INDIAN WELLS, CALIF. — Elderly patients with at least four of six markers of frailty before elective major surgery were significantly more likely to die within 6 months after surgery, a prospective study of 110 subjects showed.
More than half of all operations in the United States are performed on patients older than 65 years. Including six frailty markers in geriatric preoperative assessments can help predict postoperative mortality and the need for institutional care after discharge, Dr. Thomas N. Robinson and associates reported at the annual meeting of the American Surgical Association.
“Recognition of frailty markers in a preoperative assessment of geriatric patients represents a paradigm shift from the traditional preoperative evaluation techniques,” which typically stratify risk based on a single organ system assessment, said Dr. Robinson of the University of Colorado, Denver.
“We used to only look at comorbidities, urgency of procedure, and cardiac risk stratification to determine risk. Only recently have we recognized that frailty, disability, and alterations in serum markers like albumin and hematocrit can affect the outcome,” said Dr. Michael E. Zenilman, professor and chair of surgery at the State University of New York Downstate Medical Center, Brooklyn, N.Y.
The investigators chose 12 of more than 70 frailty markers to include in assessments within 30 days before elective major surgery at the Denver Veterans Affairs Medical Center. The patients, who underwent general, thoracic, vascular, or urologic surgery, had an average age of 74 years, and 95% were men.
The assessments covered age, cognition, falls, history of depression, anemia, disability, undernutrition, and comorbidity level (based on the Charlson Index, the number of outpatient medications being used, and the American Society of Anesthesiologists score).
All patients survived surgery and postoperative care in the ICU. A total of 15% of patients died within 6 months of undergoing surgery, and 26% required institutionalization in nursing homes or other care institutions upon discharge, Dr. Robinson reported.
The six frailty markers that were significantly associated with a higher risk of 6-month mortality and discharge to institutional care were:
▸ Cognitive impairment on the Mini-Cog Test. This is a simple and validated way to test for impaired cognition or dementia.
▸ Lower albumin level. This averaged 2.93 g/dL in patients who died, compared with 3.69 g/dL in patients who survived 6 months after surgery.
▸ Increased falls. Patients who died averaged 1.6 falls in the 6 months before surgery, compared with 0.7 falls in survivors.
▸ Lower hematocrit. This was 35% in patients who died and 41% in those alive 6 months after surgery.
▸ Higher Katz disability score. This averaged 3.2 among patients who died and 4.8 among survivors.
▸ Greater burden of comorbidities. Patients who died had an average Charlson Index score of 5.1, compared with 3.1 among survivors.
Dr. Robinson and his associates stated that they have no conflicts of interest.
'Recognition of frailty markers in a preoperative assessment of geriatric patients represents a paradigm shift.'
Source DR. ROBINSON