Does Preoperative Comprehensive Geriatric Assessment and Frailty Predict Postoperative Complications?

The perioperative frailty index derived from the Chinese hospital information system: a validation study

BACKGROUND

There are various frailty assessment tools in the world, and the application choice of frailty assessment tools for the elderly perioperative population varies. It remains unclear which frailty assessment tool is more suitable for the perioperative population in China. To validate the Perioperative Frailty Index (FI-32) derived from the Chinese Hospital Information System by investigating the impact of preoperative frailty on postoperative outcomes, and ascertain the diagnostic value of FI-32 for predicting postoperative complications through comparing with the FRAIL scale and the modified Frailty Index (mFI-11).

METHODS

A prospective cohort study was conducted in a tertiary hospital. Elderly patients who were 60 years or older and underwent selective operation were included. The FI-32, FRAIL scale, and mFI-11 were assessed. Demographic, surgical variables and outcome variables were extracted from medical records. The data of readmission and mortality within 30 days and 90 days of surgery were ascertained by Telephone follow-up by professionally trained researchers. Multiple logistic regression was used to examine the association between frailty and complications. Receiver operating characteristic curves(ROC) were used to compare FI-32 with mFI-11 and FRAIL, to explore the predictive ability of frailty.

RESULTS

335 patients qualified for the inclusion criteria and were enrolled in the study, and among them, 201 (60.0%) were females, and the Median(P25, P75)age at surgery was 69 (65,74) years. The prevalence of frailty in the study population was 16.4% (assessed by FI-32). After adjusting for concomitant variables including demographic characteristics (such as gender, BMI, smoking, drinking, average monthly income and educational level) and surgical factors (such as surgical approach, surgical site, anesthesia method, operation time, intraoperative bleeding, and intraoperative fluid intake), there was a statistically significant association between frailty and the development of postoperative complication after surgery (OR = 3.051, 95% CI:1.460-6.378, P = 0.003). There were also significant differences in mortality within 30 days of surgery, the length of hospital stay (LOS) and the hospitalization costs. FI-32, FRAIL and mFI-11 showed a moderate predictive ability for postoperative complications, the Area Under Curves (AUCs) were 0.582, 0.566 and 0.531, respectively. With adjusting concomitant variables associated with postoperative complications, the AUCs of FI-32, FRAIL and mFI-11 in the adjusted prediction models were 0.824, 0.827 and 0.820 respectively.

CONCLUSIONS

The FI-32 has a predictive effect on postoperative adverse outcomes in elderly Chinese patients. Compared to FRAIL and mFI-11, the FI-32 had the same ability to predict postoperative complications, and FI-32 can be extracted directly from HIS, which greatly saves the time for clinical medical staff to evaluate perioperative frailty.

Comprehensive Peri-Operative Risk Assessment and Management of Geriatric Patients

Background: As the population ages, the prevalence of surgical interventions in individuals aged 65+ continues to increase. This poses unique challenges due to the higher incidence of comorbidities, polypharmacy, and frailty in the elderly population, which result in high peri-operative risks. Traditional preoperative risk assessment tools often fail to accurately predict post-operative outcomes in the elderly, overlooking the complex interplay of factors that contribute to risk in the elderly. Methods: A literature review was conducted, focusing on the predictive value of CGA for postoperative prognosis and the implementation of perioperative interventions. Results: Evidence shows that CGA is a superior predictive tool compared to traditional models, as it more accurately identifies elderly patients at higher risk of complications such as postoperative delirium, infections, and prolonged hospital stays. CGA includes assessments of frailty, sarcopenia, nutritional status, cognitive function, mental health, and functional status, which are crucial in predicting post-operative outcomes. Studies demonstrate that CGA can also guide personalized perioperative care, including nutritional support, physical training, and mental health interventions, leading to improved surgical outcomes and reduced functional decline. Conclusions: The CGA provides a more holistic approach to perioperative risk assessment in elderly patients, addressing the limitations of traditional tools. CGA can help guide surgical decisions (e.g., curative or palliative) and select the profiles of patients that will benefit from perioperative interventions to improve their prognosis and prevent functional decline.

The interrelationship between multiple long-term conditions (MLTC) and delirium: a scoping review

INTRODUCTION

Delirium and multiple long-term conditions (MLTC) share numerous risk factors and have been shown individually to be associated with adverse outcomes following hospitalisation. However, the extent to which these common ageing syndromes have been studied together is unknown. This scoping review aims to summarise our knowledge to date on the interrelationship between MLTC and delirium.

METHODS

Searches including terms for delirium and MLTC in adult human participants were performed in PubMed, EMBASE, Medline, Psycinfo and CINAHL. Descriptive analysis was used to summarise findings, structured according to Synthesis Without Meta-analysis reporting guidelines.

RESULTS

After removing duplicates, 5256 abstracts were screened for eligibility, with 313 full-texts sought along with 17 additional full-texts from references in review articles. In total, 140 met inclusion criteria and were included in the final review. Much of the literature explored MLTC as a risk factor for delirium (n = 125). Fewer studies explored the impact of MLTC on delirium presentation (n = 5), duration (n = 3) or outcomes (n = 6) and no studies explored how MLTC impacts the treatment of delirium or whether having delirium increases risk of developing MLTC. The most frequently used measures of MLTC and delirium were the Charlson Comorbidity Index (n = 98/140) and Confusion Assessment Method (n = 81/140), respectively.

CONCLUSION

Existing literature largely evaluates MLTC as a risk factor for delirium. Major knowledge gaps identified include the impact of MLTC on delirium treatment and the effect of delirium on MLTC trajectories. Current research in this field is limited by significant heterogeneity in defining both MLTC and delirium.

Association of postoperative delirium with serum and cerebrospinal fluid proteomic profiles: a prospective cohort study in older hip fracture patients

Postoperative delirium (POD) is a common neuropsychiatric complication in geriatric inpatients after hip fracture surgery and its occurrence is associated with poor outcomes. The purpose of this study was to investigate the relationship between preoperative biomarkers in serum and cerebrospinal fluid (CSF) and the development of POD in older hip fracture patients, exploring the possibility of integrating objective methods into future predictive models of delirium. Sixty hip fracture patients were recruited. Blood and CSF samples were collected at the time of spinal anesthesia when none of the subjects had delirium. Patients were assessed daily using the 4AT scale, and based on these results, they were divided into POD and non-POD groups. The Olink® platform was used to analyze 45 cytokines. Twenty-one patients (35%) developed POD. In the subsample of 30 patients on whom proteomic analyses were performed, a proteomic profile was associated with the incidence of POD. Chemokine (C-X-C motif) ligand 9 (CXCL9) had the strongest correlation between serum and CSF samples in patients with POD (rho = 0.663; p < 0.05). Although several cytokines in serum and CSF were associated with POD after hip fracture surgery in older adults, there was a significant association with lower preoperative levels of CXCL9 in CSF and serum. Despite the small sample size, this study provides preliminary evidence of the potential role of molecular biomarkers in POD, which may provide a basis for the development of new delirium predictive models.

Value of a multidisciplinary geriatric oncology committee on patient care in a community-based, academic cancer center

INTRODUCTION

The heterogeneity in health and functional ability among older patients makes the management of cancer a unique challenge. The Geriatric Oncology Program at the University of Maryland Baltimore Washington Medical Center (BWMC) was created to optimize cancer management for older patients. This study aimed to assess the benefits of the implementation of such a program at a community-based academic cancer center.

MATERIALS AND METHODS

We analyzed patients aged ≥80 years presenting to the Geriatric Oncology Program between 2017 and 2022. A multidisciplinary team of specialists collectively reviewed each patient using geriatric-specific domains and stratified each patient into one of three management groups- Group 1: those deemed fit to receive standard oncologic care (SOC); Group 2: those recommended to receive optimization services prior to reassessment for SOC; and Group 3: those deemed to be best suited for supportive care and/or hospice care.

RESULTS

The study cohort consisted of 233 patients, of which 76 (32.6%) received SOC, 43 (18.5%) were optimized, and 114 (49.0%) received supportive care or hospice referral. Among the optimized patients, 69.8% were deemed fit for SOC upon re-evaluation following their respective optimization services. The Canadian Study of Health and Aging-Clinical Frailty Scale (CSHA-CFS) score was implemented in 2019 (n = 90). Patients receiving supportive/hospice care only had an average score of 5.8, while the averages for those in the optimization and SOC groups were 4.6 and 4.1, respectively (p ≤0.001). Patients receiving SOC had the longest average survival of 2.71 years compared to the optimization (2.30 years) and supportive care groups (0.93 years) (p ≤0.001). For all patients that underwent surgical interventions post-operatively, 23 patients (85%) were discharged home and four (15%) were discharged to a rehabilitation facility.

DISCUSSION

The present study demonstrates the profound impact that the complexities in health status and frailty among older individuals can have during cancer management. The Geriatric Oncology Program at BWMC maximized treatment outcomes for older adults through the provision of SOC therapies and optimization services, while also minimizing unnecessary interventions on an individual patient-centric level.

Risk Factors for Postoperative Cognitive Decline After Orthopedic Surgery in Elderly Chinese Patients: A Retrospective Cohort Study

Purpose

We aimed to identify the risk factors for postoperative cognitive decline (POCD) by evaluating the outcomes from preoperative comprehensive geriatric assessment (CGA) and intraoperative anesthetic interventions.

Patients and Methods

Data used in the study were obtained from the Aged Patient Perioperative Longitudinal Evaluation-Multidisciplinary Trial (APPLE-MDT) cohort recruited from the Department of Orthopedics in Xuanwu Hospital, Capital Medical University between March, 2019 and June, 2022. All patients accepted preoperative CGA by the multidisciplinary team using 13 common scales across 15 domains reflecting the multi-organ functions. The variables included demographic data, scales in CGA, comorbidities, laboratory tests and intraoperative anesthetic data. Cognitive function was assessed by Montreal Cognitive Assessment scale within 48 hours after admission and after surgery. Dropping of ≥1 point between the preoperative and postoperative scale was defined as POCD.

Results

We enrolled 119 patients. The median age was 80.00 years [IQR, 77.00, 82.00] and 68 patients (57.1%) were female. Forty-two patients (35.3%) developed POCD. Three cognitive domains including calculation (P = 0.046), recall (P = 0.047) and attention (P = 0.007) were significantly worsened after surgery. Univariate analysis showed that disability of instrumental activity of daily living, incidence rate of postoperative respiratory failure (PRF) ≥4.2%, STOP-Bang scale score, Caprini risk scale score and Sufentanil for maintenance of anesthesia were different between the POCD and non-POCD patients. In the multivariable logistic regression analysis, PRF ≥ 4.2% (odds ratio [OR] = 2.343; 95% confidence interval [CI]: 1.028-5.551; P = 0.046) and Sufentanil for maintenance of anesthesia (OR = 0.260; 95% CI: 0.057-0.859; P = 0.044) was independently associated with POCD as risk and protective factors, respectively.

Conclusion

Our study suggests that POCD is frequent among older patients undergoing elective orthopedic surgery, in which decline of calculation, recall and attention was predominant. Preoperative comprehensive geriatric assessments are important to identify the high-risk individuals of POCD.

Head & Neck Trauma in the Geriatric Population

Craniofacial trauma in the geriatric population is increasing as our population ages. Due to loss of bone quality and medical comorbidities, injuries for minor trauma can be severe. A more extensive medical evaluation is usually warranted in this population before proceeding with surgery. In addition, unique surgical considerations exist in the repair of atrophic and edentulous bony fractures. Some quality improvement measures have already been undertaken but more is needed to help standardize care in this vulnerable population.

Factors associated with maintaining walking ability postoperation for hip fractures and the predictive value of the CGA7 score for postoperative walking ability

AIM

Patients with hip fractures have a high rate of mortality or decreased mobility, despite early operative treatment and rehabilitation. The first aim of this study was to investigate the factors of decreased walking ability after hip fracture based on whether walking ability was or was not maintained postoperatively. The second aim was to examine the usefulness of the Comprehensive Geriatric Assessment 7 (CGA7), modified from the conventional Comprehensive Geriatric Assessment, for predicting postoperative walking ability.

METHODS

This study included patients who were treated surgically for hip fractures. We divided patients by whether they did or did not maintain their walking ability postoperatively. We registered the following demographic data: walking ability preadmission and at discharge, CGA7 score, cognitive impairment, the patient's prefracture status, fracture type, surgical waiting time, hospital stay duration, limitation of weight-bearing, postoperative complications, transfer to rehabilitation hospital, final living place, and follow-up period. The characteristics of the two groups were compared using Wilcoxon's rank-sum test, the chi-squared test, or Fisher's exact test.

RESULTS

Among 855 patients, 616 (73.0%) patients maintained walking ability and 239 (27.0%) patients did not. Multivariate logistic regression revealed that the factors of age, sex, preoperative walking ability, and postoperative complications were significantly associated with maintaining postoperative walking ability. Furthermore, the higher the CGA7 score, the more likely were patients to maintain their walking ability (odds ratio, 0.72; 95% confidence interval, 0.61-0.85; P < 0.001).

CONCLUSIONS

Patients who had a low CGA7 score had the potential risk of decreased walking ability. Geriatr Gerontol Int 2023; 23: 830-835.

Frailty combined with nutritional risk score in predicting postoperative complications of elderly patients with gastrointestinal malignancies

OBJECTIVE

Exploring the predictive power of frailty combined with nutritional risk on postoperative complications in elderly gastrointestinal malignancies patients.

METHODS

Elderly patients who underwent gastrointestinal cancer surgery at Gastrointestinal Surgery Department of the Affiliated Hospital of Binzhou Medical University from August 2021 to June 2022 were selected as the research subjects. The patients' frailty and nutritional status were assessed using the Fried Frailty Scale and the NRS2002 Nutritional Risk Scale within 24 h of admission. Observing and recording the diagnosis and treatment of postoperative complications during the hospitalization.

RESULTS

202 patients were enrolled, including 119 patients (58.91%) with nutritional risk and 89 patients (44.06%) with frailty. Frailty was an independent risk factor for postoperative complications [OR = 5.904, 95%CI (3.103, 11.233)]. The AUC value of frailty assessment was 0.780, which was greater than the AUC value of NRS2002 score of 0.705 (P < 0.01). The AUC value of frailty assessment combined with NRS-2002 score was 0.844, which was significantly higher than that alone (P < 0.01).

CONCLUSIONS

The ability of frailty to predict postoperative complications is better than the NRS-2002 score. Frailty combined with nutritional risk assessment can increase the predictive power of postoperative complications in elderly gastrointestinal malignancies patients.

Inflammation-based prognostic scores in geriatric patients with rectal cancer

BACKGROUND

Morbidity/mortality and oncologic outcomes can be worsened in geriatric rectal cancer patients due to comorbidities and frailty. The aim of this study was to compare surgical and oncological results of geriatric rectal cancer patients using inflammation-based prognostic scores.

METHODS

The prospectively maintained database of 991 rectal cancer patients treated at our center between 2007 and 2020 were analyzed. All conventional clinicopathologic features, and oncologic outcomes are compared between patients ≥ 65 years old (geriatric patients: Group I) and < 65 years old (non-geriatric patients: Group II). The modified Glasgow Prognostic Score (mGPS) and the C-reactive protein-albumin ratio (CAR), were determined. The prognostic value of mGPS and CAR as well as the well-known clinico-pathologic factors to predict surgical morbidity, mortality, local and/or distant recurrence, and overall survival was assessed.

RESULTS

There were 567 (57.2%) patients who were ≥ 65 years old (Group I; 349 males, median age 74 [range 65-9]) years) and 424 (42.8%) who were < 65 years old (Group II; 252 males, median age 58 [range 20-64] years). The high-grade [Clavien-Dindo III-IV] complications rates of Group I and Group II patients sere 20% (n = 113), and 9% (n = 37), respectively. High-grade complications were related to mGPS (p < 0.001) and CAR (p < 0.001) values. The high-grade complication rate was found to be higher in Group I than in Group II, and this was statistically significant (p < 0.001). High preoperative mGPS and CAR values were significantly associated with postoperative mortality (p < 0.001). In Cox multivariate analysis, mGPS (p = 0.003) and CAR (p = 0.001) were significantly in correlation with lowered overall survival. The mGPS and CAR were found to be independent prognostic factors for overall survival.

CONCLUSIONS

The mGPS and CAR can predict severe postoperative complications and early mortality. mGPS, and CAR have a powerful prognostic value and the potential clinical usefulness to predict decreased overall survival in both geriatric and non-geriatric rectal cancer patients.

Team Approach: Management of Geriatric Acetabular Fractures

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Geriatric acetabular fractures are defined as fractures sustained by patients who are ≥60 years old. With the rapidly aging American populace and its increasingly active lifestyle, the prevalence of these injuries will continue to increase.

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An interdisciplinary approach is necessary to ensure successful outcomes. This begins in the emergency department with hemodynamic stabilization, diagnosis of the fracture, identification of comorbidities and concomitant injuries, as well as early consultation with the orthopaedic surgery service. This multifaceted approach is continued when patients are admitted, and trauma surgery, geriatrics, and cardiology teams are consulted. These teams are responsible for the optimization of complex medical conditions and risk stratification prior to operative intervention.

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Treatment varies depending on a patient's preinjury functional status, the characteristics of the fracture, and the patient's ability to withstand surgery. Nonoperative management is recommended for patients with minimally displaced fractures who cannot tolerate the physiologic stress of surgery. Percutaneous fixation is a treatment option most suited for patients with minimally displaced fractures who are at risk for displacing the fracture or are having difficulty mobilizing because of pain. Open reduction and internal fixation is recommended for patients with displaced acetabular fractures who are medically fit for surgery and have a displaced fracture pattern that would do poorly without operative intervention. Fixation in combination with arthroplasty can be done acutely or in delayed fashion. Acute fixation combined with arthroplasty benefits patients who have poorer bone quality and fracture characteristics that make healing unlikely. Delayed arthroplasty is recommended for patients who have had failure of nonoperative management, have a fracture pattern that is not favorable to primary total hip arthroplasty, or have developed posttraumatic arthritis.

The Mini-Cog: A simple screening tool for cognitive impairment useful in predicting the risk of delirium after major urological cancer surgery

AIM

The purpose of this study was to evaluate the impact of the mini-cognitive assessment instrument (Mini-Cog) on postoperative delirium after major urological cancer surgery.

METHODS

In this single-center retrospective observational study, medical records were collected for patients who underwent major urologic cancer surgery at our department between 2020 and 2021, and underwent preoperative cognitive screening based on the Mini-Cog test (n = 331). The probable cognitive impairment is defined as a Mini-Cog score of <3. Univariate and multivariate logistic regression analysis were used to identify the risk factors for postoperative delirium.

RESULTS

Patients with probable cognitive impairment were 60 (18%). Postoperative delirium occurred in 26 patients (8%). Using multivariate analysis, the Mini-Cog score of <3 (odds ratio [OR] = 12.7; P < 0.001), decline of instrumental activities of daily living (OR = 3.0; P = 0.04) and preoperative benzodiazepine use (OR = 8.3; P < 0.001) were independent risk factors for postoperative delirium. For predicting postoperative delirium, Mini-Cog score with a cutoff value of <3 granting sensitivity of 69.2%, specificity of 86.2%, positive predictive value of 30.0% and negative predictive value of 97.1%.

CONCLUSIONS

The Mini-Cog test is a simple screening tool with only two components (a delayed, three-word recall task and a clock drawing test): it is useful in identifying potential cases of cognitive decline and patients at risk for postoperative delirium along with other information routinely collected preoperatively. Effective screening using the Mini-Cog test opens the possibility to provide optimal urologic care for older patients Geriatr Gerontol Int 2022; 22: 319-324.

Octogenarian patients with colon cancer - postoperative morbidity and mortality are the major challenges

Background

Few studies have addressed colon cancer surgery outcomes in an unselected cohort of octogenarian patients. The present study aimed to evaluate the relative survival of octogenarian patients after a major resection of colon cancer with a curative intent.

Methods

All patients diagnosed with colon cancer at Levanger Hospital between 1980 and 2016 were included. We performed logistic regression to test for associations between 90-day mortality and explanatory variables. We performed a relative survival analysis to identify factors associated with short- and long-term survival.

Results

Among 237 octogenarian patients treated with major resections with curative intent, the 90-day mortality was 9.3%. Among 215 patients that survived the first 90 days, the 5 year relative survival rate was 98.7%. The 90-day mortality of octogenarian patients was significantly higher than that of younger patients, but the long-term survival converged with that of younger patients. Among octogenarian patients, the incidence of colon cancer more than doubled during our 37-year observation period. The relative increase in patients undergoing surgery exceeded the increase in incidence; hence, more patients were selected for surgery over time. A high 90-day mortality was associated with older age, a high American Society of Anaesthesiologists (ASA) score, and emergency surgery. Moreover, worse long-term survival was associated with a high Charlson Comorbidity Index, a high ASA score, a worse TNM stage, emergency surgery and residual tumours. Both the 90-day and long-term survival rates improved over time.

Conclusion

Among octogenarian patients with colon cancer that underwent major resections with curative intent, the 90-day mortality was high, but after surviving 90 days, the relative long-term survival rate was comparable to that of younger patients. Further improvements in survival will primarily require measures to reduce the 90-day mortality risk.

Does Preoperative Cognitive Optimization Improve Postoperative Outcomes in the Elderly?

Perioperative neurocognitive disorder (PND) is a growing concern, affecting several million elderly patients each year in the United States, but strategies for its effective prevention have not yet been established. Humeidan et al. recently demonstrated that preoperative brain exercise resulted in a decrease in postoperative delirium incidence in elderly surgical patients, suggesting the potential of presurgical cognitive optimization to improve postoperative cognitive outcomes. This brief review summarizes the current knowledge regarding preoperative cognitive optimization and highlights landmark studies, as well as current ongoing studies, as the field is rapidly growing. This review further discusses the benefit of cognitive training in non-surgical elderly populations and the role of cognitive training in patients with preexisting cognitive impairment or dementia. The review also examines preclinical evidence in support of cognitive training, which can facilitate understanding of brain plasticity and the pathophysiology of PND. The literature suggests positive impacts of presurgical cognitive optimization, but further studies are encouraged to establish effective cognitive training programs for elderly presurgical patients.

Presurgical Screening Improves Risk Prediction for Delirium in Elective Surgery of Older Patients: The PAWEL RISK Study

Introduction: The number of elective surgeries for patients who are over 70 years of age is continuously growing. At the same time, postoperative delirium (POD) is common in older patients (5–60%) depending on predisposing risk factors, such as multimorbidity, cognitive impairment, neurodegenerative disorders and other dementing disorders, and precipitating factors, such as duration of surgery. Knowledge of individual risk profiles prior to elective surgery may help to identify patients at increased risk for development of POD. In this study, clinical and cognitive risk factors for POD were investigated in patients undergoing various elective cardiac and non-cardiac surgeries.

Methods: The PAWEL study is a prospective, interventional trial on delirium prevention. At baseline, 880 inpatients at five surgical centers were recruited for sub-sample PAWEL-R. Multimodal assessments included clinical renal function, medication, American Society of Anesthesiologists (ASA) Physical Status Classification System, geriatric and cognitive assessments, which comprised the Montreal Cognitive Assessment Scale (MoCA), Trail-making Test, and Digit Span backward. Delirium incidence was monitored postoperatively by the Confusion Assessment Method (CAM) and a chart review for up to a week or until discharge. Multivariate regression models and Chi-square Automatic Interaction Detectors (CHAID) analyses were performed using delirium incidence as the primary outcome.

Results: Eighteen risk factors were investigated in elective cardiovascular and orthopedic or general surgery. A total of 208 out of 880 patients (24%) developed POD. A global regression model that included all risk variables predicted delirium incidence with high accuracy (AUC = 0.81; 95% CI 0.77, 0.85). A simpler model (clinical and cognitive variables; model CLIN-COG) of 10 factors that only included surgery type, multimorbidity, renal failure, polypharmacy, ASA, cut-to-suture time, and cognition (MoCA, Digit Span backward, and preexisting dementia), however, exhibited similar predictive accuracy (AUC = 0.80; 95% CI 0.76, 0.84).

Conclusion: The risk of developing POD can be estimated by preoperative assessments, such as ASA classification, expected cut-to-suture time, and short cognitive screenings. This rather efficient approach predicted POD risk over all types of surgery. Thus, a basic risk assessment including a cognitive screen can help to stratify patients at low, medium, or high POD risk to provide targeted prevention and/or management strategies for patients at risk.