FRAILTY AND THE PREOPERATIVE ASSESSMENT

Thomas Robinson, MDAssociate Professor, Surgery

University of ColoradoAugust 5th, 2009

THE AMERICAN GERIATRICS SOCIETY

Geriatrics Health Professionals.

Leading change. Improving care for older adults.

AGS

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

• 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

DEFINITION OF FRAILTY

FRAILTY

Depressed

Mood

Functional

Impairment

Geriatric

Syndromes

Low

Albumin

FRAILTY CHARACTERISTICS

Impaired

Cognition

BurdenChronicDisease

Slide 4

Depressed

Mood

Functional

Impairment

Geriatric

Syndromes

Low

Albumin

Impaired

Cognition

Burden ofChronicDisease

ACCUMULATION OF FRAILTY CHARACTERISTICS

AVERAGE

OUTCOMES

POOR

OUTCOMES Slide 5

FRAILTY

FunctionalImpairment

NormalMood

Slide 6

AVERAGE

OUTCOMES

POOR

OUTCOMES

FRAILTY

ACCUMULATION OF FRAILTY CHARACTERISTICS

ImpairedCognition

FunctionalImpairment

No GeriatricSyndromes

NormalMood

Slide 7

AVERAGE

OUTCOMES

POOR

OUTCOMES

FRAILTY

ACCUMULATION OF FRAILTY CHARACTERISTICS

Impaired

Cognition

Functional

Impairment

No Geriatric

Syndromes

NormalMood

Low Burden

of Chronic

Disease

Normal

Albumin

Slide 8

AVERAGE

OUTCOMES

POOR

OUTCOMES

FRAILTY

ACCUMULATION OF FRAILTY CHARACTERISTICS

High Burdenof ChronicDisease

ImpairedCognition

FunctionalImpairment

LowAlbumin

No GeriatricSyndromes

NormalMood

Slide 9

AVERAGE

OUTCOMES

POOR

OUTCOMES

FRAILTY

ACCUMULATION OF FRAILTY CHARACTERISTICS

FRAILTY AND POSTOPERATIVE COMPLICATIONS

Long-Term Hospital CourseOPERATION

Slide 10

• 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 < .01)

Arch Gerontol Geriatr (2009) 48:78.

Crit Rev Onc/Heme. (2009) epub.Slide 11

FRAILTY AND POSTOPERATIVE COMPLICATIONS

Long-Term Hospital CourseOPERATION

• 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) 250:449.Slide 12

FRAILTY AND POSTOPERATIVE COMPLICATIONS

Long-Term Hospital CourseOPERATION

FRAILTY

Depressed

Mood

Functional

Impairment

Geriatric

Syndromes

Low

Albumin

FRAILTY CHARACTERISTICS

Impaired

Cognition

BurdenChronicDisease

Slide 13

Depressed

Mood

Functional

Impairment

Geriatric

Syndromes

Low

Albumin

Impaired

Cognition

Burden ofChronicDisease

FRAILTY

Depressed

Mood

Functional

Impairment

Geriatric

Syndromes

Low

Albumin

FRAILTY CHARACTERISTICS

Impaired

Cognition

BurdenChronicDisease

Slide 14

Depressed

Mood

Functional

Impairment

Geriatric

Syndromes

Low

Albumin

Impaired

Cognition

BurdenChronicDisease

FRAILTY CHARACTERISTIC: FUNCTION

JACS. (2010) 210:503. Slide 15

FRAILTY CHARACTERISTIC: FUNCTION

JACS. (2010) 210:503. Slide 16

FRAILTY

Depressed

Mood

Functional

Impairment

Geriatric

Syndromes

Low

Albumin

FRAILTY CHARACTERISTICS

Impaired

Cognition

BurdenChronicDisease

Slide 17

Depressed

Mood

Functional

Impairment

Geriatric

Syndromes

Low

Albumin

Impaired

Cognition

Burden ofChronicDisease

FRAILTY CHARACTERISTIC: HYPOALBUMINEMIA

Arch Surg. (1999) 134:36.

J Am Coll Surg. (1997) 185:315. Slide 18

• 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.

FRAILTY

Depressed

Mood

Functional

Impairment

Geriatric

Syndromes

Low

Albumin

FRAILTY CHARACTERISTICS

Impaired

Cognition

BurdenChronicDisease

Slide 19

Depressed

Mood

Functional

Impairment

Geriatric

Syndromes

Low

Albumin

Impaired

Cognition

Burden ofChronicDisease

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

Depressed

Mood

Functional

Impairment

Geriatric

Syndromes

Low

Albumin

FRAILTY CHARACTERISTICS

Impaired

Cognition

BurdenChronicDisease

Slide 21

Depressed

Mood

Functional

Impairment

Geriatric

Syndromes

Low

Albumin

Impaired

Cognition

Burden ofChronicDisease

FRAILTY CHARACTERISTIC: COGNITION

Dan Wu, Tom Robinson. American College of Surgeon’s Surgical Forum (2010).

Slide 22

FRAILTY

Depressed

Mood

Functional

Impairment

Geriatric

Syndromes

Low

Albumin

FRAILTY CHARACTERISTICS

Impaired

Cognition

BurdenChronicDisease

Slide 23

Depressed

Mood

Functional

Impairment

Geriatric

Syndromes

Low

Albumin

Impaired

Cognition

Burden ofChronicDisease

FRAILTY CHARACTERISTIC: MOOD

Ann Thor Surg. (2005) 79:1255.Slide 24

FRAILTY

Depressed

Mood

Functional

Impairment

Geriatric

Syndromes

Low

Albumin

FRAILTY CHARACTERISTICS

Impaired

Cognition

BurdenChronicDisease

Slide 25

Depressed

Mood

Functional

Impairment

Geriatric

Syndromes

Low

Albumin

Impaired

Cognition

Burden ofChronicDisease

FRAILTY CHARACTERISTIC:GERIATRIC SYNDROMES

Ann Surg. (2009) 250:449.Slide 26

High Burdenof ChronicDisease

ImpairedCognition

FunctionalImpairment

LowAlbumin

No GeriatricSyndromes

NormalMood

Slide 27

AVERAGE

OUTCOMES

POOR

OUTCOMES

FRAILTY

ACCUMULATION OF FRAILTY CHARACTERISTICS

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