, 95% CI (-0.83,-0.45), Z=6.55, p<0.001], balance [MD=4.72, 95% CI (3.54, 5.90), Z=7.84, p<0.001], lower limb strength [SMD=-1.09, 95% CI (-1.40, -0.79), Z=7.01, p<0.001]; frailty [SMD=-0.73, 95% CI (-1.01, -0.45), Z=5.13, p<0.001] and health status [SMD=0.47, 95% CI (0.20, 0.74), Z=3.44, p=0.0006]. Subgroup analysis revealed that 30-minute sessions were more beneficial for improving balance than >30-minute sessions (p=0.0004). The training was coordinated with physiotherapists, who were more skilled at improving mobility than providing health training education (p=0.04).

CONCLUSIONS

Group-based OEP is helpful for improving physical function, frailty and health status in older nursing home residents. Specifically, 30-minute sessions and coordinating with physiotherapists may be the most appropriate and effective options.

Preoperative Evaluation and Cardiac Risk Assessment in Vascular Surgery

We summarize epidemiologic trends, outcomes, and preoperative guidelines for vascular surgery patients from 2010 to 2022. Vascular surgery continues to evolve in technology and engineering to treat a surgical population that suffers from a high prevalence of comorbidities. Preoperative optimization seeks to characterize the burden of disease and to achieve medical control in the timeline available before surgery. Risk assessment, evaluation, optimization, and prediction of major adverse cardiac events is an evolving science where the Vascular Surgery Quality Initiative has made an impact. Ongoing investigation may demonstrate value for preoperative echocardiography, functional capacity, frailty, and mobility assessments.

Potentially Inappropriate Medication Administration Is Associated With Adverse Postoperative Outcomes in Older Surgical Patients: A Retrospective Cohort Study

BACKGROUND

The American Geriatrics Society (AGS) Beers Criteria is an explicit list of potentially inappropriate medications (PIMs) best avoided in adults ≥65 years of age. Cognitively impaired and frail surgical patients often experience poor outcomes after surgery, but the impacts of PIMs on these patients are unclear. Our objective was to assess whether perioperative PIM administration was associated with poor outcomes in geriatric surgical patients. We then evaluated the association between PIM administration and postoperative outcomes in subgroups of patients who were frail or cognitively impaired.

METHODS

We performed a retrospective cohort study of patients ≥65 years of age who underwent elective inpatient surgery at a large academic medical center from February 2018 to January 2020. Edmonton Frail Scale and Mini-Cog screening tools were administered to all patients at their preoperative clinic visit. A Mini-Cog score of 0 to 2 was considered cognitive impairment, and frailty was defined by an Edmonton Frail Scale score of ≥8. Patients were divided into 2 groups depending on whether they received at least 1 PIM (PIM+), based on the 2019 AGS Beers Criteria, in the perioperative period or none (PIM-). We assessed the association of preoperative frailty, cognitive impairment, and perioperative PIM administration with the length of hospital stay and discharge disposition using multiple regression analyses adjusted for age, sex, ASA physical status, and intensive care unit (ICU) admission.

RESULTS

Of the 1627 included patients (mean age, 73.7 years), 69.3% (n = 1128) received at least 1 PIM. A total of 12.7% of patients were frail, and 11.1% of patients were cognitively impaired; 64% of the frail patients and 58% of the cognitively impaired patients received at least 1 PIM. Perioperative PIM administration was associated with longer hospital stay after surgery (PIM-, 3.56 ± 5.2 vs PIM+, 4.93 ± 5.66 days; P < .001; 95% confidence interval [CI], 0.360-0.546). Frail patients who received PIMs had an average length of stay (LOS) that was nearly 2 days longer than frail patients who did not receive PIMs (PIM-, 4.48 ± 5.04 vs PIM+, 6.33 ± 5.89 days; P = .02). Multiple regression analysis revealed no significant association between PIM administration and proportion of patients discharged to a care facility (PIM+, 26.3% vs PIM-, 28.7%; P = .87; 95% CI, -0.046 to 0.054).

CONCLUSIONS

Perioperative PIM administration was common in older surgical patients, including cognitively impaired and frail patients. PIM administration was associated with an increased hospital LOS, particularly in frail patients. There was no association found between PIM administration and discharge disposition.

Frailty in the over 65's undergoing elective surgery (FIT-65) - a three-day study examining the prevalence of frailty in patients presenting for elective surgery

Background

Frailty increases the risk of perioperative complications, length of stay, and the need for assisted-living after discharge. As the UK population ages the number of frail patients presenting for elective surgery in the UK is likely to grow. Despite the potential benefits of early diagnosis, frailty is not uniformly screened for in UK elective surgical patients and its prevalence remains unclear. The primary aim of this study was to assess the prevalence of frailty in patients aged over 65 years undergoing elective surgery.

Methods

We performed a prospective cross-sectional observational study in eight UK hospitals. Data were collected over three consecutive days with follow-up at 30 days. HRA approval was obtained (REC 20/SC/0121) and signed informed consent obtained. Participants were eligible for inclusion if they were 65 years or older and undergoing elective surgery. Pre-operative data were collected from hospital notes by anaesthetic trainees. A member of the research team blinded to the pre-operative dataset screened each participant for frailty pre-operatively using the Reported Edmonton Frail Scale (REFS). Post-operative data were collected from the notes on day of surgery and at 30 days. Participants were defined as “frail” if they scored 8 or more on the REFS.

Results

Two hundred twenty eight participants were recruited during the study period of whom 218 proceeded to surgery. There were 103 females and 115 males. Median age was 75 years (interquartile range 70–80). Thirty-seven participants (17.0%) were identified as frail. Frail patients were older, had a higher ASA score, were more likely to have carers and were more likely to be anaemic or present with ECG abnormalities. There were no differences in gender, BMI, place of residence or smoking status for patients identified as frail versus non-frail. There was no difference in length-of-stay between frail and non-frail patients, although those identified as frail were less likely to be discharged to their own home.

Conclusion

We found the prevalence of frailty in a mixed population of elective surgical patients aged 65 or over to be 17.0%. Furthermore, we found the REFS to be a practical tool for pre-operative frailty screening. Frail patients presented for elective surgery with modifiable co-morbidities which could have been optimised pre-operatively. Early screening could highlight frail patients, allowing time for pre-operative planning and evidence-based optimisations of comorbidities. We therefore encourage the adoption of frailty assessment as a routine part of pre-operative assessment.

Clinical outcomes of brain metastasectomy from soft tissue and bone sarcomas: a systematic review

BACKGROUND

Brain metastasis in sarcomas is associated with a poor prognosis. Data regarding prognostic factors and clinical outcomes of surgical resection of brain metastasis from sarcomas are limited. The objective of this systematic review was to evaluate survival outcomes post-brain metastasectomy for patients with soft tissue and bone sarcomas.

METHODS

A systematic review was conducted examining survival outcomes among adults and children with soft tissue and bone sarcoma undergoing brain metastasectomy, in the English language from inception up to May 31, 2021. Two reviewers independently evaluated and screened the literature, extracted the data, and graded the included studies. The body of evidence was evaluated and graded according to the Newcastle-Ottawa Quality Assessment Scale for Cohort Studies and the Joanna Briggs Institute Critical Appraisal Checklist for Case Series. Results were synthesized using descriptive methods. A meta-analysis was not possible due to the low quality and heterogeneity of studies.

RESULTS

Ten studies published between 1994 and 2020 were included: three were retrospective cohort studies and seven were case series. 507 patients were included, of whom 269 underwent brain metastasectomy. The median follow-up period ranged between 14 and 29 months. The median survival period after metastasectomy ranged from 7 to 25 months. The most common prognostic factors associated with survival included presenting performance status, age, number of brain metastases, presence of lung metastases, and peri-operative radiation therapy administration.

DISCUSSION

Although the level of evidence is low, retrospective studies support that brain metastasectomy can be performed with reasonable post-operative survival in selected individuals.

Resilience is associated with frailty and older age in hospitalised patients

Background

Little is known about resilience in an internal medicine setting. We aimed to assess the relationship between resilience and frailty and other clinical and sociodemographic characteristics in a cohort of prospectively enrolled hospitalised patients.

Methods

In 2017–2019, we consecutively enrolled patients in our internal medicine wards. We selected all patients who filled in the 25-item Connor-Davidson resilience scale (CD-RISC). Mean resilience was evaluated according to baseline demographic (i.e., age, sex, marital and socioeconomic status) and clinical (i.e., Cumulative Illness Rating Scale [CIRS], Edmonton Frail Scale [EFS], Barthel index, Short Blessed test, length of stay [LOS]) data. A multivariable analysis for assessing factors affecting resilience was fitted.

Results

Overall, 143 patients (median age 69 years, interquartile range 52–79, 74 females) were included. Resilience was significantly lower in frail (p = 0.010), elderly (p = 0.021), dependent (p = 0.032), and more clinically (p = 0.028) and cognitively compromised patients (p = 0.028), and in those with a low educational status (p = 0.032). No relation between resilience and LOS was noticed (p = 0.597). Frail patients were significantly older (p < 0.001), had a greater disease burden as measured by CIRS comorbidity (p < 0.001) and severity indexes (p < 0.001), were more dependent (p < 0.001), more cognitively impaired (p < 0.001), and displayed a lower educational level (p = 0.011) compared to non-frail patients. At multivariable analysis, frailty (p = 0.022) and dependency (p = 0.031; according to the Barthel index) were associated with lower resilience in the age groups 18–64 and ≥ 65 years, respectively.

Conclusions

Low resilience was associated with frailty and dependency with an age-dependent fashion. Studies assessing the impact of this finding on important health outcomes are needed.

Trial registration

Clinical Complexity in Internal Medicine Wards. San MAtteo Complexity Study (SMAC); NCT03439410. Registered 01/11/2017.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12877-022-03251-9.

Frailty in Aging and the Search for the Optimal Biomarker: A Review

In the context of accelerated aging of the population worldwide, frailty has emerged as one of the main risk factors that can lead to loss of self-sufficiency in older people. This syndrome is defined as a reduced state of physiological reserve and functional capacity. The main diagnostic tools for frailty are based on scales that show deficits compared to their clinical application, such as the Fried frailty phenotype, among others. In this context, it is important to have one or more biomarkers with clinical applicability that can objectively and precisely determine the degree or risk of frailty in older people. The objective of this review was to analyze the biomarkers associated with frailty, classified according to the pathophysiological components of this syndrome (inflammation, coagulation, antioxidants, and liver function, among others). The evidence demonstrates that biomarkers associated with inflammation, oxidative stress, skeletal/cardiac muscle function, and platelet function represent the most promising markers of frailty due to their pathophysiological association with this syndrome. To a lesser extent but with the possibility of greater innovation, biomarkers associated with growth factors, vitamins, amino acids, and miRNAs represent alternatives as markers of this geriatric syndrome. Likewise, the incorporation of artificial intelligence represents an interesting approach to strengthening the diagnosis of frailty by biomarkers.

Wearable-Based Assessment of Frailty Trajectories During Cardiac Rehabilitation After Open-Heart Surgery

Frailty in patients after open-heart surgery influences the type and intensity of a cardiac rehabilitation program. The response to tailored exercise training can be different, requiring convenient tools to assess the effectiveness of a training program routinely. The study aims to investigate whether kinematic measures extracted from the acceleration signals can provide information about frailty trajectories during rehabilitation. One hundred patients after open-heart surgery, assigned to the equal-sized intervention and control groups, participated in exercise training during inpatient rehabilitation. After rehabilitation, the intervention group continued exercise training at home, whereas the control group was asked to maintain the usual physical activity regimen. Stride time, cadence, movement vigor, gait asymmetry, Lissajous index, and postural sway were estimated during the clinical walk and stair-climbing tests before and after inpatient rehabilitation as well as after home-based exercise training. Frailty was assessed using the Edmonton frail scale. Most kinematic measures estimated during walking improved after rehabilitation along with the improvement in frailty status, i.e., stride time, cadence, postural sway, and movement vigor improved in 71%, 77%, 81%, and 83% of patients, respectively. Meanwhile, kinematic measures during stair-climbing improved to a lesser extent compared to walking. Home-based exercise training did not result in a notable change in kinematic measures which agrees well with only a negligible deterioration in frailty status. The study demonstrates the feasibility to follow frailty trajectories during inpatient rehabilitation after open-heart surgery based on kinematic measures extracted using a single wearable sensor.

The Impact of the Otago Exercise Program on Frailty and Empowerment in Older Nursing Home Residents: A Randomized Controlled Trial

Background

This study assessed the impact of Otago exercises on frailty and empowerment in older nursing home residents.

Methods

This randomized controlled trial included 72 individuals aged over 65 years residing in a single nursing home in Izmir, Turkey. The participants were randomly assigned to the Otago exercise group (OEG) or control group (CG). The OEG performed Otago exercises for 45 minutes, 3 days per week for 12 weeks plus a walking program the 3 other days of the week. In addition to Otago exercise training, the OEG received training based on empowerment consisting of 10 sessions lasting 30 minutes each. The CG received no intervention except routine care in the nursing home. The data collected were sociodemographic characteristics, Edmonton Frail Scale (EFS) scores, and Elderly Empowerment Scale (EES) scores before and 3 months after the intervention.

Results

We observed significant differences between the mean EFS (p=0.0001) and mean EES (p=0.0001) before and 3 months after the intervention in the OEG compared to the CG. We also observed a significant difference between the OEG and CG in mean EFS (p=0.018) and EES (p=0.0001) 3 months after the intervention.

Conclusion

The results of the present study demonstrated the positive impact of the Otago exercise program on preventing/delaying frailty and enhancing empowerment in older people.

Frailty and Different Exercise Interventions to Improve Gait Speed in Older Adults after Acute Coronary Syndrome

Background and Objectives: The world’s population is rapidly aging, and it is estimated that, by 2050, every sixth person on earth will be older than 65 years. Around 30% of older adults entering cardiac rehabilitation (CR) meet the criteria of frailty. Frailty identification has not been included in the routine evaluation of CR patients yet, and there is a lack of evidence on what training regimen for improving physical performance in frail people is optimal. Therefore, the aim of our study was to determine the prevalence of frailty and to evaluate the effect of two different complementary training programs on the gait speed of older vulnerable and frail patients with acute coronary syndrome and mid-range-to-preserved left ventricular ejection fraction (≥40%) during short-term CR. Materials and Methods: This randomized controlled trial was conducted from January 2020 to September 2021. CR participants (n = 97) with a mean age of 73.1 ± 5.3 years were randomly allocated into three groups: control (CG, n = 32), intervention-1 (IG-1, n = 32) and intervention-2 (IG-2, n = 33). The patients of all three groups attended a usual inpatient CR program, and two intervention groups additionally received different resistance and balance training programs 3 days a week: the IG-1 underwent complementary training with traditional means of physical therapy, while the IG-2 underwent complementary training with mechanical devices. The mean CR duration was 18.9 ± 1.7 days. Frailty was assessed with the Edmonton Frail Scale, and the 5 m walk test was used to evaluate gait speed. Results: Frailty was determined in 37.1% of participants, and 42.3% met the criteria of being vulnerable. After CR, the gait speed of frail and vulnerable patients significantly improved in all three groups (p < 0.05). In the IG-2, slow gait speed was reversed to normal in the overwhelming majority of patients (p < 0.05), while the CG had the greatest proportion of patients who remained to be slow after CR (p < 0.05). Conclusions: A considerable part of patients entering CR are frail or vulnerable; therefore, it is of crucial importance to assess frailty status in all older people. All three CR programs improved gait speed in frail and vulnerable older patients with ischemic heart disease. Complementary resistance and balance training with mechanical devices more effectively reversed slow gait speed to normal during short-term CR.

Prevalence and risk factors of preoperative malnutrition risk in older patients and its impact on surgical outcomes: a retrospective observational study

PURPOSE

Elderly patients are vulnerable to malnutrition and we have started systematic screening for preoperative malnutrition risk in our institution. This study aims to determine the prevalence and risk factors of preoperative malnutrition risk among elderly surgical patients, and its impact on surgical outcomes.

METHODS

In this retrospective cohort study of patients ≥ 65 yr old undergoing elective surgery, we recorded demographics, medications, preoperative effort tolerance, Malnutrition Universal Screening Tool (MUST) score, American Society of Anesthesiologists physical status (ASA), Charlson Comorbidity Index (CCI), and Edmonton Frailty Score (EFS). Postoperative complications based on the Clavien-Dindo (CD) classification and hospital length of stay (LOS) were also recorded.

RESULTS

Of the 1,033 patients studied, 123 (11.9%) were at risk of malnutrition (MUST ≥ 1), with 48 (4.6%) at high risk (MUST ≥ 2). Unadjusted predictors for high malnutrition risk included ASA ≥ III, higher EFS, higher CCI, polypharmacy (≥ ten medications), poor effort tolerance (metabolic equivalent of tasks < 3), malignancy, general surgery patients, and lower hemoglobin. These patients had higher odds of CD grade ≥ 1 complications compared with those without risk (adjusted odds ratio, 2.30; 95% confidence interval [CI], 1.11 to 4.78; P = 0.025) and 22% longer hospital LOS (adjusted incidence rate ratio,1.22; 95% CI, 1.00 to 1.49; P = 0.049) after multivariate adjustment for sex, severity of surgery, comorbidities, frailty, malignancy, and anemia.

CONCLUSION

Preoperative malnutrition risk is prevalent among the elderly. Patients at high malnutrition risk have increased risk of postoperative complications and longer hospital LOS. Patients with high comorbidity burden and frailty should be screened for malnutrition so that nutritional optimization can be sought.

Role of Cachexia and Fragility in the Patient Candidate for Cardiac Surgery

Frailty is the major expression of accelerated aging and describes a decreased resistance to stressors, and consequently an increased vulnerability to additional diseases in elderly people. The vascular aging related to frail phenotype reflects the high susceptibility for cardiovascular diseases and negative postoperative outcomes after cardiac surgery. Sarcopenia can be considered a biological substrate of physical frailty. Malnutrition and physical inactivity play a key role in the pathogenesis of sarcopenia. We searched on Medline (PubMed) and Scopus for relevant literature published over the last 10 years and analyzed the strong correlation between frailty, sarcopenia and cardiovascular diseases in elderly patient. In our opinion, a right food intake and moderate intensity resistance exercise are mandatory in order to better prepare patients undergoing cardiac operation.