FRAILTY AND THE PREOPERATIVE ASSESSMENT AGS Thomas Robinson

FRAILTY AND THE PREOPERATIVE ASSESSMENT AGS Thomas Robinson, MD Associate Professor, Surgery University of Colorado August 5 th, 2009 THE AMERICAN GERIATRICS SOCIETY Geriatrics Health Professionals. Leading change. Improving care for older adults.

TRADITIONAL PREOPERATIVE EVALUATION Single end-organ function assessment does not capture all the information required to predict adverse outcomes for the geriatric patient Slide 2

DEFINITION OF FRAILTY • Frailty is an excess vulnerability to stressors, with reduced ability to maintain or regain homeostasis after a destabilizing event • A non-specific state of increasing risk… measured by the accumulation of frailty traits JAGS. (2006) 54: 991. JAGS. (2007) 7: 722. Slide 3

FRAILTY CHARACTERISTICS Functional Impairment Geriatric Low Syndromes Albumin FRAILTY Burdenof Chronic Disease Depressed Mood Impaired Cognition Slide 4

ACCUMULATION OF FRAILTY CHARACTERISTICS FRAILTY AVERAGE POOR OUTCOMES Slide 5

ACCUMULATION OF FRAILTY CHARACTERISTICS Normal Mood FRAILTY Functional Impairment AVERAGE POOR OUTCOMES Slide 6

ACCUMULATION OF FRAILTY CHARACTERISTICS No Geriatric Syndromes Normal Mood Impaired Cognition FRAILTY Functional Impairment AVERAGE POOR OUTCOMES Slide 7

ACCUMULATION OF FRAILTY CHARACTERISTICS Normal Albumin Low Burden of Chronic Disease No Geriatric Syndromes Normal Mood Impaired Cognition FRAILTY Functional Impairment AVERAGE POOR OUTCOMES Slide 8

ACCUMULATION OF FRAILTY CHARACTERISTICS Low Albumin High Burden of Chronic Disease No Geriatric Syndromes Normal Mood FRAILTY Impaired Cognition Functional Impairment AVERAGE POOR OUTCOMES Slide 9

FRAILTY AND POSTOPERATIVE COMPLICATIONS OPERATION Hospital Course Long-Term Slide 10

FRAILTY AND POSTOPERATIVE COMPLICATIONS OPERATION Hospital Course Long-Term • Patients age ≥ 70 years undergoing inpatient operations (n = 125) underwent baseline frailty assessment • Increased frailty score was associated with: Ø Increased post-op complications (P =. 02) Ø Longer hospital stay (P <. 01) Arch Gerontol Geriatr (2009) 48: 78. Crit Rev Onc/Heme. (2009) epub. Slide 11

FRAILTY AND POSTOPERATIVE COMPLICATIONS OPERATION Hospital Course Long-Term • Patients age ≥ 65 years undergoing inpatient operations (n = 110) underwent baseline frailty assessment • Four or more frailty markers predicted 6 -month mortality: Ø Sensitivity 81% Ø Specificity 86% Ann Surg. (2009) 250: 449. Slide 12

FRAILTY CHARACTERISTICS Functional Impairment Geriatric Low Syndromes Albumin FRAILTY Burdenof Chronic Disease Depressed Mood Impaired Cognition Slide 13

FRAILTY CHARACTERISTICS Functional Impairment Geriatric Low Syndromes Albumin FRAILTY Burden Chronic Disease Depressed Mood Impaired Cognition Slide 14

FRAILTY CHARACTERISTIC: FUNCTION NSQIP IMPORTANCE OF RISK ADJUSTMENT VARIABLES Importance Order 1 Mortality Models 2 3 Cholecystectomy Functional Status ASA Class Ascites Ventral Hernia Functional Status Dialysis ASA Class Gastric Bypass Functional Status CHF Hypertension Pancreatectomy Functional Status CHF ASA Class Colectomy ASA Class Functional Status Emergency JACS. (2010) 210: 503. Slide 15

FRAILTY CHARACTERISTIC: FUNCTION NSQIP IMPORTANCE OF RISK ADJUSTMENT VARIABLES Rank 1 Mortality Models 2 3 Cholecystectomy Functional Status ASA Class Ascites Ventral Hernia Functional Status Dialysis ASA Class Gastric Bypass Functional Status CHF Hypertension Pancreatectomy Functional Status CHF ASA Class Colectomy ASA Class Functional Status Emergency JACS. (2010) 210: 503. Slide 16

FRAILTY CHARACTERISTICS Functional Impairment Geriatric Low Syndromes Albumin FRAILTY Burdenof Chronic Disease Depressed Mood Impaired Cognition Slide 17

FRAILTY CHARACTERISTIC: HYPOALBUMINEMIA • Lower albumin is related to increased thirty -day morbidity and mortality across multiple surgical specialties in a dose response fashion. • Low serum albumin level was found to be most closely related to 30 -day postoperative mortality from more than 30 preoperative variables. Arch Surg. (1999) 134: 36. J Am Coll Surg. (1997) 185: 315. Slide 18

FRAILTY CHARACTERISTICS Functional Impairment Geriatric Low Syndromes Albumin FRAILTY Burdenof Chronic Disease Depressed Mood Impaired Cognition Slide 19

FRAILTY CHARACTERISTIC: GERIATRIC SYNDROMES • ASA score of III or IV is closely related to 1 -year mortality following hip fracture (P <. 001) • Pre-existing burden of chronic disease predicts 1 -year mortality following hip fracture J Bone Joint Surg. (1995) 77: 1551. J Bone Min Res. (2005) 20: 494. Slide 20

FRAILTY CHARACTERISTICS Functional Impairment Geriatric Low Syndromes Albumin FRAILTY Burdenof Chronic Disease Depressed Mood Impaired Cognition Slide 21

FRAILTY CHARACTERISTIC: COGNITION PRE-EXISTING COGNITIVE IMPAIRMENT Present (n = 52) Absent (n = 114) Hospital stay, days 13. 4 ± 9. 6 9. 9 ± 8. 4 P =. 029 ICU stay, days 8. 3 ± 8. 0 5. 8 ± 4. 6 P <. 043 35% 10% P <. 001 19. 1% 5. 4% P =. 016 D/C institutionalization 6 -month mortality Dan Wu, Tom Robinson. American College of Surgeon’s Surgical Forum (2010). Slide 22

FRAILTY CHARACTERISTICS Functional Impairment Geriatric Low Syndromes Albumin FRAILTY Burdenof Chronic Disease Depressed Mood Impaired Cognition Slide 23

FRAILTY CHARACTERISTIC: MOOD CARDIAC VALVE SURGERY Depression No Depression 6 -month mortality 13. 2% 7. 6% P =. 03 Ann Thor Surg. (2005) 79: 1255. Slide 24

FRAILTY CHARACTERISTICS Functional Impairment Geriatric Low Syndromes Albumin FRAILTY Burdenof Chronic Disease Depressed Mood Impaired Cognition Slide 25

FRAILTY CHARACTERISTIC: GERIATRIC SYNDROMES Number of falls in prior 6 months 6 -month mortality 1. 6 ± 1. 6 Alive at 6 Months 0. 7 ± 1. 4 D/C to an institution 1. 5 ± 1. 7 D/C to home 0. 5 ± 1. 2 Ann Surg. (2009) 250: 449. P <. 01 Slide 26

ACCUMULATION OF FRAILTY CHARACTERISTICS Low Albumin High Burden of Chronic Disease No Geriatric Syndromes Normal Mood FRAILTY Impaired Cognition Functional Impairment AVERAGE POOR OUTCOMES Slide 27

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