Preoperative Frailty Assessment and Outcomes at 6 Months or Later in Older Adults Undergoing Cardiac Surgical Procedures: A Systematic Review

Association between a laboratory-based frailty index and mortality of critically ill patients with acute pancreatitis: a retrospective study

Background

Acute pancreatitis (AP) is associated with significant global mortality and morbidity. Frailty, which can be assessed through clinical indicators and life history, is known to impact adverse outcomes across different medical conditions. The frailty index derived from laboratory tests (FI-Lab) is a novel approach to the quantification of frailty. This study sought to investigate the relationship between the FI-Lab and mortality among critically ill patients with AP.

Methods

We utilized data on patients diagnosed with AP from the Medical Information Mart for Intensive Care-IV database. The FI-Lab was calculated using a specific set of laboratory parameters indicative of physiological disturbances. The primary outcomes examined were 30-day and 90-day mortality rates. Multivariate Cox regression was used for the statistical analysis, with adjustments for age, gender, Acute Physiology and Chronic Health Evaluation II scores, and other variables. Propensity matching scores were used to ensure the robustness of our findings.

Results

A total of 1,116 AP patients were included in the analysis (mean age = 58.4 years; 57.9% male). Each 0.1 increment of FI-Lab was found to increase the risks of 30-day and 90-day mortality by 30% (hazard ratio (HR) = 1.30, p < 0.001 for both). The propensity score matching (PSM) analysis validated these results. The FI-Lab demonstrated an association with acute kidney injury and the requirement for continuous renal replacement therapy. However, these associations were not significant after the PSM analysis.

Conclusion

An elevated FI-Lab was associated with higher mortality rates among critically ill AP patients. Randomized controlled trials are needed to confirm these findings and to explore their clinical implications.

Effects of Midazolam and Dexmedetomidine on Cognitive Dysfunction Following Open-Heart Surgery: A Comprehensive Review

PURPOSE

Patients undergoing open-heart surgery often face significant challenges in postoperative cognitive dysfunction (POCD). There has been growing interest in understanding how anesthesia medications, such as dexmedetomidine (DEX) and midazolam, impact cognitive function in these patients.

METHOD

This comprehensive review aims to detail the effect of DEX and midazolam on cognitive outcomes following open-heart surgery.

FINDINGS

Midazolam, a highly selective and commonly used benzodiazepine for preoperative anxiolytics and sedation has been associated with POCD. However, evidence regarding its impact on cognitive function is vague; some studies suggest a potential link between midazolam administration and cognitive impairment, while others report no effect or even an improvement in cognitive abilities. DEX is a potential neuroprotective agent in cardiac surgery. The effects of DEX on cognitive function, including a reduction in POCD incidence and severity, have been reported in several studies. It modulates the inflammatory responses, attenuates oxidative stress, and preserves cerebral perfusion. Although DEX and midazolam show promising results, their effects on cognitive function following open-heart surgery are yet to be elucidated.

CONCLUSION

Various factors, including patient characteristics, perioperative management, and surgical procedures, may influence these outcomes, highlighting the need for further research to better understand the roles of these agents in cognitive function following open-heart surgery.

Intravenous lidocaine decreased the incidence of SRAEs for ERCP procedures in elderly frailty patients, a randomized controlled trial

OBJECTIVES

Elderly frailty patients are at particular risk of sedation-related adverse events (SRAEs) during sedation. This study aimed to assess whether intravenous lidocaine could reduce the incidence of SRAEs in elderly frailty patients undergoing endoscopic retrograde cholangiopancreatography (ERCP).

METHODS

A total of 210 elderly frailty patients scheduled for ERCP were randomly divided into two groups: lidocaine and control. Patients in the lidocaine group received intravenous lidocaine (1.0 mg/kg) before anesthesia induction, followed by continuous intravenous infusion (2.0 mg/kg/h) during ERCP. The control group received an equal volume of saline solution. The primary endpoint was the composite incidence of SRAEs during ERCP. Secondary endpoints were propofol consumption, VAS score, endoscopists' and patients' satisfaction scores and lidocaine-related adverse events and so on.

RESULTS

The composite incidence of SRAEs in the lidocaine group was significantly lower than in the control group (41.05% vs. 21.86%, p < 0.05). The propofol requirement (436.11 ± 118.90, 388.54 ± 149.65. p < 0.001) and VAS score of patients (3.02 ± 1.07, 2.54 ± 1.10. p < 0.05) in the lidocaine group were significantly lower than those in the control group. The endoscopists' satisfaction scores (7.77 ± 1.12, 8.23 ± 1.10. p < 0.05) and patients' satisfaction scores (8.53 ± 0.95, 8.98 ± 0.86. p < 0.05) in lidocaine group were significantly higher than those in the control group.

CONCLUSIONS

Intravenous lidocaine can significantly decrease the incidence of SRAEs for ERCP procedures in elderly frailty patients, with no increase in lidocaine or other related adverse events.

TRIAL REGISTRATION

Chinese Clinical Trial Registry (Trial ID: ChiCTR2300067796, https://www.chictr.org.cn/showproj.html?proj=185763 ).

The effect of frailty on postoperative recovery in patients with cardiovascular surgery

This study aimed to examine the impact of frailty on postoperative morbidity and mortality in patients undergoing cardiovascular surgery, questioning the adequacy of the preoperative American Society of Anesthesiologists (ASA) as the sole assessment tool. In a cohort of 76 patients undergoing cardiovascular interventions, we analyzed demographic data, Edmonton Frail Scale (EFS), ASA scores, Charlson Comorbidity Index values, surgery and hospitalization durations, intraoperative blood pressures, inotropic needs, erythrocyte transfusions, and pre/postoperative hemoglobin levels. Pearson chi-squared and Spearman tests were performed. Correlation of postoperative intensive care unit (ICU) stay, extubation time, ward stay, discharge status, morbidity rates, and ASA and EuroSCORE II results with EFS scores. The demographic profile indicated a mean age of 59.67 ± 13.02 years, with a majority of male patients (59.2%). Frailty status varied, with 48.7% non-frail, 26.3% vulnerable, 18.4% mildly frail, and 6.6% moderately frail. Surgical data revealed an average duration of 300.93 minutes and a mean ICU stay of 54.48 ± 101.16 hours. Statistical analysis showed significant differences in frailty levels based on initial morbidity (χ2 = 10.612, P = .014) but not in ASA score distribution by morbidity status (χ2 = 1.634, P = .442). A negative correlation was observed between EFS scores and hemoglobin levels, along with a positive correlation between the EuroSCORE II score and the duration of intubation, extubation, and ICU stay. Frailty significantly contributes to increased morbidity and necessitates evaluation alongside preoperative ASA scores to inform the need for prehabilitation. The ultimate goal extends beyond patient survival, aiming to ensure recovery while maintaining the quality of life and functional independence.

Patient-reported physical activity, pain, and fear of movement after cardiac surgery: a descriptive cross-sectional study

OBJECTIVES

After cardiac surgery, there may be barriers to being physically active. Patients are encouraged to gradually increase physical activity, but limited knowledge exists regarding postoperative physical activity levels. This study aimed to assess patient-reported physical activity six months after cardiac surgery, determine adherence to WHO's physical activity recommendations, and explore potential relationships between pain, dyspnea, fear of movement, and activity levels.

METHODS

The study design was a cross-sectional study at Örebro University Hospital, Sweden. Preoperative and surgical data were retrieved from medical records and questionnaires concerning physical activity (Frändin-Grimby Activity Scale, the Physical activity Likert-scale Haskell, Patient-Specific Functional Scale, and Exercise Self-efficacy Scale) were completed six months after surgery. Data were collected on pain, dyspnea, general health status and kinesiophobia i.e. fear of movement, using the Tampa Scale of Kinesiophobia Heart.

RESULTS

In total, 71 patients (68 ± 11 years, males 82%) participated in this study. Most patients (76%) reported a light to moderate activity level (Frändin-Grimby levels 3-4) six months after cardiac surgery. In total, 42% of the patients adhered to the WHO's physical activity recommendations (150 min/week). Pain and dyspnea were low. Patients with lower activity levels exhibited significantly higher levels of fear of movement (p =.025).

CONCLUSIONS

The majority of patients reported engaging in light to moderate activity levels six months after cardiac surgery. Despite this, less than half of the patients met the WHO's physical activity recommendations. Potential barriers to physical activity such as pain, dyspnea and fear of movement were reported to be low.

Enhancing Frailty Assessments for Transcatheter Aortic Valve Replacement Patients Using Structured and Unstructured Data: Real-World Evidence Study

Background

Transcatheter aortic valve replacement (TAVR) is a commonly used treatment for severe aortic stenosis. As degenerative aortic stenosis is primarily a disease afflicting older adults, a frailty assessment is essential to patient selection and optimal periprocedural outcomes.

Objective

This study aimed to enhance frailty assessments of TAVR candidates by integrating real-world structured and unstructured data.

Methods

This study analyzed data from 14,000 patients between January 2018 and December 2019 to assess frailty in TAVR patients at the University of Florida. Frailty was identified using the Fried criteria, which includes weight loss, exhaustion, walking speed, grip strength, and physical activity. Latent Dirichlet allocation for topic modeling and Extreme Gradient Boosting for frailty prediction were applied to unstructured clinical notes and structured electronic health record (EHR) data. We also used least absolute shrinkage and selection operator regression for feature selection. Model performance was rigorously evaluated using nested cross-validation, ensuring the generalizability of the findings.

Results

Model performance was significantly improved by combining unstructured clinical notes with structured EHR data, achieving an area under the receiver operating characteristic curve of 0.82 (SD 0.07), which surpassed the EHR-only model's area under the receiver operating characteristic curve of 0.64 (SD 0.08). The Shapley Additive Explanations analysis found that congestive heart failure management, back problems, and atrial fibrillation were the top frailty predictors. Additionally, the latent Dirichlet allocation topic modeling identified 7 key topics, highlighting the role of specific medical treatments in predicting frailty.

Conclusions

Integrating unstructured clinical notes and structured EHR data led to a notable enhancement in predicting frailty. This method shows great potential for standardizing frailty assessments using real-world data and improving patient selection for TAVR.

Risk of sarcopenia, frailty and malnutrition as predictors of postoperative delirium in surgery

BACKGROUND

The risk factors for postoperative delirium are numerous and complex. One approach to identifying patients at risk is to evaluate their nutritional status. The aim of this prospective study is to better understand nutrition as a potential risk factor for postoperative delirium.

METHODS

A comprehensive preoperative assessment (Clinical Frailty Scale (CFS), the SARC-F questionnaire, Mini Nutritional Assessment-Short Form (MNA-SF)) were carried out as a prospective clinical study on 421 patients (70+) from 4 different surgical disciplines. Postoperatively, patients are examined daily for the presence of delirium using the 4AT screening tool (Arousal, Attention, Abbreviated Mental Test - 4, Acute change), the Nursing Delirium Screening Scale (NuDesc) and the Confusion Assessment Method (CAM) with its adaptation for the intensive care unit (CAM-ICU).

RESULTS

If there were indications of frailty or sarcopenia in the CFS or SARC-F, the association with delirium was increased 5.34-fold (OR of 5.34 [95% CI: 2.57;11.1]) and 5.56-fold (OR of 5.56 [95% CI: 2.97;10.4]) respectively. Delirium also occurred significantly more frequently with the risk of malnutrition or manifest malnutrition (MNA-SF) than with a normal nutritional status.

CONCLUSIONS

Patients' preoperative and nutritional status significantly impact the risk of developing postoperative delirium. Factors such as frailty, sarcopenia and possible malnutrition must be considered when implementing an effective and targeted preoperative assessment.

TRAIL REGISTRATION

German Clinical Trials Registry at https://www.drks.de/DRKS00028614 , Registered 25 March 2022.

Added Value of Medical Subject Headings Terms in Search Strategies of Systematic Reviews: Comparative Study

BACKGROUND

The massive increase in the number of published scientific articles enhances knowledge but makes it more complicated to summarize results. The Medical Subject Headings (MeSH) thesaurus was created in the mid-20th century with the aim of systematizing article indexing and facilitating their retrieval. Despite the advent of search engines, few studies have questioned the relevance of the MeSH thesaurus, and none have done so systematically.

OBJECTIVE

The objective of this study was to estimate the added value of using MeSH terms in PubMed queries for systematic reviews (SRs).

METHODS

SRs published in 4 high-impact medical journals in general medicine over the past 10 years were selected. Only SRs for which a PubMed query was provided were included. Each query was transformed to obtain 3 versions: the original query (V1), the query with free-text terms only (V2), and the query with MeSH terms only (V3). These 3 queries were compared with each other based on their sensitivity and positive predictive values.

RESULTS

In total, 59 SRs were included. The suppression of MeSH terms had an impact on the number of relevant articles retrieved for 24 (41%) out of 59 SRs. The median (IQR) sensitivities of queries V1 and V2 were 77.8% (62.1%-95.2%) and 71.4% (42.6%-90%), respectively. V1 queries provided an average of 2.62 additional relevant papers per SR compared with V2 queries. However, an additional 820.29 papers had to be screened. The cost of screening an additional collected paper was therefore 313.09, which was slightly more than triple the mean reading cost associated with V2 queries (88.67).

CONCLUSIONS

Our results revealed that removing MeSH terms from a query decreases sensitivity while slightly increasing the positive predictive value. Queries containing both MeSH and free-text terms yielded more relevant articles but required screening many additional papers. Despite this additional workload, MeSH terms remain indispensable for SRs.

Surgery in patients with infective endocarditis and prognostic importance of patient frailty

PURPOSE

Surgery is required in 20-50% of patients with infective endocarditis (IE). Frailty increases surgical risk; however, the prognostic implications of frailty in patients undergoing IE-related surgery remain poorly understood. We aimed to assess the association between frailty and all-cause mortality or rehospitalization after discharge (≥ 14 days).

METHODS

We identified all IE patients who underwent surgery during admission (2010-2020) in Denmark. The Hospital Frailty Risk Score was used to categorize patients into two frailty risk groups, patients with low frailty scores (< 5 points) and frail patients (≥ 5 points). We analyzed time hospitalized after discharge and all-cause mortality from the date of surgery with a one-year follow-up. Statistical analyses utilized the Kaplan-Meier estimator, Aalen-Johansen estimator, and the Cox regression model.

RESULTS

We identified 1282 patients who underwent surgery during admission, of whom 967 (75.4%) had low frailty scores, and 315 (24.6%) were frail. Frail patients were characterized by advanced age, a lower proportion of males, and a higher burden of comorbidities. Frail patients were more hospitalized (> 14 days) in the first post-discharge year (19.1% vs.12.3%) compared to patients with low frailty scores. Additionally, frail patients had higher rates of all-cause mortality including in-hospital deaths (27% vs. 15%) and rehospitalizations (43.5% vs 26.1%) compared to patients with low frailty scores. This was also evident in the adjusted analysis (hazard ratio 1.36 [CI 95% 1.09-1.71]).

CONCLUSION

Frailty was associated with an ≈40% increased rate of rehospitalization (≥ 14 days) or death. Further studies are needed to assess the effectiveness of surgery with a focus on frailty to improve prognostic outcomes in these patients.

Exploring the acceptability of and adherence to prehabilitation and rehabilitation in patients undergoing major abdominal surgery: A systematic review and meta-analysis

BACKGROUND AND AIMS

Prehabilitation combines exercise, nutritional, and psychological interventions administered before surgery to improve patient outcomes. This comprehensive review and meta-analysis examined the feasibility, adherence, and effectiveness of prehabilitation in frail, high-risk individuals undergoing major abdominal surgery.

METHODS

We searched the Cochrane Central Register of Controlled Trials, Web of Science, MEDLINE, Embase, and Cumulative Index to Nursing & Allied Health Literature (CINAHL) databases to identify relevant studies evaluating prehabilitation programs published between 2010 and 2023, either as observational studies or randomized clinical trials (RCTs).

RESULTS

The 23 articles (13 RCTs and 10 observational studies) included 1849 older male and female patients aged 68.7 ± 7.2 years. Nineteen of the included studies reported on adherence to prehabilitation programmes, which was generally good (>75%) over different models, settings, and durations. Factors such as patients' desire for expedited surgery, self-assessment of fitness, personal and professional obligations, health issues, holidays, and advancement of surgery dates negatively affected adherence to prehabilitation programmes. When compared with rehabilitation or standard pre- and post-surgical care, prehabilitation was associated with a 25%, albeit not statistically significant reduction in postoperative complications, according to data from 14 studies reporting on postoperative complications (OR 0.75, 95% CI 0.48 to 1.17, P = 0.43; I2 = 65%). Prehabilitation has been found to improve the 6-min walk test significantly by 29.4 m (MD +29.4 m, 95% CI 5.6 to 53.3, P = 0.02; I2 = 39%), compared with rehabilitation or standard pre- and post-surgical care.

CONCLUSION

Prehabilitation was acceptable to patients, with good adherence, and improved physical function.

The impact of frailty on long-term functional outcomes in severely injured geriatric patients

BACKGROUND

The incidence of severe injury in the geriatric population is increasing. However, the impact of frailty on long-term outcomes after injury in this population remains understudied. Therefore, we aimed to understand the impact of frailty on long-term functional outcomes of severely injured geriatric patients.

METHODS

We conducted a retrospective cohort study, including patients ≥65 years old with an Injury Severity Score ≥15, who were admitted between December 2015 and April 2022 at one of 3 level 1 trauma centers in our region. Patients were contacted between 6 and 12 months postinjury and administered a trauma quality of life survey, which assessed for the presence of new functional limitations in their activities of daily living. We defined frailty using the mFI-5 validated frailty tool: patients with a score ≥2 out of 5 were considered frail. The impact of frailty on long-term functional outcomes was assessed using 1:1 propensity matching adjusting for patient characteristics, injury characteristics, and hospital site.

RESULTS

We included 580 patients, of whom 146 (25.2%) were frail. In a propensity-matched sample of 125 pairs, frail patients reported significantly higher functional limitations than nonfrail patients (69.6% vs 47.2%; P < .001). This difference was most prominent in the following activities: climbing stairs, walking on flat surfaces, going to the bathroom, bathing, and cooking meals. In a subgroup analysis, frail patients with traumatic brain injuries experienced significantly higher long-term functional limitations.

CONCLUSION

Frail geriatric patients with severe injury are more likely to have new long-term functional outcomes and may benefit from screening and postdischarge monitoring and rehabilitation services.

Preoperative bioelectrical impedance, measured phase angle, and hand-grip strength as predictors of postoperative outcomes in patients undergoing cardiac surgery: a systematic review

BACKGROUND

Postoperative problems are a major danger for patients after heart surgery. Predicting postoperative outcomes for cardiac surgery is limited by current preoperative evaluations. Handgrip strength (HGS) testing and bioelectrical impedance analysis (BIA) may provide extra ways to identify individuals at risk of surgical problems, enhancing risk assessment and results.

OBJECTIVE

The purpose of this systematic review is to assess the utility of measured phase angle (PA), HGS, and bioelectrical impedance as perioperative risk markers in adult patients undergoing elective heart surgery.

METHOD

The PRISMA principles were followed in this review. We searched all available electronic databases, including the Science Direct search engine and PubMed, MEDLINE, EMBASE, Cochrane Library, Web of Science, PsycINFO, CINAHL, Google Scholar, Scopus, and the Science Direct search engine, from their creation to the present, as well as the medRxiv pre-print site. We considered studies with adult subjects undergoing elective heart surgery who were monitored for problems after surgery and had perioperative BIA and HGS testing.

RESULTS

As a result, out of the 1544 pieces of research that were discovered, eight studies were deemed suitable for inclusion in the review and supplied data from 2781 people. The findings demonstrated a substantial correlation between poor preoperative PA and a higher risk of serious postoperative morbidity, as well as prolonged hospital stays. Furthermore, poor HGS and low PA were linked to greater death rates. Additionally, there was a strong correlation found between low PA and HGS and longer stays in the ICU, as well as an increased chance of dying from all causes in a year. In conclusion these results imply that preoperative HGS and PA may be significant indicators of postoperative results and may assist in identifying patients who are more vulnerable to problems and death.

Measuring Frailty Using Self-Report or Automated Tools to Identify Risk of Cardiovascular Events and Mortality: The Million Veteran Program

BACKGROUND

Frailty, a syndrome of physiologic vulnerability, increases cardiovascular disease (CVD) risk. Whether in person or automated frailty tools are ideal for identifying CVD risk remains unclear. We calculated 3 distinct frailty scores and examined their associations with mortality and CVD events in the Million Veteran Program, a prospective cohort of nearly 1 million US veterans.

METHODS AND RESULTS

Veterans aged ≥50 years and enrolled from 2011 to 2018 were included. Two frailty indices (FI) based on the deficit accumulation theory were calculated: the questionnaire-based 36-item Million Veteran Program-FI and 31-item Veterans Affairs-FI using claims data. We calculated Fried physical frailty using the self-reported, 3-item Study of Osteoporotic Fractures. Multivariable-adjusted Cox models examined the association of frailty by each score with primary (all-cause and CVD mortality) and secondary (myocardial infarction, stroke, and heart failure) outcomes. In 190 688 veterans (69±9 years, 94% male, 85% White), 33, 233 (17%) all-cause and 10 115 (5%) CVD deaths occurred. Using Million Veteran Program-FI, 29% were robust, 42% pre-frail, and 29% frail. Frailty prevalence increased by age group (27% in 50-59 to 42% in ≥90 years). Using the Million Veteran Program-FI, over 6±2 years, frail veterans had a higher hazard of all-cause (hazard ratio [HR], 3.05 [95% CI, 2.95-3.16]) and CVD mortality (HR, 3.65 [95% CI, 3.43-3.90]). Findings were concordant for the Veterans Affairs-FI and Study of Osteoporotic Fractures frailty definitions, and remained significant even among younger veterans aged 50-59 years.

CONCLUSIONS

Irrespective of frailty measure, frailty is associated with a higher risk of all-cause mortality and adverse CVD events. Further study of frailty in veterans aged <60 years old is warranted.

Preoperative rectus femoris muscle ultrasound, its relationship with frailty scores, and the ability to predict recovery after cardiac surgery: a prospective cohort study

BACKGROUND

Frailty is common in patients undergoing cardiac surgery and is associated with poorer postoperative outcomes. Ultrasound examination of skeletal muscle morphology may serve as an objective assessment tool as lean muscle mass reduction is a key feature of frailty.

METHODS

This study investigated the association of ultrasound-derived muscle thickness, cross-sectional area, and echogenicity of the rectus femoris muscle (RFM) with preoperative frailty and predicted subsequent poor recovery after surgery. Eighty-five patients received preoperative RFM ultrasound examination and frailty-related assessments: Clinical Frailty Scale (CFS) and 5-m gait speed test (GST5m). Association of each ultrasound measurement with frailty assessments was examined. Area under receiver-operating characteristic curve (AUROC) was used to assess the discriminative ability of each ultrasound measurement to predict days at home within 30 days of surgery (DAH30).

RESULTS

By CFS and GST5m criteria, 13% and 34% respectively of participants were frail. RFM cross-sectional area alone demonstrated moderate predictive association for frailty by CFS criterion (AUROC: 0.76, 95% CI: 0.66-0.85). Specificity improved to 98.7% (95% CI: 93.6%-100.0%) by utilising RFM cross-sectional area as an 'add-on' test to a positive gait speed test, and thus a combined muscle size and function test demonstrated higher predictive performance (positive likelihood ratio: 40.4, 95% CI: 5.3-304.3) for frailty by CFS criterion than either test alone (p < 0.001). The combined 'add-on' test predictive performance for DAH30 (AUROC: 0.90, 95% CI: 0.81-0.95) may also be superior to either CFS or gait speed test alone.

CONCLUSIONS

Preoperative RFM ultrasound examination, especially when integrated with the gait speed test, may be useful to identify patients at high risk of frailty and those with poor outcomes after cardiac surgery.

TRIAL REGISTRATION

The study was registered on the Chinese Clinical Trials Registry (ChiCTR2000031098) on 22 March 2020.

A qualitative study of the experiences and perceptions of older patients and relatives prior to cardiac surgery

BACKGROUND

Shared decision-making plays an important role in ensuring value-based healthcare in cardiac surgery. However, the personal situations of patients in cardiac care have not been widely explored, and thus, little is known about the decision-making experiences of patients and their relatives before surgery.

OBJECTIVE

To explore the perceptions of patients indicated for cardiac surgery and their relatives during the decision-making process, as well as their experiences of a conversation aimed at achieving shared decision-making in the treatment trajectory.

METHODS

The data were collected through semi-structured in-depth interviews with patients aged ≥70 years who were indicated for cardiac surgery and their relatives until theme saturation. Both inductive and deductive analysis were conducted based on the principles of reflexive thematic analysis.

RESULTS

Interviews with 16 patients and 10 relatives provided in-depth insights into the experiences of patients and their relatives in terms of a shared decision-making process prior to surgery. Overall, 15 subthemes were identified, and these were divided into three themes. In general, the patients' experiences and perceptions were influenced by their (1) general daily functioning. The relatives were more concerned about (2) social expectations and (3) existential uncertainty.

CONCLUSIONS

Patients eligible for cardiac surgery and their families have unique experiences and perceptions during the process of shared decision-making. The subthemes emerging from this study, such as the overestimation of potential medical outcomes by patients and their relatives, who experience fear about the current health situation of their loved one, require careful attention from healthcare professionals during decision-making conversations.

Preoperative diagnosis of frailty

The aging world population obliges physicians to establish measures to optimize and estimate the outcomes of increasingly frail patients. Thus, in the last few years there has been an increase in the application of frailty indices. Multiple scales have emerged that can be applied in the perioperative setting. Each one has demonstrated some utility, either by way of establishing postoperative prognosis or as a method for the clinical optimization of patient care. Anaesthesiologists are offered a wide choice of scales, the characteristics and appropriate management of which they are often unaware. This narrative review aims to clarify the concept of frailty, describe its importance in the perioperative setting and evaluate the different scales that are most applicable to the perioperative setting. It will also establish paths for the future optimization of patient care.

Multicomponent perioperative interventions to improve outcomes for frail patients: a systematic review

BACKGROUND

Preoperative frailty is associated with increased risk of adverse outcomes. In 2017, McIsaac and colleagues' systematic review found that few interventions improved outcomes in this population and evidence was low-quality. We aimed to systematically review the evidence for multicomponent perioperative interventions in frail patients that has emerged since McIsaac et al.'s review.

METHODS

PUBMED, EMBASE, Cochrane, and CINAHL databases were searched for English-language studies published since January 1, 2016, that evaluated multicomponent perioperative interventions in patients identified as frail. Quality was assessed using the National Institute of Health Quality Assessment Tool. A narrative synthesis of the extracted data was conducted.

RESULTS

Of 2835 articles screened, five studies were included, all of which were conducted in elective oncologic gastrointestinal surgical populations. Four hundred and thirteen patients were included across the five studies and the mean/median age ranged from 70.1 to 87.0 years. Multicomponent interventions were all applied in the preoperative period. Two studies also applied interventions postoperatively. All interventions addressed exercise and nutritional domains with variability in timing, delivery, and adherence. Multicomponent interventions were associated with reduced postoperative complications, functional deterioration, length of stay, and mortality. Four studies reported on patient-centred outcomes. The quality of evidence was fair.

CONCLUSIONS

This systematic review provides evidence that frail surgical patients undergoing elective oncologic gastrointestinal surgery may benefit from targeted multicomponent perioperative interventions. Yet methodological issues and substantial heterogeneity of the interventions precludes drawing clear conclusions regarding the optimal model of care. Larger, low risk of bias studies are needed to evaluate optimal intervention delivery, effectiveness in other populations, implementation in health care settings and ascertain outcomes of importance for frail patients and their carers.

Estimated prevalence of frailty and prefrailty in patients undergoing coronary artery or valvular surgeries/procedures: A systematic review and proportional meta-analysis

BACKGROUND

The aging population has led to an increasing number of older patients undergoing cardiac surgeries/procedures. Frailty and prefrailty have emerged as important prognostic indicators among these patients. This proportional meta-analysis estimated the prevalence of frailty and prefrailty among patients undergoing cardiac surgery.

METHODS

We searched seven electronic databases for observational studies that used validated measure(s) of frailty and reported prevalence data on frailty and/or prefrailty in older patients undergoing coronary artery or valvular surgeries or transcatheter procedures. Meta-analyses were performed using a random-effects model.

RESULTS

One hundred and one articles involving 626,863 patients were included. The pooled prevalence rates of frailty and prefrailty were 28% (95% confidence interval [CI]: 23%-33%) and 40% (95% CI: 31%-50%), respectively, for patients scheduled for open-heart surgeries and 40% (95% CI: 36%-45%) and 43% (95% CI: 34%-53%), respectively, for patients undergoing transcatheter procedures. Frailty measured using a multidimensional approach identified a higher proportion of frail patients when compared with measures solely focused on physical frailty. Older age, female sex, and lower body mass index and hemoglobin concentrations were significantly associated with higher frailty prevalence. Moreover, countries with higher gross domestic product spent on healthcare exhibited a higher frailty prevalence.

CONCLUSION

Frailty represents a considerable health challenge among patients undergoing cardiac surgeries/procedures. Routine screening for frailty should be considered during perioperative care planning.

Development and multicentre validation of the FLEX score: personalised preoperative surgical risk prediction using attention-based ICD-10 and Current Procedural Terminology set embeddings

BACKGROUND

Preoperative knowledge of surgical risks can improve perioperative care and patient outcomes. However, assessments requiring clinician examination of patients or manual chart review can be too burdensome for routine use.

METHODS

We conducted a multicentre retrospective study of 243 479 adult noncardiac surgical patients at four hospitals within the Mass General Brigham (MGB) system in the USA. We developed a machine learning method using routinely collected coding and patient characteristics data from the electronic health record which predicts 30-day mortality, 30-day readmission, discharge to long-term care, and hospital length of stay.

RESULTS

Our method, the Flexible Surgical Set Embedding (FLEX) score, achieved state-of-the-art performance to identify comorbidities that significantly contribute to the risk of each adverse outcome. The contributions of comorbidities are weighted based on patient-specific context, yielding personalised risk predictions. Understanding the significant drivers of risk of adverse outcomes for each patient can inform clinicians of potential targets for intervention.

CONCLUSIONS

FLEX utilises information from a wider range of medical diagnostic and procedural codes than previously possible and can adapt to different coding practices to accurately predict adverse postoperative outcomes.

Development of an Algorithm to Screen for Frailty Using the Clinical Frailty Scale with Postoperative Patients Entering Cardiac Rehabilitation

Purpose

Frailty is not commonly assessed on intake to cardiac rehabilitation (CR), but screening could enable targeted interventions and potentially reduce secondary complications. This study aimed to develop and retrospectively examine the feasibility of utilizing a CR-specific algorithm based on the Clinical Frailty Scale (CFS). Our CFS-CR algorithm endeavoured to screen for frailty in older adults (> 65 y) entering CR following cardiac surgery/procedure.

Method

The charts of 30 former patients (mean age: 74.0 ± 6.9 y) were examined by a clinician working in CR.

Results

The clinician was unable to score any of the patients based on their medical charts using the CFS-CR due to insufficient data. Documentation was typically limited in the areas of instrumental and basic activities of daily living whereas exercise data were readily available.

Conclusions

Current intake documentation in CR limited the ability to retrospectively screen for frailty. This finding suggests a need for a frailty-specific tool to support routine clinical screening. Prospective evaluation of the CFS-CR is warranted to further examine the clinical utility of the algorithm during CR intake assessments.

Machine learning vs. conventional methods for prediction of 30-day readmission following percutaneous mitral edge-to-edge repair

BACKGROUND

Identifying predictors of readmissions after mitral valve transcatheter edge-to-edge repair (MV-TEER) is essential for risk stratification and optimization of clinical outcomes.

AIMS

We investigated the performance of machine learning [ML] algorithms vs. logistic regression in predicting readmissions after MV-TEER.

METHODS

We utilized the National-Readmission-Database to identify patients who underwent MV-TEER between 2015 and 2018. The database was randomly split into training (70 %) and testing (30 %) sets. Lasso regression was used to remove non-informative variables and rank informative ones. The top 50 informative predictors were tested using 4 ML models: ML-logistic regression [LR], Naive Bayes [NB], random forest [RF], and artificial neural network [ANN]/For comparison, we used a traditional statistical method (principal component analysis logistic regression PCA-LR).

RESULTS

A total of 9425 index hospitalizations for MV-TEER were included. Overall, the 30-day readmission rate was 14.6 %, and heart failure was the most common cause of readmission (32 %). The readmission cohort had a higher burden of comorbidities (median Elixhauser score 5 vs. 3) and frailty score (3.7 vs. 2.9), longer hospital stays (3 vs. 2 days), and higher rates of non-home discharges (17.4 % vs. 8.5 %). The traditional PCA-LR model yielded a modest predictive value (area under the curve [AUC] 0.615 [0.587-0.644]). Two ML algorithms demonstrated superior performance than the traditional PCA-LR model; ML-LR (AUC 0.692 [0.667-0.717]), and NB (AUC 0.724 [0.700-0.748]). RF (AUC 0.62 [0.592-0.677]) and ANN (0.65 [0.623-0.677]) had modest performance.

CONCLUSION

Machine learning algorithms may provide a useful tool for predicting readmissions after MV-TEER using administrative databases.

Evaluating the Safety and Outcomes of Oesophagogastroduodenoscopy in Elderly Patients Presenting With Acute Upper Gastrointestinal Bleeding

AIMS

In the absence of evidence-based guidelines regarding the safety and appropriateness of emergency endoscopy in elderly, co-morbid and frail patients, we aimed to find clinical outcomes in elderly patients who have undergone gastroscopy following an acute upper gastrointestinal bleeding (UGIB).

METHODS

We carried out a retrospective observational study of patients aged 70 years and older who had undergone emergency oesophagogastroduodenoscopy (OGD) at the Royal Sussex County Hospital, Brighton, United Kingdom, between May 2020 and January 2022. Data collected for analysis included Glasgow-Blatchford score, age, gender, endoscopic findings, endoscopic treatments, immediate complications, 90-day complications, 30-day and 90-day survival, length of hospital stay and re-bleeding.

RESULTS

A total of 248 study participants were categorised into two groups: age 70-79 years (n=102) and ≥80 years (n=146). Melaena (n=226, 91%, p=0.0001) was the commonest indication for emergency OGD in both groups, with the majority of patients presenting with a Glasgow-Blatchford score of ≥1 (n=200, 80.6%, p=0.2). Endoscopy findings were normal in 26.4% (n=27) of those 70-79 years and 32% (n=47) of those ≥80 years (p=0.01). Duodenal ulcer, oesophagitis and gastric ulcer were the commonest abnormal findings (n=50, 20%; n=29, 11.7%; and n=28, 11.3%, respectively). Of the participants, 93.8% (n=212) had no immediate complications. Bleeding and hypotension occurred in 2.7% (n=6) and 2% (n=5) of patients, respectively. At 90 days post-procedure, 83.3% (n=85) of those 70-79 years and 67.8% (n=99) of those ≥80 years had survived (p=0.180).

CONCLUSIONS

We conclude that OGD is largely a safe procedure in older adults with acute UGIB; however, the high proportion of OGDs with normal findings reinforces the importance of careful selection of patients.

Clinical Frailty Scale as a predictor of adverse outcomes following aortic valve replacement: a systematic review and meta-analysis

OBJECTIVES

Assessment of frailty prior to aortic valve intervention is recommended in European and North American valvular heart disease guidelines. However, there is a lack of consensus on how it is best measured. The Clinical Frailty Scale (CFS) is a well-validated measure of frailty that is relatively quick to calculate. This meta-analysis sought to examine whether the CFS predicts mortality and morbidity following either transcatheter aortic valve implantation (TAVI) or surgical aortic valve replacement (SAVR).

METHODS

Nine electronic databases were searched systematically for data on clinical outcomes post-TAVI/SAVR, where patients had undergone preoperative frailty assessment using the CFS. The primary endpoint was 12-month mortality. TAVI and SAVR data were assessed and reported separately. For each individual study, the incidence of adverse outcomes was extracted according to a CFS score of 5-9 (ie, frail) versus 1-4 (ie, non-frail), with meta-analysis performed using a random effects model.

RESULTS

Of 2612 records screened, nine were included in the review (five TAVI, three SAVR and one which included both interventions). Among 4923 TAVI patients, meta-analysis showed 12-month mortality rates of 19.1% for the frail cohort versus 9.8% for the non-frail cohort (RR 2.53 (1.63 to 3.95), p<0.001, I2=83%). For the smaller cohort of SAVR patients (n=454), mortality rates were 20.3% versus 3.9% for the frail and non-frail cohorts, respectively (RR 5.08 (2.31 to 11.15), p<0.001, I2=5%).

CONCLUSIONS

Frailty, as determined by the CFS, was associated with an increased mortality risk in the 12 months following either TAVI or SAVR. These data would support its use in the preoperative assessment of elderly patients undergoing aortic valve interventions.

Frailty and Pre-Frailty in the Setting of Total Joint Arthroplasty: A Narrative Review

Background

Total joint arthroplasties are among the most common surgical procedures performed in the United States. Although numerous safeguards are in place to optimize patient health and safety pre-, intra-, and postoperatively, patient frailty is often incompletely assessed or not assessed at all. Frailty has been shown to increase rates of adverse events and length of stay. We discuss the impact of frailty on patient outcomes and healthcare economics as well as provide widely accepted models to assess frailty and their optimal usage.

Methods

Several databases were searched using the keywords "frailty," "TJA," "THA," "frailty index," "frailty assessment," and "frailty risk." A total of 45 articles were used in this literature review.

Results

It is estimated that nearly half of patients over the age of 85 meet criteria for frailty. Frailty in surgical patients has been shown to increase total costs as well as length of stay. Additionally, increased rates of numerous adverse events are associated with increased frailty.

Conclusions

The literature demonstrates that frailty poses increased risk of adverse events, increased length of stay, and increased cost. There are several models that accurately assess frailty and can feasibly be implemented into preoperative screening.

Barriers and facilitators to participation in exercise prehabilitation before cancer surgery for older adults with frailty: a qualitative study

BACKGROUND

Older adults with frailty are at an increased risk of adverse outcomes after surgery. Exercise before surgery (exercise prehabilitation) may reduce adverse events and improve recovery after surgery. However, adherence with exercise therapy is often low, especially in older populations. The purpose of this study was to qualitatively assess the barriers and facilitators to participating in exercise prehabilitation from the perspective of older people with frailty participating in the intervention arm of a randomized trial.

METHODS

This was a research ethics approved, nested descriptive qualitative study within a randomized controlled trial of home-based exercise prehabilitation vs. standard care with older patients (≥ 60 years) having elective cancer surgery, and who were living with frailty (Clinical Frailty Scale ≥ 4). The intervention was a home-based prehabilitation program for at least 3 weeks before surgery that involved aerobic activity, strength and stretching, and nutritional advice. After completing the prehabilitation program, participants were asked to partake in a semi-structured interview informed by the Theoretical Domains Framework (TDF). Qualitative analysis was guided by the TDF.

RESULTS

Fifteen qualitative interviews were completed. Facilitators included: 1) the program being manageable and suitable to older adults with frailty, 2) adequate resources to support engagement, 3) support from others, 4) a sense of control, intrinsic value, noticing progress and improving health outcomes and 5) the program was enjoyable and facilitated by previous experience. Barriers included: 1) pre-existing conditions, fatigue and baseline fitness, 2) weather, and 3) guilt and frustration when unable to exercise. A need for individualization and variety was offered as a suggestion by participants and was therefore described as both a barrier and facilitator.

CONCLUSIONS

Home-based exercise prehabilitation is feasible and acceptable to older people with frailty preparing for cancer surgery. Participants identified that a home-based program was manageable, easy to follow with helpful resources, included valuable support from the research team, and they reported self-perceived health benefits and a sense of control over their health. Future studies and implementation should consider increased personalization based on health and fitness, psychosocial support and modifications to aerobic exercises in response to adverse weather conditions.

How Can We Best Measure Frailty in Cardiosurgical Patients?

BACKGROUND

Frailty is gaining importance in cardiothoracic surgery and is a risk factor for adverse outcomes and mortality. Various frailty scores have since been developed, but there is no consensus which to use for cardiac surgery.

METHODS

In an all-comer prospective study of patients presenting for cardiac surgery, we assessed frailty and analyzed complication rates in hospital and 1-year mortality, as well as laboratory markers before and after surgery.

RESULTS

246 included patients were analyzed. A total of 16 patients (6.5%) were frail, and 130 patients (52.85%) were pre-frail, summarized in the frail group (FRAIL) and compared to the non-frail patients (NON-FRAIL). The mean age was 66.5 ± 9.05 years, 21.14% female. The in-hospital mortality rate was 4.88% and the 1-year mortality rate was 6.1%. FRAIL patients stayed longer in hospital (FRAIL 15.53 ± 8.5 days vs. NON-FRAIL 13.71 ± 8.94 days, p = 0.004) and in intensive/intermediate care units (ITS/IMC) (FRAIL 5.4 ± 4.33 days vs. NON-FRAIL 4.86 ± 4.78 days, p = 0.014). The 6 min walk (6 MW) (317.92 ± 94.17 m vs. 387.08 ± 93.43 m, p = 0.006), mini mental status (MMS) (25.72 ± 4.36 vs. 27.71 ± 1.9, p = 0.048) and clinical frail scale (3.65 ± 1.32 vs. 2.82 ± 0.86, p = 0.005) scores differed between patients who died within the first year after surgery compared to those who survived this period. In-hospital stay correlated with timed up-and-go (TUG) (TAU: 0.094, p = 0.037), Barthel index (TAU-0.114, p = 0.032), hand grip strength (TAU-0.173, p < 0.001), and EuroSCORE II (TAU 0.119, p = 0.008). ICU/IMC stay duration correlated with TUG (TAU 0.186, p < 0.001), 6 MW (TAU-0.149, p = 0.002), and hand grip strength (TAU-0.22, p < 0.001). FRAIL patients had post-operatively altered levels of plasma-redox-biomarkers and fat-soluble micronutrients.

CONCLUSIONS

frailty parameters with the highest predictive value as well as ease of use could be added to the EuroSCORE.

Perioperative Optimization of the Cardiac Surgical Patient

Perioperative optimization of cardiac surgical patients is imperative to reduce complications, utilize health care resources efficiently, and improve patient recovery and quality of life. Standardized application of evidence-based best practices can lead to better outcomes. Although many practices should be applied universally to all patients, there are also opportunities along the surgical journey to identify patients who will benefit from additional interventions that will further ameliorate their recovery. Enhanced recovery programs aim to bundle several process elements in a standardized fashion to optimize outcomes after cardiac surgery. A foundational concept of enhanced recovery is attaining a better postsurgical end point for patients, in less time, through achievement and maintenance in their greatest possible physiologic, functional, and psychological state. Perioperative optimization is a broad topic, spanning multiple phases of care and involving a variety of medical specialties and nonphysician health care providers. In this review we highlight a variety of perioperative care topics, in which a comprehensive approach to patient care can lead to improved results for patients, providers, and the health care system. A particular focus on patient-centred care is included. Although existing evidence supports all of the elements reviewed, most require further improvements in implementation, as well as additional research, before their full potential and usefulness can be determined.

Performance of administrative database frailty instruments in predicting clinical outcomes and cost for patients undergoing transcatheter aortic valve implantation: a historical cohort study

PURPOSE

Frailty instruments may improve prognostic estimates for patients undergoing transcatheter aortic valve implantation (TAVI). Few studies have evaluated and compared the performance of administrative database frailty instruments for patients undergoing TAVI. This study aimed to examine the performance of administrative database frailty instruments in predicting clinical outcomes and costs in patients who underwent TAVI.

METHODS

We conducted a historical cohort study of 3,848 patients aged 66 yr or older who underwent a TAVI procedure in Ontario, Canada from 1 April 2012 to 31 March 2018. We used the Johns Hopkins Adjusted Clinical Group (ACG) frailty indicator and the Hospital Frailty Risk Score (HFRS) to assign frailty status. Outcomes of interest were in-hospital mortality, one-year mortality, rehospitalization, and healthcare costs. We compared the performance of the two frailty instruments with that of a reference model that adjusted baseline covariates and procedural characteristics. Accuracy measures included c-statistics, Akaike information criterion (AIC), Bayesian information criterion (BIC), integrated discrimination improvement (IDI), net reclassification index (NRI), bias, and accuracy of cost estimates.

RESULTS

A total of 863 patients (22.4%) were identified as frail using the Johns Hopkins ACG frailty indicator and 865 (22.5%) were identified as frail using the HFRS. Although agreement between the frailty instruments was fair (Kappa statistic = 0.322), each instrument classified different subgroups as frail. Both the Johns Hopkins ACG frailty indicator (rate ratio [RR], 1.13; 95% confidence interval [CI], 1.06 to 1.20) and the HFRS (RR, 1.14; 95% CI, 1.07 to 1.21) were significantly associated with increased one-year costs. Compared with the reference model, both the Johns Hopkins ACG frailty indicator and HFRS significantly improved NRI for one-year mortality (Johns Hopkins ACG frailty indicator: NRI, 0.160; P < 0.001; HFRS: NRI, 0.146; P = 0.001) and rehospitalization (Johns Hopkins ACG frailty indicator: NRI, 0.201; P < 0.001; HFRS: NRI, 0.141; P = 0.001). These improvements in NRI largely resulted from classification improvement among those who did not experience the event. With one-year mortality, there was a significant improvement in IDI (IDI, 0.003; P < 0.001) with the Johns Hopkins ACG frailty indicator. This improvement in performance resulted from an increase in the mean probability of the event among those with the event.

CONCLUSION

Preoperative frailty assessment may add some predictive value for TAVI outcomes. Use of administrative database frailty instruments may provide small but significant improvements in case-mix adjustment when profiling hospitals for certain outcomes.

Poor nutritional status and frailty associated with acute kidney injury after cardiac surgery: A retrospective observational study

BACKGROUND

Acute kidney injury (AKI) is a major determinant of short- and long-term morbidity and mortality following cardiac surgery. The present study examines the effect of preoperative nutritional status and frailty on this significant adverse event.

METHODS

The data of 455 patients who underwent on-pump coronary artery bypass grafting (CABG) were analyzed retrospectively. Demographic data were recorded, and intraoperative and postoperative parameters, frailty score, geriatric nutritional risk index (GNRI), and prognostic nutritional index (PNI) were calculated. Risk factors for AKI within 7 postoperative days were investigated in accordance with the kidney disease improving global outcomes classification.

RESULTS

Preoperative urea and creatinine values were significantly higher (p = .006 vs. p = .006), while hemoglobin, hematocrit, and estimated glomerular filtration rate values were significantly lower (p = .011, p = .008 vs. p = .006) in the AKI group than no AKI group. In the intraoperative period, the cardiopulmonary bypass time was longer in the AKI group (p = .031), and the need for dopamine, steradine, and red blood cells transfusion was greater (p = .026, p = .038 vs. p = .015) than no AKI group. The number of patients with a frailty score of 1-3 was significantly higher in the AKI group (p = .042). Similarly, the GNRI and PNI values, indicating nutritional status, were higher in the AKI group (p = .047 vs. p = .024). The independent risk factors for AKI were a GNRI of <91, the intraoperative need for dobutamine, preoperative serum creatinine of >1.3, and hemoglobin of <10 (p < .05).

CONCLUSIONS

Malnutrition and frailty are strongly associated with AKI after CABG. Clinicians can effectively predict the risk of AKI through an evaluation of frailty and nutritional scores, which can be easily calculated in the preoperative period.

Identifying barriers and facilitators to routine preoperative frailty assessment: a qualitative interview study

PURPOSE

Preoperative frailty assessment is recommended by multiple practice guidelines and may improve outcomes, but it is not routinely performed. The barriers and facilitators of routine preoperative frailty assessment have not been formally assessed. Our objective was to perform a theory-guided evaluation of barriers and facilitators to preoperative frailty assessment.

METHODS

This was a research ethics board-approved qualitative study involving physicians who perform preoperative assessment (consultant and resident anesthesiologists and consultant surgeons). Semistructured interviews were conducted by a trained research assistant informed by the Theoretical Domains Framework to identify barriers and facilitators to frailty assessment. Interview transcripts were independently coded by two research assistants to identify specific beliefs relevant to each theoretical domain.

RESULTS

We interviewed 28 clinicians (nine consultant anesthesiologists, nine consultant surgeons, and ten anesthesiology residents). Six domains (Knowledge [100%], Social Influences [96%], Social Professional Role and Identity [96%], Beliefs about Capabilities [93%], Goals [93%], and Intentions [93%]) were identified by > 90% of respondents. The most common barriers identified were prioritization of other aspects of assessment (e.g., cardio/respiratory) and a lack of awareness of evidence and guidelines supporting frailty assessment. The most common facilitators were a high degree of familiarity with frailty, recognition of the importance of frailty assessment, and strong intentions to perform frailty assessment.

CONCLUSION

Barriers and facilitators to preoperative frailty assessment are multidimensional, but generally consistent across different types of perioperative physicians. Knowledge of barriers and facilitators can guide development of evidence-based strategies to increase frailty assessment.

Potential association between frailty and pTau in community-dwelling older adults

Background

Frailty is a geriatric syndrome characterized by a decline in physiological reserves, and multiple factors contribute to the occurrence and development of frailty. Growing evidence supports a strong link and overlap between frailty and cognitive impairment, but the mechanisms involved have not yet been fully elucidated.

Aim

To identify associations between 12 plasma cognition-related biomarkers and frailty in community-dwelling older adults.

Methods

A total of 375 participants (age 70.9 ± 5.8, 165 men and 210 women) were included in this study. Frailty was assessed using the modified Fried frailty phenotype. Participants were divided into not-frail group (n = 313) and frail group (n = 62). Twelve plasma cognitive biomarkers were detected by enzyme-linked immunosorbent assay (ELISA). Multinomial logistic regression was used to explore the association between different biomarkers and frailty status.

Results

Among the 12 biomarkers, only pTau was higher in frail individuals than in their not-frail peers (471.3 ± 58.1 pg/mL vs. 451.9 ± 61.1 pg/mL, p = 0.022). No other biomarkers had any significant association with frailty, including total-Tau (tTau), neurofilament light (NFL), amyloid-β 40 (Aβ40), amyloid-β 40 (Aβ42), S100 calcium binding protein B (S100B), visinin-like protein 1 (VLP-1), Alzheimer-associated neuronal thread protein (AD7cNTP), β-amyloid precursor protein (βAPP), chitinase-3-like-1 (CHI3L1), soluble complement receptor 1 (sCR1) and heart-type fatty acid binding protein (hFABP). Furthermore, pTau was compared between negative and positive subject groups for each individual criterion of frailty. Significantly higher levels of pTau were observed in those who were positive for the criteria of low grip strength (451.2 ± 61.4 pg/mL vs. 469.1 ± 57.6 pg/mL, p = 0.019), exhaustion (451.2 ± 61.6 pg/mL vs. 466.4 ± 58.4 pg/mL, p = 0.035) and low physical activity (451.1 ± 60.7 pg/mL vs. 465.7 ± 60.7 pg/mL, p = 0.034) when compared to those who were negative for each corresponding criterion. Finally, in the multivariable-adjusted analysis, the association between pTau and frailty was statistically significantly associated (OR: 1.40, 95% CI: 1.04–1.89), even after adjusting.

Conclusions

The present study found a potential association between pTau and frailty. Future works should monitor the longitudinal trajectory of changes of pTau concentrations in frailty older adults. A better understanding of the molecular mechanisms behind will contribute to biomarker research in frailty.

The Utility of Grip Strength as a Simplified Measure of Frailty in the Older Adult in the Preoperative Clinic

Objective

 The aim of this study was to compare the measure of grip strength against other validated methods of measuring frailty.

Materials and methods

This was a single-center, cross-sectional study that took place at the Westchester Medical Center Pre-Procedural Testing Clinic. The patient population included n = 73 patients ≥65 years of age evaluated for elective surgery. During the study, patients’ grip strength, CFS-I (Clinical Frailty Score of Investigator), CFS-P (Clinical Frailty Score of Participant), and FRAIL (Fatigue, Resistance, Aerobic capacity, Illnesses, and Loss of weight) scores were measured.

Results

Grip strength correlated negatively with the CFS-I, CFS-P, and FRAIL scores for females. Reduced grip strength in females correlated with higher frailty scores and vice versa. Male grip strength showed no significant relationship with the frailty scales. In addition, multivariate linear regression analysis revealed that the independent measure that demonstrated a significant inverse association with grip strength was age (β= -0.43, p = <0.001).

Conclusions

 There exists a difference in the utility of grip strength as a measure of frailty between males and females.

Comparison of Multidimensional Frailty Instruments for Estimation of Long-term Patient-Centered Outcomes After Cardiac Surgery

Importance

Little is known about the performance of available frailty instruments in estimating patient-relevant outcomes after cardiac surgery.

Objective

To examine how well the Johns Hopkins Adjusted Clinical Groups (ACG) frailty indicator, the Hospital Frailty Risk Score (HFRS), and the Preoperative Frailty Index (PFI) estimate long-term patient-centered outcomes after cardiac surgery.

Design, Setting, and Participants

This retrospective cohort study was conducted in Ontario, Canada, among residents 18 years and older who underwent coronary artery bypass grafting or aortic, mitral or tricuspid valve, or thoracic aorta surgery between October 2008 and March 2017. Long-term care residents, those with discordant surgical encounters, and those receiving dialysis or dependent on a ventilator within 90 days were excluded. Statistical analysis was conducted from July 2021 to January 2022.

Main Outcomes and Measures

The primary outcome was patient-defined adverse cardiovascular and noncardiovascular events (PACE), defined as the composite of severe stroke, heart failure, long-term care admission, new-onset dialysis, and ventilator dependence. Secondary outcomes included mortality and individual PACE events. The association between frailty and PACE was examined using cause-specific hazard models with death as a competing risk, and the association between frailty and death was examined using Cox models. Areas under the receiver operating characteristic curve (AUROC) were determined over 10 years of follow-up for each frailty instrument.

Results

Of 88 456 patients (22 924 [25.9%] female; mean [SD] age, 66.3 [11.1] years), 14 935 (16.9%) were frail according to ACG criteria, 63 095 (71.3%) according to HFRS, and 76 754 (86.8%) according to PFI. Patients with frailty were more likely to be older, female, and rural residents; to have lower income and multimorbidity; and to undergo urgent surgery. Patients meeting ACG criteria (hazard ratio [HR], 1.66; 95% CI, 1.60-1.71) and those with higher HFRS scores (HR per 1.0-point increment, 1.10; 95% CI, 1.09-1.10) and PFI scores (HR per 0.1-point increment, 1.75; 95% CI, 1.73-1.78) had higher rates of PACE. Similar magnitudes of association were observed for each frailty instrument with death and individual PACE components. The HFRS had the highest AUROC for estimating PACE during the first 2 years and death during the first 4 years, after which the PFI had the highest AUROC.

Conclusions and Relevance

These findings could help to tailor the use of frailty instruments by outcome and follow-up duration, thus optimizing preoperative risk stratification, patient-centered decision-making, candidate selection for prehabilitation, and personalized monitoring and health resource planning in patients undergoing cardiac surgery.

PREPARE trial: a protocol for a multicentre randomised trial of frailty-focused preoperative exercise to decrease postoperative complication rates and disability scores

INTRODUCTION

Frailty is a strong predictor of adverse postoperative outcomes. Prehabilitation may improve outcomes after surgery for older people with frailty by addressing physical and physiologic deficits. The objective of this trial is to evaluate the efficacy of home-based multimodal prehabilitation in decreasing patient-reported disability and postoperative complications in older people with frailty having major surgery.

METHODS AND ANALYSIS

We will conduct a multicentre, randomised controlled trial of home-based prehabilitation versus standard care among consenting patients >60 years with frailty (Clinical Frailty Scale>4) having elective inpatient major non-cardiac, non-neurologic or non-orthopaedic surgery. Patients will be partially blinded; clinicians and outcome assessors will be fully blinded. The intervention consists of >3 weeks of prehabilitation (exercise (strength, aerobic and stretching) and nutrition (advice and protein supplementation)). The study has two primary outcomes: in-hospital complications and patient-reported disability 30 days after surgery. Secondary outcomes include survival, lower limb function, quality of life and resource utilisation. A sample size of 750 participants (375 per arm) provides >90% power to detect a minimally important absolute difference of 8 on the 100-point patient-reported disability scale and a 25% relative risk reduction in complications, using a two-sided alpha value of 0.025 to account for the two primary outcomes. Analyses will follow intention to treat principles for all randomised participants. All participants will be followed to either death or up to 1 year.

ETHICS AND DISSEMINATION

Ethical approval has been granted by Clinical Trials Ontario (Project ID: 1785) and our ethics review board (Protocol Approval #20190409-01T). Results will be disseminated through presentation at scientific conferences, through peer-reviewed publication, stakeholder organisations and engagement of social and traditional media.

TRIAL REGISTRATION NUMBER

NCT04221295.

Effectiveness and Approach of Rehabilitation in Patients With Acute Heart Failure: A Review

Acute heart failure is associated with high mortality and frequent rehospitalization, resulting in enormous healthcare costs and declining physical function, activities of daily living, and quality of life. Cardiac rehabilitation has been recommended as one of the non-pharmacologic treatments for patients with heart failure. However, much of the evidence for cardiac rehabilitation interventions reported to date has been limited to chronic heart failure. In recent years, the effectiveness of rehabilitation intervention in patients with acute heart failure has been reported, led by the Rehabilitation Therapy in Older Acute Heart Failure Patients (REHAB-HF) trial. This review overviews the recent evidence of rehabilitation in patients with acute heart failure.

Effects of frailty on postoperative clinical outcomes of aneurysmal subarachnoid hemorrhage: results from the National Inpatient Sample database

Background

This study aimed to investigate the potential effect of preoperative frailty on postoperative clinical outcomes of patients with aneurysmal subarachnoid hemorrhage (aSAH).

Methods

Data of patients aged 18 years and older who were diagnosed with subarachnoid hemorrhage or intracerebral hemorrhage, underwent aneurysm repair surgical intervention from 2005 to 2014. A retrospective database analysis was performed based on U.S. National Inpatient Sample (NIS) from 2005 to 2014. Frailty was determined using the Johns Hopkins Adjusted Clinical Groups (ACG) frailty-defining diagnoses indicator. Patients were stratified into frail and non-frail groups and the study endpoints were incidence of postoperative complications and related adverse clinical outcomes.

Results

Among 20,527 included aSAH patients, 2303 (11.2%) were frail and 18,224 (88.8%) were non-frail. Significant differences were found between frailty and non-frailty groups in the four clinical outcomes (all p < 0.05). Multivariate analysis showed that frailty was associated with significant higher risks of discharge to institutional care (aOR: 2.50, 95%CI: 2.10–2.97), tracheostomy or gastrostomy tube replacement (aOR: 4.41, 95%CI: 3.81–5.10) and postoperative complications (aOR: 3.29, 95%CI: 2.55–4.25) but a lower risk of death in hospital (aOR: 0.40, 95%CI: 0.33–0.49) as compared with non-frailty. Stratified analysis showed the impact of frailty on some of the outcomes were greater among patients younger than 65 years than their older counterparts.

Conclusions

Frailty is significantly correlated with the increased risk of discharge to institutional care, tracheostomy or gastrostomy tube placement, and postoperative complications but with the reduced risk of in-hospital mortality outcomes after aneurysm repair. Frailty seems to have greater impact among younger adults than older ones. Baseline frailty evaluation could be applied to risk stratification for aSAH patients who were undergoing surgery.

Preoperative frailty based on laboratory data and postoperative health outcomes in patients undergoing coronary artery bypass graft surgery

BACKGROUND

Frailty is associated with adverse surgical outcomes. Patients with cardiovascular diseases have many risk factors of frailty; thus, preoperative frailty evaluation is necessary to predict adverse outcomes after coronary artery bypass graft (CABG) surgery. Laboratory data based-frailty assessments are objective and not time-consuming, addressing the need for an accurate but simple frailty screening for patients awaiting CABG surgery.

OBJECTIVES

This retrospective study aimed to determine the association between laboratory based-frailty and patient health outcomes after CABG surgery.

METHODS

We evaluated 896 patients who underwent on-pump or off-pump CABG surgery between August 1, 2015 and July 31, 2020 at a tertiary hospital. The frailty index-laboratory (FI-LAB), which comprises 32 laboratory parameters and vital signs, was used for frailty assessment.

RESULTS

The patients were divided into three groups according to their preoperative FI-LAB level as low (FI-LAB <0.25, 23.0%), moderate (FI-LAB ≥0.25 to ≤0.4, 54.9%), and high (FI-LAB>0.4, 22.1%) frailty groups. In the confounder-adjusted analysis, the lengths of hospital stay and intensive care unit stay were longer by 2.20 days (p=.023) and by 0.89 days (p=.009), respectively, in the high frailty group than those in the low frailty group. The odds ratio for 30-day readmission was also 2.58 times higher in the high frailty group than that in the low frailty group.

CONCLUSION

A high preoperative FI-LAB score indicates increasing risks of adverse postoperative outcomes among CABG surgery patients. FI-LAB has potential strengths to capture the need for a more thorough frailty assessment for cardiac surgery patients.

Home-based prehabilitation with exercise to improve postoperative recovery for older adults with frailty having cancer surgery: the PREHAB randomised clinical trial

BACKGROUND

Frailty is a state of vulnerability as a result of decreased reserves. Prehabilitation may increase reserve and improve postoperative outcomes. Our objective was to determine if home-based prehabilitation improves postoperative functional recovery in older adults with frailty having cancer surgery.

METHODS

This double blind randomised trial enrolled people ≥60 yr having elective cancer surgery and ≥3 weeks from enrolment to surgery as eligible. Participation in a remotely supported, home-based exercise prehabilitation program plus nutritional guidance was compared with standard care plus written advice on age-appropriate activity and nutrition. The primary outcome was 6-min walk test (6MWT) distance at the first postoperative clinic visit. Secondary outcomes included physical performance, quality of life, disability, length of stay, non-home discharge, and 30-day readmission.

RESULTS

Of 543 patients assessed, 254 were eligible and 204 (80%) were randomised (102 per arm); 182 (94 intervention and 88 control) had surgery and were analysed. Mean age was 74 yr and 57% were female. Mean duration of participation was 5 weeks, mean adherence was 61% (range 0%-100%). We found no significant difference in 6MWT at follow-up (+14 m, 95% confidence interval -26-55 m, P=0.486), or for secondary outcomes. Analyses using a prespecified adherence definition of ≥80% supported improvements in 6MWT distance, complication count, and disability.

CONCLUSIONS

A home-based prehabilitation program did not significantly improve postoperative recovery or other outcomes in older adults with frailty having cancer surgery. Program adherence may be a key mediator of prehabilitation efficacy.

CLINICAL TRIAL REGISTRATION

NCT02934230.

Decision making in treatment of symptomatic severe aortic stenosis: a survey study in Dutch heart centres

Aim

To provide insight into the basic characteristics of decision making in the treatment of symptomatic severe aortic stenosis (SSAS) in Dutch heart centres with specific emphasis on the evaluation of frailty, cognition, nutritional status and physical functioning/functionality in (instrumental) activities of daily living [(I)ADL].

Methods

A questionnaire was used that is based on the European and American guidelines for SSAS treatment. The survey was administered to physicians and non-physicians in Dutch heart centres involved in the decision-making pathway for SSAS treatment.

Results

All 16 Dutch heart centres participated. Before a patient case is discussed by the heart team, heart centres rarely request data from the referring hospital regarding patients’ functionality (n = 5), frailty scores (n = 0) and geriatric consultation (n = 1) as a standard procedure. Most heart centres ‘often to always’ do their own screening for frailty (n = 10), cognition/mood (n = 9), nutritional status (n = 10) and physical functioning/functionality in (I)ADL (n = 10). During heart team meetings data are ‘sometimes to regularly’ available regarding frailty (n = 5), cognition/mood (n = 11), nutritional status (n = 8) and physical functioning/functionality in (I)ADL (n = 10). After assessment in the outpatient clinic patient cases are re-discussed ‘sometimes to regularly’ in heart team meetings (n = 10).

Conclusions

Dutch heart centres make an effort to evaluate frailty, cognition, nutritional status and physical functioning/functionality in (I)ADL for decision making regarding SSAS treatment. However, these patient data are not routinely requested from the referring hospital and are not always available for heart team meetings. Incorporation of these important data in a structured manner early in the decision-making process may provide additional useful information for decision making in the heart team meeting.

Supplementary Information

The online version of this article (10.1007/s12471-022-01676-w) contains supplementary material, which is available to authorized users.

Influence of preoperative frailty on quality of life after cardiac surgery: Protocol for a systematic review and meta-analysis

BACKGROUND

Frailty has emerged as an important prognostic marker of adverse outcomes after cardiac surgery, but evidence regarding its ability to predict quality of life after cardiac surgery is currently lacking. Whether frail patients derive the same quality of life benefit after cardiac surgery as patients without frailty remains unclear.

METHODS

This systematic review will include interventional studies (RCT and others) and observational studies evaluating the effect of preoperative frailty on quality-of-life outcomes after cardiac surgery amongst patients 65 years and older. Studies will be retrieved from major databases including the Cochrane Central Register of Controlled Trials, Embase, and Medline. The primary exposure will be frailty status, independent of the tool used. The primary outcome will be change in quality of life, independent of the tool used. Secondary outcomes will include readmission during the year following the index intervention, discharge to a long-term care facility and living in a long-term care facility at one year. Screening, inclusion, data extraction and quality assessment will be performed independently by two reviewers. Meta-analysis based on the random-effects model will be conducted to compare the outcomes between frail and non-frail patients. The evidential quality of the findings will be assessed with the GRADE profiler.

CONCLUSION

The findings of this systematic review will be important to clinicians, patients and health policy-makers regarding the use of preoperative frailty as a screening and assessment tool before cardiac surgery.

STUDY REGISTRATION

OSF registries (https://osf.io/vm2p8).

Association between frailty and patient outcomes after cancer surgery: a population-based cohort study

BACKGROUND

Frailty is associated with poor postoperative outcomes, but existing data do not describe frailty's interaction with tumour characteristics at the time of cancer surgery. Our objective was to estimate the association between frailty and long-term survival, and to explore any interaction with tumour stage and grade.

METHODS

This was a population-based cohort study conducted using linked provincial health administrative data in Ontario, Canada (2009-20). Using a cancer registry, we identified adults having elective cancer surgery. Frailty was measured using a validated index (range 0-1; higher score=greater frailty). Associations between frailty and long-term postoperative survival (primary outcome) were estimated using proportional hazards regression. Secondary outcomes were length of stay, discharge destination, days alive at home, and healthcare costs.

RESULTS

We identified and included 52 012 patients. Mean frailty score was 0.13 (standard deviation 0.07). During follow-up, 19 378 (37.3%) patients died. After adjustment for risk factors, each 10% increase in frailty was associated with a 1.60-fold relative decrease in survival (95% confidence interval: 1.56-1.64). The frailty-survival association was strongest for patients with lower stage and grade cancers. Increased frailty was associated with longer hospital stays (3 days), fewer days alive and at home (42 days yr^-1), more frequent discharge to a nursing facility (2.38-fold), and increased healthcare costs ($6048).

CONCLUSIONS

Patient frailty is associated with decreased long-term survival after cancer surgery. The association is stronger for early-stage and -grade cancers, which would otherwise have a better survival prognosis.

Rockwood Clinical Frailty Scale as a predictor of adverse outcomes among older adults undergoing aortic valve replacement: a protocol for a systematic review

INTRODUCTION

Frailty is associated with adverse outcomes relating to cardiac procedures. It has been proposed that frailty scoring should be included in the preoperative assessment of patients undergoing aortic valve replacement. We aim to examine the Rockwood Clinical Frailty Scale (CFS), as a predictor of adverse outcomes following aortic valve replacement.

METHODS AND ANALYSIS

Prospective and retrospective cohort studies and randomised controlled trials assessing both the preoperative frailty status (as per the CFS) and incidence of adverse outcomes among older adults undergoing either surgical aortic valve replacement or transcatheter aortic valve replacement will be included. Adverse outcomes will include mortality and periprocedural complications, as well as a composite of 30-day complications. A search will be conducted from 2005 to present using a prespecified search strategy. Studies will be screened for inclusion by two reviewers, with methodological quality assessed using the Quality Assessment of Diagnostic Accuracy Studies (QUADAS-2) tool. Relative risk ratios with 95% CIs will be generated for each outcome of interest, comparing frail with non-frail groups. Data will be plotted on forest plots where applicable. The quality of the evidence will be determined using the Grading of Recommendations, Assessment, Development and Evaluation tool.

ETHICS AND DISSEMINATION

Ethical approval is not required for this study as no primary data will be collected. We will publish the review in a peer-reviewed journal on completion.

PROSPERO REGISTRATION NUMBER

CRD42020213757.

Impact of frailty on early and mid-term outcomes of hybrid aortic arch repair

PURPOSE

The purpose of this study was to investigate the impact of frailty on the clinical outcomes of hybrid aortic arch repair with debranching of the supra-aortic arteries.

METHODS

Consecutive patients ≥ 75 years old who underwent hybrid aortic arch repair from January 2010 to December 2019 were retrospectively analyzed. Using the Canadian Study of Health and Aging (CSHA) scale, all patients with a CSHA scale score > 4 were defined as frail. The frail patients (FP) group and the non-frail patients (NFP) group were compared regarding the early and mid-term outcomes of hybrid aortic arch repair.

RESULTS

A total of 84 patients were included. The early postoperative results were not markedly different between the groups, except that the rate of transfer to a rehabilitation hospital was higher in the FP group than in the NFP group. The survival at 5 years was significantly lower in the FP group at 43.0% than in the NFP group at 67.7% (P = 0.015). However, the freedom from aorta-related death was not significantly different between the two groups.

CONCLUSION

Frailty did not affect the short-term outcomes of hybrid aortic arch repair; however, the mid-term outcomes, including the survival, of the frail patients were significantly worse than those of the non-frail patients, mostly because of non-aorta-related causes.

Frailty as a Predictor of Postoperative Outcomes in Invasive Cardiac Surgery: A Systematic Review of Literature

OBJECTIVES

Frailty is a syndrome characterized by increased vulnerability and reduced ability to maintain homeostasis after stressful events that results in an increased risk for poor outcomes. Frailty screening could potentially be valuable in cardiac surgery risk assessment. The purpose of this review is to evaluate the current literature linking multicomponent frailty assessment and invasive cardiac surgery outcomes.

METHODS

We searched PubMed, EMBASE, and CINAHL; 1887 articles met the search criteria, and each was independently reviewed by 2 reviewers.

RESULTS

The 19 eligible studies assessed 52 291 subjects using 17 different frailty measurements. The most commonly used instruments were the Fried Frailty Phenotype and the Clinical Frailty Scale. Between 9% and 61% of participants were found to be frail in each study. All 19 studies included mortality as an outcome, 12 included surgical complications, 12 included hospital length of stay, 3 included quality of life, and 2 included functional status. Nine found statistically significant differences in survival between frail and nonfrail patients, 6 of 12 found that frail patients had a longer length of stay, 4 of 12 found that frail patients were more likely to experience major complications, and 2 of 2 found that frail patients were more likely to have a decrease in functional status.

CONCLUSION

Although some studies lacked power, the majority confirmed that frail patients are more likely to experience poor outcomes. Further research is needed to determine which frailty measure provides the best predictive validity and to identify interventions to mitigate the risks that major cardiac surgery poses to frail patients.

Comparison of Frailty Index to Pneumonia Severity Measures in Older Patients With Pneumonia

OBJECTIVES

Risk stratification tools are useful to provide appropriate clinical care for older patients with pneumonia. This study aimed to compare a Frailty Index (FI) with pneumonia severity measures, CURB-65, and the Pneumonia Severity Index (PSI), for predicting mortality and persistent disability after pneumonia.

DESIGN

Single-center prospective cohort study.

SETTING AND PARTICIPANTS

The study included 190 patients aged ≥65 years who were hospitalized with pneumonia at a university hospital in Korea between October 2019 and September 2020.

METHODS

At admission, a 50-item deficit-accumulation FI (range: 0-1), CURB-65 (range: 0-5), and PSI (range: 0-395) scores were calculated. The outcomes were death and a composite outcome of death or decline in ability to perform daily activities and physical task 6 months later.

RESULTS

The median age was 79 years (interquartile range: 74-85), and 70 (36.8%) patients were women. The patients who died (n = 53) had higher FI (median, 0.46 vs 0.20; P < .011), CURB-65 score (median, 3 vs 2; P = .001), and PSI score (median, 149 vs 116; P < .001) than those who did not. The C-statistics (95% confidence intervals) for 6-month mortality were 0.69 (0.61-0.77) for the FI, 0.62 (0.53-0.71) for CURB-65, and 0.71 (0.62-0.79) for the PSI (P = .019). The C-statistics for the 6-month composite outcome were 0.73 (0.65-0.81) for the FI, 0.64 (0.55-0.73) for CURB-65, and 0.69 (0.60-0.77) for the PSI (P = .096). The C-statistics improved when the FI was added to CURB-65 (from 0.64 to 0.74; P = .003) and to the PSI (from 0.69 to 0.75; P = .044) for the composite outcome.

CONCLUSIONS AND IMPLICATIONS

Measuring frailty provides additive value to widely used pneumonia severity measures in predicting death or persistent hospitalization-associated disability in older adults after pneumonia hospitalization. Early recognition of frailty may be useful to identify those who require in-hospital and post-acute care interventions for functional recovery.

Frailty Is Independently Associated with Mortality and Readmission in Hospitalized Patients with Inflammatory Bowel Diseases

BACKGROUND & AIMS

Old age must be considered in weighing the risks of complications vs benefits of treatment for patients with inflammatory bowel diseases (IBD). We conducted a nationally representative cohort study to estimate the independent effects of frailty on burden, costs, and causes for hospitalization in patients with IBD.

METHODS

We searched the Nationwide Readmissions Database to identify 47,402 patients with IBD, hospitalized from January through June 2013 and followed for readmission through December 31, 2013. Based on a validated hospital frailty risk scoring system, 15,507 patients were considered frail and 31,895 were considered non-frail at index admission. We evaluated the independent effect of frailty on longitudinal burden and costs of hospitalization, inpatient mortality, risk of readmission and surgery, and reasons for readmission.

RESULTS

Over a median follow-up time of 10 months, adjusting for age, sex, income, comorbidity index, depression, obesity, severity, and indication for index hospitalization, frailty was independently associated with 57% higher risk of mortality (adjusted hazard ratio [aHR], 1.57; 95% CI, 1.34-1.83), 21% higher risk of all-cause readmission (adjusted hazard ratio [HR], 1.21; 95% CI, 1.17-1.25), and 22% higher risk of readmission for severe IBD (aHR, 1.22; 95% CI, 1.16-1.29). Frail patients with IBD spent more days in the hospital annually (median 9 days; interquartile range, 4-18 days vs median 5 days for non-frail patients; interquartile range, 3-10 days; P < .01) with higher costs of hospitalization ($17,791; interquartile range, $8368-$38,942 vs $10,924 for non-frail patients, interquartile range, $5571-$22,632; P < .01). Infections, rather than IBD, were the leading cause of hospitalization for frail patients.

CONCLUSIONS

Frailty is independently associated with higher mortality and burden of hospitalization in patients with IBD; infections are the leading cause of hospitalization. Frailty should be considered in treatment approach, especially in older patients with IBD.

Evaluating the impact of frailty on periprocedural adverse events and mortality among patients with GI bleeding

BACKGROUND AND AIMS

Frailty is a known predictor of mortality and adverse events in the inpatient setting; however, it has not been studied as a modality to assess risk among patients undergoing endoscopy for GI bleeding (GIB). We aimed to determine the association between frailty status and risk of adverse events in hospitalized patients with GIB who underwent endoscopy.

METHODS

We performed a cohort study using the 2016 and 2017 National Inpatient Sample database, using International Classification of Diseases diagnostic codes to identify adult patients with GIB who underwent endoscopic procedures within 2 days of admission and the Hospital Frailty Risk Score to classify patients as frail or nonfrail. Univariable and multivariable logistic regression models were constructed to assess the predictors of periprocedural adverse events, and marginal standardization analysis was performed to assess for possible interaction between age and frailty.

RESULTS

A total of 757,920 patients met inclusion criteria, of which 44.4% (336,895) were identified as frail and 55.6% (421,025) as nonfrail; 49.2% of frail patients had composite periprocedural adverse events compared with 25.5% of nonfrail patients (P < .001). Frail patients notably had more cardiovascular (32.1% vs 17.1%, P < .001), pulmonary (18.5% vs 4.3%, P < .001), GI (10.1% vs 6.1%, P < .001), and infectious (9.9% vs .7%, P < .001) adverse events compared with nonfrail patients. Frail patients also had higher all-cause inpatient mortality rates (4.8% vs .5%, P < .001). On multivariable analysis, positive frailty status was associated with a 2.13 times increased likelihood of having composite periprocedural adverse events.

CONCLUSIONS

In hospitalized patients undergoing endoscopy for GIB, frailty status is associated with increased periprocedural adverse events including all-cause mortality. The use of frailty assessments can thus further guide clinical decision-making when considering endoscopy and risk of adverse events in adult patients with GI hemorrhage.