The 5-Factor Modified Frailty Index in the Geriatric Surgical Population

Impact of Controlled Versus Uncontrolled mFI-5 Frailty on Perioperative Complications After Adult Spinal Deformity Surgery

STUDY DESIGN

Retrospective review.

OBJECTIVES

We substratified the mFI-5 frailty index to reflect controlled and uncontrolled conditions and assess their relationship to perioperative complications.

SUMMARY OF BACKGROUND DATA

Risk assessment before adult spinal deformity (ASD) surgery is critical because the surgery is highly invasive with a high complication rate. Although frailty is associated with risk of surgical complications, current frailty measures do not differentiate between controlled and uncontrolled conditions.

METHODS

Frailty was calculated using the mFI-5 index for 170 ASD patients with fusion of ≥5 levels. Uncontrolled frailty was defined as blood pressure >140/90 mm Hg, HbA1C >7% or postprandial glucose >180 mg/dL, or recent chronic obstructive pulmonary disease (COPD) exacerbation, while on medication. Patients were divided into nonfrailty, controlled frailty, and uncontrolled frailty cohorts. The primary outcome measure was perioperative major and wound complications. Bivariate analysis was performed. Multivariable analysis assessed the relationship between frailty and perioperative complications.

RESULTS

The cohorts included 97 nonfrail, 54 controlled frail, and 19 uncontrolled frail patients. Compared with nonfrail patients, patients with uncontrolled frailty were more likely to have age older than 60 years (84% vs. 24%), hyperlipidemia (42% vs. 20%), and Oswestry Disability Index (ODI) score >42 (84% vs. 52%) ( P <0.05 for all). Controlled frailty was associated with those older than 60 years (41% vs. 24%) and hyperlipidemia (52% vs. 20%) ( P <0.05 for all). On multivariable regression analysis controlling for hyperlipidemia, functional independence, motor weakness, ODI>42, and age older than 60 years, patients with uncontrolled frailty had greater odds of major complications (OR 4.24, P =0.03) and wound complications (OR 9.47, P =0.046) compared with nonfrail patients. Controlled frailty was not associated with increased risk of perioperative complications ( P >0.05 for all).

CONCLUSIONS

Although patients with uncontrolled frailty had higher risk of perioperative complications compared with nonfrail patients, patients with controlled frailty did not, suggesting the importance of controlling modifiable risk factors before surgery.

LEVEL OF EVIDENCE

3.

Elective Surgery Trends and Outcomes of Nonagenarians and Centenarians in Otolaryngology-Head and Neck Surgery: A NSQIP Study

OBJECTIVE

To describe types and outcomes of elective otolaryngological surgeries undergone by patients ≥90 years of age and to assess whether very old age is an independent risk factor for postsurgical complications and death.

METHODS

The National Surgical Quality Improvement Program, a validated national prospective surgical outcomes database, was used to identify all patients aged 65 years and older who underwent elective otolaryngological procedures from 2011 to 2020. Study outcomes included minor complications, major life-threatening complications, and 30-day mortality. Predictors of outcomes, including frailty, were identified using univariable analyses and age was added into the final logistic regression models with stepwise selection.

RESULTS

A total of 40,723 patients met inclusion criteria; 629 (1.5%) patients were ≥90 years of age. Of the 63,389 procedures, head and neck (67.6%) and facial plastics and reconstructive (15.0%) procedures were most common. The overall incidence of major life-threatening complications, minor complications, and death was 2.0%, 3.5%, and 0.4%, respectively. Age ≥90 was significantly associated with an increased risk for 30-day mortality, but not with major or minor postoperative complications. A high modified frailty index was significantly associated with an increased risk for major postoperative complications and death amongst patients ≥90 years.

CONCLUSIONS

Elective otolaryngological surgery can be safe in relatively healthy nonagenarians and centenarians, though there is a small increased risk of 30-day mortality. Although older age can predispose patients to other comorbidities, age alone should not deter surgeons and patients from considering elective otolaryngological procedures. Frailty may be a better predictor for surgical outcomes.

LEVEL OF EVIDENCE

IV Laryngoscope, 134:3989-3996, 2024.

Utility of the mFI-5 as a predictor of post-operative outcomes following gastrectomy for gastric cancer: an ACS-NSQIP analysis

BACKGROUND

Gastric cancer is the 5th most common malignancy worldwide. Surgical treatment for the disease can often be highly morbid, especially in elderly patients. The modified 5-item frailty index (mFI-5), a recently developed tool for assessing patient frailty, has been shown to be an effective predictor of post-operative outcomes in various surgical fields. This study aims to assess the utility of the mFI-5 in predicting adverse postoperative outcomes following gastrectomy for gastric cancer.

METHODS

The National Surgical Quality Improvement Program (NSQIP) database was queried for patients who underwent partial or total gastrectomy for gastric cancer between 2011 and 2021. The mFI-5 score was calculated based on the presence of hypertension, congestive heart failure, diabetes mellitus, chronic obstructive pulmonary disease, and partially or fully dependent functional status. Patients were stratified into 3 groups according to mFI-5 score (mFI-5 = 0, mFI-5 = 1, mFI-5 ≥ 2). Univariate analysis and multivariate logistic regression were used to evaluate the association between mFI-5 score and post-operative outcomes.

RESULTS

7438 patients were identified (mFI-5 = 0: 3032, mFI-5 = 1: 2805, mFI-5 ≥ 2: 1601). mFI-5 ≥ 2 was an independent predictor of overall complications (OR 1.43, p < 0.001), serious complications (OR 1.42, p < 0.001), pneumonia (OR 1.43, p = 0.010), MI (OR 2.91, p = 0.005), and readmission within 30 days (OR 1.33, p = 0.008). Patients with higher frailty were more likely to experience unplanned intubation (OR 2.06, p < 0.001; OR 2.47, p < 0.001), failure to wean from the ventilator (OR 1.68, p = 0.003; OR 2.00, p < 0.001), acute renal failure (OR 3.25, p = 0.003; OR 3.27, p = 0.005), 30-day mortality (OR 1.73, p = 0.009; OR 1.94, p = 0.004), and non-home discharge (OR 1.34, p = 0.001; OR 1.74, p < 0.001) relative to non-frail patients.

CONCLUSION

Higher frailty, as indicated by an increased mFI-5 score, raises the risk of serious post-operative complications in patients with gastric cancer undergoing gastrectomy. The mFI-5 has the potential to help identify high-risk patients and enhance pre-operative discussions and optimization.

Prevalence and impact of frailty in patients undergoing colorectal cancer surgery: A systematic review and meta-analysis based on modified frailty index

Frailty has been linked to unfavorable postoperative outcomes in patients with colorectal cancer (CRC). However, the prevalence of frailty among CRC surgery patients and its association with mortality and postoperative complications, as evaluated by the modified frailty index (mFI), have not been thoroughly investigated and necessitate clarification. PubMed, Web of Science, Embase, and CBM databases were systematically searched for relevant studies (up to January 2024), and the pooled prevalence and odds ratio (OR) estimate were calculated. A total of 16 studies containing 245 747 patients undergoing CRC surgery were included. The prevalence of frailty among CRC surgery patients was 31% (95% confidence interval [CI] = 20%-42%; I2 = 100%, p < 0.001). In patients undergoing CRC surgery, frailty was associated with a higher incidence of postoperative complications (OR = 1.94; 95% CI = 1.47-2.56; I2 = 91.9%, p < 0.001), but it did not exhibit any significant correlation with the 30-day mortality (OR = 5.17; 95% CI = 0.39-68.64; I2 = 94.4%, p < 0.001). Frailty is common in CRC surgery and exerts a significant negative impact on the postoperative outcomes. Future research could explore the potential of the mFI to facilitate a more streamlined and precise quantification of frailty, thereby establishing a refined understanding of its correlation with surgery prognosis.

The impact of frailty on facial nerve recovery following Bell's palsy

OBJECTIVES

Patients with Bell's palsy, the sudden onset of facial paralysis, have variable recovery. Frailty has been recognized as an important factor in predicting recovery. This study investigated the relationship between frailty and facial nerve recovery in Bell's palsy patients.

METHODS

A retrospective review was conducted on 95 Bell's palsy patients at a single institution's Department of Otolaryngology from 2014 to 2023. A clinically relevant facial nerve recovery was defined as a House-Brackmann (HB) score decrease>1 between the initial and most recent visit. Patients without follow-up visits or initial HB scores <3 were excluded. Frailty was measured by modified frailty index-5 (mFI-5) at the time of Bell's palsy diagnosis. Elderly patients were those over 65 years at presentation (n = 29). Frail patients had mFI-5 > 1 (n = 8). Chi-squared analyses, Fisher's exact tests, and logistic regression models were conducted in SPSS.

RESULTS

The analytic sample included 95 patients (median age = 56.8 years, IQR = 24.1) presenting with an initial HB score > 2. 36 % of patients' HB scores decreased by ≥2 within the follow-up period. Frailty (unadjusted Odds Ratio (OR) = 6.3, 95 % CI = [1.2, 33.1], p = .023) was associated with facial nerve recovery while age was not (unadjusted OR = 1.07, 95 % CI = [0.44, 2.59], p = .889). The mFI-5 adjusted OR was 8.43 (95 % CI = [1.38, 51.4], p = .021) when adjusting for age, gender, treatment modality, access to care, and follow-up duration in a logistic regression.

CONCLUSIONS

Frailty correlated with enhanced facial nerve recovery after Bell's palsy in this cohort; age was not significantly associated. Further investigation into factors associated with frailty, including increased surveillance and treatment frequency, is warranted.

Patience is key: Association of surgical timing with clinical outcomes in elderly patients with sigmoid volvulus

BACKGROUND

Current guidelines for sigmoid volvulus recommend endoscopy as a first line of treatment for decompression, followed by colectomy as early as possible. Timing of the latter varies greatly. This study compared early (≤2 days) versus delayed (>2 days) sigmoid colectomy.

METHODS

2016-2019 NRD database was queried to identify patients aged ≥65 years admitted for sigmoid volvulus who underwent sequential endoscopic decompression and sigmoid colectomy. Outcomes included mortality, complications, hospital length of stay, readmissions, and hospital costs.

RESULTS

842 patients were included, of which 409 (48.6 ​%) underwent delayed sigmoid colectomy. Delayed sigmoid colectomy was associated with reduced cardiac complications (1.1 ​% vs 0.0 ​%, p ​= ​0.045), reduced ostomy rate (38.3 ​% vs 29.4 ​%, p ​= ​0.013), an increased overall length of stay (12 days vs 8 days, p ​< ​0.001) and increased overall costs (27,764 dollar vs. 24,472 dollar, p ​< ​0.001).

CONCLUSION

In geriatric patient with sigmoid volvulus, delayed surgical resection after decompression is associated with reduced cardiac complications and reduced ostomy rate, while increasing overall hospital length of stay and costs.

Frailty in inflammatory bowel disease: analysis of the National Inpatient Sample 2015-2019

AIM

Preoperative frailty has been associated with adverse postoperative outcomes in various populations, but of its use in patients with inflammatory bowel disease (IBD) remains sparse. The present study aimed to characterize the impact of frailty, as measured by the modified frailty index (mFI), on postoperative clinical and resource utilization outcomes in patients with IBD.

METHODS

This retrospective population-based cohort study assessed patients from the National Inpatient Sample database from 1 September 2015 to 31 December 2019. Corresponding International Classification of Diseases 10th Revision Clinical Modification codes were used to identify adult patients (>18 years of age) with IBD, undergoing either small bowel resection, colectomy or proctectomy. Patient demographics and institutional data were collected for each patient to calculate the 11-point mFI. Patients were categorized as either frail or robust using a cut-off of 0.27. Primary outcomes were postoperative in-hospital morbidity and mortality, whilst secondary outcomes included system-specific morbidity, length of stay, in-hospital healthcare costs and discharge disposition. Logistic and linear regression models were used for primary and secondary outcomes.

RESULTS

Overall, 7144 patients with IBD undergoing small bowel resection, colectomy or proctectomy were identified, 337 of whom were classified as frail (i.e., mFI < 0.27). Frail patients were more likely to be women, older, have lower income and a greater number of comorbidities. After adjusting for relevant covariates, frail patients were at greater odds of in-hospital mortality (adjusted odds ratio [aOR] 5.42, 95% CI 2.31-12.77, P < 0.001), overall morbidity (aOR 1.72, 95% CI 1.30-2.28, P < 0.001), increased length of stay (adjusted mean difference 1.3 days, 95% CI 0.09-2.50, P = 0.035) and less likely to be discharged to home (aOR 0.59, 95% CI 0.45-0.77, P < 0.001) compared to their robust counterparts.

CONCLUSIONS

Frail IBD patients are at greater risk of postoperative mortality and morbidity, and reduced likelihood of discharge to home, following surgery. This has implications for clinicians designing care pathways for IBD patients following surgery.

Comparison of three frailty scales for prediction of prolonged postoperative ileus following major abdominal surgery in elderly patients: a prospective cohort study

BACKGROUND

To determine whether frailty can predict prolonged postoperative ileus (PPOI) in older abdominal surgical patients; and to compare predictive ability of the FRAIL scale, the five-point modified frailty index (mFI-5) and Groningen Frailty Indicator (GFI) for PPOI.

METHODS

Patients (aged ≥ 65 years) undergoing major abdominal surgery at our institution between April 2022 to January 2023 were prospectively enrolled. Frailty was evaluated with FRAIL, mFI-5 and GFI before operation. Data on demographics, comorbidities, perioperative management, postoperative recovery of bowel function and PPOI occurrence were collected.

RESULTS

The incidence of frailty assessed with FRAIL, mFI-5 and GFI was 18.2%, 38.4% and 32.5% in a total of 203 patients, respectively. Ninety-five (46.8%) patients experienced PPOI. Time to first soft diet intake was longer in patients with frailty assessed by the three scales than that in patients without frailty. Frailty diagnosed by mFI-5 [Odds ratio (OR) 3.230, 95% confidence interval (CI) 1.572-6.638, P = 0.001] or GFI (OR 2.627, 95% CI 1.307-5.281, P = 0.007) was related to a higher risk of PPOI. Both mFI-5 [Area under curve (AUC) 0.653, 95% CI 0.577-0.730] and GFI (OR 2.627, 95% CI 1.307-5.281, P = 0.007) had insufficient accuracy for the prediction of PPOI in patients undergoing major abdominal surgery.

CONCLUSIONS

Elderly patients diagnosed as frail on the mFI-5 or GFI are at an increased risk of PPOI after major abdominal surgery. However, neither mFI-5 nor GFI can accurately identify individuals who will develop PPOI.

TRIAL REGISTRATION

This study was registered in Chinese Clinical Trial Registry (No. ChiCTR2200058178). The date of first registration, 31/03/2022, https://www.chictr.org.cn/ .

Predictive performance of different measures of frailty (CFS, mFI-11, mFI-5) on postoperative adverse outcomes among colorectal cancer patients: a diagnostic meta-analysis

PURPOSE

To clarify the predictive performance of different measures of frailty, including Clinical Frailty Scale (CFS), 11-factor modified Frailty Index (mFI-11), and 5-factor modified Frailty Index (mFI-5), on adverse outcomes.

METHODS

PubMed, Embase, Web of Science, and other databases were retrieved from the inception of each database to June 2023. The pooled sensitivity, specificity, and the area under the summary receiver operating curve (SROC) values were analyzed to determine the predictive power of CFS, mFI-11, and mFI-5 for adverse outcomes.

RESULTS

A total of 25 studies were included in quantitative synthesis. The pooled sensitivity values of CFS for predicting anastomotic leakage, total complications, and major complications were 0.39, 0.57, 0.45; pooled specificity values were 0.70, 0.58, 0.73; the area under SROC values were 0.58, 0.6, 0.66. The pooled sensitivity values of mFI-11 for predicting total complications and delirium were 0.38 and 0.64; pooled specificity values were 0.83 and 0.72; the area under SROC values were 0.64 and 0.74. The pooled sensitivity values of mFI-5 for predicting total complications, 30-day mortality, and major complications were 0.27, 0.54, 0.25; pooled specificity values were 0.82, 0.84, 0.81; the area under SROC values were 0.63, 0.82, 0.5.

CONCLUSION

The results showed that CFS could predict anastomotic leakage, total complications, and major complications; mFI-11 could predict total complications and delirium; mFI-5 could predict total complications and 30-day mortality. More high-quality research is needed to support the conclusions of this study further.

Predictors of non-home discharge after pancreatoduodenectomy in patients aged 80 years and above

BACKGROUND

Pancreatic cancer has the highest growth in incidence among patients aged ≥80 years. Discharge destination after hospitalization is increasingly recognized as a marker of return to baseline functional status. Our aim was to identify the preoperative and intraoperative predictors of non-home discharge in those aged 80 or older.

METHODS

The ACS-NSQIP pancreas-targeted database was queried to identify patients aged ≥80 years who underwent pancreatoduodenectomy (PD) from 2014 to 2020. Home discharge (HD) versus non-HD cohorts were compared using univariate logistic regression. Multivariable logistic regression was used to identify predictors of non-HD.

RESULTS

Non-HD was over twice as likely to occur in patients aged ≥80 years than in those aged 65-79 years (p < 0.01). Comorbidity factors significantly associated with non-HD in patients aged ≥80 years included COPD, hypertension, HF, lower preoperative albumin, but not obesity. Non-comorbidity factors included older age, female gender, ASA III-IV, preoperative dependent functional status, and transfer origin before PD.

CONCLUSION

Individuals ≥80 years have possibly delayed or lower rate of return to baseline functional status following PD compared to those aged 65-79 years. Predictors of non-HD can be identified to facilitate preoperative counseling and discharge planning, thus enhancing care workflow efficiency.

Association between frailty and clinical outcomes in patients undergoing craniotomy-systematic review and meta-analysis of observational studies

BACKGROUND

Frailty in patients undergoing craniotomy may affect perioperative outcomes. There have been a number of studies published in this field; however, evidence is yet to be summarized in a quantitative review format. We conducted a systematic review and meta-analysis to examine the effects of frailty on perioperative outcomes in patients undergoing craniotomy surgery.

METHODS

Our eligibility criteria included adult patients undergoing open cranial surgery. We searched MEDLINE via Ovid SP, EMBASE via Ovid SP, Cochrane Library, and grey literature. We included retrospective and prospective observational studies. Our primary outcome was a composite of complications as per the Clavien-Dindo classification system. We utilized a random-effects model of meta-analysis. We conducted three preplanned subgroup analyses: patients undergoing cranial surgery for tumor surgery only, patients undergoing non-tumor surgery, and patients older than 65 undergoing cranial surgery. We explored sources of heterogeneity through a sensitivity analysis and post hoc analysis.

RESULTS

In this review of 63,159 patients, the pooled prevalence of frailty was 46%. The odds ratio of any Clavien-Dindo grade 1-4 complication developing in frail patients compared to non-frail patients was 2.01 [1.90-2.14], with no identifiable heterogeneity and a moderate level of evidence. As per GradePro evidence grading methods, there was low-quality evidence for patients being discharged to a location other than home, length of stay, and increased mortality in frail patients.

CONCLUSION

Increased frailty was associated with increased odds of any Clavien-Dindo 1-4 complication. Frailty measurements may be used as an integral component of risk-assessment strategies to improve the quality and value of neurosurgical care for patients undergoing craniotomy surgery.

ETHICS AND DISSEMINATION

Formal ethical approval is not needed, as primary data were not collected.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO identification number: https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=405240.

Development and clinical application of a tool to identify frailty in elderly patients with gynecological cancers

OBJECTIVE

Frailty is more reliable than chronological age in predicting the effectiveness and tolerability of treatments in cancer patients. An increasing number of screening tools have been proposed, however none have received unanimous consent or been specifically designed for women with gynecological malignancies.This study's aim was to develop a clinical application of a screening tool to identify frail patients >70 years old diagnosed with either ovarian or endometrial cancers.

METHODS

A 20 item questionnaire was developed and administered to the cohort before surgery or neoadjuvant chemotherapy. A cut-off for frailty definition was determined by analyzing the correlation of questionnaire scores with the completion of treatments. The association between frailty and treatment related complications was assessed using a Chi-squared test for categorical variables and a t-test for continuous variables.

RESULTS

Our study included 100 patients, 50% diagnosed with endometrial cancer and 50% with ovarian cancer. A questionnaire score of 4 was the best cut-off for frailty definition (sensitivity 77%, specificity 100%). Surgical grade III and grade IV complications were observed only in frail patients (p=0.01) and hospitalization was significantly longer in frail women affected by ovarian cancer (p=0.01). Frail patients were more exposed to chemotherapy administration delay (p=0.0005), treatment discontinuation (p=0.001) and hematological toxicities, especially anemia ≥grade 2 (p=0.009) and thrombocytopenia any grade (p=0.0001).

CONCLUSION

With a cut-off score of 4, our tool can identify frail patients with significantly higher incidence of grade III-IV postoperative complications, length of stay, medical treatment discontinuation rates and hematological toxicities.

Transfusion futility thresholds and mortality in geriatric trauma: Does frailty matter?

BACKGROUND

Data on massive transfusion (MT) in geriatric trauma patients is lacking. This study aims to determine geriatric transfusion futility thresholds (TT) and TT variations based on frailty.

METHODS

Patients from 2013 to 2018 TQIP database receiving MT were stratified by age and frailty. TTs and outcomes were compared between geriatric and younger adults and among geriatric adults based on frailty status.

RESULTS

The TT was lower for geriatric than younger adults (34 vs 39 units; p ​= ​0.03). There was no difference in TT between the non-frail, frail, and severely frail geriatric adults (37, 30 and 25 units, respectively, p ​> ​0.05). Geriatric adults had higher mortality than younger adults (63.1% vs 45.8%, p < 0.01). Non-frail geriatric adults had the highest mortality (69.4% vs 56.5% vs 56.2%, p < 0.01).

CONCLUSIONS

Geriatric patients have a lower TT than younger adults, irrespective of frailty. This may help improve outcomes and optimize MT utilization.

Association of Age and Frailty With 30-Day Outcomes Among Patients Undergoing Oral Cavity Cancer Surgery

OBJECTIVE

To evaluate the impact of age and frailty on 30-day outcomes following surgery for oral squamous cavity carcinoma (OSCC).

STUDY DESIGN

Retrospective cross-sectional analysis.

SETTING

American College of Surgeons' National Quality Improvement Program (NSQIP) database.

METHODS

Patients who underwent OSCC resection were queried via NSQIP (2015-2020). Cases were stratified by age (18-65, 65-75, and older than 75) as well as by modified frailty index scores (mFI 0, mFI 1, and mFI 2+) for comparative analyses. Univariate and multivariable analyses were conducted to examine demographics, perioperative outcomes, and 30-day postoperative adverse events.

RESULTS

A total of 3238 patients who underwent OSCC surgery were identified and categorized as nongeriatric ("NGA," age 18-65), younger geriatric ("YGA," age 65-75), and older geriatric ("OGA," age >75) adults. Compared to NGA, geriatric patients had higher the American Society of Anesthesiologists classification, higher modified frailty index scores, and more comorbidities such as hypertension, congestive heart failure, chronic obstructive disease, and diabetes (p < .001). YGAs and OGAs were also less likely to undergo neck dissection (p < .001), composite resection (p = .006), and free flap reconstruction compared to NGAs (p < .001). When controlling for confounders, age was not independently associated with an increased risk of poor outcomes. On the other hand, frailty was found to be independently associated with a higher risk of adverse events (odds ratio: 1.40 [1.15-1.70], p < .001 for mFI 1, odds ratio: 1.45 [1.04-2.02], p = .027 for mFI 2+).

CONCLUSION

A higher mFI score, not older age, is associated with an increased risk of 30-day complications following OSCC surgery.

Five-factors Modified Frailty Index role as predictors of outcomes after proximal abdominal aortic aneurysms

BACKGROUND

The aim of the study was to evaluate the correlation between frailty, measured by the Five-Factor Modified Frailty Index (mFI-5) and mortality and all major adverse events (MAE) in patients who underwent proximal abdominal aortic aneurysm (p-AAA) open surgery (OS).

METHODS

Data of all elective patients submitted to p-AAA OS from 2010 to 2021 were recorded. Primary endpoints were 30-day mortality and mid-term survival and secondary endpoints included postoperative acute kidney injury (AKI), freedom from aortic reintervention and any MAE. The impact of frailty was assessed by univariate and multivariate analysis; mid-term overall survival were estimated using Kaplan-Meier method (log-rank test).

RESULTS

Two-hundred twenty-one patients (197 male, 24 female; aged 72.2±7.4) were included. Thirty-seven (16.4%) were octogenarians (>80 years). The mFI-5 was assessed in the entire group: mean mFI-5 was 0.29±0.12. One-hundred patients (100/221, 45.25%, 91:9 male-to-female ratio) were defined "frail" considering the mFI-5 cut-off >0.25. At univariate analysis a correlation was found between mFI-5>0.25 and mid-term mortality (Pearson correlation [r] 0.280, P<0.001) and AKI (r=0.146, P=0.030). No correlation with 30-day mortality was found (P not significant). At multivariate analysis mFI-5>0.25 increased the risk for midterm mortality (odds ratio 3.32, P=0.021) and postoperative AKI (OR 2.09, P<0.001). The effect of mFI-5>0.25 on mid-term mortality persisted after adjustment for age (P<0.001). Survival was estimated with Kaplan-Meyer method (mean follow-up of 52.7 months, 95% CI: 48.6-56.8); 68 (30.7%) deaths were recorded: 23 among non-frail patients (19.0%) and 45 among frail patients (45/100, 45%, P<0.001).

CONCLUSIONS

These findings suggest that mFI-5 is a tool capable to identify "frail" patients, who appear to be at increased risk of postoperative AKI and mid-term mortality, but not 30-day mortality. Five-factor modified Frailty Index assessment is simple, fast and can be widely applied in surgical practice to perform appropriate risk stratifications.

The 5-factor modified frailty index is a novel predictive marker of death from other diseases after curative gastrectomy for gastric cancer

AIM

The 5-factor modified frailty index (MFI-5) is a stratification tool to evaluate a patient's frailty. This study determined whether the MFI-5 is associated with short- and long-term outcomes after curative gastrectomy in patients with gastric cancer.

METHODS

We retrospectively reviewed 447 consecutive patients who underwent curative gastrectomy, and evaluated their overall survival (OS), relapse-free survival (RFS) and cancer-specific survival.

RESULTS

A total of 75 patients (16.8%) had high MFI-5 scores (MFI-5 ≥3). A high MFI-5 score was significantly associated with advanced age, male sex and severe postoperative complications. Patients with high MFI-5 scores had significantly poorer OS and RFS than those with low MFI-5 scores (5-year OS, 80.3% vs 59.7%, P < 0.01; 5-year RFS, 77.4% vs 54.9%, P < 0.01). Additionally, a high MFI-5 score was an independent predictor for OS (hazard ratio 1.69, 95% CI 1.09-2.61; P = 0.02) and RFS (hazard ratio, 1.80, 95% CI 1.19-2.74; P = 0.01). However, cancer-specific survival was not significantly different between the two groups.

CONCLUSIONS

The MFI-5 score can be predictive of postoperative morbidity and deaths from other disease after curative gastrectomy after curative gastrectomy for gastric cancer. Geriatr Gerontol Int 2023; 23: 750-756.

Older age impacts outcomes after adrenalectomy

BACKGROUND

Adrenalectomy is well tolerated with low complication rates. It is unclear if these excellent outcomes are consistent across all age groups.

METHODS

The 2015-2020 American College of Surgeons National Surgical Quality Improvement Program datasets were used. Patients who underwent adrenalectomy were identified and grouped based on age: ≤60, 61 to 70, 71 to 80, and >80 years. Patient characteristics, surgical indications, operative characteristics, and postoperative outcomes were compared between age groups. Primary outcome measures were mortality, morbidity, postoperative length of stay, non-home discharge, and unplanned readmission. Multivariable logistic regression analysis was performed.

RESULTS

Adrenalectomy was performed on 6,114 patients. Younger patients more frequently had surgery for non-functional benign neoplasms compared with older (55.7% vs 52.8% vs 45.9% vs 45.3%, for patients ≤60, 61 to 70, 71 to 80, and >80 years, respectively, P < .001), and less frequently had surgery for malignancy (8.8% vs 14.4% vs 22.5% vs 24.5%, P < .001). The median length of stay for patients ≤60 was 1 day compared with 2 days for patients 61-70, 71-80, and >80 (P < .001). The overall mortality rate was <1% and did not differ based on age (P = .18). Morbidity occurred less frequently in the younger age groups (7.3% vs 8.9% vs 11.2% vs 16.0%, P < .001) compared with older. Similar trends were seen for non-home discharge (1.4% vs 2.5% vs 4.8% vs 17.0%, P < .001). On multivariable analysis, patients aged >80 had a 2-fold increased likelihood of morbidity and a 9-fold increased likelihood of non-home discharge compared to patients aged ≤60.

CONCLUSION

Older age is associated with morbidity and non-home discharge after adrenalectomy. Knowledge of these risks is critical when counseling an aging surgical population.

Application of MFI-5 in severe complications and unfavorable outcomes after radical resection of colorectal cancer

BACKGROUND

Frailty is considered a characteristic manifestation of physiological decline in multiple organ systems, which significantly increases the vulnerability of elderly individuals with colorectal cancer (CRC) and is associated with a poor prognosis. While studies have demonstrated that the 11-factor Modified Frailty Index (mFI-11) can effectively predict adverse outcomes following radical resection of CRC, there is a lack of research on the applicability of the 5-factor Modified Frailty Index (mFI-5) within this patient population.

METHODS

In this retrospective analysis, we examined a cohort of CRC patients aged 65 years and above who had undergone radical resection. For each patient, we calculated their mFI-5 score, considering a score of ≥ 2 as an indication of frailty. We conducted univariate and multivariate analyses to assess the association between the mFI-5 and adverse outcomes as well as postoperative complications.

RESULTS

Patients with an mFI-5 score ≥ 2 exhibited a significantly higher incidence of serious postoperative complications (53% vs. 30%; P = 0.001) and experienced a longer hospital stay [19.00 (15.00-24.50) vs. 17.00 (14.00-20.00); P < 0.05]. Notably, an mFI-5 score greater than 2 emerged as an independent risk factor for severe postoperative complications (odds ratio: 2.297; 95% confidence interval: 1.216 to 4.339; P = 0.01). Furthermore, the mFI-5 score displayed predictive capabilities for severe postoperative complications with an area under the receiver operating characteristic (ROC) curve of 0.629 (95% confidence interval: 0.551 to 0.707; P < 0.05).

CONCLUSION

The mFI-5 demonstrates a high level of sensitivity in predicting serious complications, prolonged hospital stays, and mortality following radical resection of colorectal carcinoma. As a practical clinical assessment tool, the mFI-5 enables the identification of high-risk patients and facilitates preoperative optimization.

Predictive Ability of Comorbidity Indices for Surgical Morbidity and Mortality: a Systematic Review and Meta-analysis

BACKGROUND

Several contemporary risk stratification tools are now being used since the development of the Charlson Comorbidity Index (CCI) in 1987. The purpose of this systematic review and meta-analysis was to compare the utility of commonly used co-morbidity indices in predicting surgical outcomes.

METHODS

A comprehensive review was performed to identify studies reporting an association between a pre-operative co-morbidity measurement and an outcome (30-day/in-hospital morbidity/mortality, 90-day morbidity/mortality, and severe complications). Meta-analysis was performed on the pooled data.

RESULTS

A total of 111 included studies were included with a total cohort size 25,011,834 patients. The studies reporting the 5-item Modified Frailty Index (mFI-5) demonstrated a statistical association with an increase in the odds of in-hospital/30-day mortality (OR:1.97,95%CI: 1.55-2.49, p < 0.01). The pooled CCI results demonstrated an increase in the odds for in-hospital/30-day mortality (OR:1.44,95%CI: 1.27-1.64, p < 0.01). Pooled results for co-morbidity indices utilizing a scale-based continuous predictor were significantly associated with an increase in the odds of in-hospital/30-day morbidity (OR:1.32, 95% CI: 1.20-1.46, p < 0.01). On pooled analysis, the categorical results showed a higher odd for in-hospital/30-day morbidity (OR:1.74,95% CI: 1.50-2.02, p < 0.01). The mFI-5 was significantly associated with severe complications (Clavien-Dindo ≥ III) (OR:3.31,95% CI:1.13-9.67, p < 0.04). Pooled results for CCI showed a positive trend toward severe complications but were not significant.

CONCLUSION

The contemporary frailty-based index, mFI-5, outperformed the CCI in predicting short-term mortality and severe complications post-surgically. Risk stratification instruments that include a measure of frailty may be more predictive of surgical outcomes compared to traditional indices like the CCI.

The Relationship Between Frailty and Functional Outcomes, Range of Motion, and Reoperation After Reverse Total Shoulder Arthroplasty for Proximal Humerus Fracture

The objective of this study was to investigate whether frailty is associated with functional outcomes, motion, and reoperation at a minimum of 2 years after reverse total shoulder arthroplasty (rTSA) for proximal humerus fracture. We performed a retrospective study of 153 patients who underwent rTSA for proximal humerus fracture at two level 1 trauma centers from 2003 to 2018 with minimum 2-year follow-up. Frailty was assessed using the modified 5-item frailty index (mFI). The primary outcome variable was the American Shoulder and Elbow Surgeons (ASES) shoulder score at minimum 2-year follow-up. The secondary outcome variables were the Shoulder Pain and Disability Index (SPADI), the Shoulder Subjective Value (SSV), the 0 to 10 numeric rating scale (NRS) pain score, surgical complication, and reoperation. Bivariate comparisons were made between mFI and outcome variables. The mean age of the 153 patients was 70 years, and 76% were women. Forty patients (26%) had a mFI score of 0, 65 patients (42%) had a mFI score of 1, 40 patients (26%) had a mFI score of 2, and 8 patients (5%) had a mFI score of 3. Twenty-seven patients (18%) had complications, and 21 patients (14%) underwent reoperation. At minimum 2-year follow-up, mFI was not associated with ASES shoulder score, SPADI, SPADI pain or disability subscales, SSV, NRS pain score, active and passive shoulder forward flexion, abduction, and external rotation, complication, or reoperation. Provided they survive the initial physiologic insults of trauma and surgery, patients with higher mFI scores treated with rTSA for proximal humerus fracture can expect similar medium-term restoration of shoulder function. [Orthopedics. 2023;46(5):274-279.].

Evaluation of a commonly used tool: Does the 5-item frailty index predict phenotypic frailty?

BACKGROUND

The simplified frailty index (sFI) is a commonly used instrument to estimate postoperative risk, but its correlation with phenotypic frailty has been questioned. This study evaluates the relationship between sFI and phenotypic frailty, as measured by the Sinai Abbreviated Geriatric Evaluation (SAGE).

METHODS

Charts were retrospectively reviewed from patients ≥75 years old who underwent surgery between 2012-2022. The sFI score was calculated by adding 1 point for hypertension, COPD, congestive heart failure, functional dependence, and diabetes (score 0-5). SAGE was calculated by adding 1 point for normal gait speed, normal Mini-Cog©, and independent activities of daily living (ADL) (0-3). Spearman rank correlation was used to test the relationship between sFI and SAGE. SAGE components were used as binary-dependent outcomes in covariate-adjusted logistic regression modeling to evaluate associations with sFI scores while adjusting for potential confounders.

RESULTS

334 patients were assessed, with a mean age of 84.0. SAGE and sFI scores were significantly associated, with a modest inverse relationship (r=-0.24, p<0.0001). Each 1-point increase in sFI score was associated with increased odds of ADL deficit (OR 2.3, 95%CI [1.5-3.8], p<0.0001) and abnormal gait speed (OR 1.9, 95%CI 1.2-3.0, p<0.01). The sFI score was not associated with deficits in the Mini-Cog (OR 1.5, 95%CI [0.96-2.3], p=0.07).

CONCLUSION

Higher sFI was significantly associated with increased phenotypic frailty, particularly with the loss of physical condition and function but not associated with cognitive deficit. Therefore, sFI may not be an appropriate tool to estimate postoperative complications related to cognition, such as delirium risk.

Update on Perioperative Delirium

A strong association between frailty and in-hospital delirium in nonsurgical patients has been shown. Physical and cognitive frailties have been associated with decline and dysfunction in the frontal cognitive domains. Risk factors for frailty are similar to risk factors for postoperative delirium (POD). Frailty can be screened and diagnosed by various tools and instruments. Different anesthetic techniques have been studied to decrease the incidence of POD. However, no anesthetic technique has been conclusively proven to decrease the risk of POD. Patients with dementia develop delirium more often, and delirium is associated with accelerated cognitive decline.

The five-item modified frailty index predicts long-term outcomes in elderly patients undergoing colorectal cancer surgery

BACKGROUND

Frailty has been globally recognized as a predictor of adverse postoperative outcomes. Frailty assessment using the five-factor modified frailty index (5-mFI) has recently gained traction; however, long-term outcomes are unknown in colorectal cancer (CRC) surgery. This study aimed to investigate whether the 5-mFI predicted long-term survival and cause of death on the basis of frailty severity in elderly patients who underwent CRC surgery and to determine the risk factors for mortality.

METHODS

A total of 299 patients underwent CRC surgery with curative intent between January 2013 and December 2017. Patients were divided into three groups by the 5-mFI score: group 1 (5-mFI: 0 or 1; n = 164): no frailty; group 2 (5-mFI: 2; n = 91): moderate frailty; and group 3 (5-mFI: ≥ 3; n = 44): severe frailty. Clinicopathological variables, namely comorbidities, 5-mFI, prognostic nutrition index, operative/postoperative data, and outcome, including cause of death, were compared between the three groups. To identify factors associated with death from CRC- and non-CRC-related causes, univariate and multivariate analyses using a Cox regression model were performed.

RESULTS

The immediate postoperative morbidity of patients with Clavien-Dindo grade ≥ III complications (9.1%) in group 3 was not significantly different from that in group 1 (9.1%) or group 2 (14.3%); however, the 30-day mortality rate (4.5%) in group 3 was significantly higher. Long-term disease-free survival was similar between frailty groups, suggesting that CRC surgery provides oncological benefit to patients irrespective of frailty. The 5-year survival rates in groups 1, 2, and 3 were 83.5%, 71.2%, and 47.9%, respectively, showing a significantly lower survival rate as frailty advanced. Sixty percent of the deaths in frail patients were due to respiratory failure and cardiovascular diseases. Multivariate analysis demonstrated that advanced age, higher 5-mFI score, and longer postoperative hospital stay were risk factors for mortality unrelated to CRC. Multivariate analysis also revealed that advanced tumor stage, carcinoembryonic antigen ≥ 5 ng/ml, undifferentiated tumor, and R1 resection were risk factors for CRC-related mortality.

CONCLUSIONS

The 5-mFI score can predict postoperative short- and long-term outcomes and risk factors for mortality unrelated to CRC. Additionally, long-term survival was negatively associated with the 5-mFI score.

Impact of Chart-Derived Frailty Index on 1-Year Mortality After Radical Cystectomy in 1004 Patients with Bladder Cancer

BACKGROUND

Radical cystectomy is a major urological procedure with high morbidity and mortality. The chart-derived frailty index (CFI), a measure of preoperative frailty, can be calculated by using demographic and routine laboratory variables. We assessed the impact of CFI on 1-year mortality after radical cystectomy.

METHODS

This retrospective study included patients with bladder cancer who underwent radical cystectomy between 2007 and 2021. The CFI was calculated as the sum of the presence of the following parameters: age > 70 years, body mass index < 18.5 kg/m2, hematocrit < 35%, albumin < 3.4 g/dL, and creatinine > 2.0 mg/dL. Patients were divided into those with low (0-2) and high (3-5) CFI. The 1-year, all-cause and cancer-specific mortalities after radical cystectomy were evaluated.

RESULTS

Of the 1004 patients, 914 (91.0%) had a low CFI and 90 (9.0%) had a high CFI. The 1-year, all-cause mortality in the low and high CFI groups was 12.0% and 27.8%, respectively (P < 0.001). Multivariate Cox regression analysis revealed that high CFI (P < 0.001), tumor stage (P = 0.003), and red blood cell transfusion amount (P < 0.001) were significantly associated with 1-year, all-cause mortality after radical cystectomy. Kaplan-Meier survival analysis demonstrated significantly different 1-year, all-cause and cancer-specific mortalities after radical cystectomy between patients with a high CFI and those with a low CFI (log-rank test, both P < 0.001).

CONCLUSIONS

High CFI is associated with higher 1-year mortality after radical cystectomy, suggesting that the CFI can effectively predict mortality after radical cystectomy.

Baseline frailty status, not advanced patient age, predicts epilepsy surgery outcomes: An analysis of 696 patients from the NSQIP database

OBJECTIVE

Preoperative risk stratification of patients undergoing epilepsy surgery remains challenging. Recently, the efforts to look beyond age alone as an outcomes predictor has resulted in the development of measures of physiological reserve, or 'frailty indices.' The most frequently cited index in neurosurgery is the 11-item or 5-item modified frailty index (mFI11 or mFI-5). The present study aimed to use a large national registry to evaluate the effect of frailty (as measured by mFI-5 versus age on postoperative outcomes of patients undergoing epilepsy surgery.

METHODS

The National Surgical Quality Improvement Program (NSQIP) database, overseen by the American College of Surgeons (ACS), was used to extract data for patients undergoing epilepsy surgery from 2015 to 2019. Univariate and multivariate analyses for age and mFI-5 were performed for the following 30-day outcomes of extended length of hospital stay (eLOS) and non-home discharge (NHD). The effect sizes were summarized by odds ratio and associated 95 % confidence intervals. Receiver operating characteristic (ROC) curve analysis, including area under the curve (AUC), was used to quantify the discrimination.

RESULTS

Univariate and multivariate analyses demonstrated that frailty statuses from mFI-5, not age, were significantly predictive of eLOS and NHD. On ROC curve analysis, mFI-5 was a stronger predictor of eLOS (C = 0.59, 95 % CI 0.54-0.64, p < 0.001) and NHD (C = 0.69, 95 % CI 0.64-0.76, p < 0.001) than age (C = 0.53, 95 % CI 0.48-0.58, p = 0.21 and C = 0.53, 95 % CI 0.46-0.59, p = 0.44, respectively).

CONCLUSION

Frailty, not age, is an independent risk factor for poor postoperative outcomes, particularly eLOS and NHD, in patients undergoing epilepsy surgery. Usage of mFI-5 for preoperative risk stratification of epilepsy surgery patients can help in prognostication.

Comparison of Frailty Indices and the Charlson Comorbidity Index in Traumatic Brain Injury

BACKGROUND

Comorbidity scales for outcome prediction in traumatic brain injury (TBI) include the 5-component modified Frailty Index (mFI-5), the 11-component modified Frailty Index (mFI-11), and the Charlson Comorbidity Index (CCI).

OBJECTIVE

To compare the accuracy in predicting clinical outcomes in TBI of mFI-5, mFI-11, and CCI.

METHODS

The National Trauma Data Bank (NTDB) of the American College of Surgeons (ACS) was utilized to study patients with isolated TBI for the years of 2017 and 2018. After controlling for age and injury severity, individual multivariable logistic regressions were conducted with each of the 3 scales (mFI-5, mFI-11, and CCI) against predefined outcomes, including any complication, home discharge, facility discharge, and mortality.

RESULTS

All 3 scales demonstrated adequate internal consistency throughout their individual components (0.63 for mFI-5, 0.60 for CCI, and 0.56 for mFI-11). Almost all studied complications were significantly more likely in frail patients. mFI-5 and mFI-11 had similar areas under the curve (AUC) for all outcomes, while CCI had lower AUCs (0.62-0.61-0.53 for any complication, 0.72-0.72-0.52 for home discharge, 0.78-0.78-0.53 for facility discharge, and 0.71-0.70-0.52 for mortality, respectively).

CONCLUSION

mFI-5 and mFI-11 demonstrated similar accuracy in predicting any complication, home discharge, facility discharge, and mortality in TBI patients across the NTDB. In addition, CCI's performance was poor for the aforementioned metrics. Since mFI-5 is simpler, yet as accurate as the 2 other scales, it may be the most practical both for clinical practice and for future studies with the NTDB.

Management of Older Patients with Head and Neck Cancer: A Comprehensive Review

The projected increase in life expectancy over the next few decades is expected to result in a rise in age-related diseases, including cancer. Head and neck cancer (HNC) is a worldwide health problem with high rates of morbidity and mortality. In this report, we have critically reviewed the literature reporting the management of older patients with HNC. Older adults are more prone to complications and toxicities secondary to HNC treatment, especially those patients who are frail or have comorbidities. Thus, this population should be screened prior to treatment for such predispositions to maximize medical management of comorbidities. Chronologic age itself is not a reason for choosing less intensive treatment for older HNC patients. Whenever possible, also older patients should be treated according to the best standard of care, as nonstandard approaches may result in increased treatment failure rates and mortality. The treatment plan is best established by a multidisciplinary tumor board with shared decision-making with patients and family. Treatment modifications should be considered for those patients who have severe comorbidities, evidence of frailty (low performance status), or low performance status or those who refuse the recommendations of the tumor board.

Mortality Risks after Two Years in Frail and Pre-Frail Older Adults Admitted to Hospital

BACKGROUND

Frailty is characterized by a progressive decline in the physiological functions of multiple body systems that lead to a more vulnerable condition, which is prone to the development of various adverse events, such as falls, hospitalization, and mortality. This study aims to determine whether frailty increases mortality compared to pre-frailty and to identify variables associated with a higher risk of mortality.

MATERIALS

Two cohorts, frail and pre-frail subjects, are evaluated according to the Fried phenotype. A complete examination of frailty, cognitive status, comorbidities and pharmacology was carried out at hospital admission and was extracted through electronic health record (EHR). Mortality was evaluated from the EHR.

METHODS

Kaplan-Meier estimates of survival probability functions were calculated at two years censoring time for frail and pre-frail cohorts. The log-rank test assessed significant differences between survival probability functions. Significant variables for frailty (p < 0-05) were extracted by independent sample t-test. Further selection was based on variable significance found in multivariate logistic regression discrimination between frail and pre-frail subjects. Cox regression over univariate t-test-selected variables was calculated to identify variables associated with higher proportional hazard risks (HR) at two years.

RESULTS

Frailty is associated with greater mortality at two years censoring time than pre-frailty (log-rank test, p < 0.0001). Variables with significant (p < 0.05) association with mortality identified in both cohorts (HR 95% (CI in the frail cohort) are male sex (0.44 (0.29-0.66)), age (1.05 (1.01-1.09)), weight (0.98 (0.96-1.00)), and use of proton-pump inhibitors (PPIs) (0.60 (0.41-0.87)). Specific high-risk factors in the frail cohort are readmission at 30 days (0.50 (0.33-0.74)), SPPB sit and stand (0.62 (0.45-0.85)), heart failure (0.67 (0.46-0.98)), use of antiplatelets (1.80 (1.19-2.71)), and quetiapine (0.31 (0.12-0.81)). Specific high-risk factors in the pre-frail cohort are Barthel's score (120 (7.7-1700)), Pfeiffer test (8.4; (2.3-31)), Mini Nutritional Assessment (MNA) (1200 (18-88,000)), constipation (0.025 (0.0027-0.24)), falls (18,000 (150-2,200,000)), deep venous thrombosis (8400 (19-3,700,000)), cerebrovascular disease (0.01 (0.00064-0.16)), diabetes (360 (3.4-39,000)), thyroid disease (0.00099 (0.000012-0.085)), and the use of PPIs (0.062 (0.0072-0.54)), Zolpidem (0.000014 (0.0000000021-0.092)), antidiabetics (0.00015 (0.00000042-0.051)), diuretics (0.0003 (0.000004-0.022)), and opiates (0.000069 (0.00000035-0.013)).

CONCLUSIONS

Frailty is associated with higher mortality at two years than pre-frailty. Frailty is recognized as a systemic syndrome with many links to older-age comorbidities, which are also found in our study. Polypharmacy is strongly associated with frailty, and several commonly prescribed drugs are strongly associated with increased mortality. It must be considered that frail patients need coordinated attention where the diverse specialist taking care of them jointly examines the interactions between the diversity of treatments prescribed.

A retrospective study on the relationship between 5 modified frailty index (5-mFI) and postoperative complications of gynecological elderly patients undergoing abdominal surgery

INTRODUCTION

Aim to evaluate the application of 5 modified frailty index (5-mFI) in predicting postoperative complications in elderly gynecological patients undergoing abdominal surgery.

METHODS

A total of 294 elderly gynecological patients who were hospitalized in the affiliated Hospital of North Sichuan Medical College and underwent abdominal surgery from November 2019 to May 2022 were collected from the Union Digital Medical Record (UniDMR) Browser of the hospital. According to whether postoperative complications (infection, hypokalemia, hypoproteinemia, poor wound healing and intestinal obstruction) occurred, the patients were divided into complication group (n = 98) and non-complication group (n = 196). Univariate and multivariate logistic regression analysis were used to analyze the risk factors of complications in elderly gynecological patients undergoing abdominal surgery. The receiver operating characteristic (ROC) curve was used to determine the predictive value of the frailty index score in elderly gynecological patients with postoperative complications after abdominal surgery.

RESULTS

Postoperative complications occurred in 98 of 294 elderly gynecological patients undergoing abdominal surgery, accounting for 33.3%, 5-mFI (OR1.63, 95%CI 1.07-2.46,P = 0.022), age (OR1.08,95%CI 1.02-1.15, P = 0.009), operation time (OR 1.01, 95%CI 1.00-1.01). P < 0.001) were independent risk factors for postoperative complications in elderly patients undergoing abdominal surgery, and the area under the curve of postoperative complications in elderly gynecological patients was 0.60. (95%CI: 0.53-0.67, P = 0.005) CONCLUSION: Five modified frailty index can effectively predict the occurrence of postoperative complications in elderly gynecological patients.

Frailty is the New Age: A Retrospective Study of Modified Frailty Index for Preoperative Risk Assessment in Autologous Breast Reconstruction

BACKGROUND

 Age is a poor predictor of postoperative outcomes in breast reconstruction necessitating new methods for risk-stratifying patients preoperatively. The 5-item modified frailty index (mFI-5) is a validated measure of frailty which assesses patients' global health. The purpose of this study was to compare the effectiveness of mFI-5 and age as independent predictors of 30-day postoperative complications following autologous breast reconstruction.

METHODS

 Patients who underwent autologous breast reconstruction between 2005 and 2019 were identified from the American College of Surgeons National Surgical Quality Improvement Program. Patients were stratified based on presence of major, minor, both minor and major, and no complications. Univariate and multivariate logistic regression were performed to determine the predictive power of mFI-5, age, and other preoperative risk factors for development of minor and major 30-day postoperative complications in all patients and stratified by flap type.

RESULTS

 A total of 25,215 patients were included: 20,366 (80.8%) had no complications, 2,009 (8.0%) had minor complications, 1,531 (6.1%) had major complications, and 1,309 (5.2%) had both minor and major complications. Multivariate regression demonstrated age was not a predictor of minor (odds ratio [OR]: 1.0, p = 0.045), major (OR: 1.0, p = 0.367), or both minor and major (OR: 1.0, p = 0.908) postoperative complications. mFI-5 was a significant predictor of minor complications for mFI-5 scores 1 (OR: 1.3, p < 0.001), 2 (OR: 1.8, p < 0.001), and 3 (OR: 2.8, p = 0.043). For major complications, mFI-5 was a significant predictor for scores 1 (OR: 1.2, p = 0.011) and 2 (OR: 1.3, p = 0.03).

CONCLUSION

 Compared with age, mFI-5 scores were better predictors of 30-day postoperative complications following autologous breast reconstruction regardless of flap type. Additionally, higher mFI-5 scores were associated with increased odds of minor and major complications. Our findings indicate that reconstructive breast surgeons should consider using the mFI-5 in lieu of age to risk-stratify patients prior to autologous breast reconstruction surgery.

Surgical Tolerability and Frailty in Elderly Patients Undergoing Robot-Assisted Radical Prostatectomy: A Narrative Review

Simple Summary

Life expectancy in Western countries and East Asian countries has incremented over the past decades, resulting in a rapidly aging world, while in general, radical prostatectomy (RP) is not recommended in elderly men aged ≥75 years. Together with the evolving technique of robotic surgeries, surgical indications for RP should be reconsidered in ‘elderly’ and ‘frail’ men, since this procedure has now become one of the safest and most effective cancer treatments for prostate cancer. One important element to determine surgical indications is surgical tolerability. However, evidence is scarce regarding the surgical tolerability in elderly men undergoing robot-assisted radical prostatectomy (RARP). In this review, we focused on the surgical tolerability in ‘elderly’ and/or ‘frail’ men undergoing RARP, with the intent to provide up-to-date information on this matter and to support the decision making of therapeutic options in this spectrum of patients.

Abstract

Robot-assisted radical prostatectomy (RARP) has now become the gold standard treatment for localized prostate cancer. There are multiple elements in decision making for the treatment of prostate cancer. One of the important elements is life expectancy, which the current guidelines recommend as an indicator for choosing treatment options. However, determination of life expectancy can be complicated and difficult in some cases. In addition, surgical tolerability is also an important issue. Since frailty may be a major concern, it may be logical to use geriatric assessment tools to discriminate ‘surgically fit’ patients from unfit patients. Landmark studies show two valid models such as the phenotype model and the cumulative deficit model that allow for the diagnosis of frailty. Many studies have also developed geriatric screening tools such as VES-13 and G8. These tools may have the potential to directly sort out unfit patients for surgery preoperatively.

Evaluating the Impact of Preoperative Geriatric-Specific Variables and Modified Frailty Index on Postoperative Outcomes After Elective Pancreatic Surgery

BACKGROUND

Pursuing pancreatic resection in elderly patients is often complex and limited by concern for functional status and postoperative risk. This study examines the associations between two different preoperative functional status metrics with postoperative outcomes in the geriatric population.

METHODS

Patients who participated in the ACS NSQIP Geriatric Surgery Research File pilot program (2014-2018) undergoing elective pancreatic operations were included. Two clinically meaningful functional status scores were calculated: the presence of one or more geriatric-specific variable (GSV) and a 5-factor modified frailty index (mFI-5). Multivariable logistic regression adjusting for ACS NSQIP-estimated risk was performed to evaluate associations between preoperative GSV, mFI-5 and 30-day outcome measures.

RESULTS

A total of 1266 patients were included: 808 (64%) age 65-74, 302 (24%) age 75-80, and 156 (12%) age ≥ 81; 843 (67%) patients underwent pancreatoduodenectomy. Operations were performed for pancreatic adenocarcinoma in 712 (56%) patients. Older patients had greater likelihood of postoperative morbidity (35% vs 31% vs 47%, by age group, p = 0.004) and discharge to a facility (12% vs 23% vs 48%, by age group, p < 0.001). Adjusting for ACS NSQIP predicted risk, patients with a preoperative GSV were more likely to require reoperation and discharge to a facility (OR 1.81 [95% CI 1.03-3.16] and 3.95 [95% CI 2.91-5.38], respectively). The mFI-5 was not associated with postoperative outcomes (all p ≥ 0.18).

CONCLUSION

The presence of a preoperative GSV is associated with reoperation and discharge to a skilled facility following elective pancreatic resection. Geriatric-specific variables should be considered in joint preoperative decision making to optimize care.

Frailty Is Superior to Age for Predicting Readmission, Prolonged Length of Stay, and Wound Infection in Elective Otology Procedures

OBJECTIVE

To determine the predictive ability of the 5-point modified frailty index relative to age in elective otology patients.

STUDY DESIGN

Retrospective database analysis.

SETTING

Multicenter, national database of surgical patients.

PATIENTS

We selected all elective surgical patients who received tympanoplasty, tympanomastoidectomy, mastoidectomy, revision mastoidectomy, and cochlear implant procedures from 2016 to 2019 from the National Surgical Quality Improvement database.

INTERVENTIONS

Therapeutic.

MAIN OUTCOME MEASURES

Readmission rates, discharge disposition, reoperation rates, and extended length of hospital stay.

RESULTS

Utilizing receiver operating characteristics with area under the curve (AUC) analysis, nonrobust status was determined to be a superior predictor relative to age of readmission (AUC = 0.628 [p < 0.001] versus AUC = 0.567 [p = 0.047], respectively) and open wound infection relative to age (AUC = 0.636 [p = 0.024] versus AUC = 0.619 [p = 0.048], respectively). Nonrobust otology patients were more likely to have dyspnea at rest and an American Society of Anesthesiology score higher than 2 before surgery (odds ratios, 13.304 [95% confidence interval, 2.947-60.056; p < 0.001] and 7.841 [95% confidence interval, 7.064-8.704; p < 0.001], respectively).

CONCLUSION

Nonrobust status was found to be a useful predictor of readmission and prolonged length of stay in patients undergoing elective otology procedures, which generally have low complication rate. Given the aging population and corresponding increase in otology disease, it is important to use age-independent risk stratification measures. Frailty may provide a useful risk stratification tool to select surgical candidates within the aging population.

Can the 5-item Modified Frailty Index Predict Outcomes in Geriatric Trauma? A National Database Study

BACKGROUND

Frailty results in increased vulnerability to adverse outcomes following trauma. We investigated the association between the 5-item modified frailty index (mFI-5) and outcomes in geriatric trauma patients.

METHODS

The 2011-2016 Trauma Quality Improvement Program database was used to study outcomes in patients ≥ 65 years old. The mFI-5 was measured and categorized into no frailty (mFI-5 = 0), moderate frailty (mFI-5 = 0.2), and severe frailty (mFI-5 ≥ 0.4). Multivariable logistic regression analyses were performed to identify independent factors of mortality and complications.

RESULTS

26,963 cases met the inclusion criteria, of whom 25.5% were not frail, 38% were moderately frail, and 36.6% were severely frail. Mean age (± SD) was 76 ± 7 years, 61.5% were male, and 97.8% sustained blunt injuries. Median Injury Severity Score (ISS) was 17 (IQR = 10-26), and the median Glasgow Coma Scale was 15 (IQR = 12-15). Overall mortality was 30.6%. Factors independently associated with mortality were age (OR = 1.07 per year, 95%CI 1.06-1.07), blunt trauma (OR = 1.44, 95%CI 1.19 -1.75), ISS (OR = 1.04 per unit increase in ISS, 95%CI 1.03-1.04), and severe frailty (OR = 1.23, 95%CI 1.15-1.32). Interestingly, male sex and GCS appeared to be protective factors with OR of 0.88 (95%CI 0.83 - 0.93) and 0.89 per point change in GCS (95%CI 0.88-0.9), respectively. Moderate (OR = 1.27, 95%CI 1.19-1.25) and severe frailty (OR = 1.49, 95%CI 1.-1.59) were significantly associated with in-hospital complications.

CONCLUSION

Moderate and severe frailty were significant predictors of complications. Only severe frailty was associated with short-term mortality. The mFI-5 can be used as an objective measure to stratify risks in geriatric trauma.

The five-factor modified frailty index predicts adverse postoperative and chemotherapy outcomes in gynecologic oncology

INTRODUCTION

Frailty is increasingly recognized as a predictor of postoperative morbidity and oncologic outcomes. Evidence of the predictive value of frailty assessment in gynecologic oncology remains sparse.

OBJECTIVES

To evaluate the National Surgical Quality Improvement Program (NSQIP) comorbidity-based modified Frailty Index-5 (mFI-5) as predictor of severe postoperative complications, non-completion of chemotherapy and other patient-centered outcomes in gynecologic oncology patients >70 years-old undergoing surgery.

METHODS

Prospectively-collected NSQIP data and retrospective chart review of patients undergoing elective laparotomies for gynecologic malignances at a tertiary academic center in Ontario, Canada, between 01/2016-09/2020 were reviewed. Primary outcome was rate of 30-day Clavien-Dindo (Clavien) grade III-V complications. Secondary outcomes included Clavien II-V complications, postoperative length of stay (LOS), non-home discharge and non-completion of chemotherapy. Logistic regression analyses and receiver-operator curves were performed.

RESULTS

Two-hundred and fifty-nine patients were included; 103 were planned to receive adjuvant chemotherapy. Fifty-three patients (20.5%) had an mFI ≥ 2 and were categorized as frail. On multivariable analyses, frailty independently predicted grade III-V complications (OR 24.49, 95%CI 9.72-70.67, p < 0.0001), grade II-V complications (OR 4.64, 95%CI 2.31-9.94, p < 0.0001), non-home discharge (OR 7.37, 95%CI 2.81-20.46, p < 0.0001), LOS ≥ 7d (OR 3.6, 95% CI 1.54-8.6, p = 0.003) and non-completion of chemotherapy (OR 8.42, 95%CI 2.46-32.79, p = 0.001). Adjusted C-statistics demonstrated strong predictive value of the mFI-5 for grade III-V (0.92, 95%CI 0.86-0.97) and grade II-V (0.74, 95%CI 0.68-0.8) complications as well as non-home discharge (0.86, 95%CI 0.78-0.95) and chemotherapy non-completion (0.87, 95%CI 0.8-0.95).

CONCLUSION

Frailty as assessed with the mFI-5 predicted adverse postoperative and chemotherapy outcomes in gynecologic oncology patients aged ≥70 undergoing a laparotomy. The mFI-5 is a concise tool that can be used for routine frailty screening and risk stratification.

Comparison of Electronic Frailty Metrics for Prediction of Adverse Outcomes of Abdominal Surgery

Importance

Electronic frailty metrics have been developed for automated frailty assessment and include the Hospital Frailty Risk Score (HFRS), the Electronic Frailty Index (eFI), the 5-Factor Modified Frailty Index (mFI-5), and the Risk Analysis Index (RAI). Despite substantial differences in their construction, these 4 electronic frailty metrics have not been rigorously compared within a surgical population.

Objective

To characterize the associations between 4 electronic frailty metrics and to measure their predictive value for adverse surgical outcomes.

Design, Setting, and Participants

This retrospective cohort study used electronic health record data from patients who underwent abdominal surgery from January 1, 2010, to December 31, 2020, at 20 medical centers within Kaiser Permanente Northern California (KPNC). Participants included adults older than 50 years who underwent abdominal surgical procedures at KPNC from 2010 to 2020 that were sampled for reporting to the National Surgical Quality Improvement Program.

Main Outcomes and Measures

Pearson correlation coefficients between electronic frailty metrics and area under the receiver operating characteristic curve (AUROC) of univariate models and multivariate preoperative risk models for 30-day mortality, readmission, and morbidity, which was defined as a composite of mortality and major postoperative complications.

Results

Within the cohort of 37 186 patients, mean (SD) age, 67.9 (female, 19 127 [51.4%]), correlations between pairs of metrics ranged from 0.19 (95% CI, 0.18- 0.20) for mFI-5 and RAI 0.69 (95% CI, 0.68-0.70). Only 1085 of 37 186 (2.9%) were classified as frail based on all 4 metrics. In univariate models for morbidity, HFRS demonstrated higher predictive discrimination (AUROC, 0.71; 95% CI, 0.70-0.72) than eFI (AUROC, 0.64; 95% CI, 0.63-0.65), mFI-5 (AUROC, 0.58; 95% CI, 0.57-0.59), and RAI (AUROC, 0.57; 95% CI, 0.57-0.58). The predictive discrimination of multivariate models with age, sex, comorbidity burden, and procedure characteristics for all 3 adverse surgical outcomes improved by including HFRS into the models.

Conclusions and Relevance

In this cohort study, the 4 electronic frailty metrics demonstrated heterogeneous correlation and classified distinct groups of surgical patients as frail. However, HFRS demonstrated the highest predictive value for adverse surgical outcomes.

Predicting Outcomes in Thyroidectomy and Parathyroidectomy: The Modified Five-Point Frailty Index Versus American Society of Anesthesiologists Classification

INTRODUCTION

Thyroidectomy and parathyroidectomy are relatively safe procedures, with overall morbidity rates of 2%-5%. The increasing age is associated with higher likelihood of poor outcomes. The modified five-point frailty index (mFI-5) is associated with complications, but many surgeons are unfamiliar with mFI-5. We assessed the accuracy of the mFI-5 versus the commonly-used American Society of Anesthesiologists (ASA) classification to predict complications following thyroidectomy and parathyroidectomy.

METHODS

Patients undergoing thyroidectomy or parathyroidectomy in 2015-2018 NSQIP datasets were identified. The mFI-5 scores were calculated by adding the number of the following comorbidities: congestive heart failure, hypertension requiring medication, chronic obstructive pulmonary disease, diabetes, and nonindependent functional status. Receiver operating characteristics curves were plotted for 30-d mortality and serious morbidity (defined as deep surgical site infection, dehiscence, unplanned intubation, failure to wean from the ventilator 48-h postoperatively, acute renal failure, pneumonia, pulmonary embolism, myocardial infarction, cardiac arrest requiring cardiopulmonary resuscitation, sepsis, septic shock, cerebrovascular accident, or reoperation) using mFI-5 and ASA classification. Areas under these curves (AUC) were compared.

RESULTS

Ninety-two thousand, six hundred and ninety-one patients were studied. The mFI-5 and ASA were fair predictors of 30-d mortality (AUC 0.75 and 0.82, respectively) and good predictors of serious morbidity (AUC 0.61 and 0.64). After stratification by age, ASA was superior to mFI-5 in predicting mortality for patients aged 65, 70, 80 y, and older, for the entire population and for thyroidectomy and parathyroidectomy separately.

CONCLUSIONS

The ASA classification is a better predictor of mortality and serious morbidity than mFI-5 among patients undergoing thyroidectomy or parathyroidectomy and may be a better prognostic indicator to use when counseling patients before low-risk neck surgery.

Association Between Frailty and Clinical Outcomes and Quality of Life in Older Adults Following Hip Fracture Surgery: A Retrospective Cohort Study

BACKGROUND

Hip fracture is a serious event in the older population and is associated with morbidity, mortality, and disability among those who survive. Emerging evidence suggests that frailty is pertinent to the clinical outcomes of older patients with hip fracture.

METHODS

We conducted a retrospective cohort study on older patients (aged ≥65 years) who underwent orthopedic repair with hip fracture under spinal or general anesthesia between June 1, 2019 and May 31, 2020. Demographic, surgical, and anesthetic features; chart-derived frailty index (CFI); occurrence of complications; and length of stay were retrospectively collected by reviewing patients' anesthesia records and medical charts. Patients were divided into 2 groups according to their CFI: high CFI group (CFI, 3-5) and low CFI group (CFI, 0-2). The CFI was calculated as the addition of the patient's conditions, including age >70 years, preoperative body mass index <18.5 kg/m2, hematocrit <35%, albumin <34 g/L, and serum creatinine >176.8 mol/L (2.0 mg/dL). The EuroQol 5-dimensional questionnaire (EQ-5D) was obtained through telephone interviews 12 months after surgery to assess mortality and long-term quality of life.

RESULTS

During the study period, 381 patients met the inclusion criteria. Patients in the high CFI group had an increased incidence of delirium by 13.80% (95% confidence interval [CI], 6.31-21.29) (17 [16.6%] vs 8 [2.8%]; P < .001) compared to patients in the low CFI group. More patients in the high CFI group had pneumonia with an increased incidence of 17.71% (95% CI, 7.08-23.34) (40 [39.2%] vs 60 [21.5%]; P < .001) than patients in the low CFI group. Postoperative hospital stay was significantly longer in the high CFI group (8 [6-12] vs 7 [5-10] days; P = .0222) than in the low CFI group. More patients died in the high CFI group 1 year after surgery with an increased mortality of 19.33% (95% CI, 9.47-29.18) (26.4% [23/87] vs 7.1% [16/225]; P < .001) than patients in the low CFI group. A total of 64 patients in the high CFI group and 209 patients in the low CFI group completed the EQ-5D survey 1 year after surgery. The EQ-5D score in the high CFI group was significantly lower than that in the low CFI group (0.63 ± 0.22 vs 0.72 ± 0.22; P = .002).

CONCLUSIONS

Frailty status is associated with adverse postoperative outcomes, mortality, and low quality of life 12 months after hip fracture surgery in older patients.

A Simplified Frailty Index Predicts Mortality in Older Adults in Beijing

Objective

The comprehensive geriatric assessment (CGA) is an integral tool used to identify vulnerable older adults in need of individualized plans to delay the course of diseases and monitor treatment outcomes. We previously developed and validated a 68-item frailty index (FI) based on the CGA in a large, older, Chinese population. However, substantial time is needed to evaluate the 68 items. Therefore, we aimed to develop and validate a simplified FI for use in Chinese older population.

Design

Longitudinal study.

Setting and Participants

Data were drawn from the Beijing Longitudinal Study of Aging. The study was conducted in 2004 with 1808 participants evaluated using the CGA and was followed-up for 13 years. Mortality was recorded at 3, 5, 8, 10, and 13 years intervals.

Measures

27-Item, 50-item, and 68-item frailty indices were investigated. A Cox proportional hazards model and area under the curve of the receiver operating characteristic (AUC-ROC) were calculated to compare mortality predictions.

Results

The FI was positively correlated with age in males (r = 0.174, P <0.001) and females (r = 0.270, P <0.001). The mean baseline FI was 0.225 ± 0.085 (range: 0.04-0.56) as evaluated by the 27-item FI, 0.181 ± 0.117 (range: 0.02-0.62) by the 50-item FI, and 0.167 ± 0.101 (range: 0.02-0.59) by the 68-item FI. Cox regression models showed that mortality was significantly higher in frail people than in non-frail people for all 3 indices (p<0.001). The AUCs of the 68-item FI, 50-item FI, and 27-item FI for predicting mortality were 0.720, 0.717, and 0.677, respectively (p<0.001).

Conclusion

The 27-item FI is reasonable to expect that the AUC of the indices with the higher items number is inferior to the performance of the indices with higher number of items (FI50 and FI68). But 27-item maybe used as a tool to identify frail older adults and predict mortality in clinical and primary care practices in China.