Are the frail destined to fail? Frailty index as predictor of surgical morbidity and mortality in the elderly

Department of Surgery, Henry Ford Hospital, Detroit, Michigan 48202, USA.
The journal of trauma and acute care surgery 06/2012; 72(6):1526-30; discussion 1530-1. DOI: 10.1097/TA.0b013e3182542fab
Source: PubMed


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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    • "Unfortunately, it is not always possible to perform a comprehensive pre-surgical assessment in the emergency setting. Frail elderly patients are often associated with poorer surgical outcomes and increased morbidity (surgical site infections, end organ dysfunction, anastomosis leakage, and sepsis), post-operative delirium and in-hospital falls [11,12], however long term age-related health status following acute care surgery (ACS) is unknown. To date there has been limited published reports of post-operative outcomes following ACS in older patients. "
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    ABSTRACT: OPINION STATEMENT: Elderly patients with advanced epithelial ovarian cancer present a complex treatment dilemma. On the one hand, patients can be treated with primary debulking surgery to achieve the ideal oncologic outcomes but at the expense of risk of surgical morbidity and mortality. On the other hand, they can be treated with alternative, less morbid approaches, reducing toxicity, but sacrificing the survival benefits of low residual disease by surgical cytoreduction. Retrospective studies have attempted to identify risk factors for poor surgical outcome. Although there is no consensus to define "elderly" or "frail," current evidence identifies age, performance status, nutritional status, and surgical complexity as major risk factors for surgical morbidity. Accepting the shortcomings of these retrospective data, candidates for primary debulking surgery can be assessed for risk of surgical morbidity. Age is likely a contributor to morbidity, particularly in the face of comorbid conditions. Clinicians should strive to treat elderly patients with a standard approach of primary debulking surgery and adjuvant chemotherapy when healthy and in the absence of other risk factors. Elderly patients with the following are poor surgical candidates and an alternative treatment approach should be considered: poor nutritional status (characterized by serum albumin <3.0 g/dL), or poor performance status (ASA ≥3), and stage IV disease. Several of these factors are modifiable by treating the underlying cancer. These patients should be treated with two to three cycles of neoadjuvant chemotherapy and reassessed for surgical debulking. Patients with improvement in their nutritional or performance status can undergo interval debulking with the goal to resect all visible disease.
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