Anaesthesia geriatric evaluation to guide patient selection for preoperative multidisciplinary team care in cardiac surgery

Abstract

Background: A multidisciplinary approach to improve postoperative outcomes in frail elderly patients is gaining interest. Multidisciplinary team care should be targeted at complex patients at high risk for adverse postoperative outcome to limit the strain on available resources and to prevent an unnecessary increase in patient burden. This study aimed to improve patient selection for multidisciplinary care by identifying risk factors for disability after cardiac surgery in elderly patients. Methods: This was a two-centre prospective cohort study of 537 patients aged !70 yr undergoing elective cardiac surgery. Before surgery, 11 frailty characteristics were investigated. Outcome was disability at 3 months defined as World Health Organization Disability Assessment Schedule 2.0 !25%. Multivariable modelling using logistic regression, concordance statistic (c-statistic), and net reclassification index was used to identify factors contributing to patient selection. Results: Disability occurred in 91 (17%) patients. Ten out of 11 frailty characteristics were associated with disability. A multivariable model, including the European System for Cardiac Operative Risk Evaluation II and preoperative haemoglobin, yielded a c-statistic of 0.71 (95% confidence interval [CI]: 0.66e0.77). After adding pre-specified frailty characteristics (polypharmacy, gait speed, physical disability, preoperative health-related quality of life, and living alone) to this model, the c-statistic improved to 0.78 (95% CI: 0.73e0.83). The net reclassification index was 0.32 (P<0.001), showing improved discrimination for patients at risk for disability at 3 months. Conclusions: The addition of preoperative frailty characteristics to a multivariable model improved discrimination between elderly patients with and without disability at 3 months after cardiac surgery, and can be used to guide patient selection for preoperative multidisciplinary team care. Clinical trial registration: NCT02535728.

Determinants of non-recovery in physical health-related quality of life one year after cardiac surgery: a prospective single Centre observational study

“…In general, our study fully complies with 8 out of 10 recommended quality criteria for HRQoL research in the specific field of cardiac surgery [26]. Furthermore we were unable to incorporate frailty in our model, which may have yielded additional information [27,28]. Overlap with items such as 'poor mobility' that characterizes vitality to some extent remain to be established.…”

The association of polypharmacy with functional decline in elderly patients undergoing cardiac surgery

“…These comprised sex, age, type of surgery and frailty characteristics including living alone, Timed Get Up & Go, and Nagi physical functioning. 6,7,20 The association between different types of medication and functional decline was analysed in a similar manner.…”

“…This study reports the results of a post hoc analysis of the Anaesthesia Geriatric Evaluation and Quality of Life After Cardiac Surgery (AGE) study and analysed patients included at St. Antonius Hospital, the Netherlands. 7 The AGE study was a prospective observational cohort study in patients aged 70 years and older, that focused on the association between preoperative frailty domains and health-related quality of life (HRQL) and disability after 1 year in elective cardiac surgery patients (i.e. coronary, valve, rhythm, aortic or any combination of these procedures).…”

“…Postoperative complications were graded according to severity by members of the AGE research team. 7 A severe complication was defined as in-hospital mortality or a life-threatening event and included: re-operation, respiratory insufficiency, reintubation, stroke, renal replacement therapy, life threatening bleeding or re-admittance to the intensive care unit. 7 What is already known about this subject • Polypharmacy is highly prevalent in the elderly and is associated with adverse outcome in noncardiac surgery.…”

“…There is growing evidence suggesting that a preoperative comprehensive frailty assessment can improve risk stratification in older cardiac surgery patients. [6][7][8] However, a comprehensive frailty assessment is time consuming. Polypharmacy is easily identified in surgical patients as a systematic assessment of prescribed drugs, which is part of routine preoperative care.…”