Elderly Patients

Wilkinson K. An age-old problem: care of older people undergoing surgery. Br J Hosp Med (Lond). 2011;72(3):126-127. doi:10.12968/hmed.2011.72.3.126

Bottom line: This 2011 BJHM article is a brief synopsis of the findings of full 148-page report  An Age Old Problem by the National Confidential Enquiry into Patient Outcome and Death in the UK. The author's highlight that in reviewing ~800 cases involving patients who were >80 years old and died within 30-days post-op, they found that only 37.5% received "good care" as per peer review.  


The most cited reason for substandard care was preventable delays in the lead up to the OR. Geriatricians were seldom involved in the perioperative period. Complications were common despite adequate senior staff involvement -- for example, perioperative hypotension occurred in half the patients. Finally, 30% of patients received critical care at some point, and 10% of these admissions were unplanned. 

    Frailty

    Definition: Deterioration of physiological function that affects multiple organs.

     

    A frail patient undergoing surgery is more susceptible to profound change in function.

     

    Can be described in two different models: frailty phenotype and frailty index recognizing that there is a requirement of time and skill for administration of these tools and that is often a barrier to assessment.

     

    Assessment of frailty can be done via tools like the Edmonton Frail Scale or Clinical Frailty Score.

    Clegg A, Young J, Iliffe S, Rikkert MO, Rockwood K. Frailty in elderly people [published correction appears in Lancet. 2013 Oct 19;382(9901):1328]. Lancet. 2013;381(9868):752-762. doi:10.1016/S0140-6736(12)62167-9

    Bottom line: This 2013 review article is a comprehensive review of frailty. It posits a definition of frailty, reviews the pathophysiology behind the condition, discusses the two basic models of frailty (the phenotype model and the cumulative deficit model) and the evidence behind each. The author summarizes the epidemiology of frailty as well the assessments/questionnaires available to identify the condition. Finally, the article summarizes what interventions are available once the condition has been diagnosed and the expected outcomes. 

    Major points:

    1. Frailty is the accumulation of deficits across multiple organ systems which results in a striking and disproportionate response to what would otherwise be a minor stressor (minor surgery, new drug, minor infection) in a non-frail person. Unlike the rest of modern medicine, where the focus is on single-systems, frailty highlights the fact that in the frail elderly people the deficits lie across multiple organ systems. Therefore, treating these patients requires a more holistic approach. 

    2. Clinical judgement should be shifted away from chronological age and towards distinguishing between the frail patient vs non-frail patient. Failure to detect frailty in an elderly patient puts them at risk from an invasive intervention that might do more harm than good given their state. Conversely, without distinguishing between frail vs non-frail, a non-frail patient may be harmed by being denied an otherwise beneficial intervention simply because of their age.


    3. Frailty is important because it focuses clinicians away from the idea of chronological age and towards the idea of frailty - a better gauge of a patient's physiologic reserve and response to potential stressors. Presently, the comprehensive geriatric assessment is the gold standard for diagnosing frailty but is expensive and resource-intensive. Questionnaires such as the Groningen frailty indicator or Tillburg frailty indicator are candidates for cheaper questionairre-based alternatives, but their diagnostic accuracy has not yet been proven. Other physical exam-based assessments exist to identify frailty (timed up-and-go test, hand grip strength, pulmonary function, gait speed or a combination of these as used in the Edmonton Frail Scale) which have showed validity but their diagnostic accuracy is yet to be proven. 

    4. Once frailty is identified complex interventions based on a comprehensive geriatric assessment has been shown to prolong the time a person can live at home. Exercise regimens have been shown to improve outcomes of mobility and functional status. In both cases, the most frail see the least benefit. Nutritional interventions have a lack of evidence to date. Pharmacological interventions including ACEi for improved muscle strength, and Vit D/Calcium for reduction of falls are promising areas of future research for treating frailty. 

      Chan SP, Ip KY, Irwin MG. Peri-operative optimisation of elderly and frail patients: a narrative review. Anaesthesia. 2019;74 Suppl 1:80-89. doi:10.1111/anae.14512

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      Chan SP, Ip KY, Irwin MG. Peri-operative optimisation of elderly and frail patients: a narrative review. Anaesthesia. 2019;74 Suppl 1:80-89. doi:10.1111/anae.14512

      Bottom line: There are multiple models of care available for managing the elderly in the pre-operative setting --  anesthesiologist-led, geriatrician-led or other innovative models. Whatever the model, various tools exist to identify the frail elderly patient (e.g. Clinical Frailty Scale, Edmonton Frail Scale) - who is at an increased risk for post-operative adverse events (increased LOS, hospitalization, morbidity and mortality).

      Once identified as a frail patient, the process of shared-decision making should begin so that an informed decision can be had about the decision to proceed with surgery. Subsequently, any frailty-related pre-operative interventions (such as exercise or nutrition supplementation) can be applied and finally, the risk factors for post-operative cognitive disorders can be identified so that appropriate interventions can be made. 

      Major points: 

      1. Multiple models exist for peri-operative care of the elderly patient. Geriatrician-led teams such as Older People Undergoing Surgery Service. Anesthesiologist-led teams such as Torbay Pre-operative Preparation Clinic. Other innovative models such as Michigan Surgical Home and Optimisation Program. 

      2. The traditional models of identifying frail patients (phenotype model and deficit accumulation model) are too cumbersome and resource-intensive to be used routinely in the pre-operative setting. Adjustments to the Rockwood model by Farhat et al cut the original 70 variables down to 11 and verified the predictive value for 30-day post-operative mortality. The Edmonton Frail Scale is a 17-point scale which can be used by non-geriatricians in 5 minutes. The Clinical Frailty Scale is semi-qualitative tool that can be used in the outpatient setting by any trained staff. 

      3. There is still a lack of evidence as to whether or not frailty can be delayed or reversed. Exercise interventions can improve mobility and functional ability. Nutritional screens can also be used. Sarcopenia can be corrected. There is no evidence available for the optimal intervention for improving post-operative outcomes. 

      4. Malnutrition (e.g. BMI <18.5) is a strong predictor of mortality, morbidity, increased LOS and readmission rates. All-cause mortality increases at BMI < 24 and doubles when BMI < 22 in men and 20 in women. Albumin is an inexpensive and routinely available biomarker that - when decreased - is associated with increased surgical risk and mortality. Unfortunately, it is neither sensitive, nor specific for malnutrition. 

      5. Post-operative delirium is associated with prolonged LOS and higher mortality. CAM, DSI or NuDESC screens can be used. Various pre-operative risk factors (i.e. malnutrition, hypo/hyperNa, pre-existing cognitive impairment etc.) and peri-operative factors (emergency surgery, longer surgery, more bleeding etc.) can identify patients at increased risk. Benzodiazapenes should then be avoided, depth of anesthesia controlled (40-60 via BIS according to some) and pain tightly controlled to minimize the risk. Low-dose haloperidol or atypical neuroleptics can be used for severe cases once delirium has developed. Compared to sevoflurane, TIVA is associated with less post-operative delirium.

      6. Post-operative cognitive dysfunction is an elusive clinical entity associated with impaired memory, concentration, executive function and mental processing speed that arises after a surgical procedure and is associated with increased mortality, inability to work and social dependency. Found in ~26% of >60 y/o patients 1 week post-op and 9.9% 3 months out, compared to ~3% in controls. Numerous pre-operative and operative risk factors have been identified. There are no guidelines for management or preference for any particular anesthetic technique. Regional anesthesia does not decrease risk. Patients at risk should be identified and counselled appropriately. 

      Partridge JS, Harari D, Dhesi JK. Frailty in the older surgical patient: a review. Age Ageing. 2012;41(2):142-147. doi:10.1093/ageing/afr182

      Bottom Line: This 2012 review article highlights that as more elderly patients are undergoing surgical procedures, many of these patients are "frail" - which has been shown to be an independent risk factor for adverse post-operative outcomes.


      Furthermore, as more evidence is emerging that frailty is potentially modifiable, the natural question arises of whether frailty should be regularly screened for in the pre-operative assessment of the elderly patient and whether optimisation of the "frail syndrome" can improve post-operative outcomes. 

      Major points:


      1. The case for assessing frailty pre-operatively is based on frailty being an independent risk factor for post-operative major morbidity, mortality and prolonged LOS. Assessing frailty can serve two purposes: (1) risk stratify patients so that they can make a fully informed decision, (2) highlight areas for pre-operative optimisation should the decision be made to proceed with surgery. 

      2. The difficulty in assessing frailty is primarily because there is no consensus universal definition of frailty. There are multiple tools available to the clinician, each with their own pros and cons. The Edmonton Frail Scale is one such tool which has been validated for use by non-geriatricians and can be completed in less than 5 minutes. 

      3. Because of varying definitions and differences among populations, prevalence of frailty among older surgical patients varies greatly in the literature (anywhere from 4.1%-50%) with post-discharge institutionalization rates as high as 30%. This raises the question as to whether frailty can be modified pre-operatively and whether those modifications can improve post-operative outcomes. The author discusses emerging evidence on the potential the roles of exercise, nutrition and pharmacotherapy (albeit to a lesser extent) in improving long-term outcomes in frail patients. Whether or not these effects exist in surgical patients is not yet known.

      Michel JP, Cruz-Jentoft AJ, Cederholm T. Frailty, Exercise and Nutrition. Clin Geriatr Med. 2015;31(3):375-387. doi:10.1016/j.cger.2015.04.006

      Bottom line: In this 2015 review article, the author posits that the European prevalence of frailty (5.8-27.3%) and pre-frailty (34.6-50.9%) varied across countries and was associated with exponential increases in mortality between the three groups (robust, pre-frail, frail). With time there is a back-and-forth transition between the three states,  but a gradual trend toward the frail state, with death as the eventual consequence. 

      Interventions involving exercise with or without nutritional supplementation and targeted interventions on specific frailty components have been shown to effectively delay or even reverse the frailty process. 

      Factors associated with transition to a more frail state varied between genders. Older age, previous cancer, previous hospitalization for men. Older age, COPD, previous stroke, hospitalization and OA for women. Factors associated with improvements are lower age, higher MMSE score, and absence of stroke for men. Improvement is seen with lower age, no diabetes, no prior hospitalization and higher socioeconomic status in women.

      McIsaac DI, Aucoin SD, van Walraven C. A Bayesian Comparison of Frailty Instruments in Noncardiac Surgery: A Cohort Study. Anesth Analg. 2020 Nov 30. doi: 10.1213/ANE.0000000000005290. Epub ahead of print. PMID: 33264118

      Bottom line: Frailty is a complex syndrome encompassing age, medical comorbidities as well as other dimensions, and is associated with increased risk of adverse post-operative outcomes. Research in this area can be impeded by the heterogeneity of frailty measurement instruments. 

       

      The RAI-A (risk analysis index-administrative) is a multidimensional frailty assessment instrument. Compared to the more comorbidity-focused 5-item modified frailty index (mFI-5), the RAI-A appear superior for predicting outcomes for inpatient noncardiac surgery. It also improves predictive performance when added to the NSQIP calculator, and can be used more consistently in research related to frailty. 

       

      Major points:

      1. Frailty is a multidimensional syndrome and important prognostic factor for post-operative outcomes. It is a complex concept that encompasses age as well as comorbidities. There is considerable heterogeneity in the ways to measure frailty, which can hinder the translation of research in this area. 

      2. Two tools commonly used in research using the NSQIP data are the RAI-A (risk analysis index-administrative) and 5-item modified frailty index (mFI-5).  The mFI-5 has a heavy focus on comorbidities, whereas the RAI-A is more multidimensional and appears more reflective of nature of the frailty syndrome. 

      3. Using a Bayesian approach to model assessment, RAI-A appears superior to mFI-5 as a predictive instrument for post-operative outcomes in patients with frailty, including when added to the NSQIP calculator for noncardiac inpatient surgery. This further enforces the idea that frailty is a multidimensional concept, and that the instruments chosen for consistent use for research in this area should be reflective of this idea.