Although frailty obviously is an important perioperative risk factor, interventional research on the subject has been sparse. A systematic review from the University of Ottawa found a marked shortage of studies on frailty, but it also found that exercise therapy is consistently associated with improved outcomes in this at-risk patient population.
“Frailty is a key prognostic marker for adverse events after surgery,” said Abhilasha Patel, BS, a second-year medical student at the Ontario institution. “Frailty not only increases in prevalence with aging, but elderly patients undergo surgery at a much higher rate than any other age group. So as our population ages, we expect an increasing number of frail patients presenting for surgery.
“Although there is wide recognition of the association between frailty and perioperative outcomes, intervention studies on frail surgical patients are not commonly described in the literature, nor have they been systematically reviewed,” Ms. Patel said. Given that frailty may be a modifiable risk factor, the researchers set out to determine which interventions, if any, would improve outcomes in these patients.
Many Frailty Assessment Instruments
Ms. Patel and her colleagues searched a variety of relevant databases for studies that tested interventions in frail surgical patients or those in which frailty-specific subgroup analyses were possible. “Studies that described how they defined frailty were included,” she said, “although we did not limit patients based on the specific frailty instruments that were used.”
The investigators’ initial screening identified 2,593 titles and abstracts for review. Of these, 11 were included in the final analysis, six of which were randomized controlled trials. Surgical populations included general surgery, cardiac, orthopedic and mixed; interventions were applied during the perioperative (one study), preoperative (three studies) and postoperative (seven studies) periods. Interventions included exercise, multicomponent geriatric-specific care protocols and blood transfusion triggers.
As reported at the 2017 annual meeting of the Canadian Anesthesiologists’ Society (abstract 282657), exercise therapy was consistently associated with improved outcomes. “These outcomes were measured by a variety of media, including the Modified Physical Performance Test, the Functional Status Questionnaire and the Short Physical Performance Battery score,” Ms. Patel said.
While exercise proved to have positive effects, similar results were not found for geriatric-specific enhanced-care protocols, which the researchers said suffered from difficulties in implementation and poor adherence. Similarly, liberal blood transfusion triggers did not change mortality or other outcomes. The investigators found substantial heterogeneity across the 11 studies in frailty instruments used as well as types of outcomes reported. The risk for bias was moderate to high in all studies.
“So, although we know that frailty has an association with adverse health outcomes, only a few studies have looked at interventions to improve these outcomes,” Ms. Patel concluded. “Going forward, we need more studies with low risk of bias that look at frailty-specific interventions to improve outcomes in these patients, especially since our population is rapidly aging.”
Session moderator Stephen Kowalski, MD, professor of anesthesia at the University of Manitoba, in Winnipeg, questioned how the results of the systematic review fit in with previous research presented at the meeting that demonstrated the benefits of preoperative geriatric consultation with qualified clinicians. “Dr. [Daniel I.] McIsaac’s research showed improvements in mortality after preoperative consultation with a geriatrician,” he noted. “In your review, was there any type of common theme with the geriatric protocols used in the various studies?”
“We did see that they had poor implementation,” Ms. Patel said. “Moreover, the complexity of the protocols made it difficult to address the outcomes. That said, only one study really showed a decrease in hospital stay, while the others really didn’t show any effect on the primary outcomes.”