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FRAILTY AND THE PREOPERATIVE ASSESSMENT Thomas Robinson, MD Associate Professor, Surgery University of Colorado August 5th, 2009

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Title: FRAILTY AND THE PREOPERATIVE ASSESSMENT Thomas Robinson, MD Associate Professor, Surgery University of Colorado August 5th, 2009


1
FRAILTY AND THE PREOPERATIVE ASSESSMENT Thomas
Robinson, MD Associate Professor,
Surgery University of Colorado August 5th, 2009
AGS
THE AMERICAN GERIATRICS SOCIETY Geriatrics Health
Professionals. Leading change. Improving care for
older adults.
2
Traditional PreOperative Evaluation
Single end-organ function assessment does not
capture all the information required to predict
adverse outcomes for the geriatric patient
3
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) 54991. JAGS. (2007) 7722.
4
Frailty Characteristics
Functional Impairment
Functional Impairment
Geriatric Syndromes
Low Albumin
Geriatric Syndromes
Low Albumin
FRAILTY
Depressed Mood
Burden of Chronic Disease
Depressed Mood
Burden Chronic Disease
Impaired Cognition
Impaired Cognition
5
Accumulation of Frailty Characteristics
FRAILTY
6
Accumulation of Frailty Characteristics
FRAILTY
Functional Impairment
Normal Mood
7
Accumulation of Frailty Characteristics
No Geriatric Syndromes
Impaired Cognition
FRAILTY
Functional Impairment
Normal Mood
8
Accumulation of Frailty Characteristics
Normal Albumin
Low Burden of Chronic Disease
Impaired Cognition
FRAILTY
No Geriatric Syndromes
Functional Impairment
Normal Mood
9
Accumulation of Frailty Characteristics
Low Albumin
High Burden of Chronic Disease
No Geriatric Syndromes
FRAILTY
Impaired Cognition
Normal Mood
Functional Impairment
10
Frailty and PostOperative Complications
11
Frailty and PostOperative Complications
  • Patients age 70 years undergoing inpatient
    operations (n 125) underwent baseline frailty
    assessment
  • Increased frailty score was associated with
  • Increased post-op complications (P .02)
  • Longer hospital stay (P lt .01)

Arch Gerontol Geriatr (2009) 4878.
Crit Rev Onc/Heme. (2009) epub.
12
Frailty and PostOperative Complications
  • Patients age 65 years undergoing inpatient
    operations (n 110) underwent baseline frailty
    assessment
  • Four or more frailty markers predicted 6-month
    mortality
  • Sensitivity 81
  • Specificity 86

Ann Surg. (2009) 250449.
13
Frailty Characteristics
Functional Impairment
Functional Impairment
Geriatric Syndromes
Low Albumin
Geriatric Syndromes
Low Albumin
FRAILTY
Depressed Mood
Burden of Chronic Disease
Depressed Mood
Burden Chronic Disease
Impaired Cognition
Impaired Cognition
14
Frailty Characteristics
Functional Impairment
Functional Impairment
Geriatric Syndromes
Low Albumin
Geriatric Syndromes
Low Albumin
FRAILTY
Depressed Mood
Burden Chronic Disease
Depressed Mood
Burden Chronic Disease
Impaired Cognition
Impaired Cognition
15
Frailty Characteristic Function
NSQIP IMPORTANCE OF RISK ADJUSTMENT VARIABLES NSQIP IMPORTANCE OF RISK ADJUSTMENT VARIABLES NSQIP IMPORTANCE OF RISK ADJUSTMENT VARIABLES NSQIP IMPORTANCE OF RISK ADJUSTMENT VARIABLES
Importance Order Importance Order Importance Order
Mortality Models 1 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) 210503.
16
Frailty Characteristic Function
NSQIP IMPORTANCE OF RISK ADJUSTMENT VARIABLES NSQIP IMPORTANCE OF RISK ADJUSTMENT VARIABLES NSQIP IMPORTANCE OF RISK ADJUSTMENT VARIABLES NSQIP IMPORTANCE OF RISK ADJUSTMENT VARIABLES
Rank Rank Rank
Mortality Models 1 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) 210503.
17
Frailty Characteristics
Functional Impairment
Functional Impairment
Geriatric Syndromes
Low Albumin
Geriatric Syndromes
Low Albumin
FRAILTY
Depressed Mood
Burden of Chronic Disease
Depressed Mood
Burden Chronic Disease
Impaired Cognition
Impaired Cognition
18
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 post-operative
    mortality from more than 30 pre-operative
    variables.

Arch Surg. (1999) 13436. J Am Coll Surg. (1997)
185315.
19
Frailty Characteristics
Functional Impairment
Functional Impairment
Geriatric Syndromes
Low Albumin
Geriatric Syndromes
Low Albumin
FRAILTY
Depressed Mood
Burden of Chronic Disease
Depressed Mood
Burden Chronic Disease
Impaired Cognition
Impaired Cognition
20
Frailty Characteristic Geriatric Syndromes
  • ASA score of III or IV is closely related to
    1-year mortality following hip fracture (P lt
    .001)
  • Pre-existing burden of chronic disease predicts
    1-year mortality following hip fracture

J Bone Joint Surg. (1995) 771551. J Bone Min
Res. (2005) 20494.
21
Frailty Characteristics
Functional Impairment
Functional Impairment
Geriatric Syndromes
Low Albumin
Geriatric Syndromes
Low Albumin
FRAILTY
Depressed Mood
Burden of Chronic Disease
Depressed Mood
Burden Chronic Disease
Impaired Cognition
Impaired Cognition
22
Frailty Characteristic Cognition
PRE-EXISTING COGNITIVE IMPAIRMENT PRE-EXISTING COGNITIVE IMPAIRMENT PRE-EXISTING COGNITIVE IMPAIRMENT 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 lt .043
D/C institutionalization 35 10 P lt .001
6-month mortality 19.1 5.4 P .016
Dan Wu, Tom Robinson. American College of
Surgeons Surgical Forum (2010).
23
Frailty Characteristics
Functional Impairment
Functional Impairment
Geriatric Syndromes
Low Albumin
Geriatric Syndromes
Low Albumin
FRAILTY
Depressed Mood
Burden of Chronic Disease
Depressed Mood
Burden Chronic Disease
Impaired Cognition
Impaired Cognition
24
Frailty Characteristic Mood
CARDIAC VALVE SURGERY CARDIAC VALVE SURGERY CARDIAC VALVE SURGERY
Depression No Depression
6-month mortality 13.2 7.6 P .03
Ann Thor Surg. (2005) 791255.
25
Frailty Characteristics
Functional Impairment
Functional Impairment
Geriatric Syndromes
Low Albumin
Geriatric Syndromes
Low Albumin
FRAILTY
Depressed Mood
Burden of Chronic Disease
Depressed Mood
Burden Chronic Disease
Impaired Cognition
Impaired Cognition
26
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 P lt .01
D/C to an institution 1.5 1.7
D/C to home 0.5 1.2 P lt .01
Ann Surg. (2009) 250449.
27
Accumulation of Frailty Characteristics
Low Albumin
High Burden of Chronic Disease
No Geriatric Syndromes
FRAILTY
Impaired Cognition
Normal Mood
Functional Impairment
28
THANK YOU FOR YOUR TIME!
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