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: While advanced age is often associated with poorer surgical outcomes, long-term age-related health status following acute care surgery is unknown. The objective of our study was to assess post-operative cognitive impairment, functional status, and quality of life in elderly patients who underwent emergency surgery. We identified 159 octo- and nonagenarians who underwent emergency surgery between 2008 and 2010 at a single tertiary hospital. Patients were grouped into three cohorts: 1, 2, and 3 years post-operative. We conducted a survey in 2011, with octo- and nonagenarians regarding the impact of emergency surgical procedures. Consenting participants responded to four survey questionnaires: (1) Abbreviated Mental Test Score-4, (2) Barthel Index, (3) Vulnerable Elders Survey, and (4) EuroQol-5 Dimensional Scale. Of the 159 octo- and nonagenarians, 88 (55.3%) patients were alive at the time of survey conduction, and 55 (62.5%) of the surviving patients consented to participate. At 1, 2, and 3 years post-surgery, mortality rates were 38.5%, 44.7%, and 50.0%, respectively. More patients had cognitive impairments at 3 years (33.3%) than at 1 (9.5%) and 2 years (9.1%) post-operatively. No statistical difference in the ability to carry out activities of daily living or functional decline with increasing time post-operatively. However, patients perceived a significant health decline with the greater time that passed following surgery. Our study showed that half of the patients over the age of 80 are surviving up to 3 years post-operatively. While post-operative functional status appears to be stable across the 3 cohorts of patients, perceived health status declines over time. Understanding the long-term post-operative impact on cognitive impairment, functional status, and quality of life in elderly patients who undergo acute care surgery allows health care professionals to predict their patients' likely post-operative needs.
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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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    ABSTRACT: Introduction: Years ago, patients with recent myocardial infarction (MI) were reported to be at high risk of reinfarction (27%) and death after surgery. Therapy has changed in the 3 decades since those reports, so we reexamined that risk as well as other cardiac comorbidities and surgical work values in predicting adverse outcome. Methods: We used the National Surgical Quality Improvement Program Participant Use Data File for 2005 to 2009. We included all patients of all included specialties, for outpatient and inpatient surgery. Cardiac comorbidities included history of congestive heart failure (30 days) or MI (6 months), percutaneous coronary intervention, previous cardiac surgery, and history of angina (30 days). Other predictors included a frailty index and American Society of Anesthesiologists (ASA) class. Adverse cardiac events included cardiac arrest requiring cardiopulmonary resuscitation, MI, and death. Cases were stratified according to surgical work units. Univariate χ(2) analysis and multivariate logistic regression established simple relationships and interactions, with p < 0.05 significant. Results: Of patients who had recent MI, 2.1% had reinfarction perioperatively and 26% of those died. The odds ratio for infarction with vs without recent MI in inpatients age 40 years and older was 4.6. Frailty and ASA class were stronger predictors of perioperative MI and cardiac arrest than was history of MI, and risk increased as surgical work increased. Discussion: The risk caused by preoperative MI has improved by an order of magnitude in the last 30 years. The ASA class and especially frailty are better predictors of adverse cardiac events.
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