Frailty is a risk factor for death and disability following TAVR and SAVR. A brief 4-item scale encompassing lower-extremity weakness, cognitive impairment, anemia, and hypoalbuminemia outperformed other frailty scales and is recommended for use in this setting. (Frailty Assessment Before Cardiac Surgery& Transcatheter Interventions; NCT01845207).

Background Frailty assessment may inform surgical risk and prognosis that are not captured by conventional surgical risk scores. Purpose To evaluate the evidence for various frailty instruments to predict mortality, functional status, or major adverse cardiovascular and cerebrovascular events (MACCE) in older adults undergoing cardiac surgical procedures. Data Sources MEDLINE and EMBASE (without language restrictions), from their inception to May 2, 2016. Study Selection Cohort studies that evaluated the association of frailty with mortality or functional status at ≥6 months in patients aged ≥60 years undergoing major or minimally invasive cardiac surgical procedures. Data Extraction Two reviewers independently extracted study data and assessed study quality. Data Synthesis Mobility, disability, and nutrition were frequently assessed domains of frailty in both types of procedures. In patients undergoing major procedures (N=18388, 8 studies), 9 frailty instruments were evaluated. There was moderate-quality evidence to assess mobility or disability and very-low-to-low-quality evidence to use a multi-component instrument to predict mortality or MACCE. No studies examined functional status. In patients undergoing minimally invasive procedures (N=5177, 17 studies), 13 frailty instruments were evaluated. There was moderate-to-high-quality evidence to assess mobility to predict mortality or functional status. Several multi-component instruments predicted mortality, functional status, or MACCE, but the quality of evidence was low to moderate. Multi-component instruments that measure different frailty domains seemed to outperform single-component instruments. Limitations Heterogeneity of frailty assessment, limited generalizability of multi-component frailty instruments, few validated frailty instruments, and potential publication bias. Conclusions Frailty status, assessed by mobility, disability, and nutritional status, can predict mortality at 6 months or later after major cardiac surgical procedures and functional decline after minimally invasive cardiac surgical procedures. Primary Funding Source National Institute on Aging and National Heart, Lung, and Blood Institute; there was no registration for this review.

Purpose To evaluate the performance of delirium-identification algorithms in administrative claims and drug utilization data. Methods We used data from a prospective study of 184 older adults who underwent aortic valve replacement at a single academic medical center to evaluate the following delirium-identification algorithms: 1) International Classification of Diseases (ICD) diagnosis codes for delirium, 2) antipsychotics use, 3) either ICD diagnosis codes or antipsychotics use, and 4) both ICD diagnosis codes and antipsychotics use. These algorithms were evaluated against a validated bedside assessment, the Confusion Assessment Method, and a validated delirium severity scale, the CAM-S. Results Delirium occurred in 66 patients (36%), of which 14 (21%) had hyperactive or mixed features and 15 (23%) had severe delirium. ICD diagnosis codes for delirium were present in 15 patients (8%). Antipsychotics were used in 13 patients (7%). ICD diagnosis codes alone and antipsychotics use alone had comparable sensitivity (18% vs. 18%) and specificity (98% vs. 99%). Defining delirium using either ICD diagnosis codes or antipsychotics use, sensitivity improved to 30% with little change in specificity (97%). This algorithm showed higher sensitivity for hyperactive or mixed delirium (64%) and severe delirium (73%). Requiring both ICD diagnosis codes and antipsychotics use resulted in perfect specificity, but low sensitivity (6%). Conclusion Delirium-identification algorithms in claims data have low sensitivity and high specificity. Defining delirium using ICD diagnosis codes or antipsychotics use performs better than considering either type of information alone. This information should inform the design and interpretation of claims-based comparative effectiveness and safety research.