Identify Frail Patients Research Articles

Do first impressions count? Frailty judged by initial clinical impression predicts medium-term mortality in vascular surgical patients.

Recognising frailty during pre-operative assessment is important. Frail patients experience higher mortality rates and are less likely to return to baseline functional status following the physiological insult of surgery. We evaluated the association between an initial clinical impression of frailty and all-cause mortality in 392 patients attending our vascular pre-operative assessment clinic. Prevalence of frailty assessed by the initial clinical impression was 30.6% (95% CI 26.0-35.2%). There were 133 deaths in 392 patients over a median follow-up period of 4years. Using Cox regression, adjusted for age, sex, revised cardiac risk index and surgery (yes/no), the hazard ratio for mortality for frail vs. not-frail was 2.14 (95% CI 1.51-3.05). The time to 20% mortality was 16months in the frail group and 33months in the not-frail group. The initial clinical impression is a useful screening tool to identify frail patients in pre-operative assessment.

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.

Geriatric Conditions in Patients Undergoing Defibrillator Implantation for Prevention of Sudden Cardiac Death

Geriatric conditions may influence outcomes among patients receiving implantable cardioverter-defibrillators (ICDs). We sought to determine the prevalence of frailty and dementia among older adults receiving primary prevention ICDs and to determine the impact of multimorbidity on mortality within 1 year of ICD implantation. The cohort included 83 792 Medicare patients from the National Cardiovascular Data Registry ICD Registry who underwent first primary prevention ICD implantation between 2006 and 2009. These data were merged with Medicare analytic files to determine the prevalence of frailty, dementia, and other conditions before ICD implantation, as well as 1-year mortality. A validated claim-based algorithm was used to identify frail patients. Mutually exclusive patterns of chronic conditions were examined. The association of each pattern with 1-year mortality was assessed using logistic regression models adjusted for selected patient characteristics. Approximately 1 in 10 Medicare patients with heart failure receiving a primary prevention ICD had frailty (10%) or dementia (1%). One-year mortality was 22% for patients with frailty, 27% for patients with dementia, and 12% in the overall cohort. Several multimorbidity patterns were associated with high 1-year mortality rates: dementia with frailty (29%), frailty with chronic obstructive pulmonary disease (25%), and frailty with diabetes mellitus (23%). These patterns were present in 8% of the cohort. More than 10% of Medicare beneficiaries with heart failure receiving primary prevention ICDs have frailty or dementia. These patients had significantly higher 1-year mortality than those with other common chronic conditions. Frailty and dementia should be considered in clinical decision-making and guideline development.

Inclusion of Sarcopenia Outperforms the Modified Frailty Index in Predicting 1-Year Mortality among 1,326 Patients Undergoing Gastrointestinal Surgery for a Malignant Indication

Although it is a useful metric for preoperative risk stratification, frailty can be difficult to identify in patients before surgery. We sought to develop a preoperative frailty-risk model combining sarcopenia with clinical parameters to predict 1-year mortality using a cohort of patients undergoing gastrointestinal cancer surgery. We identified 1,326 patients undergoing hepatobiliary, pancreatic, or colorectal surgery between 2011 and 2014. Sarcopenia defined by psoas density was measured using preoperative cross-sectional imaging. Multivariable Cox regression analysis was performed to identify preoperative risk factors associated with 1-year mortality and used to develop a preoperative risk-stratification score. Among all patients identified, 640 (48.3%) patients underwent pancreatic surgery, 347 (26.2%) underwent a hepatobiliary procedure, and 339 (25.5%) a colorectal procedure. Using sex-specific cut-offs, 398 (30.0%) patients were categorized as sarcopenic. Sarcopenic patients were more likely to develop postoperative complications vs non-sarcopenic patients (odds ratio [OR] 1.80, 95% CI 1.42 to 2.29; p < 0.001). Overall 1-year mortality was 9.4%. On multivariable analysis, independent risk factors for 1-year mortality included increasing age (65 to 75 years: [hazard ratio (HR) 1.81, 95% CI 1.05 to 3.14] greater than 75 years [HR 2.79, 95% CI 1.55 to 5.02]), preoperative anemia hemoglobin < 12.5 g/dL (HR 1.68, 95% CI 1.17 to 2.40), and preoperative sarcopenia (HR 1.98, 95% CI 1.36 to 2.88; all p < 0.05). Using these variables, a 28-point weighed composite score was able to stratify patients by their risk for mortality 1 year after surgery (C-statistic= 0.70). The proposed score outperformed other indices of frailty including the modified Frailty Index (C-statistic= 0.55) and the Eastern Cooperative Oncology Group (ECOG) performance score (C-statistic= 0.57) (both p < 0.05). Sarcopenia was combined with clinical factors to generate a composite risk-score that can be used to identify frail patients at greatest risk for 1-year mortality after gastrointestinal cancer surgery.

Frail Elders at High Mortality Risk in the Year Following Surgery

SAN DIEGO — Frail elderly patients face a significantly increased risk of mortality in the year after undergoing major elective noncardiac surgery, a large study from Canada showed. “The current literature on perioperative frailty clearly shows that being frail before surgery substantially increases your risk of adverse postoperative outcomes,” Daniel I. McIsaac, MD, said in an interview prior to the annual meeting of the American Society of Anesthesiologists, where the study was presented. “In fact, frailty may underlie a lot of the associations between advanced age and adverse postoperative outcomes. Frailty increases in prevalence with increasing age, and as we all know, the population is aging. Therefore, we expect to see an increasing number of frail patients coming for surgery.” To determine the risk of 1-year mortality in frail elderly patients having major elective surgery, the researchers used population-based health administrative data in Ontario, to identify 202,811 patients over the age of 65 who had intermediate- to high-risk elective noncardiac surgery between 2002 and 2012. They used the Johns Hopkins Adjusted Clinical Groups frailty indicator and captured all deaths that occurred within 1 year of surgery. Proportional hazards regression models adjusted for age, gender, and socioeconomic status were used to evaluate the impact of frailty on 1-year postoperative mortality. Of the 202,811 patients, 6,289 (3.1%) were frail, reported Dr. McIsaac, an assistant professor of anesthesiology at the University of Ottawa. The 1-year postoperative mortality was 13.6% among frail patients, compared with 4.8% of nonfrail patients, for an adjusted hazard ratio of 2.23. Mortality was higher among frail patients for all types of surgery, compared with their nonfrail counterparts, with the exception of pancreaticoduodenectomy. Frailty had the strongest impact on the risk of mortality after total joint arthroplasty. The risk of postoperative mortality for frail patients was much higher than for nonfrail patients in the early time period after surgery, especially during the first postoperative week. “Depending on how you control for other variables, a frail patient was 13 to 35 times more likely to die in the week after surgery than a nonfrail patient of the same age having the same surgery,” said Dr. McIsaac, who is also a staff anesthesiologist at the Ottawa Hospital. “This makes a lot of sense; frail patients are vulnerable to stressors, and surgery puts an enormous physiological stress on even healthy patients. Future work clearly needs to focus [on] addressing this high-risk time in the immediate postoperative period.” Clinicians should focus on identifying frail patients prior to surgery, and “support them to ensure they are more likely to derive benefit from surgery than harm, and focus on optimizing their care after surgery to address this early mortality risk,” Dr. McIsaac said. Doug Brunk is with the San Diego bureau of Frontline Medical News. There is increasing evidence that physical frailty, which can be rapidly determined by the FRAIL scale (fatigue, resistance, ambulation, illness, loss of weight), is highly predictive of outcomes. In many cases it is more predictive of outcomes than well recognized risk factors. For example, in diabetes, frailty predicts hospitalization and mortality to a greater extent than cardiovascular disease, HgBA1C, and cholesterol. It would appear that the time has come for all older persons to be screened for frailty as part of the annual Medicare wellness exam. In the December issue of JAMDA an article from Hong Kong suggests that the FRAIL-NH scale may be a better marker for poor outcomes in nursing home residents (see page 22). —John Morley, MD St. Louis University School of Medicine

A patient-centered prescription model assessing the appropriateness of chronic drug therapy in older patients at the end of life

IntroductionOlder patients with multimorbidity usually present with progressively worse impairment, resulting in a limited life prognosis. Consequently, drug therapy, which was previously appropriate can become inappropriate and be associated with negative health outcomes. The main objective is to identify inappropriate prescriptions in older patients and to optimize them according to patient directed care goals, established through the application of the patient-centered prescription model, which is based on a shared decision-making process including the patient, physicians and a clinical pharmacist. MethodsThis was a prospective observational study of patients admitted to an Acute Care Elderly Unit. Comprehensive Geriatric Assessment was applied to each patient in order to identify advanced frailty as an indicator of an end of life situation. In order to identify inappropriate prescriptions, each patient's pharmacotherapeutic plan was assessed by applying the Patient-Centered Prescription Model, a three-step process: (i) patient centered assessment, where care goals were established, setting the stage for the second and third steps; (ii) diagnosis-centered assessment; (iii) medication-centered assessment. ResultsThree hundred and nine patients (mean age 86.7 years) were included. Inappropriate prescribing occurred in 39.8% of patients, more frequently amongst end-of-life patients (47.2%) (P < 0.05). During admission, 93.4% of patients with inappropriate prescriptions received an optimized therapeutic plan. ConclusionsA high prevalence of inappropriate prescriptions among patients with multimorbidity was detected, especially in patients at end of life. The patient-centered prescription model helps to identify frail patients on potentially inappropriate prescriptions by means of a holistic review of each patient's situation, in a shared decision-making process.

Usefulness of Clinical Data and Biomarkers for the Identification of Frailty After Acute Coronary Syndromes

BackgroundFrailty predicts mortality after acute coronary syndrome (ACS). The standard frailty scales, such as the Fried score, consist of a variety of questionnaires and physical tests. Our aim was to investigate easily available clinical data and blood markers to predict frailty at discharge, in elderly patients after ACS. MethodsA total of 342 patients older than 65 years, survivors after ACS, were included. A high number of clinical variables were collected. In addition, blood markers potentially linked to frailty and related to the processes of inflammation, coagulation, hormonal dysregulation, nutrition, renal dysfunction, and heart dysfunction were determined. Frailty was evaluated using the Fried score at discharge. The main outcome was frailty defined by a Fried score ≥ 3 points. Secondary endpoints were mortality and myocardial infarction at 30-month median follow-up. ResultsA total of 116 patients were frail. Seven clinical variables or biomarkers predicted frailty: age ≥ 75 years, female, prior ischemic heart disease, admission heart failure, haemoglobin ≤ 12.5 g/dL, vitamin D ≤ 9 ng/mL, and cystatin-C ≥ 1.2 mg/L. This model based on clinical data and biomarkers showed an excellent discrimination accuracy for frailty (C-statistic = 0.818). During the follow-up, 105 patients died and 137 died or suffered myocardial infarction. The clinical data and biomarker model (C-statistics = 0.730 and 0.691) performed better than the Fried score (C-statistics = 0.676 and 0.650) for death and death or myocardial infarction, respectively. ConclusionsEasy available clinical data and biomarkers can identify frail patients at discharge after ACS and predict outcomes better than the standard Fried's frailty scale.

Evaluation of preoperative geriatric assessment of elderly patients with colorectal carcinoma. A retrospective study

AimsElderly patients with colorectal carcinoma are screened with the Identification of Seniors at Risk (ISAR) questionnaire to identify frail patients. These patients are more at risk for mortality and morbidity and are referred to the geriatric specialist for assessment (Dutch acronym: DOG). The DOG assessment aims to preoperatively optimize the patient in order to improve postoperative outcomes.This study evaluates if the DOG assessment influences postoperative outcome after colorectal surgery. MethodsRetrospective cohort and match-control study. Elderly patients who underwent elective resection between 01-01-2008 and 01-08-2013 in the Medical Centre Alkmaar were included.Patients with a positive ISAR score were referred to the geriatric specialists for DOG assessment (DOG patients).DOG assessment encompassed comprehensive geriatric assessment and interventions. Primary outcomesMortality, delirium and length of hospital stay. Secondary outcomes: postoperative complications. Cohort comparisonCohort ISAR− (2008–2010, no ISAR questionnaire) is compared with cohort ISAR+ (2011–2013, ISAR questionnaire). Match-control comparison: DOG patients are compared with matched controls from cohort ISAR−. ResultsCompared to their matched controls, DOG patients were older and had a higher prevalence of certain risk factors for postoperative delirium. In both comparisons, no statistical significant differences were found between the groups in mortality and postoperative delirium. Length of stay was significantly shorter in cohort ISAR+. ConclusionsWhile the DOG patients were significantly more at risk for postoperative complications, the DOG patients had comparable postoperative outcomes as their matched controls. We therefore conclude that the DOG assessment has a positive influence on the postoperative outcomes after colorectal surgery.

Nutritional and global indexes of progression in dementia: a 12-month prospective study.

To assess the influence of body mass index (BMI) on the progression of dementia. Sixty elderly outpatients with untreated dementia followed for 12 months. All patients underwent clinical, cognitive, functional, and nutritional assessment at the baseline and after 12 months. Patients were divided into 2 groups by baseline BMI (< or ≥25 kg/m(2)). Participants with a baseline BMI ≥25 kg/m(2) had significantly higher Mini-Mental State Examination (MMSE) scores (21 ± 5.1 vs 15.9 ± 5.5; P < .001), while clinical dementia rating (CDR) and multidimensional prognostic index (MPI) scores were similar in the 2 groups. After 12 months, the MMSE score decreased significantly in both groups compared to the baseline, while the CDR and MPI scores increased significantly for patients with a baseline BMI <25 kg/m(2). A BMI cutoff of 25 kg/m(2) could be useful for identifying frail patients with dementia who will experience a more rapid global impairment, which could be assessed adequately using multidimensional evaluation tools.

Assessment of Frailty Measures and Their Effect on Survival in a Population of Patients Registered At Marche Region Multiple Myeloma (MM) Registry

Abstract 2873International staging system (ISS) and cytogenetics are the main prognostic factors of Multiple Myeloma (MM) but they reflect biologic characteristics of disease without taking into account individual host features. On the contrary, clinical characteristics of single patient could be substantial as to various points of view. For instance, in elderly MM patients, novel therapies reduction or interruption due to toxicity represent the major cause of unsatisfactory outcome. Therefore, it was empirically suggested different schedule of drugs in these “frail” patients but, how the “frailty” should be assessed in every single patient, is still unsettled. Advanced age, poor performance status (PS) and comorbidities are usually applied to recognize the “frailty” but it is not well known which of them are really prominent and whether these parameters, adjusted for conventional prognostic factors, still affect final outcome.We analyzed a population of symptomatic MM diagnosed from 2007 to 2010 included in the Marche Region MM Registry, to assess the frequency of “frailty” features, such as age, PS, comorbidities, cytopenias, renal insufficiency (RI) and lytic bone lesions, and their role on the overall survival (OS) when adjusted for prognostic factors. Comorbidities were scored according to Charlson Comorbidity Index (CCI) that split patients in 4 categories according to number and type of comorbidity. Patients were treated with transplant or standard therapy according to their eligibility. Overall, 88% of patients were treated with new drug-based therapies and 12% with MP.Median age of the 266 patients analyzed was 73 years (range 38–90). Twenty-four percent of patients had IgA MM, fifty patients (23%) had ISS stage=3 and 29/166 (17.5%) had unfavourable cytogenetics. Regarding “frailty” measures, 38% of patients had > 75 years, 39% had PS=2–4, 34% had 1 or more comorbidities. The most frequent comorbidities were hypertension (35%), heart diseases (22%), diabetes (15%), neurological diseases (16%), COBP (8%), secondary malignancies (8%) and chronic renal failure (6%). CCI ≥1 was detected in 51%. Increasing comorbitities number and CCI were associated with increased age although 37% of patients aged less than 65 years had CCI ≥2. Moreover, 35% had at least 2 cytopenias, 76% had bone disease and 14% had RI. Fifty patients (19%) died during follow-up. OS at 3 years was 74%. Univariate analysis performed on the total population determined age > 65 years (p=0.065), PS=2–4 (p<0.001), Hb < 10 g/dl (p=0.035), ISS=3 (p=0.017), unfavourable cytogenetics (p=0.074), cytopenias (p=0.024), RI (p=0.036) and CCI=1–3 (p=0.005) as factors that significantly decrease OS. Multivariate stepwise analysis selected ISS=3 (HR=1.6; p=0.033), PS=2–4 (HR=2.5; p=0.007) and CCI=1–3 (HR=2.1; p=0.028) as factors affecting worse OS. To obtain a clinical applicable prognostic model, we assigned 1 point to each unfavourable finding such as PS=2–4 or CCI=1–3. A “frailty score” (FS) was thus developed as low (0 point), intermediate (1 point) and high (2 points). Patients in the low category had 91% OS at 3 years vs 83% in the intermediate one (p=0.205) vs 36% in the high category (p< 0.0001). According to these results we performed a multivariate analysis adding FS (0–1 vs 2) to the above frailty covariates and to prognostic factors. This analysis was carried out splitting patients in two subgroups according to the age ≤65 years or older; high FS was recognized in 10% and 30% of subgroups, respectively. In younger patients, multivariate analysis selected ISS=3 (median OS 41.5 months vs NR; HR=5.2; p=0.006) and FS=2 (median OS 46.5 vs NR; HR=5.5; p=0.024;) as factors diminishing OS whereas only FS=2 (HR=3.5; p=0.002) affects worse survival in older ones. Patients with FS=2 had a median survival of 27 months vs NR in patients with FS=0-1.This study demonstrated that, behind biologic features of MM, host characteristics are of utmost importance regarding final outcome prediction. Two easy, reliable and not time-consuming measures normally used in clinical practice such as PS and CCI, scored as we found, seem to be very useful tool to identify frail patients independently by age or other single frailty parameter. These findings maybe used to try to explain why outcome of some patients poorly improved despite new-drugs introduction and should be taking into account planning future clinical trials. Disclosures:No relevant conflicts of interest to declare.

Allogreffe de cellules souches hématopoïétiques et sujets âgés

Most of patients with hematological malignancies are elderly (more than 60 years). Allogeneic stem cell transplantation is an important and effective treatment for most of these diseases. However, the toxicity and the supposed frailty of elderly patients, have limited the applicability of allogeneic transplantation for these patients. Elderly patients are at high risk to develop life-threatening complications, if allogeneic transplantation is performed with myeloablative conditioning regimens and using bone marrow stem source. Since more than 10 years, reduced intensity conditioning regimen have been developed, allowing to overcome the age as contra-indication for allogeneic transplantation. On the other hand, it is the presence of comorbidities which identify frail patients. For these subjects, allogeneic transplantation should be not indicated. Furthermore, advances in the supportive care and the development of new molecules could allow to reduce the toxicity of myeloablative conditioning regimens and thus to offer more intensive regimens before transplantation also in elderly population.

Home and Clinical Assessments of Instrumental Activities of Daily Living: What Could Explain the Difference between Settings in Frail Older Adults, If Any?

Background: Older patients are usually assessed by occupational therapists in hospital before going home. However, for many frail older adults, this assessment in an unfamiliar environment might not be as representative of their functional abilities as an assessment at home. The aim of this literature review was to determine if differences exist between home and clinical instrumental activities of daily living (IADL) assessments of frail older adults and identify factors that might explain those differences, if any. Method: The sources of the review data were Medline, CINAHL, AMED, PsycINFO, Embase and Current Content from 1988 to 2008. As few relevant studies concerning frail people were found, the search was extended to mixed-age and older adult populations. Ten articles were retained. Main findings: The results suggest differences in IADL assessment between settings for older adults without dementia. Some factors, such as familiarity with the environment and coping skills, might explain those differences. Based on this review, similar results might be expected with frail older people. Implications for practice: Given the dearth of literature on this topic, further research is needed to compare home and clinical assessments and measure relevant factors in a frail population. Helping occupational therapists to identify frail patients, who may show different abilities in unfamiliar settings, could mean more appropriate services after discharge from hospital.