Baseline Frailty Research Articles

Frailty in Late Midlife to Old Age and Its Relationship to Medical Imaging Use and Imaging-related Costs: A Longitudinal Study.

Background Frailty, defined as an increased vulnerability to and impaired recovery from stressors, is common in individuals in late midlife to old age. While frailty predisposes individuals to adverse health outcomes and increased health care utilization, how it impacts imaging service use and related costs remains unclear. Purpose To determine whether frailty is associated with greater use of imaging services and higher imaging-related costs. Materials and Methods This longitudinal study included a subset of participants from the Helsinki Birth Cohort Study who were clinically assessed up to three times from late midlife to old age between August 2001 and September 2018. A frailty index (FI) based on 41 variables was calculated, and an FI of 0.25 or more indicated frailty. Associations of baseline frailty and its rate of change during the study with medical imaging service use and imaging-related costs were assessed using covariate-adjusted negative binomial and other generalized linear models. Results Of the 1995 participants (mean age, 61.5 years ± 2.9 [SD]; 1074 female participants) included in this study, 569 (28.5%) were identified as frail at baseline, and these participants underwent 10 677 (42.4%) of the 25 172 medical imaging examinations among the participants. Compared to participants who were not frail at baseline, participants who were frail at baseline showed increased use of all imaging modalities (incidence rate ratio [IRR], 2.28 [95% CI: 1.97, 2.64]; P < .001) and higher imaging costs (log annual cost, 3.26 [95% CI: 2.36, 4.50]; P < .001). Compared to participants with stable or slow change in frailty (<0.0010 FI units per year), participants with a rapid increase in frailty (>0.0064 FI units per year) from late midlife to old age showed greater use of all medical imaging services, independent of FI at baseline (IRR, 1.82 [95% CI: 1.53, 2.17]; P < .001) and had higher imaging costs (log annual cost, 1.62 [95% CI: 1.30, 2.01)]; P < .001). Conclusion The presence of frailty and its progression rate are associated with increased use of imaging services and higher imaging-related costs. © RSNA, 2023 Supplemental material is available for this article.

Does Case-Finding for Admission to Aged Care Rapid Investigation and Assessment Unit for Older Patients Improve Hospital Length of Stay? Evaluation of ARIA Unit.

Many older people present to emergency departments annually, often with complex geriatric syndromes, yet current acute care models and traditional admissions process may under-serve their needs. The multidisciplinary Aged Care Rapid Investigation and Assessment (ARIA) Unit seeks to bridge this gap, by actively identifying and assessing patients. A prospective case-control study was undertaken at a single-centre tertiary referral institution. Patients were eligible for inclusion in ARIA group if admitted to ARIA via case-finding by the geriatrician or Aged Care Services Emergency Team, whilst standard geriatric admissions formed the control group. This study evaluates whether ARIA reduced hospital length-of-stay (LOS) and representation rates. 370 patients were included (185 each arm) with similar baseline demographics, frailty scores, and Charlson Comorbidity Indices. Patients admitted to ARIA had significantly shorter hospital LOS than those via standard pathway (3.3 days [IQR2.2-5.8] vs 7.5 days [IQR4.2-13.7], p < 0.00001). There were no significant differences in 90-day representation rates (n = 66 [35.7%] vs n = 64 [34.6%], p = 0.82). Introduction of an ARIA unit with a targeted approach to frontline geriatric services and case-finding is associated with improved LOS of older acute hospital patients. An economical cost analysis of this study would be beneficial in exploring potential financial savings.

A prospective, observational study of frailty, quality of life and dialysis in older people with advanced chronic kidney disease

BackgroundFrailty is prevalent in older people with chronic kidney disease (CKD) and robust evidence supporting the benefit of dialysis in this setting is lacking. We aimed to measure frailty and quality of life (QOL) longitudinally in older people with advanced CKD and assess the impact of dialysis initiation on frailty, QOL and mortality.MethodsOutpatients aged ≥65 with an eGFR ≤ 20ml/minute/1.73m2 were enrolled in a prospective observational study and followed up four years later. Frailty status was measured using a Frailty Index (FI), and QOL was evaluated using the EuroQol 5D-5L instrument. Mortality and dialysis status were determined through inspection of electronic records.ResultsNinety-eight participants were enrolled. Between enrolment and follow-up, 36% of participants commenced dialysis and 59% died. Frailty prevalence increased from 47% at baseline to 86% at follow-up (change in median FI = 0.22, p < 0.001). Initiating dialysis was not significantly associated with change in FI. QOL declined from baseline to follow-up (mean EQ-5D-5L visual analogue score of 70 vs 63, p = 0.034), though commencing dialysis was associated with less decline in QOL. Each 0.1 increment in baseline FI was associated with 59% increased mortality hazard (HR = 1.59, 95%CI = 1.20 to 2.12, p = 0.001), and commencing dialysis was associated with 59% reduction in mortality hazard (HR = 0.41, 95%CI = 0.20 to 0.87, p = 0.020) irrespective of baseline FI.ConclusionsFrailty increased substantially over four years, and higher baseline frailty was associated with greater mortality. Commencing dialysis did not affect the trajectory of FI but positively influenced the trajectory of QOL from baseline to follow-up. Within the limitations of small sample size, our data suggests that frail participants received similar survival benefit from dialysis as non-frail participants.

Relating depression, anxiety, stress and loneliness to 5-year decline in physical function and frailty

ObjectivesWhile depression has been associated with physical function decline and worsening frailty in older adults, the impact of other mental health symptoms on physical function and frailty is unknown. The study objective was to determine whether depression, perceived stress, loneliness, and anxiety symptoms affect 5-year physical function and frailty trajectories of older adults. MethodsThe National Social Life, Health, and Aging Project (NSHAP) is a nationally-representative study of adults born between 1920 and 1947. The analysis included data collected in 2010–11 and 2015–16. Mental health symptoms were quantified using NSHAP's measures of anxiety (range:0–21), perceived stress (0–8), depression (0–22), and loneliness (0–6); higher scores indicated worse symptoms. We regressed 2015–16 3 m usual walk time, five-repeated chair stand time or an adapted frailty phenotype scale (0–4) separately on each 2010–11 mental health scale, adjusting for baseline physical function or frailty, demographics, and comorbidities. ResultsIn separate models, every one-point increase on the depression or perceived stress scales was associated with, respectively, a 0.06 s slower (95 % CI: 0.03, 0.10) or 0.09 s slower (95 % CI: 0.01, 0.16) 5-year walk time. Every one-point increase on the depression or perceived stress scales was associated with a 0.15 s slower (95 % CI: 0.06, 0.23) or 0.16 s slower (95 % CI: 0.02, 0.29) 5-year chair stand time. Every one-point increase on the depression scale predicted 0.06 higher log odds of having a worse frailty score 5 years later. Only depression's association with 3 m walk time and chair stands remained significant in models including all four mental health scales. DiscussionOlder adults with more depression and to a lesser extent stress symptoms may experience faster physical function decline and worsening frailty. Future work exploring and addressing the mechanisms underlying these relationships are warranted.

Association of geriatric measures and global frailty with cognitive decline after allogeneic hematopoietic cell transplantation in older adults

IntroductionAllogeneic hematopoietic cell transplantation (alloHCT) is increasingly offered to older adults, and its potential impact on cognition in this population is understudied. This work aims to evaluate the ability of cancer-specific geriatric assessments (cGA) and a global frailty index based on accumulation of deficits identified in the cGA to predict the risk of cognitive decline after alloHCT in older adults. Materials and MethodsAlloHCT recipients aged 50 years or older completed a cGA, including a cognitive evaluation by the Blessed Orientation Memory Concentration (BOMC) test, at baseline prior to alloHCT and then at 3, 6, and 12 months after transplant. Baseline frailty was assessed using a deficit accumulation frailty index (DAFI) calculated from the cGA. A multinomial logit model was used to examine the association between predictors (individual cGA measures, DAFI) and the following three outcomes: alive with stable or improved cognition, alive with cognitive decline, and deceased. In post-hoc analyses, analysis of variance was used to compare BOMC scores at baseline, 3, 6, and 12 months across frailty categories. ResultsIn total, 148 participants were included, with a median age of 62 (range 50–76). At baseline, 12% had cognitive impairment; at one year, 29% of survivors had improved BOMC scores, 33% had stable BOMC, and 37% had worse BOMC. Prior to transplant, 25% were pre-frail and 11% were frail. Individual baseline cGA measures were not associated with cognitive change at one year as assessed by BOMC. Adjusting for age, sex, and education, those who were frail at baseline were 7.4 times as likely to develop cognitive decline at one year than those who were non-frail, although this finding did not reach statistical significance (95% confidence interval [CI] 0.74–73.8, p = 0.09). The probability of being alive with stable/improved cognition at 12 months for the non-frail, pre-frail, and frail groups was 43%, 34%, and 8%, respectively. DiscussionBaseline geriatric measures and frailty were not significantly associated with cognitive change as assessed by BOMC in adults aged 50 or older after alloHCT. However, the study was underpowered to detect clinically meaningful differences, and future work to elucidate potential associations between frailty and cognitive outcomes is warranted.

Frailty and outcomes in heart failure patients from high-, middle- and low-Income countries.

There is little information on the incremental prognostic importance of frailty beyond conventional prognostic variables in heart failure (HF) populations from different country income levels. 3429 adults with HF (age 61±14 years, 33% women) from 27 high-, middle- and low-income countries were prospectively studied. Baseline frailty was evaluated by the Fried index, incorporating handgrip strength, gait speed, physical activity, unintended weight loss and self-reported exhaustion. Mean left ventricular ejection fraction was 39±14% and 26% had New York Heart Association (NYHA) class III/IV symptoms. Participants were followed for a median (25th-75th percentile) 3.1 (2.0-4.3) years. Cox proportional hazards models for death and HF hospitalization adjusted for country income level; age; sex; education; HF etiology; left ventricular ejection fraction; diabetes; tobacco and alcohol use; NYHA functional class; HF medication use; blood pressure; hemoglobin, sodium and creatinine concentrations were performed. The incremental discriminatory value of frailty over and above the MAGGIC risk score was evaluated by the area under the receiver-operating characteristic curve. At baseline, 18% of participants were robust, 61% pre-frail and 21% frail. During follow-up, 565 (16%) participants died and 471 (14%) were hospitalized for HF. Respective adjusted hazard ratios [HRs (95% CI)] for death among the prefrail and frail were 1.59 (1.12-2.26) and 2.92 (1.99-4.27). Respective adjusted HRs (95% CI) for HF hospitalization were 1.32 (0.93-1.87) and 1.97 (1.33-2.91). Findings were consistent among different country income levels and by most subgroups. Adding frailty to the MAGGIC risk score improved the discrimination of future death and HF hospitalization. Frailty confers substantial incremental prognostic information to prognostic variables for predicting death and HF hospitalization. The relationship between frailty and these outcomes is consistent across countries at all income levels.

Prevalence and Association of Frailty with Clinical Outcomes in Myeloproliferative Neoplasms: A Population-Based Study.

Clinical implications of frailty in myeloproliferative neoplasms (MPN)- essential thrombocythemia (ET), polycythemia vera (PV), myelofibrosis (MF) is unknown. In this population-based study, all incident cases of MPN from Ontario cancer registry between 2004-2019 (N=10,336, ET=5,108; PV=3,843; MF=1,385) and their matched controls (for age, sex, residence, income) in 1:4 ratio were included. Baseline frailty measured using Johns Hopkins Adjusted Clinical Groups frailty indicator and McIsaac's frailty index (mFI), categorized as fit, prefrail, or frail if mFI <0.10, 0.11-0.20, > 0.20) was significantly higher in ET, PV and MF compared to matched controls [standardized mean difference 0.27, 0.27 and 0.28]. Over 23%, 20% and 34% patients with ET, PV and MF were frail or prefrail despite younger age (<65 years) or minimal comorbidities. In Cox-proportional regression, frailty was independently associated with worse overall survival (OS) after adjusting for age, sex, comorbidities compared to mFI-fit patients: hazard ratio (95% CI) for OS for mFI-prefrail and mFI-frail patients were: 1.6 (1.3-1.9), and 3.6 (2.9-4.4) in ET; 1.3 (1.1-1.5) and 2.7 (2.1-3.4) in PV, and 1.2 (1.0-1.5) and 2.0 (1.5-2.7) in MF. MPN patients have substantially higher prevalence of frailty compared to matched controls which is associated with reduced OS, independent of age or comorbidities.

24. Adult cervical deformity patients have higher baseline frailty, disability, and comorbidities compared with complex adult thoracolumbar deformity patients: a comparative cohort study of 616 patients

24. Adult cervical deformity patients have higher baseline frailty, disability, and comorbidities compared with complex adult thoracolumbar deformity patients: a comparative cohort study of 616 patients

Sustained improvement of intrinsic capacity in community-dwelling older adults: The +AGIL Barcelona multidomain program.

Different programs promote healthy ageing through the optimization of intrinsic capacity. However, a major challenge is to assess their sustained effects over time. +AGIL Barcelona, a consolidated multidomain program, aims to optimize older adults' intrinsic capacity through a coordinated approach among primary care, geriatrics and community resources, in agreement with the integrated care for older people (ICOPE) guidelines. We aimed to evaluate the +AGIL Barcelona longitudinal effect on older adults' physical performance. All +AGIL Barcelona consecutive participants since 2016 were enrolled. After a comprehensive geriatric assessment, a tailored, multidisciplinary intervention aligned with the ICOPE guidelines is offered. It includes a 10-week boost multicomponent exercise program, nutritional and sleep-hygiene counselling, revision and optimization of pharmacological treatments and screening for cognitive impairment, depression and loneliness. Changes in physical performance after 3 and 6 months were assessed using mixed models including baseline frailty degree, time and all potential significant confounders. We included 194 participants in the analysis (mean age=81.6 [standard deviation=5.8], 68% women). An independent, clinically and statistically significant improvement in physical performance (Short Physical Performance Battery [SPPB] test, combining gait speed, strength and balance) was found at 3 months (SPPB mean change: 1.4; 95% CI: 1.1-1.6) and 6 months (SPPB mean change: 1.1; 95% CI 0.8-1.5). Equivalent results were observed for all the SPPB sub-tests. A coordinated, multidisciplinary and integrated program can benefit older adults' intrinsic capacity. The participants' empowerment and the connection with the available community resources are critical points for a successful intervention.

Frailty Is Common in Heart Transplant Candidates But Is Not Associated With Clinical Events and Is Reversible After Heart Transplantation

Assessment of frailty before heart transplant (HT) is recommended but is not standard in most HT protocols. Our objective was to evaluate frailty at inclusion in HT list and during follow-up and to assess the influence of baseline frailty on prognosis. A prospective multicenter study in all adults included in the nonurgent HT waiting list. Frailty was defined as Fried's frailty phenotype score ≥3. Mean follow-up was 25.9±1.2months. Of 99 patients (mean age 54.8 [43.1 to 62.5]years, 70 men [70.7%]), 28 were frail (28.3%). A total of 85 patients received HT after 0.5±0.01years. Waiting time was shorter in frail patients (0.6years [0.3 to 0.8] vs 0.2years [0.1 to 0.4], p=0.001) because of an increase in priority. Baseline frailty was not associated with overall mortality, (hazard ratio 0.99 [95% confidence interval 0.41 to 2.37, p=0.98]). A total of 16 transplant recipients died (18.8%). Of the remaining 69 HT recipients, 65 underwent frailty evaluation during follow-up. Patients without baseline frailty (n=49) did not develop it after HT. Of 16 patients with baseline frailty, only 2 were still frail at the end of follow-up. Frailty is common in HT candidates but is reversible in most cases after HT and is not associated with post-transplant mortality. Our results suggest that frailty should not be considered an exclusion criterion for HT.

Social interaction level modulates the impact of frailty on cognitive decline: a longitudinal study

Objectives This study evaluates whether social interaction level modifies the association between frailty and cognitive decline in older adults. Methods A total of 2701 adults aged ≥65 years enrolled in the Progetto Veneto Anziani (Pro.V.A.), participated in the study. At baseline, participants were classified as having low, moderate, or high social interactions based on: cohabiting status, frequency of contacts with relatives/friends or involvement in childcare activities, and frequency of participation in social or community activities. Baseline frailty was defined as the presence of ≥3 criteria among: weight loss, weakness, slowness, low physical activity, and exhaustion. Cognitive function was assessed through the Mini-Mental State Examination (MMSE) at baseline and after 4.4 and 7 years. The association between frailty and MMSE changes over time was evaluated through linear mixed models. Interaction and subgroup analyses explored the modifying effect of social interaction level on the above association. Results The mean age of participants was 76.1 years, and 59.1% were women. Frail individuals had a steeper annual MMSE decline than their non-frail counterparts (ß=-0.40, 95%CI: −0.59, −0.20). When stratifying participants by social interaction level, we found that the association between frailty and MMSE changes over time was stronger in those with low social interactions (ß=-0.74, 95%CI: −1.33, −0.15) while attenuated in those with moderate (ß=-0.42, 95%CI: −0.74, −0.11) or high social interaction level (ß=-0.29, 95%CI: −0.58, 0.01). Conclusion Maintaining frequent social interactions might mitigate the negative impact of frailty on older people’s cognitive functions.

Frailty Status Modifies the Efficacy of ICD Therapy for Primary Prevention Among Patients With HF

BackgroundImplantable cardioverter-defibrillator (ICD) therapy is recommended to reduce mortality risk in patients with heart failure with reduced ejection fraction (HFrEF). Frailty is common among patients with HFrEF and is associated with increased mortality risk. Whether the therapeutic efficacy of ICD is consistent among frail and nonfrail patients with HFrEF remains unclear. ObjectivesThe aim of this study was to evaluate the effect modification of baseline frailty burden on ICD efficacy for primary prevention among participants of the SCD-HeFT (Sudden Cardiac Death in Heart Failure Trial). MethodsParticipants in SCD-HeFT with HFrEF randomized to ICD vs placebo were included. Baseline frailty was estimated using the Rockwood Frailty Index (FI), and participants were stratified into high (FI > median) vs low (FI ≤ median) frailty burden groups. Multivariable Cox models with multiplicative interaction terms (frailty × treatment arm) were constructed to evaluate whether baseline frailty status modified the treatment effect of ICD for all-cause mortality. ResultsThe study included 1,676 participants (mean age: 59 ± 12 years, 23% women) with a median FI of 0.30 (IQR: 0.23-0.37) in the low frailty group and 0.54 (IQR: 0.47-0.60) in the high frailty group. In adjusted Cox models, baseline frailty status significantly modified the treatment effect of ICD therapy (Pinteraction = 0.047). In separate stratified analysis by frailty status, ICD therapy was associated with a lower risk of all-cause mortality among participants with low frailty burden (HR: 0.56; 95% CI: 0.40-0.78) but not among those with high frailty burden (HR: 0.86; 95% CI: 0.68-1.09). ConclusionsBaseline frailty modified the efficacy of ICD therapy with a significant mortality benefit observed among participants with HFrEF and a low frailty burden but not among those with a high frailty burden.

Should realignment goals vary based on patient frailty status in adult spinal deformity?

The objective of this study was to adjust the sagittal age-adjusted score (SAAS) to accommodate frailty in alignment considerations and thereby increase the predictability of clinical outcomes and junctional failure. Surgical adult spinal deformity (ASD) patients with 2-year data were included. Frailty was assessed with the continuous ASD modified frailty index (ASD-mFI). Two-year outcomes were proximal junctional kyphosis (PJK), proximal junctional failure (PJF), major mechanical complications, and best clinical outcome (BCO), defined as Oswestry Disability Index (ODI) score < 15 and Scoliosis Research Society outcomes questionnaire total score > 4.5 by 2 years. Linear regression analysis established a 6-week score based on the component scores of SAAS, frailty, and US normal values for ODI score. Logistic regression analysis followed by conditional inference tree run forest analysis generated categorical thresholds. Multivariate analysis, controlling for age, baseline deformity, and history of revision, was used to compare outcome rates, and logistic regression generated odds ratios for the continuous score. Thirty percent of the cohort was used as a random sample for internal validation. In total, 412 patients were included (mean ± SD age 60.1 ± 14.2 years, 80% female, BMI 26.9 ± 5.4 kg/m2). Baseline frailty categories were as follows: 57% not frail, 30% frail, and 14% severely frail. Overall, by 2 years, 39% of patients had developed PJK, 8% PJF, and 21% mechanical complications; 22% had undergone a reoperation; and 15% met BCO. When the cohort as a whole was assessed, the 6-week SAAS had a correlation with the development of PJK and PJF, but not mechanical complications, reoperation, or BCO. Development of mechanical complications, PJF, reoperation, and BCO demonstrated correlations with ASD-mFI (all p < 0.05). Regression analysis modifying SAAS on the basis of ODI norms and frailty generated the following equation: frailty-adjusted SAAS (FAS) = 0.108 × T1 pelvic angle + 0.162 × pelvic tilt - 0.39 × pelvic incidence - lumbar lordosis - 0.03 × ASD-mFI - 1.6771. With conditional inference tree analysis, thresholds were derived for FAS: aligned < 1.7, offset 1.7-2.2, and severely offset > 2.2. Significance between FAS categories was found for PJK, PJF, mechanical complications, reoperation, and BCO by 2 years. Binary logistic regression, controlling for baseline deformity and revision status, demonstrated significance between FAS and all 5 outcome variables (all p < 0.01). Internal validation saw each outcome variable maintain significance between categories, with even greater odds for PJF (OR 13.4, 95% CI 4.7-38.3, p < 0.001). Consideration of physiological age, in addition to chronological age, may be beneficial in the management of operative goals to maximize clinical outcomes while minimizing junctional failure. This combination enables the spine surgeon to fortify a surgical plan for even the most challenging patients undergoing ASD corrective surgery.

Post Hoc Analyses of a Randomized Controlled Trial for the Effect of Pharmacist Deprescribing Intervention on the Anticholinergic Burden in Frail Community-Dwelling Older Adults.

Anticholinergic burden is detrimental to cognitive health. Multiple studies found that a high anticholinergic burden is associated with an increased risk for dementia, changes to the brain structure, function, and cognitive decline. We performed a post hoc analysis of a randomized controlled deprescribing trial. We compared the effect of the intervention on baseline anticholinergic burden across the treatment and control groups and the time of recruitment before and after a lockdown due to the COVID pandemic with subgroup analyses by baseline frailty index. Randomized controlled trial. We analyzed data from a de-prescribing trial of older adults (>65years) previously conducted in New Zealand that was focused on reducing the Drug Burden Index (DBI). We used the anticholinergic cognitive burden (ACB) to quantify the impact of the intervention on reducing the anticholinergic burden. Participants not taking anticholinergics at the start of the trial were excluded. The primary outcome for this subgroup analysis was a change in ACB, measured with the ĝHedges statistic describing the difference in standard deviation units of this change between intervention and control. For this analysis, the trial participants were stratified into low, medium, and high frailty and timing into prior- and post-lockdown (public health measures for COVID-19). Among the 295 participants in this analysis, the median (IQR) age was 79 (74, 85), and 67% were women. For the primary outcome ĝHedges=-0.04 (95% CI-0.26 to 0.19) with a-0.23 mean reduction in ACB in the intervention arm and-0.19 in the control arm. Before lockdown ĝHedges=-0.38 (95% CI-0.84 to 0.04) and post-lockdown ĝHedges= 0.07 (95% CI-0.19 to 0.33). The mean change in ACB for each of the frailty strata was as follows: low frailty (-0.02; 95% CI-0.65 to 0.18); medium frailty (0.05; 95% CI-0.28 to 0.38); high frailty (0.08; 95% CI-0.40 to 0.56). The study did not provide evidence for the effect of pharmacist deprescribing intervention on reducing the anticholinergic burden. However, this post hoc analysis examined the impact of COVID on the effectiveness of the intervention, and further research in this area may be warranted.

Frailty and Colorectal Surgery: Review and Concept of Cancer Frailty.

Frailty is characterized by reduced physiological reserves across multiple systems. In patients with frailty, oncological surgery has been associated with a high rate of postoperative complications and worse overall survival. Further, given that cancer and frailty can co-exist in the same patient, cancer and cancer-related symptoms can rapidly accelerate the progression of baseline frailty, which we have termed "cancer frailty". This distinction is clinically meaningful because the prioritization of interventions and the treatment outcomes may differ based on health conditions. Specifically, in patients with cancer frailty, improvements in frailty may be achieved via surgical removal of tumors, while prehabilitation may be less effective, which may in turn result in delayed treatment and cancer progression. In this review, we focused on challenges in the surgical treatment of non-metastatic colorectal cancers in patients with frailty, including those related to decision making, prehabilitation, and surgery. Potential recommendations for treating patients with cancer frailty are also discussed.

Nutrition, frailty assessment, and interventions for the liver transplant candidate.

Nutrition, frailty assessment, and interventions for the liver transplant candidate.

Real-world data on incidence of frailty in cardiac surgical patients and its impact on quality of life: An observational feasibility study

Abstract Background: An improvement in quality of life (QOL) is increasingly being perceived as a quality indicator after surgical interventions, cardiac surgery being no exception. There is scarce literature on whether frailty alters this expected change in QOL. Objective: To assess the baseline frailty and QOL of cardiac surgical patients and the impact of frailty on the QOL patterns in the cardiac surgical population presenting to a tertiary care facility in south India. Materials and Methods: Prospective observational pilot study. Of the 60 patients recruited, 41 patients were assessed for baseline frailty and 37 for change in QOL 3 months after cardiac surgery. Frailty was assessed using the Fried frailty test. Baseline QOL and QOL after 3 months of surgery were calculated with the Short Form-36 questionnaire under its eight domains. Results: The median values of QOL among cardiac surgical patients are 50 and 66, respectively, for role limitation due to physical health and role limitation to emotional health, as against above 70 each in the community. Other domains of QOL were comparable with the general population. There is no change in QOL noted in the nonfrail 3 months after cardiac surgery. The frail showed an improvement in the domain of general health. Prefrail showed an improvement in domains of pain and general health but a decline in physical and emotional well-being after cardiac surgery. Conclusion: Though this is a pilot study and will be followed by a future larger study, it still does give the following clues: QOL scores in cardiac patients are lower than in the general population, and the frail benefit from cardiac surgery as it improves their QOL.

Are we improving in the optimization of surgery for high-risk adult cervical spine deformity patients over time?

The aim of this study was to investigate whether surgery for high-risk patients is being optimized over time and if poor outcomes are being minimized. Patients who underwent surgery for cervical deformity (CD) and were ≥ 18 years with baseline and 2-year data were stratified by year of surgery from 2013 to 2018. The cohort was divided into two groups based on when the surgery was performed. Patients in the early cohort underwent surgery between 2013 and 2015 and those in the recent cohort underwent surgery between 2016 and 2018. High-risk patients met at least 2 of the following criteria: 1) baseline C2-7 Cobb angle > 15°, mismatch between T1 slope and cervical lordosis ≥ 35°, C2-7 sagittal vertical axis > 4 cm, or chin-brow vertical angle > 25°; 2) age ≥ 70 years; 3) severe baseline frailty (Miller index); 4) Charlson Comorbidity Index (CCI) ≥ 1 SD above the mean; 5) three-column osteotomy as treatment; and 6) fusion > 10 levels or > 7 levels for elderly patients. The mean comparison analysis assessed differences between groups. Stepwise multivariable linear regression described associations between increasing year of surgery and complications. Eighty-two CD patients met high-risk criteria (mean age 62.11 ± 10.87 years, 63.7% female, mean BMI 29.70 ± 8.16 kg/m2, and mean CCI 1.07 ± 1.45). The proportion of high-risk patients increased with time, with 41.8% of patients in the early cohort classified as high risk compared with 47.6% of patients in the recent cohort (p > 0.05). Recent high-risk patients were more likely to be female (p = 0.008), have a lower BMI (p = 0.038), and have a higher baseline CCI (p = 0.013). Surgically, high-risk patients in the recent cohort were more likely to undergo low-grade osteotomy (p = 0.003). By postoperative complications, recent high-risk patients were less likely to experience any postoperative adverse events overall (p = 0.020) or complications such as dysphagia (p = 0.045) at 2 years. Regression analysis revealed increasing year of surgery to be correlated with decreasing minor complication rates (p = 0.030), as well as lowered rates of distal junctional kyphosis by 2 years (p = 0.048). Over time, high-risk CD patients have an increase in frequency and comorbidity rates but have demonstrated improved postoperative outcomes. These findings suggest that spine surgeons have improved over time in optimizing selection and reducing potential adverse events in high-risk patients.

Baseline frailty status, not advanced patient age, predicts epilepsy surgery outcomes: An analysis of 696 patients from the NSQIP database

ObjectivePreoperative risk stratification of patients undergoing epilepsy surgery remains challenging. Recently, the efforts to look beyond age alone as an outcomes predictor has resulted in the development of measures of physiological reserve, or ‘frailty indices.’ The most frequently cited index in neurosurgery is the 11-item or 5-item modified frailty index (mFI11 or mFI-5). The present study aimed to use a large national registry to evaluate the effect of frailty (as measured by mFI-5 versus age on postoperative outcomes of patients undergoing epilepsy surgery. MethodsThe National Surgical Quality Improvement Program (NSQIP) database, overseen by the American College of Surgeons (ACS), was used to extract data for patients undergoing epilepsy surgery from 2015 to 2019. Univariate and multivariate analyses for age and mFI-5 were performed for the following 30-day outcomes of extended length of hospital stay (eLOS) and non-home discharge (NHD). The effect sizes were summarized by odds ratio and associated 95 % confidence intervals. Receiver operating characteristic (ROC) curve analysis, including area under the curve (AUC), was used to quantify the discrimination. ResultsUnivariate and multivariate analyses demonstrated that frailty statuses from mFI-5, not age, were significantly predictive of eLOS and NHD. On ROC curve analysis, mFI-5 was a stronger predictor of eLOS (C = 0.59, 95 % CI 0.54–0.64, p < 0.001) and NHD (C = 0.69, 95 % CI 0.64–0.76, p < 0.001) than age (C = 0.53, 95 % CI 0.48–0.58, p = 0.21 and C = 0.53, 95 % CI 0.46–0.59, p = 0.44, respectively). ConclusionFrailty, not age, is an independent risk factor for poor postoperative outcomes, particularly eLOS and NHD, in patients undergoing epilepsy surgery. Usage of mFI-5 for preoperative risk stratification of epilepsy surgery patients can help in prognostication.

Overlapping status of frailty and fear of falling: an elevated risk of incident disability in community-dwelling older adults.

Although overlapping frailty and fear of falling (FoF) are likely to increase with population aging, the combined effect of frailty and FoF on incident disability is not yet well understood. The purpose of this study is to examine whether frailty combined with FoF increased the risk of incident disability in older adults. Our secondary purpose was to clarify the synergistic effect of frailty and FoF on incident disability. This is a prospective study. Participants were 9372 older adults (mean age 73.5years). Frailty status was assessed using the Japanese Cardiovascular Health Study index, and FoF was measured using two closed questions. Incident disability was prospectively monitored by their long-term care insurance records. During the follow-up period (mean duration 23.4months), 487 (5.2%) participants developed disability. The proportion of incident disability linearly increased according to FoF level regardless of baseline frailty status. Frail participants with FoF had a higher risk of incident disability than those with frailty only or neither (adjusted hazard ratio [HR] 2.63, 95% confidence interval [CI] 1.95-3.54). Frailty in combination with excessive FoF further increased the risk of incident disability (adjusted HR 4.30, 95% CI 2.56-7.23) although no synergistic effect was observed (relative excessive risk due to interaction 1.69, 95% CI - 0.55, 3.93). The overlapping status of frailty and FoF, especially excessive FoF, increases the risk of incident disability in older adults.