Frailty status as a potential factor in increased postoperative opioid use in older adults

The effects of frailty on opioid consumption after total knee arthroplasty

PURPOSE

This study evaluated the effects of frailty on postoperative opioid consumption in elderly patients.

METHODS

Patients aged 65 and older scheduled for unilateral primary total knee arthroplasty under spinal anesthesia were included. A blinded anesthesiologist assessed patients using the FRAIL scale during the preoperative visit, classifying them into robust (Group I), pre-frail (Group II), and frail (Group III) categories. The main outcome measure was total opioid consumption over 24 h. Opioid consumption was recorded at 6 (T1), 12 (T2) and 24 (T3) hours postoperatively. Secondary outcomes included visual analog pain scores (VAS) at rest (VAS-R) and during 45° knee flexion (VAS-F), as well as postoperative nausea and vomiting.

RESULTS

Seventy-five patients were included in the study, with seventy-three completing it and two being excluded. Total opioid consumption was significantly higher in Groups II and III compared to Group I (p < 0.001 for both). There were no significant differences in VAS-R scores between groups at T0, T1, T2, and T3 (p = 0.659, p = 0.425, p = 0.994, and p = 0.689, respectively), and no significant differences in VAS-F scores at the same time points (p = 0.580, p = 0.739, p = 0.322, and p = 0.679, respectively).

CONCLUSION

Our study results indicate that frailty, easily assessed preoperatively in elderly surgical patients, is a significant predictor of postoperative opioid consumption.

High Modified 5 Factor Frailty Index is Associated With Worse PROMs and Decreased Return to Activities After 1 or 2 Level MI-TLIF

STUDY DESIGN

Retrospective cohort study.

OBJECTIVE

Frailty is defined as a state of minimal "physiologic reserve." The modified 5 factor frailty index (mFI-5) is a recently proposed metric for assessing frailty and has been previously studied as a predictor of morbidity and mortality. However, its utility in predicting postoperative patient reported outcomes (PROMs) and return to activities remains understudied.

METHODS

This is a retrospective cohort study of patients undergoing 1 or 2 level minimally invasive transforaminal lumbar interbody fusion queried from a prospectively maintained multi-surgeon registry. Comorbidities including hypertension, congestive heart failure, diabetes, chronic obstructive pulmonary disease, and functional status were utilized to calculate the mFI-5. Patients were separated into 3 cohorts, "non-frail," "moderately frail" or "severely frail" based on their mFI-5. Patient outcomes were compared between the cohorts.

RESULTS

392 patients were included of which 227 patients were non-frail, 134 were moderately frail, and 31 were severely frail. Frail patients had longer operative time (P = 0.002), greater estimated blood loss (P = 0.038). Despite similar preoperative PROMs, at a longer term follow up, frail patients also had worse PROM scores for ODI (P = 0.009), VAS-back (P = 0.028), and VAS-leg (P = 0.004). Frail patients had worse preoperative (P = 0.017) and postoperative (P < 0.001) SF-12 PCS. At 1-year, frail patients had lower rates of fusion (P = 0.002). Frail patients also demonstrated lower rates of returning to work (P = 0.018), returning to driving (P = 0.027), and discontinuation of narcotics (P = 0.004).

CONCLUSION

Frail patients as measured by the mFI-5 index demonstrated worse postoperative outcomes following 1 or 2 level MI-TLIF. Careful patient selection and preoperative optimization may be especially important in frail patients.

The psychometric assessment of the older adult in pain: A systematic review of assessment instruments

We conducted a systematic review of pain assessment tools suitable for community-dwelling older adults. For this work, we conceptualized existing psychometric tools as falling under the following domains: a) pain intensity/characteristics; b) pain-related interference/disability; c) coping strategies; d) pain beliefs/attitudes/cognitions; e) pain-related fear and anxiety; and f) pain-specific emotional distress. Multi-dimensional and condition-specific tools were also considered. The COnsensus-based Standards for the selection of health Measurement INstruments (COSMIN) methodology for systematic reviews of patient-reported outcome measures guided the evaluation of measurement properties, quality of evidence ratings, and recommendations for each measure. A search of Medline, PsycINFO, Web of Science, and the Cumulative Index of Nursing and Allied Health Literature, yielded a total of 21,755 records. Of these, 120 studies, focusing on 57 psychometric tools, were included in this review and categorized into the aforementioned pain assessment domains. The availability of psychometric studies with older adult populations was insufficient for most tools and the quality of evidence ranged from very low to high. Only a small number of tools met the criteria for a strong or tentative recommendation favoring their use. We identified gaps that should be addressed in future research.

Frailty Status, Not Just Age, is Associated With Postoperative Opioid Consumption: A Retrospective, Population-based Analysis

Objective

To assess the relationship between postoperative opioid consumption and frailty status.

Background

Physiologic reserve can be assessed through both chronologic age as well as measures of frailty. Although prior studies suggest that older individuals may require less opioid following surgery, chronologic age, and frailty do not always align, and little is known regarding postoperative opioid consumption patterns by frailty.

Methods

We conducted a retrospective analysis of opioid-naïve adult patients undergoing common general, vascular, and gynecologic procedures across a statewide quality improvement program from November 6, 2017 to February 28, 2021. Our primary outcome was postoperative patient-reported opioid consumption within 30 days of surgery in oral morphine equivalents (OME). Our primary exposure was frailty status defined by the modified frailty index (mFi-5) criteria. Other covariates included patient demographic and clinical attributes, procedural factors, discharge opioid prescription size, and postoperative complications. Linear regression was performed to assess the association of frailty status and opioid consumption, stratified by age.

Results

In this cohort of 34,854 patients, 10,596 had an mFi-5 score of ≤1 and 3,635 had a score of >1. A score of >1 was associated with increased patient-reported opioid consumption (OMEs 3.3 greater; 95% CI = 1.5-5.1). This held true for individuals over 65 (OMEs 2.7 greater; 95% CI = 0.2-5.1). Frailty status, regardless of score, was negatively associated with an opioid prescription at discharge.

Conclusions

Frailty status is associated with increased opioid consumption after common operations. Future prescribing guidelines and outcomes analyses should consider this marker when reviewing opioid consumption data and related adverse outcomes.

Review of frailty in geriatric surgical oncology

Frailty is a common phenomenon in older adult population and associated with an elevated risk of adverse health outcomes. Recent studies have demonstrated that patients with frailty undergoing surgery had a significantly higher morbidity and mortality compared to those without frailty. This is particularly important in patients with cancer because the prevalence of frailty is persistently high across a spectrum of primary cancers. Identifying frailty in oncological patients undergoing surgery may provide an important preoperative intervention opportunity to mitigate operative risks. In this review, we provide an overview of frailty and its association with other geriatric syndromes. We will also review the impact of frailty on postoperative outcomes focusing on the field of surgical oncology. We then describe currently available tools to objectively measure frailty to provide clinicians with various practical tools that may be adopted in their clinical practice. Finally, we will describe potential interventional programs, including the recently introduced Geriatric Surgery Verification program by the American College of Surgeons, that may be institutionally adopted to mitigate postoperative complications and improve meeting patient-centered goals in the frail patient population.

Serratus plane block versus standard of care for pain control after totally endoscopic aortic valve replacement: a double-blind, randomized controlled, superiority trial

INTRODUCTION

Serratus anterior plane block has been proposed to reduce opioid requirements after minimally invasive cardiac surgery, but high-quality evidence is lacking.

METHODS

This prospective, double-blinded, randomized controlled trial recruited patients undergoing totally endoscopic aortic valve replacement. Patients in the intervention arm received a single-injection serratus anterior plane block on arrival to the intensive care unit added to standard of care. Patients in the control group received routine standard of care, including patient-controlled intravenous analgesia. Primary outcome was piritramide consumption within the first 24 hours after serratus anterior plane block placement. We hypothesized that compared with no block, patients in the intervention arm would consume 25% less opioids.

RESULTS

Seventy-five patients were analyzed (n=38 in intervention arm, n=37 in control arm). When comparing the serratus anterior plane group with the control group, median 24-hour cumulative opioid use was 9 (IQR 6-19.5) vs 15 (IQR 11.3-23.3) morphine milligram equivalents, respectively (p<0.01). Also, pain scores at 4, 8 and 24 hours were lower in the intervention arm at 4, 8 and 24 hours, respectively.

CONCLUSION

Combined deep and superficial single-injection serratus anterior plane block is superior to standard of care in reducing opioid requirements and postoperative pain intensity up to 24 hours after totally endoscopic aortic valve replacement.

TRIAL REGISTRATION NUMBER

NCT04699422.

Preoperative frailty predicts postoperative pain after total knee arthroplasty in older patients: a prospective observational study

PURPOSE

Frailty is reportedly associated with postoperative adverse outcomes and may increase the risk of post-surgical pain. Our study aimed to explore whether frailty was an independent risk factor for pain after total knee arthroplasty (TKA) in older patients.

METHODS

Included in this prospective observational study were patients aged 65 or older who underwent primary TKA. Frailty of the patients was assessed before surgery using the comprehensive geriatric assessment-frailty index and pain was evaluated before and after surgery using the Numerical Rating Scale.

RESULTS

Of the 164 patients including 125 females with a mean age of 71.4 ± 4.6 years, 51 patients were identified as being frail. Patients with chronic post-surgical pain had a significantly higher frailty index than those without chronic post-surgical pain, which was the same in patients with acute post-surgical pain. After adjusting for other confounding factors, frailty was shown to be an independent risk factor for both acute (OR: 13.23, 95% CI 3.73-46.93, P < 0.001) and chronic post-surgical pain (OR: 4.24, 95% CI 1.29-14.00, P = 0.02). The area under the receiver operating characteristic curve for frailty predicting chronic post-surgical pain was 0.73 (P < 0.001, 95% CI 0.65-0.81).

CONCLUSIONS

Our findings demonstrated that preoperative frailty in older patients was a predictor of acute and chronic post-surgical pain after TKA, suggesting that frailty assessment should become a necessary procedure before operations, especially in older patients.

The Effect of Preoperative Disability, Cognitive Impairment, Frailty and Opioid Use on Acute Postoperative Pain in Older Patients Undergoing Surgery A Prospective Cohort Study

Globally, life expectancy is increasing, leading to more surgeries being performed in older patients. Postoperative pain is associated with complications after surgery. The aim of this study is to explore potential age-related risk factors for acute postoperative pain in older patients undergoing surgery. This was a prospective, single-center study. Patients ≥65 years, with and without disability, as defined by the WHO Disability Assessment Schedule 2.0, undergoing elective surgery, were compared. Primary outcome was the postoperative pain (ie, numeric rating scale (NRS) score) on the first postoperative day. Secondary outcomes were postoperative pain and pain trajectories in patients with and without mild cognitive impairment (MCI), frailty, preoperative opioid use, and new-onset disability after surgery. Between February 2019 and July 2020, 155 patients were enrolled. On the first day after surgery, postoperative pain did not differ between patients with and without disability. NRS scores differed between patients with-, and without MCI on the first (P = .01), and second postoperative day (P < .01). Patients who used opioids before surgery reported higher median NRS score on the first (P < .001) and second (P < .01) postoperative day. Out of a total of 1816 NRS scores, 2 pain clusters were identified. Acute postoperative pain did not differ between patients with or without preoperative disability and frailty in older patients undergoing surgery. Reduced postoperative pain in older patients with MCI warrants further investigation. The PIANO study (Comparison of Postoperative NeurocognitiveFunction in Older Adult Patients with and without Diabetes Mellitus) was registered with www.clinicaltrialregister.nl (search term: Which can predict memory problems after surgery better; blood sugar levels or memory before surgery?). PERSPECTIVE: This study explored risk factors for acute postoperative pain in older patients. No differences in postoperative pain were observed in patients with or without preexistent disability or frailty, however, patients with mild cognitive impairment experienced reduced pain. We suggest to simplify pain assessment in this group and take functional recovery into account.

Anesthesia and perioperative pain relief in the frail elderly patient

Demand for anesthesia and analgesia for the frail elderly is continuously increasing as the likelihood of encountering very elderly, very vulnerable, and very compromised patients has, ever so subtly, increased over the last three decades. The anesthesiologist has, increasingly, been obliged to offer professional services to frail patients. Fortunately, there has been a dramatic improvement in medications, methods of drug delivery, critical monitoring, and anesthesia techniques. Specific methodologies peculiar to the frail are now taught and practiced across all anesthesia subspecialties. However, administering anesthesia for the frail elderly is vastly different to giving an anesthetic to the older patient. Frail patients are increasingly cared for in specialized units-geriatric intensive therapy units, post-acute care services, palliative, hospices, and supportive care and aged care facilities. Several medications (e.g., morphine-sparing analgesics) more suited to the frail have become universally available in most centers worldwide so that best-practice, evidence-based anesthesia combinations of drugs and techniques are now increasingly employed. Every anesthetic and pain management techniques in the frail elderly patient are going to be discussed in this review.

Postoperative Opioid Use Following Single-Level Transforaminal Lumbar Interbody Fusion Compared with Posterolateral Lumbar Fusion

OBJECTIVE

To compare postoperative opioid morphine milligram equivalents (MME) prescriptions for opioid-naïve patients undergoing single-level transforaminal lumbar interbody fusion (TLIF) versus posterolateral lumbar fusion (PLF) and total postoperative MME prescribed based on operative duration.

METHODS

Patients undergoing single-level TLIF or PLF from September 2017 to June 2020 were identified from a single institution. Patients were first grouped based on procedure type (TLIF or PLF) and subsequently regrouped based on median operative duration. Statistical tests compared patient demographics and opioid prescription data between groups. Multivariate regressions were performed to control for demographics, operative time, and procedure type.

RESULTS

Of 345 patients undergoing single-level PLF or TLIF, 174 (50.4%) were opioid-naïve; 101 opioid-naïve patients (58.0%) underwent PLF and 73 (42.0%) underwent TLIF. Patients undergoing TLIF received more opioid prescriptions (1.99 vs. 1.26, P < 0.001) and total MME (91.2 vs. 66.8, P = 0.002). After regrouping patients based on operative duration, independent of procedure type, there were no differences in postoperative opioid prescriptions, and Spearman rank correlation coefficient between total MME and operative duration was r = 0.014. Multivariate analysis identified TLIF as an independent predictor of increased postoperative opioid prescriptions (β = 0.64, P < 0.001), prescribers (β = 0.49, P = 0.003), and MME (β = 24.4, P = 0.030).

CONCLUSIONS

Opioid-naïve patients undergoing single-level TLIF receive a greater number of postoperative opioids than patients undergoing single-level PLF, and TLIF was an independent predictor of increased postoperative opioid prescribers, prescribers, and MME. There were no differences in postoperative opioid prescriptions when assessing patients based on operative duration.

Bidirectional association between visual impairment and frailty among community-dwelling older adults: a longitudinal study

Background

Vision impairment is common among older adults, and it may be related to frailty. However, the longitudinal relationship between visual impairment and frailty is still unclear.

Methods

We used data from Round 1 to Round 5 from the National Health and Aging Trend Study. Two samples were community-dwelling older adults, sample 1 (without visual impairment) was classified according to whether they have pre-frailty/frailty at R1 (N = 3013) and sample 2 (without pre-frailty/frailty) was classified according to whether they have visual impairment at R1 (N = 1422), respectively. Frailty was measured using five criteria: experiencing exhaustion, unintentional weight loss, low physical activity, slow gait, and weak grip strength. Visual impairment was assessed by asking participants if they had any visual impairment. Generalized estimating equation models were used to examine the concurrent and lagged association between visual impairment and frailty.

Results

The participants were on average 76 ± 7 years old, female (59%), non-Hispanic white (74%) with less than bachelor educated (73%), and 44% were pre-frail/frail in the older adults without visual impairment. Approximately 5% of participants had visual impairment at R1, and they tended to be female and non-Hispanic White in the older adults without frailty. The concurrent (OR, 95% CI = 1.55, 1.17-2.02) and lagged (OR, 95% CI = 1.79, 1.25-2.59) associations between frailty and visual impairment were significantly after controlling the covariates. Similarly, the concurrent (OR, 95% CI = 1.63, 1.32-2.04) and lagged (OR, 95% CI = 1.49, 1.20-1.87) associations between visual impairment and frailty were also significant.

Conclusions

Overall, this study provides evidence for a longitudinal, bidirectional association between self-reported visual impairment and frailty. Future intervention programs to delay frailty progression should include strategies that may reduce the incidence of visual impairment.

Association of Pre-operative Functional Disability with Chronic Postsurgical Pain: A Prospective Observational Study

BACKGROUND

Chronic postsurgical pain negatively affects postoperative recovery. We aimed to assess the association between pre-operative functional disability and chronic postsurgical pain.

METHODS

This secondary analysis of a prospective observational study included 920 inpatients aged≥55 years undergoing elective abdominal surgery. We assessed functional disability using the 12-item World Health Organization Disability Assessment Schedule 2.0 before surgery and measured postoperative pain using a numerical rating scale at a postanaesthetic clinic 3 months and 1 year after surgery. We performed multiple logistic regression analysis to determine associations with chronic postsurgical pain 1 year after surgery. We analysed the sequential pain score using a mixed-effects model in patients with and without pre-operative functional disability. The primary outcome in this study was chronic postsurgical pain and its associated factors with a focus on preoperative functional disability. The secondary outcome was pain trajectories in patients with and without preoperative functional disability.

RESULTS

Of the 899 patients included in the analysis, 11.9% had chronic postsurgical pain 1 year later. The multiple logistic regression analysis revealed that pre-operative functional disability was associated with this outcome (OR 2.80, 95% CI, 1.70 to 4.59) as well as use of pre-operative pain medication (OR 2.74, 95% CI, 1.24 to 6.03) and pain numerical rating scale at the postanaesthetic clinic (OR 1.19, 95% CI 1.10 to 1.29). The pain trajectories were different in the presence or absence of functional disability (P<0.001) and the time of measurement (P<0.001).

CONCLUSIONS

Pre-operative functional disability was associated with chronic postsurgical pain and pain trajectories.