Are the frail destined to fail? Frailty index as predictor of surgical morbidity and mortality in the elderly.
ABSTRACT America's aging population has led to an increase in the number of elderly patients necessitating emergency general surgery. Previous studies have demonstrated that increased frailty is a predictor of outcomes in medicine and surgical patients. We hypothesized that use of a modification of the Canadian Study of Health and Aging Frailty Index would be a predictor of morbidity and mortality in patients older than 60 years undergoing emergency general surgery.
Data were obtained from the National Surgical Quality Improvement Program Participant Use Files database in compliance with the National Surgical Quality Improvement Program Data Use Agreement. We selected all emergency cases in patients older than 60 years performed by general surgeons from 2005 to 2009. The effect of increasing frailty on multiple outcomes including wound infection, wound occurrence, any infection, any occurrence, and mortality was then evaluated.
Total sample size was 35,334 patients. As the modified frailty index increased, associated increases occurred in wound infection, wound occurrence, any infection, any occurrence, and mortality. Logistic regression of multiple variables demonstrated that the frailty index was associated with increased mortality with an odds ratio of 11.70 (p < 0.001).
Frailty index is an important predictive variable in emergency general surgery patients older than 60 years. The modified frailty index can be used to evaluate risk of both morbidity and mortality in these patients. Frailty index will be a valuable preoperative risk assessment tool for the acute care surgeon. Level of Evidence: Prognostic study, level II.
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ABSTRACT: Background While living with others has been associated with improved functional outcome after acute stroke, it is unclear if this affects adherence to stroke prevention measures.AimsWe examined the relationship between living arrangements and adherence to antiplatelet therapy assignment and participation status in an international randomized trial for secondary stroke prevention.Method Antiplatelet therapy adherence, trial retention outcomes, and baseline characteristics for participants enrolled in the Secondary Prevention of Small Subcortical Strokes study were compared between those who lived alone vs. with others (n = 2374). Participant status at end-of-trial was categorized into (1) on assigned antiplatelet, (2) off assigned antiplatelet by participant request, or (3) participant withdrew consent/lost to follow-up. Multivariable multivariate logistic regression was used to identify patient features at entry predictive of participant status at trial end.ResultsLiving arrangement, alone vs. with other(s), was not significantly associated with participant status. Participants enrolled in the United States/Canada (odds ratio 3·1, confidence intervals 2·0–5·0, vs. Latin America), taking more (7+) prescription medications (odds ratio 1·7, confidence intervals 1·1–2·7, vs. 0–2 medications), and scoring lower on the Stroke Specific Quality of Life scale (odds ratio 1·3, confidence intervals 1·1–1·5, per 10 points) were more likely to withdraw or become lost to follow-up in the study vs. completing the study on assigned antiplatelet therapy. Participants enrolled in the United States/Canada (odds ratio 5·0, confidence intervals 2·4–10·0, vs. Latin America) and taking fewer (0–2) medications (odds ratio 1·9, confidence intervals 1·2–3·1 vs. 3–6 medications) were more likely to request discontinuation of assigned antiplatelet medication vs. completing the study.Conclusion Living with others was not independently predictive of protocol adherence in this cohort. Number of medications and Stroke Specific Quality of Life scale score may be more indicative of likelihood of trial participation and acceptance of long-term antiplatelet regimen.International Journal of Stroke 04/2014; · 4.03 Impact Factor
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ABSTRACT: Becoming old is considered a privilege and results from the socioeconomic progress and improvements in health care systems worldwide. However, morbidity and mortality increases with age, and even more so in acute onset disease. With the current prospects of longevity, a considerable number of elderly patients will continue to live with good function and excellent quality of life after emergency surgical care. However, mortality in emergency surgery may be reported at 15-30%, doubled if associated with complications, and notably higher in patients over 75 years. A number of risks associated with death are reported, and a number of scores proposed for prediction of risk. Frailty, a decline in the physiological reserves that may make the person vulnerable to even the most minor of stressful event, appears to be a valid indicator and predictor of risk and poor outcome, but how to best address and measure frailty in the emergency setting is not clear. Futility may sometimes be clearly defined, but most often becomes a borderline decision between ethics, clinical predictions and patient communication for which no solid evidence currently exists. The number and severity of other underlying condition(s), as well as the treatment alternatives and their consequences, is a complex picture to interpret. Add in the onset of the acute surgical disease as a further potential detrimental factor on function and quality of life ¿ and you have a perfect storm to handle. In this brief review, some of the challenging aspects related to emergency surgery in the elderly will be discussed. More research, including registries and trials, are needed for improved knowledge to a growing health care challenge.Scandinavian Journal of Trauma Resuscitation and Emergency Medicine 02/2015; 23(1):10. · 1.93 Impact Factor
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ABSTRACT: Nearly 50% of Americans will have an operation after the age of 65 years. Traditional preoperative anesthesia consultations capture only some of the information needed to identify older patients (defined as ≥65 years of age) undergoing elective surgery who are at increased risk for postoperative complications, prolonged hospital stays, and delayed or hampered functional recovery. As a catalyst to this review, we compared traditional risk scores (eg, cardiac-focused) to geriatric-specific risk measures from two older female patients seen in our preoperative clinic who were scheduled for elective, robotic-assisted hysterectomies. Despite having a lower cardiac risk index and Charlson comorbidity score, the younger of the two patients presented with more subtle negative geriatric-specific risk predictors - including intermediate or pre-frail status, borderline malnutrition, and reduced functional/mobility - which may have contributed to her 1-day-longer length of stay and need for readmission. Adequate screening of physiologic and cognitive reserves in older patients scheduled for surgery could identify at-risk, vulnerable elders and enable proactive perioperative management strategies (eg, strength, balance, and mobility prehabilitation) to reduce adverse postoperative outcomes and readmissions. Here, we describe our initial two cases and review the stress response to surgery and the impact of advanced age on this response as well as preoperative geriatric assessments, including frailty, nutrition, physical function, cognition, and mood state tests that may better predict postoperative outcomes in older adults. A brief overview of the literature on anesthetic techniques that may influence geriatric-related syndromes is also presented.Clinical Interventions in Aging 01/2015; 10:13-27. · 2.65 Impact Factor