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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. Traditional PreOperative Evaluation. - PowerPoint PPT PresentationTRANSCRIPT
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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