Frailty: the perioperative and anesthesia challenges of an emerging pandemic

Preoperative Cognitive Optimization and Postoperative Cognitive Outcomes: A Narrative Review

Background

Perioperative neurocognitive disorder (PND) is a growing concern and affects millions of older adult surgical patients each year in the United States. However, the effective prevention of PND has yet to be established. Recently, preoperative brain exercise has been suggested to decrease postoperative delirium incidence in older patients. This review aims to interpret existing preoperative cognitive optimization research, determine if the research supports preoperative cognitive optimization, and identify gaps in the knowledge of the older surgical population.

Methods

A literature search was performed in Pub Med (1995-2024) using the keywords (Older Surgical Patients, Presurgical Assessment, Cognitive Optimization, Neurocognitive Disorder, Postoperative Cognitive Impairment, Postoperative Delirium, Dementia, Frailty Syndrome, Prehabilitation, and Brain Plasticity). The type of literature included clinical trials, case series, cohort studies, and reviews. Among these articles, I included the one in which full text is available in Pub Med and is identified that specifically investigates cognitive function in older adults.

Results and Conclusion

Evidence of the effect of preoperative cognitive optimization on postoperative cognitive functions in older adult surgical patients is still limited. Postoperative delirium was reduced by preoperative cognitive training. A limited number of clinical studies suggest the beneficial effect of preoperative cognitive training, but others show no effects. Further studies are needed on the cognitive training dosage, duration, and platform type. Studies are also required in presurgical patients with preexisting cognitive impairment or dementia.

The Surgical Pause: The Importance of Measuring Frailty and Taking Action to Address Identified Frailty

CONCEPTUAL FRAMEWORK

The Surgical Pause is a rapid, scalable strategy for health care systems to optimize perioperative outcomes for high-risk, frail patients considering elective surgery. The first and most important step is to screen for frailty, thereby identifying the 5% to 10% of patients at most risk for postoperative complications, loss of independence, institutionalization, and mortality. The second step is to take action to improve outcomes. Action may include clarifying perioperative goals, optimizing perioperative decision-making, and mitigating frailty-associated risks through prehabilitation.

HISTORY OF DISSEMINATION

Initially implemented at the Omaha Veterans Affairs (VA) Medical Center in 2012, the Surgical Pause was associated with a nearly three-fold survival advantage among the frail. The program was subsequently replicated at more than 50 VA and private sector hospitals with similarly robust results, leading the Veterans Health Administration (VHA) National Surgery Office to formally adopt the program in January 2024. The Joint Commission and the National Quality Forum recognized the program with the Eisenberg Award for Patient Safety and Quality at the National Level.

LESSONS LEARNED

Successful dissemination grew from simultaneous real-world quality projects paralleled by rigorous, high-quality, peer reviewed publications demonstrating the need for and impact of the Surgical Pause. Adoption was facilitated in an iterative process to streamline feasibility and leverage existing resources. Success was accelerated by national infrastructure catalyzing a community of practice.

CONCLUSION

The Surgical Pause is changing surgical culture by proactively identifying frail patients, aligning treatment plans with patient-defined goals, optimizing perioperative decisions, and mitigating frailty-associated risks to deliver both quality and value.

Anesthesia choice for frail patients undergoing endovascular repair of nonruptured infrarenal abdominal aortic aneurysms

BACKGROUND

Althugh general anesthesia is the predominant choice in endovascular aneurysm repair (EVAR), recent studies have suggested that locoregional anesthesia could be a viable alternative for suitable patients. Frailty has been identified as an independent predictor of increased mortality and morbidity in EVAR. However, the choice of anesthesia in frail patients undergoing EVAR has not been explored.

METHODS

This study aimed to compare the 30-day outcomes of nonemergent intact infrarenal EVAR in frail patients receiving either locoregional or general anesthesia. Patients who underwent infrarenal EVAR were identified in the American College of Surgeons National Surgical Quality Improvement Program database from 2012 to 2022. Frail patients were selected by five-item Modified Frailty Index of ≥2. Exclusion criteria included age <18 years, ruptured abdominal aortic aneurysm (AAA), emergency, and acute intraoperative conversion to open. A one:one propensity score matching strategy was used to match demographics, baseline characteristics, aneurysm diameter, distal aneurysm extent, and concomitant procedures between patients under locoregional and general anesthesia. Thirty-day postoperative outcomes were evaluated.

RESULTS

Among 16,438 patients who underwent EVAR, 4812 (29.27%) were frail. Among the frail patients, 483 (10.04%) were under locoregional anesthesia and 4329 (89.96%) were under general anesthesia. After propensity score matching, patients under locoregional or general anesthesia had comparable 30-day mortality (2.07% vs 2.48%; P = .83) or any complications.

CONCLUSIONS

Locoregional and general anesthesia were found to have comparable postoperative outcomes in frail patients undergoing EVAR unruptured AAA, which did not align with the suggestion that locoregional anesthesia might be more advantageous in frail patients. Although the patient's preferences should be considered, the choice of anesthesia should still be individualized to take into account the patient's age, comorbidities, AAA anatomy, and the complexity of the case, as well as previous surgical and anesthesia experiences.

Association of Frailty with Intraoperative Complications in Older Patients Undergoing Elective Non-Cardiac Surgery

Background: Frailty is increasingly being recognized as a risk factor for adverse outcomes in older surgical patients undergoing surgery. We investigated the association between frailty and intraoperative complications using multiple frailty assessment tools in older patients undergoing elective intermediate- to high-risk non-cardiac surgery. Methods: This retrospective cohort study included 637 older patients scheduled for elective non-cardiac surgery. Frailty was assessed using the Clinical Frailty Scale (CFS), FRAIL scale, and modified Frailty Index-11 (mFI-11). The predictive ability of frailty tools was analyzed and compared using the area under the receiver operating characteristic curve (AUC). Results: Frailty was significantly associated with higher intraoperative complication rates (FRAIL scale: p = 0.01; mFI-11: p = 0.046). Patients considered frail using the mFI-11 were more likely to have unplanned intensive care unit admissions (p < 0.001). Those classified as frail by the FRAIL scale and mFI-11 had significantly higher rates of vasopressor/inotrope use (p = 0.001 and p = 0.005, respectively) and mechanical ventilation (p = 0.033 and p = 0.007, respectively). In the univariate analysis, frailty measured using the FRAIL scale was significantly associated with intraoperative complications (odds ratio [OR], 2.41; 95% confidence interval [CI]: 1.33-4.38; p = 0.004); this association was not significant in the multivariate analysis (adjusted OR, 1.69; 95% CI: 0.83-3.43; p = 0.148; AUC = 0.550). Atrial fibrillation, hemoglobin levels, anesthesia type, and surgical subspecialty were stronger predictors of intraoperative complications. Conclusions: Frailty assessments demonstrate the limited predictive ability for intraoperative complications. Specific comorbidities, surgical techniques, and anesthesia types play more critical roles. Comprehensive preoperative evaluations integrating frailty with broader risk stratification methods are necessary to enhance patient outcomes and ensure safety.

Efficacy and safety of ciprofol for general anesthesia induction in female patients with frailty: a prospective randomized controlled trial

BACKGROUND

Ciprofol, a recently developed anesthetic agent, is not inferior to propofol in terms of efficacy and safety. However, most previous clinical experience with ciprofol was based on a robust population. This study aimed to investigate the efficacy and safety of ciprofol for anesthesia induction in female patients with frailty.

METHODS

This prospective randomized controlled trial included patients with frailty undergoing elective general anesthesia for gynecological surgery. Frailty was assessed using the modified frailty index. The patients were randomly administered propofol (2 mg/kg) or ciprofol (0.5 mg/kg) during anesthesia induction. The depth of anaesthesia was continually monitored by the bispectral index. The primary outcome was the lowest systolic blood pressure (SBP) during anesthesia induction. Secondary outcomes included the incidence of general anesthesia induction failure and adverse events.

RESULTS

Among the 69 enrolled patients with frailty, 67 were included in the final analysis. The success rate of anesthesia induction was 100% in both groups. The lowest SBP was significantly higher in the ciprofol group than in the propofol group (103 [96-110] vs. 90 [85-98] mmHg, respectively; P < 0.001), suggesting that the former caused less inhibition of hemodynamics during anesthesia induction in patients with frailty. The incidence of injection pain was lower in the ciprofol group than in the propofol group (3 [8.8%] vs. 11 patients [33.3%], respectively; P = 0.014).

CONCLUSIONS

The results of this study suggest that the efficacy of ciprofol for inducing general anesthesia in patients with frailty is comparable to that of propofol, with more stable hemodynamics.

TRIAL REGISTRATION

The trial was registered, before patient enrollment, in the Chinese Clinical Trial Registry ( www.chictr.org.cn ) (Clinical trial number: ChiCTR2300075271; https://www.chictr.org.cn/showproj.html?proj=205160 , principal investigator's name: Zifeng Xu, date of registration: 31/08/2023).

The relationship between fragility scores and intraoperative body temperature changes in geriatric patients: Prospective observational research

Today, to evaluate morbidity and mortality in elderly surgical patients, fragility scores, which reflect the patient's current condition rather than increasing age, are used as a basis. Our research examines the association between fragility groups, body temperature changes, and inadvertent perioperative hypothermia (IPH) in major orthopedic surgery patients. Patients over the age of 65 who underwent major orthopedic surgery were evaluated. Body temperature measurements were taken tympanically preoperatively and every 5 minutes during surgery. Temperature changes (Δn) were calculated. Patients whose body temperature was below 36 °C were recorded as IPH. The Canadian Study of Health and Aging-Clinical Frailty Scale scoring system, consisting of 9 categories, was used for fragility scores. As the category number increases, the level of fragility increases. These categories are classified into 3 subgroups: Group F1 (Level 1-3), Group F2 (Level 4-7), and Group F3 (Level 8-9). Age groups: it is defined as Group A1 (66-74 years), Group A2 (75-84 years), and Group A3 (85<). The median (min-max) of surgery time was determined as 75 (35-131). For Δ35 (ºC), the differences between both fragility groups (P = .054) and the age groups (P = .145) were not significant. IPH frequency is 44.0% (n = 149). No difference was detected between hypothermia frequencies in the fragility groups (P = .546) and the age groups (P = .065). Nearly half of major surgery patients developed IPH. We did not find a relationship between both fragility groups and age groups and the frequency of IPH.

Impact of frailty in hospitalized patients undergoing catheter ablation for atrial fibrillation

BACKGROUND

Catheter Ablation (CA) is an effective treatment for atrial fibrillation (AF). However, frail elderly patients have been understudied due to their exclusion from landmark trials.

OBJECTIVES

Our study aims to evaluate outcomes in this population.

METHODS

The national readmission database (2016-2020) was queried, and frailty categories were defined based on hospital risk frailty scores ≦5 as low while >5 as intermediate/high frailty (IHF). We used multivariate regression and propensity-matched analysis to compare outcomes in patients undergoing CA for atrial fibrillation based on frailty index.

RESULTS

Among 55 936 CAs for AF, 33,248 patients had low frailty, while 22 688 had intermediate/high frailty (IHF). After propensity matching (N 12 448), IHF patients were found to have higher adverse events, including mortality (3% vs. 0.3%, p < .001), stroke (1.9% vs. 0.2%, p < .001), acute heart failure (53.8% vs. 42.2%, p < .001), AKI (42.5% vs. 6.8%, p < .001), pericardial complications (2.8 vs. 1.6%, p < .001), respiratory complications (27.8 vs. 7.2%, p < .001), major adverse cardiovascular events (21.2 vs. 9.4%, p < .001) and net adverse events (76.7 vs. 55%, p < .001). IHF patients had higher readmissions at 30 (15.5 vs. 12.6%, p < .001), 90 (31.9 vs. 25.1%, p < .001), and 180-day (41 vs. 34.7%, p < .001) intervals. A higher median length of stay (LOS) (7 vs. 3 days, p < .001) and cost ($44 287 vs. $27 517, p < .001) at index admission and subsequent readmissions were also observed (p < .001).

CONCLUSION

Intermediate/high frailty patients undergoing catheter ablation had worse clinical outcomes, higher healthcare burden, and readmission rates. LOS has decreased in both groups from 2016 to 2020; however, total cost has increased.

Fried Frailty Phenotype Questionnaire scores and postoperative patient-reported outcomes of patients undergoing major abdominal cancer surgery: A secondary analysis

AIM

This study aimed to evaluate the effects of Fried Frailty Phenotype Questionnaire (FFPQ) scores on patient-reported postoperative outcomes.

METHODS

This secondary analysis of a prospective observational study included 230 inpatients aged ≥65 years undergoing elective abdominal cancer surgery. The primary outcome was the Quality of Recovery-15 score on postoperative days 2, 4 and 7. The secondary outcomes included disability-free survival, defined as a 12-item World Health Organization Disability Assessment Schedule 2.0 score of <16% at 3 months. The associations of the FFPQ scores, ranging from 0 (robust) to 5 (frailty), with the primary and secondary outcomes were assessed using multiple analysis.

RESULTS

After confirming the linearity of the FFPQ score for the outcomes, multiple regression analysis adjusted for prominent factors showed that the FFPQ score was a significant factor influencing the decrease in the Quality of Recovery-15 score on postoperative day 2 (β = -2.67, 95% confidence interval -5.20, -0.15), 4 (β = -3.54, 95% confidence interval -5.77, -1.30) and 7 (β = -3.70, 95% confidence interval -5.75, -1.65). The adjusted odds ratio of the FFPQ score for disability-free survival postoperatively was 0.66 (95% confidence interval 0.49-0.90).

CONCLUSIONS

Patients with higher FFPQ scores before elective major abdominal cancer surgery were likely to have lower postoperative Quality of Recovery-15 scores and poor disability-free survival. Geriatr Gerontol Int 2024; 24: 464-469.

A novel nomogram for predicting the prolonged length of stay in post-anesthesia care unit after elective operation

BACKGROUND

Prolonged length of stay in post-anesthesia care unit (PLOS in PACU) is a combination of risk factors and complications that can compromise quality of care and operating room efficiency. Our study aimed to develop a nomogram to predict PLOS in PACU of patients undergoing elective surgery.

METHODS

Data from 24017 patients were collected. Least absolute shrinkage and selection operator (LASSO) was used to screen variables. A logistic regression model was built on variables determined by a combined method of forward selection and backward elimination. Nomogram was designed with the model. The nomogram performance was evaluated with the area under the receiver operating characteristic curve (AUC) for discrimination, calibration plot for consistency between predictions and actuality, and decision curve analysis (DCA) for clinical application value.

RESULTS

A nomogram was established based on the selected ten variables, including age, BMI < 21 kg/m2, American society of Anesthesiologists Physical Status (ASA), surgery type, chill, delirium, pain, naloxone, operation duration and blood transfusion. The C-index value was 0.773 [95% confidence interval (CI) = 0.765 - 0.781] in the development set and 0.757 (95% CI = 0.744-0.770) in the validation set. The AUC was > 0.75 for the prediction of PLOS in PACU. The calibration curves revealed high consistencies between the predicted and actual probability. The DCA showed that if the threshold probability is over 10% , using the models to predict PLOS in PACU and implement intervention adds more benefit.

CONCLUSIONS

This study presented a nomogram to facilitate individualized prediction of PLOS in PACU for patients undergoing elective surgery.