Domains of Frailty Predict Loss of Independence in Older Adults After Noncardiac Surgery

Abstract

Importance: Preoperative frailty has been consistently associated with death, severe complications, and loss of independence (LOI) after surgery. LOI is an important patient-centered outcome, but it is unclear which domains of frailty are most strongly associated with LOI. Such information would be important to target individual geriatric domains for optimization. Objective: To assess whether impairment in individual domains of the Edmonton Frail Scale (EFS) can predict LOI in older adults after noncardiac surgery. Design: Retrospective Cohort Study. Setting: One Academic Hospital. Participants: Patients aged 65 or older who were living independently and evaluated with the EFS during a preoperative visit to the Center for Preoperative Optimization at the Johns Hopkins Hospital between June 2018 and January 2020. Main Outcome: LOI defined as discharge to increased level of care outside of the home with new mobility deficit or functional dependence. New mobility deficit and functional dependence were extracted from chart review of the standardized occupational therapy and physical therapy assessment performed before discharge. Results: A total of 3497 patients were analyzed. Age (mean±SD) was 73.4±6.2 years, and 1579 (45.2%) were female. The median total EFS score was 3 (range 0–16), and 725/3497 (27%) were considered frail (EFS≥6). The frequencies of impairment in each EFS domain were functional performance (33.5% moderately impaired, 11% severely impaired), history of hospital readmission (42%), poor self-described health status (37%), and abnormal cognition (17.1% moderately impaired, 13.8% severely impaired). Overall, 235/3497 (6.7%) patients experienced LOI. Total EFS score was associated with LOI (odds ratio: 1.37, 95% CI, 1.30–1.45, P<0.001) in a model adjusted for age, sex, body mass index, American Society of Anesthesiologists rating, congestive heart failure, valvular heart disease, hypertension diagnosis, chronic lung disease, diabetes, renal failure, liver disease, weight loss, anemia, and depression. Using a nested log likelihood approach, the domains of functional performance, functional dependence, social support, health status, and urinary incontinence improved the base multivariable model. In cross-validation, total EFS improved the prediction of LOI with the final model achieving an area under the curve of 0.840. Functional performance was the single domain that most improved outcome prediction, but together with functional dependence, social support, and urinary incontinence, the model resulted in an area under the curve of 0.838. Conclusion and Relevance: Among domains measured by the EFS before a wide range of noncardiac surgeries in older adults, functional performance, functional dependence, social support, and urinary incontinence were independently associated with and improved the prediction of LOI. Clinical initiatives to mitigate LOI may consider screening with the EFS and targeting abnormalities within these domains.

Comparison of the frailty index and frailty phenotype and their associations with postoperative delirium incidence and severity

“…In the SAGES I cohort, we found that preoperative frailty measures using both the FI and FP were associated with the development of postoperative delirium. The FI identified slightly more than one‐third of the patients as frail, and the FP identified slightly fewer than one‐third of patients as frail, consistent with other cohorts of older adults undergoing surgery 34,35 . Frail patients had approximately twice the relative risk of developing postoperative delirium.…”

“…The FI identified slightly more than one-third of the patients as frail, and the FP identified slightly fewer than one-third of patients as frail, consistent with other cohorts of older adults undergoing surgery. 34,35 Frail patients had approximately twice the relative risk of developing postoperative delirium. We found the FI was more strongly associated with delirium incidence than the FP after considering comorbidity and preoperative cognition.…”