Aging Frailty Research Articles

Use of the modified frailty index to predict 30-day morbidity and mortality from spine surgery.

OBJECTIVE Limited tools exist to stratify perioperative risk in patients undergoing spinal procedures. The modified frailty index (mFI) based on the Canadian Study of Health and Aging Frailty Index (CSHA-FI), constructed from standard demographic variables, has been applied to various other surgical populations for risk stratification. The authors hypothesized that it would be predictive of postoperative morbidity and mortality in patients undergoing spine surgery. METHODS The 2006-2010 National Surgical Quality Improvement Program (NSQIP) data set was accessed for patients undergoing spine surgeries based on Current Procedural Terminology (CPT) codes. Sixteen preoperative clinical NSQIP variables were matched to 11 CSHA-FI variables (changes in daily activities, gastrointestinal problems, respiratory problems, clouding or delirium, hypertension, coronary artery and peripheral vascular disease, congestive heart failure, and so on). The outcomes assessed were 30-day occurrences of adverse events. These were then summarized in groups: any infection, wound-related complication, Clavien IV complications (life-threatening, requiring ICU admission), and mortality. RESULTS A total of 18,294 patients were identified. In 8.1% of patients with an mFI of 0 there was at least one morbid complication, compared with 24.3% of patients with an mFI of ≥ 0.27 (p < 0.001). An mFI of 0 was associated with a mortality rate of 0.1%, compared with 2.3% for an mFI of ≥ 0.27 (p < 0.001). Patients with an mFI of 0 had a 1.7% rate of surgical site infections and a 0.8% rate of Clavien IV complications, whereas patients with an mFI of ≥ 0.27 had rates of 4.1% and 7.1% for surgical site infections and Clavien IV complications, respectively (p < 0.001 for both). Multivariate analysis showed that the preoperative mFI and American Society of Anesthesiologists classification of ≥ III had a significantly increased risk of leading to Clavien IV complications and death. CONCLUSIONS A higher mFI was associated with a higher risk of postoperative morbidity and mortality, providing an additional tool to improve perioperative risk stratification.

Rationale and design of the allogeneiC human mesenchymal stem cells (hMSC) in patients with aging fRAilTy via intravenoUS delivery (CRATUS) study: A phase I/II, randomized, blinded and placebo controlled trial to evaluate the safety and potential efficacy of allogeneic human mesenchymal stem cell infusion in patients with aging frailty

Frailty is a syndrome associated with reduced physiological reserves that increases an individual's vulnerability for developing increased morbidity and/or mortality. While most clinical trials have focused on exercise, nutrition, pharmacologic agents, or a multifactorial approach for the prevention and attenuation of frailty, none have studied the use of cell-based therapies. We hypothesize that the application of allogeneic human mesenchymal stem cells (allo-hMSCs) as a therapeutic agent for individuals with frailty is safe and efficacious. The CRATUS trial comprises an initial non-blinded phase I study, followed by a blinded, randomized phase I/II study (with an optional follow-up phase) that will address the safety and pre-specified beneficial effects in patients with the aging frailty syndrome. In the initial phase I protocol, allo-hMSCs will be administered in escalating doses via peripheral intravenous infusion (n=15) to patients allocated to three treatment groups: Group 1 (n=5, 20 million allo-hMSCs), Group 2 (n=5, 100 million allo-hMSCs), and Group 3 (n=5, 200 million allo-hMSCs). Subsequently, in the randomized phase, allo-hMSCs or matched placebo will be administered to patients (n=30) randomly allocated in a 1:1:1 ratio to one of two doses of MSCs versus placebo: Group A (n=10, 100 million allo-hMSCs), Group B (n=10, 200 million allo-hMSCs), and Group C (n=10, placebo). Primary and secondary objectives are, respectively, to demonstrate the safety and efficacy of allo-hMSCs administered in frail older individuals. This study will determine the safety of intravenous infusion of stem cells and compare phenotypic outcomes in patients with aging frailty.

Frailty as a marker of adverse outcomes in patients with bladder cancer undergoing radical cystectomy

ObjectiveTo investigate the modified frailty index (mFI) as a preoperative predictor of postoperative complications following radical cystectomy (RC) in patients with bladder cancer. Materials and methodsPatients undergoing RC were identified from the National Surgical Quality Improvement Program participant use files (2011–2013). The mFI was defined in prior studies with 11 variables based on mapping the Canadian Study of Health and Aging Frailty Index to the National Surgical Quality Improvement Program comorbidities and activities of daily livings. The mFI groups were determined by the number of risk factors per patient (0, 1, 2, and≥3). Univariable and multivariable regression were performed to determine predictors of Clavien 4 and 5 complications, and a sensitivity analysis was performed to determine the mFI value that would be a significant predictor of Clavien 4 and 5 complications. ResultsOf the 2,679 cystectomy patients identified, 843 (31%) of patients had an mFI of 0, 1176 (44%) had an mFI of 1, 555 (21%) had an mFI of 2, and 105 (4%) had an mFI≥3. Overall, 1585 (59%) of patients experienced a Clavien complication. When stratified at a cutoff of mFI≥2, the overall complication rate was not different (61.7% vs. 58.3%, P = 0.1), but the mFI2 or greater group had a significantly higher rate of Clavien grade 4 or 5 complications (14.6% vs. 8.3%, P<0.001) and overall mortality rate (3.5% vs. 1.8%, P = 0.01) in the 30-day postoperative period. The multivariate logistic regression model showed independent predictors of Clavien grade 4 or 5 complications were age>80 years (odds ratio [OR] = 1.58 [1.11–2.27]), mFI2 (OR = 1.84 [1.28–2.64]), and mFI3 (OR = 2.58 [1.47–4.55]). ConclusionsAmong patients undergoing RC, the mFI can identify those patients at greatest risk for severe complications and mortality. Given that bladder cancer is increasing in prevalence particularly among the elderly, preoperative risk stratification is crucial to inform decision-making about surgical candidacy.

Association of Self-Rated Health in Midlife With Mortality and Old Age Frailty: A 26-Year Follow-Up of Initially Healthy Men

The aim was to investigate the relationship between self-rated health (SRH) in healthy midlife, mortality, and frailty in old age. In 1974, male volunteers for a primary prevention trial in the Helsinki Businessmen Study (mean age 47 years, n = 1,753) reported SRH using a five-step scale (1 = "very good," n = 124; 2 = "fairly good," n = 862; 3 = "average," n = 706; 4 = "fairly poor," or 5 = "very poor"; in the analyses, 4 and 5 were combined as "poor", n = 61). In 2000 (mean age 73 years), the survivors were assessed using a questionnaire including the RAND-36/SF-36 health-related quality of life instrument. Simplified self-reported criteria were used to define phenotypic prefrailty and frailty. Mortality was retrieved from national registers. During the 26-year follow-up, 410 men had died. Frailty status was assessed in 81.0% (n = 1,088) of survivors: 434 (39.9%), 552 (50.7%), and 102 (9.4%) were classified as not frail, prefrail, and frail, respectively. With fairly good SRH as reference, and adjusted for cardiovascular risk in midlife and comorbidity in old age, midlife SRH was related to mortality in a J-shaped fashion: significant increase with both very good and poor SRH. In similar analyses, average SRH in midlife (n = 425) was related to prefrailty (odds ratio: 1.52, 95% confidence interval: 1.14-2.04) and poor SRH (n = 31) both to prefrailty (odds ratio: 3.56, 95% confidence interval: 1.16-10.9) and frailty (odds ratio: 8.38, 95% confidence interval: 2.32-30.3) in old age. SRH in clinically healthy midlife among volunteers of a primary prevention trial was related to the development of both prefrailty and frailty in old age, independent of baseline cardiovascular risk and later comorbidity.

Frailty and Potential Biomarkers in Aging

Frailty is an age-related syndrome that has been well-described in the last ten years. It can be characterized by diminished strength, endurance, and reduced physiologic function. With multiple causes and contributors, frailty is highly correlated with functional decline and chronic diseases. Currently, there are no standardized tests or biomarkers that can be used to identify frail patients, though there have been a number of assessments used in research such as the Fried Frailty Phenotype or the Rockwood Frailty Index. Identification of biomarkers for frailty is a major consideration for future studies of this syndrome.

The Association between High Neuroticism-Low Extraversion and Dual-Task Performance during Walking While Talking in Non-demented Older Adults.

The Walking While Talking (WWT) dual-task paradigm is a mobility stress test that predicts major outcomes, including falls, frailty, disability, and mortality in aging. Certain personality traits, such as neuroticism, extraversion, and their combination, have been linked to both cognitive and motor outcomes. We examined whether individual differences in personality dimensions of neuroticism and extraversion predicted dual-task performance decrements (both motor and cognitive) on a WWT task in non-demented older adults. We hypothesized that the combined effect of high neuroticism-low extraversion would be related to greater dual-task costs in gait velocity and cognitive performance in non-demented older adults. Participants (N=295; age range,=65-95 years; female=164) completed the Big Five Inventory and WWT task involving concurrent gait and a serial 7's subtraction task. Gait velocity was obtained using an instrumented walkway. The high neuroticism-low extraversion group incurred greater dual-task costs (i.e., worse performance) in both gait velocity {95% confidence interval (CI) [-17.68 to -3.07]} and cognitive performance (95% CI [-19.34 to -2.44]) compared to the low neuroticism-high extraversion group, suggesting that high neuroticism-low extraversion interferes with the allocation of attentional resources to competing task demands during the WWT task. Older individuals with high neuroticism-low extraversion may be at higher risk for falls, mobility decline and other adverse outcomes in aging.

Building neuroscientific evidence and creating best practices for Active and Healthy Aging through ubiquitous exergaming and Living Labs.

Ageing is a major global demographic trend, which seems to be intensified. The earlier detection of risks associated with ageing, can enable earlier intervention to ameliorate their negative consequences. Many of these recent efforts are associated with the use of Information and Communication Technologies (ICTs) and the stemming from them innovations in the fight against this age related decline and frailty. Ubiquitous unobtrusive monitoring and training (recently much blended by means of exergames) has become reality due to the availability of new mobile sensors and devices and the emergence of new technologies and services. The current piece of work presents the different milestones we have achieved as best practices during the past seven years of piloting training and exergaming ICT components in an effort to support Active and Healthy Aging. Our impact verification and results validation methodologies are revisited here in an effort to outline best practices and build up neuroscientific evidence. Finally, this paper demonstrates how the construction of an Active and Healthy Aging Living Lab was materialised in an attempt to gauge evidence based research in the field of active and health aging.

Validation of a frailty index in patients undergoing curative surgery for urologic malignancy and comparison with other risk stratification tools

ObjectiveTo retrospectively validate and compare a modified frailty index predicting adverse outcomes and other risk stratification tools among patients undergoing urologic oncological surgeries. Materials and MethodsThe American College of Surgeons National Surgical Quality Improvement Program was queried from 2005 to 2013 to identify patients undergoing cystectomy, prostatectomy, nephrectomy, and nephroureterectomy. Using the Canadian Study of Health and Aging Frailty Index, 11 variables were matched to the database; 4 were also added because of their relevance in oncology patients. The incidence of mortality, Clavien-Dindo IV complications, and adverse events were assessed with patients grouped according to their modified frailty index score. ResultsWe identified 41,681 patients who were undergoing surgery for presumed urologic malignancy. Patients with a high frailty index score of >0.20 had a 3.70 odds of a Clavien-Dindo IV event (CI: 2.865–4.788, P<0.0005) and a 5.95 odds of 30-day mortality (CI: 3.72–9.51, P<0.0005) in comparison with nonfrail patients after adjusting for race, sex, age, smoking history, and procedure. Using C-statistics to compare the sensitivity and specificity of the predictive ability of different models per risk stratification tool and the Akaike information criteria to assess for the fit of the models with the data, the modified frailty index was comparable or superior to the Charlson comorbidity index but inferior to the American Society of Anesthesiologists Risk Class in predicting 30-day mortality or Clavien-Dindo IV events. When the modified frailty index was augmented with the American Society of Anesthesiologists Risk Class, the new index was superior in all aspects in comparison to other risk stratification tools. ConclusionExisting risk stratification tools may be improved by incorporating variables in our 15-point modified frailty index as well as other factors such as walking speed, exhaustion, and sarcopenia to fully assess frailty. This is relevant in diseases such as kidney and prostate cancer, where surveillance and other nonsurgical interventions exist as alternatives to a potentially complicated surgery. In these scenarios, our modified frailty index augmented by the American Society of Anesthesiologists Risk Class may help inform which patients have increased surgical complications that may outweigh the benefit of surgery although this index needs prospective validation.

MP14-03 SIMPLIFIED FRAILTY INDEX PREDICTS ADVERSE SURGICAL OUTCOMES AND INCREASED LENGTH OF STAY IN RADICAL PROSTATECTOMY PATIENTS: AN ANALYSIS OF THE ACS-NSQIP DATABASE

You have accessJournal of UrologyProstate Cancer: Epidemiology & Natural History III1 Apr 2015MP14-03 SIMPLIFIED FRAILTY INDEX PREDICTS ADVERSE SURGICAL OUTCOMES AND INCREASED LENGTH OF STAY IN RADICAL PROSTATECTOMY PATIENTS: AN ANALYSIS OF THE ACS-NSQIP DATABASE Danny Lascano, Jamie S. Pak, Alexander C. Small, Mark V. Silva, James M. McKiernan, G. Joel DeCastro, Sven Wenske, and Mitchell C. Benson Danny LascanoDanny Lascano More articles by this author , Jamie S. PakJamie S. Pak More articles by this author , Alexander C. SmallAlexander C. Small More articles by this author , Mark V. SilvaMark V. Silva More articles by this author , James M. McKiernanJames M. McKiernan More articles by this author , G. Joel DeCastroG. Joel DeCastro More articles by this author , Sven WenskeSven Wenske More articles by this author , and Mitchell C. BensonMitchell C. Benson More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2015.02.865AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES Frailty is usually assessed in a non-standardized manner with descriptions of patients such as appearing “older than stated age”. Currently, no suitable measure exists to qualify this parameter, despite its potentially large impact on surgical outcomes. Therefore, a modified frailty index (FI) was applied to the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) data to evaluate whether it predicts adverse post-surgical outcomes. METHODS The ACS-NSQIP Participant Utilization File was queried for the years 2005–2012 for inpatient radical prostatectomy (RP) patients (n=16848). Employing the Canadian Study of Health and Aging frailty index, 11 variables were matched to NSQIP to create a modified frailty index (FI) using including diabetes mellitus, functional status, CHF, MI, prior cardiac surgery, hypertension, peripheral vascular disease, impaired sensorium, and TIA or CVA with neurological sequela. Four variables specific to cancer were also including: chemotherapy or radiation, weight loss, renal failure, and metastasis. Outcomes assessed included 30-day mortality, surgical site infection (SSI), MI, DVT/PE, Clavien IV complications, length of stay (LOS), and combined adverse events. Chi-square analysis was used for comparing categorical variables, Kruskal-Wallis for non-parametric continuous variables, and logistic regression for comparing different clinical tests. RESULTS Increasing FI was significantly associated with Clavien IV complications, number of SSI and all combined adverse events (p<0.05 for all). A Kruskal-Wallis H test demonstrated a statistically significant difference in LOS between those with different FI (χ2 = 88.02, p<0.01) with a mean rank of 3, 4, 6, 5, 2 and 1 day(s) for FI of 1, 2, 3, 4, 5 and 6 respectively. Multivariate analysis indicated that FI was significantly correlated with Clavien IV complications (OR 1.368, p< 0.01), MI (OR 2.745, p < 0.01), and adverse events including SSI, UTIs and DVT/PE (OR 1.371, p <0.01). CONCLUSIONS Using a large national database, a modified frailty index was shown to significantly correlate with 30-day morbidity and length of stay after RP but not with mortality. This simple tool may be useful for both risk assessment and surgical planning, especially in elderly patients with multiple comorbidities. © 2015 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 193Issue 4SApril 2015Page: e151-e152 Peer Review Report Advertisement Copyright & Permissions© 2015 by American Urological Association Education and Research, Inc.MetricsAuthor Information Danny Lascano More articles by this author Jamie S. Pak More articles by this author Alexander C. Small More articles by this author Mark V. Silva More articles by this author James M. McKiernan More articles by this author G. Joel DeCastro More articles by this author Sven Wenske More articles by this author Mitchell C. Benson More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

Frailty as a marker of adverse outcomes during cystectomy for urothelial cancer.

374 Background: Frailty has been identified as a marker of physiologic reserve, and a more accurate predictor of adverse postoperative outcomes compared with age. Although many definitions of frailty exist, recently a clinical predictive rule, the “modified frailty index”(mFI), has been developed utilizing administrative data to predict adverse outcomes in the lung cancer population undergoing lobectomy. Our goal was to validate this clinical rule among patients with bladder cancer undergoing cystectomy. Methods: Patients undergoing cystectomy were identified from the National Surgical Quality Improvement Program (NSQIP) participant use files (2006-2011). The mFI was defined as in prior studies with 11 variables based on mapping the Canadian Study of Health and Aging Frailty Index to NSQIP comorbidities and activities of daily living (ADL)s. These 11 variables each received 1 point, and the sum was divided by 11 for a fraction between 0 and 1. Univariate χ2, independent sample t-test, and logistic regression analyses were performed where appropriate. Results: Of the 1,302 cystectomy patients identified, 30% had mFI of 0, 40% had mFI of 0.09, 21% had mFI of 0.18, and 9% had mFI ≥0.27. Overall, 56% of patients experienced a Clavien complication. Patients with mFI ≥0.27 were older ( 72 vs 64 yrs)and more likely to be smokers (54%) compared with mFI of 0 (30%, p&lt;0.01). Mean operative times (342-349 minutes) were similar across mFI indices. Reoperation (5% vs 8.5%) and readmission (20.5% vs 25%) were higher when mFI =0 compared with mFI≥0.27 (P&lt;0.01). Clavien 4 and above complications occurred in 9.1% (36/396), 10.1% (53/526), 12.9 % (35/270) and 13.6% (15/110) among patients with an mFI of 0, 0.09, 0.18, and ≥0.27, respectively (p=0.05). Similarly, the overall mortality rate increased from 2.5% in the lowest frailty index group to 5.4% in the highest. Conclusions: Among patients undergoing cystectomy, the modified frailty index can identify those patients at greater risk for severe complications, readmissions, and mortality. Given that bladder cancer is increasing in prevalence particularly among the elderly, pre-operative risk stratification is crucial to inform decision-making.

Income as a Determinants for Old Age Institutional Care in Finland

Aim and Motivation: This paper investigates the income and socio-economic effects on institutional long-term care demand (LTC) in Finland from an economics perspective. If lessons are learned from major contributors of care needs and costs then preventative measures can be designed to answer these challenges. The motivation for this paper is that LTC costs are expected to increase in Finland by 50 percent per annum in the next 25 years due to the doubling of the 65 years old population (by 2039). Aging of populations and workforce is a European wide phenomenon. Definitions: LTC for old age people is by definition care for chronic sickness and disability in the last years of life. It can be either formal or informal care (or both) delivered to a homelike environment (home care) or given at an institution (institutional care).Methods: The economics of LTC care are reviewed based on existing literature. Next the econometric and institutional context is described. A longitudinal competing risks and multinomial logit model are estimated. The two competing risks are institutional entry or death outside institution. Data: Finnish Health2000 individual level survey data from year 2000 linked with a day-by-day care register follow-up till end of 2010. The sample consists of N=3245 over 50 year old age population.Results: It is found that higher household (OECD) and personal income reduce demand for institutional LTC care controlling for health, functional capacity and key living habits. The difference between extreme income quintiles (lowest vs. highest) is 1,3 percent for men and 0,6 percent for women. This result suggests that institutional care may include disutility from a consumer preferences point of view. The highest risks of institutional LTC care are found among small income, single living and cognitively disabled highly aged people (over 80, 90 years old). Neurological diseases and cancer are the biggest risk factors of institutional entry. For deaths outside institution the biggest risks are dementia and cancer. ADL problems and old age frailty contribute to both competing risks.Policy conclusions: There are significant socio-economic inequalities in institutional LTC care entry. Prevention of neurological and living habits diseases (smoking, weight disorders) has potential for cost savings in institutional care services.

Association of a Modified Frailty Index With Mortality After Femoral Neck Fracture in Patients Aged 60 Years and Older

Frailty, a multidimensional syndrome entailing loss of energy, physical ability, cognition, and health, plays a significant role in elderly morbidity and mortality. No study has examined frailty in relation to mortality after femoral neck fractures in elderly patients. We examined the association of a modified frailty index abbreviated from the Canadian Study of Health and Aging Frailty Index to 1- and 2-year mortality rates after a femoral neck fracture. Specifically we examined: (1) Is there an association of a modified frailty index with 1- and 2-year mortality rates in patients aged 60 years and older who sustain a low-energy femoral neck fracture? (2) Do the receiver operating characteristic (ROC) curves indicate that the modified frailty index can be a potential tool predictive of mortality and does a specific modified frailty index value demonstrate increased odds ratio for mortality? (3) Do any of the individual clinical deficits comprising the modified frailty index independently associate with mortality? We retrospectively reviewed 697 low-energy femoral neck fractures in patients aged 60 years and older at our Level I trauma center from 2005 to 2009. A total of 218 (31%) patients with high-energy or pathologic fracture, postoperative complication including infection or revision surgery, fracture of the contralateral hip, or missing documented mobility status were excluded. The remaining 481 patients, with a mean age of 81.2 years, were included. Mortality data were obtained from a state vital statistics department using date of birth and Social Security numbers. Statistical analysis included unequal variance t-test, Pearson correlation of age and frailty, ROC curves and area under the curve, Hosmer-Lemeshow statistics, and logistic regression models. One-year mortality analysis found the mean modified frailty index was higher in patients who died (4.6 ± 1.8) than in those who lived (3.0 ± 2; p < 0.001), which was maintained in a 2-year mortality analysis (4.4 ± 1.8 versus 3.0 ± 2; p < 0.001). In ROC analysis, the area under the curve was 0.74 and 0.72 for 1- and 2-year mortality, respectively. Patients with a modified frailty index of 4 or greater had an odds ratio of 4.97 for 1-year mortality and an odds ratio of 4.01 for 2-year mortality as compared with patients with less than 4. Logistic regression models demonstrated that the clinical deficits of mobility, respiratory, renal, malignancy, thyroid, and impaired cognition were independently associated with 1- and 2-year mortality. Patients aged 60 years and older sustaining a femoral neck fracture, with a higher modified frailty index, had increased 1- and 2-year mortality rates, and the ROC analysis suggests that this tool may be predictive of mortality. Patients with a modified frailty index of 4 or greater have increased risk for mortality at 1 and 2 years. Clinical deficits of mobility, respiratory, renal, malignancy, thyroid, and impaired cognition also may be independently associated with mortality. The modified frailty index may be a useful tool in predicting mortality, guiding patient and family expectations and elucidating implant/surgery choices. Further prospective studies are necessary to strengthen the predictive power of the index. Level IV, prognostic study. See Instructions for Authors for a complete description of levels of evidence.

Simplified Frailty Index to Predict Adverse Outcomes and Mortality in Vascular Surgery Patients

Frailty has been established as an important predictor of health-care outcomes. We hypothesized that the use of a modified frailty index would be a predictor of mortality and adverse occurrences in vascular surgery patients. Under the data use agreement of the American College of Surgeons, and with institutional review board (IRB) approval, the National Surgical Quality Improvement Program (NSQIP) Participant Utilization File was accessed for the years 2005-2008 for inpatient vascular surgery patients. Using the Canadian Study of Health and Aging Frailty Index (FI), 11 variables were matched to the NSQIP database. An increase in FI implies increased frailty. The outcomes assessed were mortality, wound infection, and any occurrence. We then compared the effect of FI, age, functional status, relative value units (RVU), American Society of Anesthesiology (ASA) score, and wound status on mortality. Statistical analysis was done using chi-square analysis and stepwise logistic regression. A total of 67,308 patients were identified in the database, 3913 wound occurrences, 6691 infections, 12,847 occurrences of all kinds, and 2800 deaths. As the FI increased, postoperative wound infection, all occurrences, and mortality increased (P < 0.001). Stepwise logistic regression using the FI with the NSQIP variables of age, work RVU, ASA class, wound classification, emergency status, and functional status showed FI to have the highest odds ratio (OR) for mortality (OR = 2.058, P < 0.001). A simplified FI can be obtained by easily identifiable patient characteristics, allowing for accurate prediction of postoperative morbidity and mortality in the vascular surgery population.

Leisure-Time Physical Activity in Midlife Is Related to Old Age Frailty

There are scarce studies of the long-term associations between leisure-time physical activity (LTPA) in midlife and phenotypic frailty in old age. We studied healthy Caucasian men of high socioeconomic status (N = 514), who had participated in health checkups during the 1960s (the Helsinki Businessmen Study, Finland). In 1974, they were examined with questionnaires and clinical examinations, and LTPA was collapsed into three categories: low (n = 87), moderate (n = 256), and high (n = 171). In 2000, at mean age of 74, survivors were assessed for physical activity and frailty phenotype using the modified Fried criteria validated in our cohort. Four criteria were used: (a) weight loss > 5% from midlife or current body mass index < 21kg/m(2), (b) physical inactivity, (c) low vitality, and (d) physical weakness. Responders with 3-4, 1-2, and zero criteria were classified as frail, prefrail, and nonfrail, respectively. The prevalence of frailty was 16.1%, 10.2%, and 4.7% in the low, moderate, and high LTPA groups, respectively. Higher midlife LTPA was significantly related to lower prevalence of both frailty and prefrailty in old age. After adjusting for baseline age, smoking, body mass index, blood pressure, and alcohol, the risk of frailty was 80% lower in the high LTPA group compared with the low LTPA group (odds ratio = 0.20; 95% confidence interval 0.07-0.55). This finding was supported by the relationships between the change of physical activity and frailty in old age. In this socioeconomically homogenous male cohort, higher physical activity since midlife was strongly associated with less frailty in old age.

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A modified frailty index to assess morbidity and mortality after lobectomy

BackgroundFrailty has yet to be explored as a risk factor for thoracic surgery. We hypothesized that our modified frailty index (mFI) may be a predictor of morbidity and mortality following lobectomy. MaterialsNational Surgical Quality Improvement Program (NSQIP) participant use files were reviewed (2005–2010). Patients undergoing lobectomy were identified based on Current Procedural Terminology code 32480. We used an mFI with 11 variables, based on mapping the Canadian Study of Health and Aging Frailty Index to the NSQIP comorbidities. Data were analyzed using χ2 test, independent sample t-test, Jonckheere-Terpstra test, and logistic regression. ResultsOf 1940 open lobectomy patients identified, morbidity and mortality uniformly increased as the mFI increased; 14.9% of patients (75/504) with mFI of 0 had at least one complication, compared with 32% of patients (91/284) with mFI of 0.27 (P < 0.001). An mFI of 0 was associated with a mortality rate of 1% (5/504), compared with 5.6% (16/284) for mFI of 0.27 (P < 0001). Failure to wean from the ventilator, reintubation, surgical site infections, pneumonia, and Clavien 4 and above complications occurred in 1.8% (9/504), 2.6% (13/504), 2.2% (11/504), 5.4% (27/504), and 4.2% (21/504), respectively, in patients with an mFI of 0, compared with 7.4% (21/284), 7% (22/284), 3.2% (9/284), 10.9% (31/284), and 14.4% (41/284), respectively, in patients with mFI of 0.27. ConclusionsThis study demonstrates that the mFI may identify patients at higher risk for morbidity and mortality post-lobectomy. With the aging population, preoperative selection is important in minimizing morbidity and mortality and improving risk stratification for informed decision-making.

Are the frail destined to fail? Frailty index as predictor of surgical morbidity and mortality in the elderly

America's aging population has led to an increase in the number of elderly patients necessitating emergency general surgery. Previous studies have demonstrated that increased frailty is a predictor of outcomes in medicine and surgical patients. We hypothesized that use of a modification of the Canadian Study of Health and Aging Frailty Index would be a predictor of morbidity and mortality in patients older than 60 years undergoing emergency general surgery. Data were obtained from the National Surgical Quality Improvement Program Participant Use Files database in compliance with the National Surgical Quality Improvement Program Data Use Agreement. We selected all emergency cases in patients older than 60 years performed by general surgeons from 2005 to 2009. The effect of increasing frailty on multiple outcomes including wound infection, wound occurrence, any infection, any occurrence, and mortality was then evaluated. Total sample size was 35,334 patients. As the modified frailty index increased, associated increases occurred in wound infection, wound occurrence, any infection, any occurrence, and mortality. Logistic regression of multiple variables demonstrated that the frailty index was associated with increased mortality with an odds ratio of 11.70 (p < 0.001). Frailty index is an important predictive variable in emergency general surgery patients older than 60 years. The modified frailty index can be used to evaluate risk of both morbidity and mortality in these patients. Frailty index will be a valuable preoperative risk assessment tool for the acute care surgeon. Prognostic study, level II.

Association of midlife obesity and cardiovascular risk with old age frailty: a 26-year follow-up of initially healthy men

To investigate whether old age frailty is predicted by midlife overweight/obesity and cardiovascular disease (CVD) risk. Longitudinal observational study (the Helsinki Businessmen Study). In their midlife in 1974, 1815 initially healthy men (mean age 47 years) were clinically investigated, whereupon their weight status (normal weight < 25 kg m(-2), overweight 25 ≤ body mass index <30 kg m(-2) and obese ≥ 30 kg m(-2)), CVD risk factors and a composite risk score (%) of coronary artery disease (CAD) were assessed. After a 26-year follow-up in 2000, when 425 men had died, the frailty status of survivors (80.9%, n=1125, mean age 73 years) was assessed using a postal questionnaire including the RAND-36/SF-36 instrument. Phenotypic criteria were used to define frailty, and according to these criteria, 40.0% (n=450), 50.4% (n=567) and 9.6% (n=108) were classified as not frail, prefrail and frail, respectively. Risks are presented as odds ratios (OR) with 95% confidence intervals (CI). Compared with normal weight, the development of frailty was significantly higher among those men who were overweight or obese in midlife, with fully adjusted ORs (95% CI) of 2.06 (1.21-3.52) and 5.41 (1.94-15.1), respectively. Even the development of prefrailty was significantly increased with midlife overweight (OR 1.39; 95% CI, 1.03-1.87) and obesity (OR 2.96; 95% CI, 1.49-5.88). Age-adjusted composite CAD score in midlife predicted similarly 26-year total mortality (OR per 1% increase:1.16; 95% CI, 1.08-1.24) and development of frailty (OR 1.16; 95% CI, 1.02-1.33). Overweight/obesity and higher CAD risk in midlife were associated with frailty 26 years later. Preventing old age frailty should be recognized as an important goal of obesity and CVD risk control.

Predictors of critical care-related complications in colectomy patients using the National Surgical Quality Improvement Program

Colectomy patients experience a broad set of adverse outcomes. Complications requiring critical care support are common in this group. We hypothesized that as frailty increases, the risk of Clavien class IV and V complications will increase in colectomy patients. Using the National Surgical Quality Improvement Program (NSQIP) participant use files for 2005-2009, we identified patients who underwent laparoscopic and open colectomies by Current Procedural Terminology code. Using the Clavien classification for postoperative complications, we identified NSQIP data points most consistent with Clavien class IV requiring intensive care unit (ICU) care or class V complications (death). We used a modified frailty index with 11 variables based on mapping the Canadian Study of Health and Aging Frailty Index and existing NSQIP variables. Logistic regression was performed to acuity adjust the findings. A total of 58,448 colectomies were identified. As frailty index increased from 0 to 0.55, the proportion of those experiencing Clavien class IV or V complications increased from 3.2% at baseline to 56.3%. Variables found to be significant by logistic regression (odds ratio) were frailty index (14.4; p = 0.001), open procedure (2.35; p < 0.001), and American Society of Anesthesiologists class 4 (3.2; p = 0.038) or 5 (7.1; p = 0.001) while emergency operation and wound classification 3 or 4 were not. Complications requiring ICU care represent a significant morbidity in the colectomy patient population. Frailty index seems to be an important predictor of ICU-level complications and death, and laparoscopy seems to be protective.

Frailty in older people

Old age frailty has no consensus definition so far, but it is commonly operationalised as a physical phenotype consisting of weight loss, exhaustion, physical inactivity, slowness and weakness. Phenotypic frailty is characterised by reductions in the reserves of various organ systems and impaired stress tolerance, with increased risk of important endpoints: disability, morbidity and death. The development of sarcopenia is often a conspicuous characteristic, and cognitive decline is a frequent companion; frail individuals may also be obese. According to epidemiological studies, phenotypic frailty can be discerned in 5 to 10% of community-living older individuals, prefrailty even in 20 to 40%. To prevent deterioration and development of disability, prefrail and frail individuals should be recognised in time to target interventions in primary care. There is also an emerging interest in various specialties to recognise frailty to better adjust treatments and prevent complications. Multidomain and multisystem interventions are probably the best options for prevention and treatment, but at the moment best evidence is available from exercise. Various pharmacological treatments are being investigated for frailty components, but trial data are scarce so far. In advanced frailty, treatment is moved to appropriate geriatric palliative care.