“This is important for people who are starting to slow down, not as
sharp cognitively, and have complicated medical issues,” said lead
author Dr. Daniel I. McIsaac of the University of Ottawa in Ontario,
“Every patient goes through risks and benefits deliberations before
surgery,” and frailty should be part of that discussion, he told
Reuters Health by phone.
Researchers studied data on more than 200,000 patients age 65 or
older who underwent a scheduled major noncardiac surgery between
2002 and 2012 in Ontario.
The researchers used health records from the previous two years to
define the patients as “frail” or “not frail” using a diagnostic
instrument that takes into account 12 clusters of other conditions,
like falls, low cognitive scores and poor global function.
About 3 percent of the 200,000 patients who underwent surgery were
frail, based on the diagnoses indicator. These patients were an
average age of 77 while nonfrail patients were on average 74. Frail
patients more often had high blood pressure and had been
hospitalized in the previous year.
Within a year of surgery, almost 14 percent of frail patients had
died, compared to only about five percent of others. After
accounting for sociodemographic differences and surgical details,
frail patients were still more than twice as likely to die as those
who were not frail before surgery.
The increased risk of death was largest for younger patients, in the
days directly following surgery and particularly for total joint
replacement surgery, more so than for other surgeries like arterial
bypass or liver resection, the authors reported in JAMA Surgery.
“There were significantly less frail patients undergoing operations
compared to the population and these patients died very early after
their operation within the first two to three days,” said Dr. Jason
M. Johanning of the Nebraska Western Iowa VA Medical Center in
Omaha, who coauthored a commentary on the results.
Frailty increases the risk of death, complications, longer hospital
stay and discharge to a nursing facility, but does not exclude
anyone from a particular operation, Johanning told Reuters Health by
“Rather it gives the operative team the ability to have an open and
frank discussion with the patient about their goals of care and what
to expect and how to proceed when complications occur
postoperatively,” he said.
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The American College of Surgeons in connection with the John A.
Hartford Foundation is designing a program to address these system
issues, he said.
“Before surgery, people should be identified as frail or not,”
But in the real world, there is no consistent approach, and no one
has identified which is the best tool to use before surgery to
identify frailty, he said.
In theory it could be diagnosed by a primary care provider, surgeon
or anesthesiologist, he said.
About 10 percent of people at age 65 are frail, which increases over
time to half of people age 80 or 85.
“It’s not a necessary part of aging,” McIsaac said. “Getting in
front of the curve involves making choices earlier in life,” and
even after frailty has been diagnosed there are steps to decrease
it, like exercise therapy, he said.
Frail patients have their own unique set of complex medical needs
and we need to start looking at what we can to improve their flow
through the healthcare setting,” he said.
Having special wards in hospitals dedicated to these kinds of
patients would lead to better long-term outcomes, he said.
“We can systematically tackle it now for the first time,” he said.
“Studies like ours and those like it highlight the fact that there’s
a problem and (should motivate others) to address it and get better
SOURCE: http://bit.ly/1Qsl2Tj and http://bit.ly/1OWeckq JAMA
Surgery, online January 20, 2016.
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