Redefining Geriatric Preoperative Assessment Using Frailty, Disability and Co-Morbidity

Department of Surgery, University of Colorado at Denver School of Medicine, Aurora, CO, USA.
Annals of surgery (Impact Factor: 8.33). 09/2009; 250(3):449-55. DOI: 10.1097/SLA.0b013e3181b45598
Source: PubMed


(1) Determine the relationship of geriatric assessment markers to 6-month postoperative mortality in elderly patients. (2) Create a clinical prediction rule using geriatric markers from preoperative assessment.
Geriatric surgery patients have unique physiologic vulnerability requiring preoperative assessment beyond the traditional evaluation of older adults. The constellation of frailty, disability and comorbidity predict poor outcomes in elderly hospitalized patients.
Prospectively, subjects > or =65 years undergoing a major operation requiring postoperative intensive care unit admission were enrolled. Preoperative geriatric assessments included: Mini-Cog Test (cognition), albumin, having fallen in the past 6-months, hematocrit, Katz Score (function), and Charlson Index (comorbidities). Outcome measures included 6-month mortality (primary) and postdischarge institutionalization (secondary).
One hundred ten subjects (age 74 +/- 6 years) were studied. Six-month mortality was 15% (16/110). Preoperative markers related to 6-month mortality included: impaired cognition (P < 0.01), recent falls (P < 0.01), lower albumin (P < 0.01), greater anemia (P < 0.01), functional dependence (P < 0.01), and increased comorbidities (P < 0.01). Similar statistical relationships were found for all 6 markers and postdischarge institutionalization. Logistic regression identified any functional dependence (odds ratio 13.9) as the strongest predictor of 6-month mortality. Four or more markers in any one patient predicted 6-month mortality with a sensitivity of 81% (13/16) and specificity of 86% (81/94).
Geriatric assessment markers for frailty, disability and comorbidity predict 6-month postoperative mortality and postdischarge institutionalization. The preoperative presence of > or =4 geriatric-specific markers has high sensitivity and specificity for 6-month mortality. Preoperative assessment using geriatric-specific markers is a substantial paradigm shift from the traditional preoperative evaluation of older adults.

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    • "The care and treatment of elderly trauma patients is particularly challenging to the trauma surgeon, as advanced age, extensive past medical history, and poor physiologic reserve are well-recognized risk factors for adverse outcomes following trauma [6,7]. Attempts to better characterize physiologic deficiencies in the elderly have recently been assessed via calculation of frailty indices in order to predict 6-month postoperative mortality and post-discharge institutionalization [8]. Despite increasing recognition of the unique challenges of the senior population to trauma care, little information is currently available regarding specific factors that predict morbidity and mortality in this group, including an improved understanding of long term outcome following discharge [9,10]. "
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    ABSTRACT: Long term follow up is difficult to obtain in most trauma settings, these data are essential for assessing outcomes in the older (>=60) patient. We hypothesized that clinical data obtained during initial hospital stay could accurately predict long term survival.Study design: Using our trauma registry and hospital database, we reviewed all trauma admissions (age >=60, ISS > 15) to our Level 1 center over the most recent 7 years. Mechanism of injury, co-morbidities, ICU admission, and ultimate disposition were assessed for 2-7 years post-discharge. Primary outcome was defined as long term survival to the end of the last year of the study. Of 342 patients discharged following initial admission, mean age was 76.2 +/- 9.7, and ISS was 21.5 +/- 6.9. 119 patients (34.8%) died (mean follow up 18.8 months; range 1.1-66.2 months). For 233 survivors, mean follow-up was 50.2 months (range 24.8-83.8 months). Univariate analysis disclosed post-discharge mortality was associated with age (80.1 +/- 9.64 vs. 74.2 +/- 9.07), mean number of co-morbidities (1.6 +/- 1.1 vs. 1.0 +/- 1.2), fall as a mechanism, lower GCS upon arrival (11.85 +/- 4.21 vs. 13.73 +/- 2.89), intubation at the scene and discharge to an assisted living facility (p < 0.001 for all). Cox regression analysis hazard ratio showed that independent predictors of mortality on long term follow-up included: older age, fall as mechanism, lower GCS at admission and discharge to assisted living facility (all = p < 0.0001). Nearly two-thirds of patients >=60 who were severely injured survived >4 years following discharge; furthermore, admission data, including younger age, injury mechanism other than falls, higher GCS and home discharge predicted a favorable long term outcome. These findings suggest that common clinical data at initial admission can predict long term survival in the older trauma patient.
    World Journal of Emergency Surgery 01/2014; 9(1):10. DOI:10.1186/1749-7922-9-10 · 1.47 Impact Factor
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    • "As such, frailty is a potentially useful construct for identifying those within the Medicare population who are most vulnerable to adverse events associated with hospitalization. Prompt recognition of frailty could facilitate communication, multidisciplinary care coordination, risk reduction interventions, prognostication, and appropriate treatment plan development [5,6]. "
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    ABSTRACT: There is a persistently high incidence of adverse events during hospitalization among Medicare beneficiaries. Attributes of vulnerability are prevalent, readily apparent, and therefore potentially useful for recognizing those at greatest risk for hospital adverse events who may benefit most from preventive measures. We sought to identify patient characteristics associated with adverse events that are present early in a hospital stay. An interprofessional panel selected characteristics thought to confer risk of hospital adverse events and measurable within the setting of acute illness. A convenience sample of 214 Medicare beneficiaries admitted to a large, academic medical center were included in a quality improvement project to develop risk assessment protocols. The data were subsequently analyzed as a prospective cohort study to test the association of risk factors, assessed within 24 hours of hospital admission, with falls, hospital-acquired pressure ulcers (HAPU) and infections (HAI), adverse drug reactions (ADE) and 30-day readmissions. Mean age = 75(+/-13.4) years. Risk factors with highest prevalence included >4 active comorbidities (73.8%), polypharmacy (51.7%), and anemia (48.1%). One or more adverse hospital outcomes occurred in 46 patients (21.5%); 56 patients (26.2%) were readmitted within 30 days. Cluster analysis described three adverse outcomes: 30-day readmission, and two groups of in-hospital outcomes. Distinct regression models were identified: Weight loss (OR = 3.83; 95% CI = 1.46, 10.08) and potentially inappropriate medications (OR = 3.05; 95%CI = 1.19, 7.83) were associated with falls, HAPU, procedural complications, or transfer to intensive care; cognitive impairment (OR = 2.32; 95%CI = 1.24, 4.37), anemia (OR = 1.87; 95%CI = 1.00, 3.51) and weight loss (OR = 2.89; 95%CI = 1.38, 6.07) were associated with HAI, ADE, or length of stay >7 days; hyponatremia (OR = 3.49; 95%CI = 1.30, 9.35), prior hospitalization within 30 days (OR = 2.66; 95%CI = 1.31, 5.43) and functional impairment (OR = 2.05; 95%CI = 1.02, 4.13) were associated with 30-day readmission. Patient characteristics recognizable within 24 hours of admission can be used to identify increased risk for adverse events and 30-day readmission.
    BMC Geriatrics 07/2013; 13(1):72. DOI:10.1186/1471-2318-13-72 · 1.68 Impact Factor
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    • "It is widely accepted that it is worth knowing about frailty as a means of improving care, although trials of frailty recognition versus operating without the construct are lacking [18,47-51]. Frailty has been shown to be an independent marker for worse outcomes following surgery, including postoperative complications, mortality, length of stay and discharge to care facilities [52-54]. As such, frailty has been proposed as an additional component of pre-operative risk classification and as a guide in informed decision making for patients and families. "
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    ABSTRACT: Frail, older patients pose a challenge to the primary care physician who may often feel overwhelmed by their complex presentation and tenuous health status. At the same time, family physicians are ideally suited to incorporate the concept of frailty into their practice. They have the propensity and skill set that lends itself to patient-centred care, taking into account the individual subtleties of the patient's health within their social context. Tools to identify frailty in the primary care setting are still in the preliminary stages of development. Even so, some practical measures can be taken to recognize frailty in clinical practice and begin to address how its recognition may impact clinical care. This review seeks to address how frailty is recognised and managed, especially in the realm of primary care.
    BMC Medicine 01/2012; 10(1):4. DOI:10.1186/1741-7015-10-4 · 7.25 Impact Factor
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