The American College of Surgeons and the American Geriatrics Society have suggested that preoperative cognitive screening should be performed in older surgical patients. We hypothesized that ...unrecognized cognitive impairment in patients without a history of dementia is a risk factor for development of postoperative complications.
We enrolled 211 patients 65 yr of age or older without a diagnosis of dementia who were scheduled for an elective hip or knee replacement. Patients were cognitively screened preoperatively using the Mini-Cog and demographic, medical, functional, and emotional/social data were gathered using standard instruments or review of the medical record. Outcomes included discharge to place other than home (primary outcome), delirium, in-hospital medical complications, hospital length-of-stay, 30-day emergency room visits, and mortality. Data were analyzed using univariate and multivariate analyses.
Fifty of 211 (24%) patients screened positive for probable cognitive impairment (Mini-Cog less than or equal to 2). On age-adjusted multivariate analysis, patients with a Mini-Cog score less than or equal to 2 were more likely to be discharged to a place other than home (67% vs. 34%; odds ratio = 3.88, 95% CI = 1.58 to 9.55), develop postoperative delirium (21% vs. 7%; odds ratio = 4.52, 95% CI = 1.30 to 15.68), and have a longer hospital length of stay (hazard ratio = 0.63, 95% CI = 0.42 to 0.95) compared to those with a Mini-Cog score greater than 2.
Many older elective orthopedic surgical patients have probable cognitive impairment preoperatively. Such impairment is associated with development of delirium postoperatively, a longer hospital stay, and lower likelihood of going home upon hospital discharge.
Frailty is an age-related, multi-dimensional state of decreased physiologic reserve that results in diminished resiliency and increased vulnerability to stressors. It has proven to be an excellent ...predictor of unfavorable health outcomes in the older surgical population. There is agreement in recommending that a frailty evaluation should be part of the preoperative assessment in the elderly. However, the consensus is still building with regards to how it should affect perioperative care. The Society for Perioperative Assessment and Quality Improvement (SPAQI) convened experts in the fields of gerontology, anesthesiology and preoperative assessment to outline practical steps for clinicians to assess and address frailty in elderly patients who require elective intermediate or high risk surgery. These recommendations summarize evidence-based principles of measuring and screening for frailty, as well as basic interventions that can help improve patient outcomes.
•The perioperative evaluation of elderly patients who require elective major surgery should include a frailty screen.•A positive frailty screen is best followed up with a diagnostic assessment of frailty and when feasible a comprehensive geriatric assessment•Multimodal prehabilitation programs could potentially improve the perioperative prognosis of frail patients.•Preoperative approach for frail older adults should be individualized.•Future studies should test the impact of various frailty interventions on system-centered and on patient-centered outcomes.
There are limited screening tools to predict adverse postoperative outcomes for the geriatric surgical fracture population. Frailty is increasingly recognized as a risk assessment to capture ...complexity. The goal of this study was to use a short screening tool, the FRAIL scale, to categorize the level of frailty of older adults admitted with a fracture to determine the association of each frailty category with postoperative and 30-day outcomes.
Retrospective cohort study.
Level 1 trauma center.
A total of 175 consecutive patients over age 70 years admitted to co-managed orthopedic trauma and geriatrics services.
The FRAIL scale (short 5-question assessment of fatigue, resistance, aerobic capacity, illnesses, and loss of weight) classified the patients into 3 categories: robust (score = 0), prefrail (score = 1-2), and frail (score = 3-5). Postoperative outcome variables collected were postoperative complications, unplanned intensive care unit admission, length of stay (LOS), discharge disposition, and orthopedic follow-up after surgery. Thirty-day outcomes measured were 30-day readmission and 30-day mortality. Analysis of variance (1-way) and Kruskal-Wallis tests were used to compare continuous variables across the 3 FRAIL categories. Fisher exact tests were used to compare categorical variables. Multiple regression analysis, adjusted by age, sex, and Charlson index, was conducted to study the association between frailty category and outcomes.
FRAIL scale categorized the patients into 3 groups: robust (n = 29), prefrail (n = 73), and frail (n = 73). There were statistically significant differences between groups in terms of age, comorbidity, dementia, functional dependency, polypharmacy, and rate of institutionalization, being higher in the frailest patients. Hip fracture was the most frequent fracture, and it was more frequent as the frailty of the patient increased (48%, 61%, and 75% in robust, prefrail, and frail groups, respectively). The American Society of Anesthesiologists preoperative risk significantly correlated with the frailty of the patient (American Society of Anesthesiologists score 3-4: 41%, 82% and 86%, in robust, prefrail, and frail groups, P < .001). After adjustment by age, sex, and comorbidity, there was a statistically significant association between frailty and both LOS and the development of any complication after surgery (LOS: 4.2, 5.0, and 7.1 days, P = .002; any complication: 3.4%, 26%, and 39.7%, P = .03; in robust, prefrail, and frail groups). There were also significant differences in discharge disposition (31% of robust vs 4.1% frail, P = .008) and follow-up completion (97% of robust vs 69% of the frail ones). Differences in time to surgery, unplanned intensive care unit admission, and 30-day readmission and mortality, although showing a trend, did not reach statistical significance.
Frailty, measured by the FRAIL scale, was associated with increase LOS, complications after surgery, and discharge to rehabilitation facility in geriatric fracture patients. The FRAIL scale is a promising short screen to stratify and help operationalize the perioperative care of older surgical patients.
We conducted a randomized controlled trial in older adults with hematologic malignancies to determine the impact of geriatrician consultation embedded in our oncology clinic alongside standard care. ...From February 2015 to May 2018, transplant-ineligible patients aged ≥75 years who presented for initial consultation for lymphoma, leukemia, or multiple myeloma at Dana-Farber Cancer Institute (Boston, MA, USA) were eligible. Pre-frail and frail patients, classified based on phenotypic and deficit-accumulation approaches, were randomized to receive either standard oncologic care with or without consultation with a geriatrician. The primary outcome was 1-year overall survival. Secondary outcomes included unplanned care utilization within 6 months of follow-up and documented end-of-life (EOL) goals-of-care discussions. Clinicians were surveyed as to their impressions of geriatric consultation. One hundred sixty patients were randomized to either geriatric consultation plus standard care (n=60) or standard care alone (n=100). The median age of the patients was 80.4 years (standard deviation = 4.2). Of those randomized to geriatric consultation, 48 (80%) completed at least one visit with a geriatrician. Consultation did not improve survival at 1 year compared to standard care (difference: 2.9%, 95% confidence interval: -9.5% to 15.2%, P=0.65), and did not significantly reduce the incidence of emergency department visits, hospital admissions, or days in hospital. Consultation did improve the odds of having EOL goals-of-care discussions (odds ratio = 3.12, 95% confidence interval: 1.03 to 9.41) and was valued by surveyed hematologic-oncology clinicians, with 62.9%-88.2% of them rating consultation as useful in the management of several geriatric domains.
Objective
To assess prevalence of CT imaging-derived sarcopenia, osteoporosis, and visceral obesity in clinically frail and prefrail patients and determine their association with the diagnosis of ...frailty.
Materials and methods
This cross-sectional study was constructed using our institution’s pelvic trauma registry and ambulatory database registry. The study included all elderly pelvic trauma patients and ambulatory outpatients between May 2016 and March 2020 who had a comprehensive geriatric assessment and CT abdomen/pelvis within 1 year from the date of the assessment. Patients were dichotomized in prefrail or frail groups. The study excluded patients with history of metastatic disease or malignancy requiring chemotherapy.
Results
The study cohort consisted of 151 elderly female and 65 male patients. Each gender population was subdivided into frail (114 female 75%, 51 male 78%) and prefrail (37 female 25%, 14 male 22%) patients. CT-imaging-derived diagnosis of osteoporosis (odds ratio, 2.5; 95% CI: 1.2–5.5) and sarcopenia (odds ratio, 2.6; 95% CI: 1.2–5.6) were associated with frailty in females, but did not reach statistical significance in males. BMI and subcutaneous adipose tissue at L3 level were statistically lower in the frail male group compared to the prefrail group. BMI showed strong correlation with the subcutaneous area at the L3 level in both genders (Spearman’s coefficient of 0.8,
p
< 0.001). Hypoalbuminemia and visceral obesity were not associated with frailty in either gender.
Conclusion
This proof-of-concept study demonstrates the feasibility of using CT-derived body-composition parameters as a screening tool for frailty, which can offer an opportunity for early medical intervention.
Abstract Background Although involvement of geriatricians in the care of older trauma patients is associated with changes in processes of care and improved outcomes, few geriatrician consultations ...were ordered on our service. Study Design Mandatory geriatric consults were initiated in Sept 2013 for all trauma patients 70 years and older admitted to our hospital. We prospectively collected data on patients admitted from Oct 2013–Sept 2014 (post-intervention) and compared to patients admitted from Jun 2011–Jun 2012 (pre-intervention). We collected data on processes of care (Do Not Resuscitate/ Do Not Intubate (DNR/DNI) status, delirium, referral for cognitive evaluation) and patient outcomes (mortality, readmission, length of stay). Descriptive statistics and post-hoc power analyses were performed. Results There were 215 and 191 patients included in the pre-intervention and post-intervention cohorts respectively. After the intervention, geriatric consults increased from 3.26% to 100%. Patients on DNR/DNI status increased from 10.23% to 38.22% ( P <0.01). Referral for formal cognitive evaluation increased from 2.33% to 14.21% ( P <0.01) and delirium documentation increased from 31.16% to 38.22% ( P= 0.14). In-hospital mortality and 30-day mortality in the pre- and post-intervention periods were 9.30% vs. 5.24% ( P =0.12) and 11.63% vs. 6.81% ( P =0.10) respectively. ICU readmission was 8.26% pre-intervention and 1.96% post-intervention ( P =0.06). There were no changes in 30-day hospital readmission and length of stay. Power analyses showed more patients were needed to show statistically significant outcomes. Conclusions The initiation of mandatory geriatric consults on our trauma service was associated with improved advance care planning and increased multidisciplinary care. Ensuring involvement of geriatricians may aid in reducing adverse outcomes among geriatric trauma patients.
Objective To assess the feasibility of administering the MoCA 5-minute test/Telephone (T-MoCA), an abbreviated version of the Montreal Cognitive Assessment to older adults perioperatively Design A ...feasibility study including patients aged greater than or equal to 70 years scheduled for surgery from December 2020 to March 2021 Setting Preoperative virtual clinic Patients Patients greater than or equal to70 years undergoing major elective surgery Intervention A study investigator called eligible patients prior to surgery, obtained consent, and completed the preoperative cognitive assessment. Follow-up assessment was completed 1-month postoperatively, and participating clinicians were surveyed at the completion of the study. Measurements An attention test, T-MoCA, Activities of Daily Living (ADL), Instrumental Activities of Daily Living (IADL), and Generalized Anxiety Disorder 2-item (GAD-2) Main results Overall, 37/40 (92.5%) patients completed the pre- and post-operative assessments. The cohort was 50% female, white (97.5%), with a median age of 76 years (interquartile range (IQR) 73-79), and education level was higher than high school in 82.5% of patients. Preoperatively, the median number of medications was 8 (IQR 7-11), 27/40 (67.5%) had medications with anticholinergic effects, and 6/40 (15%) had benzodiazepines. Median completion time of the phone assessment was 10 min (IQR 8.25-12) and 4 min (IQR 3-5) for the T-MoCA with a median T-MoCA score of 13 (IQR 12-14). Most patients (37/40) completed the post-operative assessment, and 6/37 (16.2%) reported they had experienced a change in memory or attention post-operatively. Clinician's survey reported ease and feasibility in performing T-MoCA as a preoperative cognitive evaluation. Conclusion Preoperative cognitive assessment of older adults using T-MoCA over the phone is easy to perform by clinicians and had a high completion rate by patients. This test is feasible for virtual assessments. Further research is needed to better define validity and correlation with postoperative outcomes. Keywords: Preoperative medicine, Cognitive assessment, Virtual visits, Older adults, Elective surgery
Objectives: Little is known about the post-operative functional outcomes of severely frail femur fracture patients, with previous studies focusing on complications and mortality. This study ...investigated patient- or proxy-reported outcomes after femur fracture surgery in older adult patients with severe frailty. Methods: This was a retrospective cross-sectional study of older adult (>70 years) patients with severe frailty (defined by a Comprehensive Geriatric Assessment-based Frailty Index (FI-CGA) ≥ 0.40), who underwent femur fracture surgery at a Level 1 Trauma Center. Patients or their proxy (i.e., close relative) reported mobility, psychosocial, and functional outcomes at least 1-year after surgery. Results: Thirty-seven predominantly female (76%) patients with a median age of 85 years (IQR 79–92), and a median FI-CGA of 0.48 (IQR 0.43–0.54) were included. Eleven patients (30%) regained pre-fracture levels of ambulation, with twenty-six patients (70%) able to walk with or without assistance. The majority of patients (76%) were able to have meaningful conversations. Of the patients, 54% of them experienced no to minimal pain, while 8% still experienced a lot of pain. Functional independence varied, as follows: five patients (14%) could bathe themselves; nine patients (25%) could dress themselves; fourteen patients (39%) could toilet independently; and seventeen patients (47%) transferred out of a (wheel)chair independently. Conclusions: Despite the high risk of mortality and perioperative complications, many of the most severely frail patients with surgically treated femur fractures regain the ability to ambulate and live with a moderate degree of independence. This information can help healthcare providers to better inform these patients and their families of the role of surgical treatment during goals of care discussions.
Geriatric trauma continues to rise, corresponding with the continuing growth of the older population. These fractures continue to expand, demonstrated by the incidence of hip fractures having grown ...to 1.5 million adults worldwide per year. This patient population and their associated fracture patterns present unique challenges to the surgeon, as well as having a profound economic impact on the health care system. Pharmacologic treatment has focused on prevention, with aging adults having impaired fracture healing in addition to diminished bone mineral density. Intraoperatively, novel ideas to assess fracture reduction to facilitate decreased fracture collapse have recently been explored. Postoperatively, pharmacologic avenues have focused on future fracture prevention, while shared care models between geriatrics and orthopaedics have shown promise regarding decreasing mortality and length of stay. As geriatric trauma continues to grow, it is imperative that we look to optimize all phases of care, from preoperative to postoperative.
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