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Frailty Influences Postop Outcomes

By Jamie Santa Cruz

Older adults' frailty increases the potential for adverse outcomes following surgery.

Frailty is a known risk factor for various adverse outcomes, including complications and prolonged hospital stays.1-5 However, few studies have examined the impact of frailty on subsequent health care utilization, especially in surgical patients. Now, however, new research from the University of Alberta in Edmonton, Alberta, Canada, has found that frailty predicts significantly greater risk of both readmission and death following surgery.6

"Surgeons in most surgical centers are not routinely assessing frailty, especially in an emergency surgery population," says Rachel Khadaroo, MD, PhD, an associate professor in the University of Alberta department of surgery and senior author of the new study. "We need to use a validated scoring method to know if our patients are frail, prefrail/vulnerable, or well."

The study, which was published in February 2018 in the Canadian Medical Association Journal (CMAJ), also found that not only frail patients were at increased risk: Vulnerable (prefrail) status also predicted poorer outcomes, although to a lesser degree.

"If you're frail, you're at increased risk. But what's important is that even those vulnerable patients (the prefrail population) were also at increased risk," Khadaroo says, adding that a vulnerable patient may have no apparent disability. "It's somebody you may not have thought was high risk."

Study Details
The new study, a subset of a larger study titled Elder-friendly Approaches to the Surgical Environment (EASE), prospectively followed 308 patients aged 65 and older who underwent emergency abdominal surgery at one of two tertiary care centers in Canada.7 Almost three-quarters of the total cohort had been living independently prior to surgery. Each patient was assessed for frailty prior to surgery using the Canadian Study of Health and Aging Clinical Frailty Scale and was categorized as "well" (score of 1 or 2), "vulnerable" (score of 3 or 4), or "frail" (score of 5 or 6).

At 30 days postdischarge, the study found significantly higher rates of readmission and death among both frail and vulnerable patients compared with well patients: 16% of vulnerable patients and 17% of frail patients had been readmitted or died, compared with just 4% of well patients.

At six months, a full one-third of study patients had either been readmitted or had died. The same pattern was evident at 30 days: Frail and vulnerable patients were both at significantly higher risk. But at six months, the study also found that the degree of frailty was relevant in predicting a negative outcome: A full 54% of frail patients had been readmitted or had died, compared with 33% of vulnerable patients and only 15% of well patients.

Though previous research on frailty in surgical patients is very limited, existing studies have generally found an association between frailty and increased likelihood of readmission.8-12 The unique contribution of the new CMAJ study is that it followed patients for a relatively long period postdischarge (six months), and it examined a dose-response relation between frailty and outcomes postsurgery.

One key finding of the new research is that frailty is quite common; approximately three-quarters of all patients included in the study were either frail or vulnerable. According to Olga Theou, MSc, PhD, an assistant professor in the department of medicine at Dalhousie University in Halifax, Nova Scotia, Canada, patients classified as vulnerable include those who are slowed down or tired during the day but who are not dependent on others for help, eg, individuals who use a cane but can bathe themselves, shop alone, and otherwise manage their own activities of daily living. (Theou was not involved in the new CMAJ study but coauthored a commentary that was published along with the study.)

Although frailty is often associated with age, the two are not the same, says Jayna M. Holroyd-Leduc, MD, FRCPC, an associate professor in the in the departments of medicine and community health sciences at the University of Calgary. The rate of frailty is approximately 25% at the age of 65, and it approaches 50% by the age of 85, according to Holroyd-Leduc, one of the coauthors of the new CMAJ study. "That means that there are still a lot of very robust people over the age of 80 who are not considered frail," Holroyd-Leduc says. "For the most part, frailty does increase with age, but it's not a universal sign of aging." That clarification is significant, Holroyd-Leduc adds, since frailty, not age, is the more significant factor in predicting negative outcomes.

Findings Suggest the Need for Routine Frailty Assessments
Many surgical patients don't receive formal preoperative frailty assessments, especially prior to emergency surgeries, Khadaroo says. A key implication of the new research, however, is that physicians should routinely assess patients for frailty. "If you don't know, then how do you actually do an intervention?" Khadaroo asks.

As for what assessment method should be used, Khadaroo doesn't recommend any one scale over others. Surgeons simply need to use a validated scoring method as opposed to eyeballing a patient's status, she says.

Once physicians know patients' levels of frailty, they need to use the information in shared decision making with patients, Holroyd-Leduc says. "We should be thinking about frailty more than we think about age when we're having discussions about risks and benefits," she says. "[Frailty] should not be the only deciding factor, but it should be part of the discussion so that people can make the most informed decision."

Implications for Treatment of Frail and Vulnerable Patients
Aside from the need to consider frailty when weighing the risks and benefits of any surgical procedure, another obvious implication of the new findings is that treatment should be adjusted for at-risk patients.

Although there is currently little evidence about which specific interventions will be most useful in reducing readmission and death in frail surgical patients, there are several that are promising. To begin with, comprehensive geriatric assessments could prove valuable. (The University of Alberta team is currently examining the impact of this and other bundled interventions as part of the larger EASE study.) The CMAJ study found that only 4% of frail or vulnerable patients were actually assessed by a geriatrician. "Typically, frail people are complex patients, so they may have individual needs, and we need to create interventions specific to their needs," Theou says. "That's why having a geriatrician involved in their case would be useful."

In geographic areas where geriatricians are in short supply, involving a geriatric specialist in the care of all frail and vulnerable individuals might not be feasible, but it would be possible to promote more geriatric training among generalists to accomplish the same results, according to Theou. "In Canada there aren't that many geriatricians around, especially in rural settings. So in this case, we need for other physicians to get more skills related to geriatric medicine," Theou says.

Other potential interventions under evaluation as part of the EASE study include housing all geriatric surgical patients in the same nursing unit, as well as focusing on delirium prevention, early mobilization, early feeding following surgery, and reconditioning programs that begin at bedside immediately postoperatively. Though little research has been done on such interventions among older emergency surgical patients in particular, research in other groups suggests they will provide benefits, according to Khadaroo.

The preliminary findings from the EASE study are promising, Holroyd-Leduc says. "Early results suggest that if we do pay attention to those at risk and target early intervention strategies, […] they're more likely to have better outcomes," she says. She adds that future research should continue exploring ways to minimize the risk of adverse outcomes in frail patients: "[We need to look] at how we can improve our system for this population so that they can remain active and living in the community."

— Jamie Santa Cruz is a freelance writer based in Englewood, Colorado.

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