Frailty Phenotype and Neuropsychological Test Performance: A Preliminary Analysis

Clinical and Neuropsychological Correlates of Prefrailty Syndrome

Physical frailty is closely associated with cognitive impairment. We aim to investigate the neuropsychological profiles of prefrail and non-frail dementia-free community-dwelling older adults using a comprehensive neuropsychological evaluation, and to examine the association between specific frailty criteria and clinical and neuropsychological scores. Participants completed a comprehensive standardized neuropsychological evaluation (covering cognitive domains such as memory, executive functions, language and attention), and frailty assessment. Frailty was assessed according to biological criteria: unintentional weight loss, exhaustion, low physical activity, slowness, and weakness. The sample comprised 60 dementia-free community-dwelling adults, aged 65 years or older (range 65-89 years; 60.0% women). Forty-two participants were classified as robust (no frailty criteria present), and 18 as prefrail (1 or 2 frailty criteria present). We explored neurocognitive differences between the groups and examined the association between specific criteria of frailty phenotype and clinical and neuropsychological outcomes with bivariate tests and multivariate models. Prefrail participants showed poorer cognitive performance than non-frail participants in both memory and non-memory cognitive domains. However, delayed episodic memory was the only cognitive subdomain that remained significant after controlling for age, gender, and educational level. Gait speed was significantly associated with general cognitive performance, immediate memory, and processing speed, while grip strength was associated with visual episodic memory and visuoconstructive abilities. Both gait speed and grip strength were negatively associated with depressive scores. Our results suggest that prefrailty is associated with cognitive dysfunction. The fact that specific cognitive domains may be susceptible to subclinical states of physical frailty may have important clinical implications. Indeed, early detection of specific cognitive dysfunctions may allow opportunities for reversibility.

Frailty Is Associated With Postoperative Delirium But Not With Postoperative Cognitive Decline in Older Noncardiac Surgery Patients

BACKGROUND

Postoperative cognitive dysfunction (POCD) and delirium are the most common perioperative cognitive complications in older adults undergoing surgery. A recent study of cardiac surgery patients suggests that physical frailty is a risk factor for both complications. We sought to examine the relationship between preoperative frailty and postoperative delirium and preoperative frailty and POCD after major noncardiac surgery.

METHODS

We performed a prospective cohort study of patients >65 years old having major elective noncardiac surgery with general anesthesia. Exclusion criteria were preexisting dementia, inability to consent, cardiac, intracranial, or emergency surgery. Preoperative frailty was determined using the FRAIL scale, a simple questionnaire that categorizes patients as robust, prefrail, or frail. Delirium was assessed with the Confusion Assessment Method for the intensive care unit (CAM-ICU) twice daily, starting in the recovery room until hospital discharge. All patients were assessed with neuropsychological tests (California Verbal Learning Test II, Trail Making Test, subtests from the Wechsler Adult Intelligence Scale, Logical Memory Story A, Immediate and Delayed Recall, Animal and Vegetable verbal fluency, Boston Naming Test, and the Mini-Mental Status Examination) before surgery and at 3 months afterward.

RESULTS

A total of 178 patients met inclusion criteria; 167 underwent major surgery and 150 were available for follow-up 3 months after surgery. The median age was 70 years old. Thirty-one patients (18.6%) tested as frail, and 72 (43.1%) prefrail before surgery. After adjustment for baseline cognitive score, age, education, surgery duration, American Society of Anesthesiologists (ASA) physical status, type of surgery, and sex, patients who tested frail or prefrail had an estimated 2.7 times the odds of delirium (97.5% confidence interval, 1.0-7.3) when compared to patients who were robust. There was no significant difference between the proportion of POCD between patients who tested as frail, prefrail, or robust.

CONCLUSIONS

After adjustment for baseline cognition, testing as frail or prefrail with the FRAIL scale is associated with increased odds of postoperative delirium, but not POCD after noncardiac surgery.

Feasibility and Rationale for Incorporating Frailty and Cognitive Screening Protocols in a Preoperative Anesthesia Clinic

BACKGROUND

Advanced age, frailty, low education level, and impaired cognition are generally reported to be associated with postoperative cognitive complications. To translate research findings into hospital-wide preoperative assessment clinical practice, we examined the feasibility of implementing a preoperative frailty and cognitive assessment for all older adults electing surgical procedures in a tertiary medical center. We examined associations among age, education, frailty, and comorbidity with the clock and 3-word memory scores, estimated the prevalence of mild to major cognitive impairment in the presurgical sample, and examined factors related to hospital length of stay.

METHODS

Medical staff screened adults ≥65 years of age for frailty, general cognition (via the clock-drawing test command and copy, 3-word memory test), and obtained years of education. Feasibility was studied in 2 phases: (1) a pilot phase involving 4 advanced nurse practitioners and (2) a 2-month implementation phase involving all preoperative staff. We tracked sources of missing data, investigated associations of study variables with measures of cognition, and used 2 approaches to estimate the likelihood of dementia in our sample (ie, using extant data and logistic regression modeling and using Mini-Cog cut scores). We explored which protocol variables related to hospital length of stay.

RESULTS

The final implementation phase sample included 678 patients. Clock and 3-word memory scores were significantly associated with age, frailty, and education. Education, clock scores, and 3-word scores were not significantly different by surgery type. Likelihood of preoperative cognitive impairment was approximately 20%, with no difference by surgery type. Length of stay was significantly associated with preoperative comorbidity and performance on the clock copy condition.

CONCLUSIONS

Frailty and cognitive screening protocols are feasible and provide information for perioperative care planning. Challenges to clinical adaptation include staff training, missing data, and additional administration time. These challenges appear minimal relative to the benefits of identifying frailty and cognitive impairment in a group at risk for negative postoperative cognitive outcome.