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Redefining Geriatric Preoperative Assessment Using Frailty, Disability and Co-Morbidity

Robinson, Thomas N. MD*†; Eiseman, Ben MD*†; Wallace, Jeffrey I. MD‡; Church, Skotti D. BS*; McFann, Kim K. PhD§; Pfister, Shirley M. RN, MS, NP¶; Sharp, Terra J. NP-C¶; Moss, Marc MD‡

Annals of Surgery:
doi: 10.1097/SLA.0b013e3181b45598
Original Articles
Abstract

Objectives: (1) Determine the relationship of geriatric assessment markers to 6-month postoperative mortality in elderly patients. (2) Create a clinical prediction rule using geriatric markers from preoperative assessment.

Background: Geriatric surgery patients have unique physiologic vulnerability requiring preoperative assessment beyond the traditional evaluation of older adults. The constellation of frailty, disability and comorbidity predict poor outcomes in elderly hospitalized patients.

Methods: Prospectively, subjects ≥65 years undergoing a major operation requiring postoperative intensive care unit admission were enrolled. Preoperative geriatric assessments included: Mini-Cog Test (cognition), albumin, having fallen in the past 6-months, hematocrit, Katz Score (function), and Charlson Index (comorbidities). Outcome measures included 6-month mortality (primary) and postdischarge institutionalization (secondary).

Results: One hundred ten subjects (age 74 ± 6 years) were studied. Six-month mortality was 15% (16/110). Preoperative markers related to 6-month mortality included: impaired cognition (P < 0.01), recent falls (P < 0.01), lower albumin (P < 0.01), greater anemia (P < 0.01), functional dependence (P < 0.01), and increased comorbidities (P < 0.01). Similar statistical relationships were found for all 6 markers and postdischarge institutionalization. Logistic regression identified any functional dependence (odds ratio 13.9) as the strongest predictor of 6-month mortality. Four or more markers in any one patient predicted 6-month mortality with a sensitivity of 81% (13/16) and specificity of 86% (81/94).

Conclusions: Geriatric assessment markers for frailty, disability and comorbidity predict 6-month postoperative mortality and postdischarge institutionalization. The preoperative presence of ≥4 geriatric-specific markers has high sensitivity and specificity for 6-month mortality. Preoperative assessment using geriatric-specific markers is a substantial paradigm shift from the traditional preoperative evaluation of older adults.

In Brief

Frailty, disability and co-morbidity cumulatively predict poor outcomes in the oldest old. Preoperative frailty markers related to 6-month mortality include impaired cognition, recent falls, lower albumin, lower hematocrit, functional dependence, and increased co-morbidities. Four or more markers predicted 6-month mortality with high sensitivity and specificity.

Author Information

From the *Department of Surgery, University of Colorado at Denver School of Medicine, Aurora, CO; †Department of Surgery, Denver Veteran's Affairs Medical Center, Denver, CO; Departments of ‡Medicine, §Biostatistics, University of Colorado at Denver School of Medicine, Aurora, CO; and ¶Department of Anesthesia, Denver Veteran's Affairs Medical Center, Denver, CO.

Supported by the American Geriatric Society's Jahnigen Scholars Award (to T.N.R.), the American Geriatric Society's Geriatrics for Specialist Residents Award (to T.N.R., J.I.W.), and NIH K24-HL-089223 (to M.M.).

Reprints: Thomas Robinson, MD, 12631 East 17th Ave., UCDHSC MS C313, Aurora, CO 80045. E-mail: thomas.robinson@ucdenver.edu.

© 2009 Lippincott Williams & Wilkins, Inc.