title: Frail Patients Are at Increased Risk for Mortality and Prolonged Institutional Care After Cardiac Surgery Gait speed as an incremental predictor of mortality and major morbidity in elderly patients undergoing cardiac surgery. Old or frail: what tells us more? Too frail for surgery? Initial results of a large multidisciplinary prospective study examining preoperative variables predictive of poor surgical outcomes. A global clinical measure of fitness and frailty in elderly people Frailty as a predictor of surgical outcomes in older patients. Addition of Frailty and Disability to Cardiac Surgery Risk Scores Identifies Elderly Patients at High Risk of Mortality or Major Morbidity Prognostic significance of potential frailty criteria. Clarifying confusion: the confusion assessment method. A new method for detection of delirium. Operationalizing a frailty index from a standardized comprehensive geriatric assessment. Failure to normalize lymphopenia following trauma is associated with increased mortality, independent of the leukocytosis pattern Risk adjustment of the postoperative morbidity rate for the comparative assessment of the quality of surgical care: results of the National Veterans Affairs Surgical Risk Study. The National Veterans Administration Surgical Risk Study: risk adjustment for the comparative assessment of the quality of surgical care. Risk stratification in heart surgery: comparison of six score systems. The impact of frailty status on survival after transcatheter aortic valve replacement in older adults with severe aortic stenosis: a single-center experience. Comprehensive geriatric assessment can predict complications in elderly patients after elective surgery for colorectal cancer: a prospective observational cohort study. Low micronutrient levels as a predictor of incident disability in older women. Risk adjustment of the postoperative mortality rate for the comparative assessment of the quality of surgical care: results of the National Veterans Affairs Surgical Risk Study. Frailty as a predictor of morbidity and mortality in inpatient head and neck surgery. Frailty and delayed graft function in kidney transplant recipients. Predictors of Short-Term Postoperative Survival After Elective Colectomy in Colon Cancer Patients ≥80 Years of Age Frailty predicts outcome of elective laparoscopic cholecystectomy in geriatric patients Geriatric Assessment Improves Prediction of Surgical Outcomes in Older Adults Undergoing Pancreaticoduodenectomy: A Prospective Cohort Study Assessment for frailty is useful for predicting morbidity in elderly patients undergoing colorectal cancer resection whose comorbidities are already optimized.
abstract: Background — Frailty is an emerging concept in medicine yet to be explored as a risk factor in cardiac surgery . Where elderly patients are increasingly referred for cardiac surgery , the prevalence of a frail group among these is also on the rise . We assessed frailty as a risk factor for adverse outcomes after cardiac surgery . Methods and Results — Functional measures of frailty and clinical data were collected prospect ively for all cardiac surgery patients at a single center . Frailty was defined as any impairment in activities of daily living ( Katz index ) , ambulation , or a documented history of dementia .  Of 3826 patients , 157 ( 4.1 % ) were frail . Frail patients were older , were more likely to be female , and had risk factors for adverse surgical outcomes . By logistic regression , frailty was an independent predictor of in-hospital mortality ( odds ratio 1.8 , 95 % CI 1.1 to 3.0 ) , as well as institutional discharge ( odds ratio 6.3 , 95 % CI 4.2 to 9.4 ) . Frailty was an independent predictor of reduced midterm survival ( hazard ratio 1.5 , 95 % CI 1.1 to 2.2 ) . Conclusions — Frailty is a risk for postoperative complications and an independent predictor of in-hospital mortality , institutional discharge , and reduced midterm survival . Frailty screening improves risk assessment in cardiac surgery patients and may identify a subgroup of patients who may benefit from innovative processes of care OBJECTIVES The purpose of this study was to test the value of gait speed , a clinical marker for frailty , to improve the prediction of mortality and major morbidity in elderly patients undergoing cardiac surgery . BACKGROUND It is increasingly difficult to predict the elderly patient 's risk posed by cardiac surgery because existing risk assessment tools are incomplete . METHODS A multicenter prospect i ve cohort of elderly patients undergoing cardiac surgery was assembled at 4 tertiary care hospitals between 2008 and 2009 . Patients were eligible if they were 70 years of age or older and were scheduled for coronary artery bypass and /or valve replacement or repair . The primary predictor was slow gait speed , defined as a time taken to walk 5 m of ≥ 6 s. The primary end point was a composite of in-hospital post-operative mortality or major morbidity . RESULTS The cohort consisted of 131 patients with a mean age of 75.8 ± 4.4 years ; 34 % were female patients . Sixty patients ( 46 % ) were classified as slow walkers before cardiac surgery . Slow walkers were more likely to be female ( 43 % vs. 25 % , p = 0.03 ) and diabetic ( 50 % vs. 28 % , p = 0.01 ) . Thirty patients ( 23 % ) experienced the primary composite end point of mortality or major morbidity after cardiac surgery . Slow gait speed was an independent predictor of the composite end point after adjusting for the Society of Thoracic Surgeons risk score ( odds ratio : 3.05 ; 95 % confidence interval : 1.23 to 7.54 ) . CONCLUSIONS Gait speed is a simple and effective test that may identify a subset of vulnerable elderly patients at incrementally higher risk of mortality and major morbidity after cardiac surgery BACKGROUND Selecting elderly persons who need geriatric interventions  and making accurate treatment decisions are recurring challenges in geriatrics . Chronological age , although often used , does not seem to be the best selection criterion . Instead , the concept of frailty , which indicates several concurrent losses in re sources , can be used . METHODS The predictive values of chronological age and frailty were investigated in a large community sample of persons aged 65 years and older , r and omly drawn from the register of six municipalities in the northern regions of the Netherl and s ( 45 % of the original addressees ) . The participants ' generative capacity to sustain well-being ( i.e. , self-management abilities ) was used as the main outcome measure . RESULTS When using chronological age instead of frailty , both too many and too few persons were selected . Furthermore , frailty related more strongly ( with beta values ranging from -.25 to -.39 ) to a decline in the participants ' self-management abilities than did chronological age ( with beta values ranging from -.06 to -.14 ) . Chronological age added very little to the explained variances of all outcomes once frailty was included . CONCLUSIONS Using frailty as the criterion to select older persons at risk for interventions may be better than selecting persons based only on their chronological age BACKGROUND The decision as to whether a patient can tolerate surgery is often subjective and can misjudge a patient 's true physiologic state . The concept of frailty is an important assessment tool in the geriatric medical population , but has only recently gained attention in surgical patients . Frailty potentially represents a measureable phenotype , which , if quantified with a st and ardized protocol , could reliably estimate the risk of adverse surgical outcomes . STUDY DESIGN Frailty was prospect ively evaluated in the clinic setting in patients consenting for major general , oncologic , and urologic procedures . Evaluation included an  established assessment tool ( Hopkins Frailty Score ) , self-administered question naires , clinical assessment of performance status , and biochemical measures .  Primary outcome was 30-day postoperative complications . RESULTS There were 189 patients evaluated : 117 from urology , 52 from surgical oncology , and 20 from general surgery clinics . Mean age was 62 years , 59.8 % were male , and 71.4 % were Caucasian . Patients who scored intermediately frail or frail on the Hopkins Frailty Score were more likely to experience postoperative complications ( odds ratio [ OR ] 2.07 , 95 % CI 1.05 to 4.08 , p = 0.036 ) . Of all other preoperative assessment tools , only higher hemoglobin ( p = 0.033 ) had a significant association and was protective for 30-day complications . CONCLUSIONS The aggregate score of patients as " intermediately frail or frail " on the Hopkins Frailty Score was predictive of a patient experiencing a postoperative complication . This preoperative assessment tool may prove beneficial when weighing the risks and benefits of surgery , allowing objective data to guide surgical decision-making and patient counseling Background : There is no single generally accepted clinical definition of frailty . Previously developed tools to assess frailty that have been shown to be predictive of death or need for entry into an institutional facility have not gained acceptance among practising clinicians . We aim ed to develop a tool that would be both predictive and easy to use . Methods : We developed the 7-point Clinical Frailty Scale and applied it and other established tools that measure frailty to 2305 elderly patients who participated in the second stage of the Canadian Study of Health and Aging ( CSHA ) . We followed this cohort prospect ively ; after 5 years , we determined the ability of the Clinical Frailty Scale to predict death or need for institutional care , and correlated the results with those obtained from other established tools . Results : The CSHA Clinical Frailty Scale was highly correlated ( r = 0.80 ) with the Frailty Index . Each 1-category increment of our scale significantly increased the medium-term risks of death ( 21.2 % within about 70 mo , 95 % confidence interval [ CI ] 12.5%–30.6 % ) and entry into an institution ( 23.9 % , 95 % CI 8.8%–41.2 % ) in multivariable models that adjusted for age , sex and education . Analyses of receiver operating characteristic curves showed that our Clinical Frailty Scale performed better than measures of cognition , function or comorbidity in assessing risk for death ( area under the curve 0.77 for 18-month and 0.70 for 70-month mortality ) . Interpretation : Frailty is a valid and clinical ly important construct that is recognizable by physicians . Clinical judgments about frailty can yield useful predictive information BACKGROUND Preoperative risk assessment is important yet inexact in older patients because physiologic reserves are difficult to measure . Frailty is thought to estimate physiologic reserves , although its use has not been evaluated in surgical patients . We design ed a study to determine if frailty predicts surgical complications and enhances current perioperative risk models . STUDY DESIGN We prospect ively measured frailty in 594 patients ( age 65 years or older ) presenting to a university hospital for elective surgery between July 2005 and July 2006 . Frailty was classified using a vali date d scale ( 0 to 5 ) that included weakness , weight loss , exhaustion , low physical activity , and slowed walking speed . Patients scoring 4 to 5 were classified as frail , 2 to 3 were intermediately frail , and 0 to 1 were nonfrail . Main outcomes measures were 30-day surgical complications , length of stay , and discharge disposition . Multiple logistic regression ( complications and discharge ) and negative binomial regression ( length of stay ) were done to analyze frailty and postoperative outcomes associations . RESULTS Preoperative frailty was associated with an increased risk for postoperative complications ( intermediately frail : odds ratio [ OR ] 2.06 ; 95 % CI 1.18 - 3.60 ; frail : OR 2.54 ; 95 % CI 1.12 - 5.77 ) , length of stay ( intermediately frail : incidence rate ratio 1.49 ; 95 % CI 1.24 - 1.80 ; frail : incidence rate ratio 1.69 ; 95 % CI 1.28 - 2.23 ) , and discharge to a skilled or assisted-living facility after previously living at home ( intermediately frail : OR 3.16 ; 95 % CI 1.0 - 9.99 ; frail : OR 20.48 ; 95 % CI 5.54 - 75.68 ) . Frailty improved predictive power ( p < 0.01 ) of each risk index ( ie , American Society of Anesthesiologists , Lee , and Eagle scores ) . CONCLUSIONS Frailty independently predicts postoperative complications , length of stay , and discharge to a skilled or assisted-living facility in older surgical patients and enhances conventional risk models . Assessing frailty using a st and ardized definition can help patients and physicians make more informed decisions Background — Cardiac surgery risk scores perform poorly in elderly patients , in part because they do not take into account frailty and disability which are critical determinants of health status with advanced age . There is an unmet need to combine established cardiac surgery risk scores with measures of frailty and disability to provide a more complete model for risk prediction in elderly patients undergoing cardiac surgery .  Methods and Results — This was a prospect i ve , multicenter cohort study of elderly patients ( ≥70 years ) undergoing coronary artery bypass and /or valve surgery in the United States and Canada . Four different frailty scales , 3 disability scales , and 5 cardiac surgery risk scores were measured in all patients . The primary outcome was the STS composite end point of in-hospital postoperative mortality or major morbidity . A total of 152 patients were enrolled , with a mean age of 75.9±4.4 years and 34 % women . Depending on the scale used , 20–46 % of patients were found to be frail , and 5–76 % were found to have at least 1 disability . The most predictive scale in each domain was : 5-meter gait speed ≥6 seconds as a measure of frailty ( odds ratio [ OR ] , 2.63 ; 95 % confidence interval [ CI ] , 1.17–5.90 ) , ≥3 impairments in the Nagi scale as a measure of disability ( OR , 2.98 ; 95 % CI , 1.35–6.56 ) and either the Parsonnet score ( OR , 1.08 ; 95 % CI , 1.04–1.13 ) or Society of Thoracic Surgeons Predicted Risk of Mortality or Major Morbidity ( STS-PROMM ) ( OR , 1.05 ; 95 % CI , 1.01–1.09 ) as a cardiac surgery risk score . Compared with the Parsonnet score or STS-PROMM alone , ( area under the curve , 0.68–0.72 ) , addition of frailty and disability provided incremental value and improved model discrimination ( area under the curve , 0.73–0.76 ) . Conclusions — Clinicians should use an integrative approach combining frailty , disability , and risk scores to better characterize elderly patients referred for cardiac surgery and identify those that are at increased risk OBJECTIVES To determine the independent prognostic effect of seven potential frailty criteria , including five from the Fried phenotype , on several adverse outcomes . DESIGN Prospect i ve cohort study . SETTING Greater New Haven , Connecticut . PARTICIPANTS Seven hundred fifty-four initially nondisabled , community-living persons aged 70 and older . MEASUREMENTS An assessment of seven potential frailty criteria ( slow gait speed , low physical activity , weight loss , exhaustion , weakness , cognitive impairment , and depressive symptoms ) was completed at baseline and every 18 months for 72 months . Participants were followed with monthly telephone interviews for up to 96 months to determine the occurrence of chronic disability , long-term nursing home ( NH ) stays , injurious falls , and death . RESULTS In analyses adjusted for age , sex , race , education , number of chronic conditions , and the presence of the other potential frailty criteria , three of the five Fried criteria ( slow gait speed , low physical activity , and weight loss ) were independently associated with chronic disability , long-term NH stays , and death . Slow gait speed was the strongest predictor of chronic disability ( hazard ratio (HR)=2.97 , 95 % confidence interval (CI)=2.32 - 3.80 ) and long-term NH stay ( HR=3.86 , 95 % CI=2.23 - 6.67 ) and was the only significant predictor of injurious falls ( HR=2.19 , 95 % CI=1.33 - 3.60 ) . Cognitive impairment was also associated with chronic disability ( HR=1.82 , 95 % CI=1.40 - 2.38 ) , long-term NH stay ( HR=2.64 , 95 % CI=1.75 - 3.99 ) , and death ( HR=1.54 , 95 % CI=1.13 - 2.10 ) , and the magnitude of these associations was comparable with that of weight loss . CONCLUSION The results of this study provide strong evidence to support the use of slow gait speed , low physical activity , weight loss , and cognitive impairment as key indicators of frailty while raising concerns about the value of self-reported exhaustion and muscle weakness OBJECTIVE To develop and vali date a new st and ardized confusion assessment method ( CAM ) that enables nonpsychiatric clinicians to detect delirium quickly in high-risk setting s. DESIGN Prospect i ve validation study . SETTING Conducted in general medicine wards and in an outpatient geriatric assessment center at Yale University ( site 1 ) and in general medicine wards at the University of Chicago ( site 2 ) . PATIENTS The study included 56 subjects , ranging in age from 65 to 98 years . At site 1 , 10 patients with and 20 without delirium participated ; at site 2 , 16 patients with and 10 without delirium participated . MEASUREMENTS AND MAIN RESULTS An expert panel developed the CAM through a consensus building process . The CAM instrument , which can be completed in less than 5 minutes , consists of nine operationalized criteria from the Diagnostic and Statistical Manual of Mental Disorders ( DSM-III-R ) . An a priori hypothesis was established for the diagnostic value of four criteria : acute onset and fluctuating course , inattention , disorganized thinking , and altered level of consciousness . The CAM algorithm for diagnosis of delirium required the presence of both the first and the second criteria and of either the third or the fourth criterion . At both sites , the diagnoses made by the CAM were concurrently vali date d against the diagnoses made by psychiatrists . At sites 1 and 2 values for sensitivity were 100 % and 94 % , respectively ; values for specificity were 95 % and 90 % ; values for positive predictive accuracy were 91 % and 94 % ; and values for negative predictive accuracy were 100 % and 90 % . The CAM algorithm had the highest predictive accuracy for all possible combinations of the nine features of delirium . The CAM was shown to have convergent agreement with four other mental status tests , including the Mini-Mental State Examination . The interobserver reliability of the CAM was high ( kappa = 0.81 - 1.0 ) . CONCLUSIONS The CAM is sensitive , specific , reliable , and easy to use for identification of delirium OBJECTIVES To construct and vali date a frailty index ( FI ) that is clinical ly sensible and practical for geriatricians by basing it on a routinely used comprehensive geriatric assessment ( CGA ) instrument . DESIGN Secondary analysis of a 3-month r and omized , controlled trial of a specialized mobile geriatric assessment team . SETTING Rural Nova Scotia . Participants were seen in their homes . PARTICIPANTS Frail older adults , of whom 92 were in the intervention group and 77 in the control group . MEASUREMENTS A st and ard CGA form that accounts for impairment , disability , and comorbidity burden was scored and summed as a frailty index ( FI-CGA ) . The FI-GCA was stratified to describe three levels of frailty . Patients were followed for up to 12 months to determine how well the index predicted adverse outcomes ( institutionalization or mortality , whichever came first ) . RESULTS The three levels of frailty were mild ( FI-CGA 0 - 7 ) , moderate ( FI-CGA 7 - 13 ) , and severe ( FI-CGA>13 ) . Demographic and social traits were similar across groups , but greater frailty was associated with worse function ( r=0.55 ) and mental status ( r=0.33 ) . Those with moderate and severe frailty had a greater risk of adverse outcomes than those with mild frailty ( unadjusted hazard ratio=1.9 and 5.5 , respectively ) . There was no difference between frailty groups in mean 3-month goal -attainment scaling scores . Intrarater reliability was 0.95 . CONCLUSION The FI-CGA is a valid , reliable , and sensible clinical measure of frailty that permits risk stratification of future adverse outcomes Introduction Following trauma and systemic inflammatory response syndrome ( SIRS ) , the typical response is an elevation of the total complete blood count ( CBC ) and a reduction of the lymphocyte count . This leukocytosis typically returns to normal within 48 hours . The persistence of a leukocytosis following trauma is associated with adverse outcomes . Although lymphocyte anergy and dysfunction following trauma is associated with increased risk for infection and sepsis , there is a paucity of data regarding the impact of a persistence of a low lymphocyte count in trauma patients . Methods This is a retrospective review of prospect ively collected data from trauma patients collected over the 5 years of September 2003 to September 2008 . Patients were included if the injury severity score ( ISS ) was > /=15 , and they survived at least 3 days . Demographic data , mechanism and injury severity score , mortality , and length of stay were collected from the medical record . Laboratory values for the first 4 hospital days were collected . Leukocyte , neutrophil and lymphocyte counts were extracted from the daily complete blood count ( CBC ) . Patients were then grouped based on response ( elevation/depression ) of each component of the CBC , and their return , or failure thereof , to normal . Proportional hazards regression with time-varying covariates as well as Kaplan-Meier curves were used to predict risk of death , time to death and time to healthy discharge based on fluctuations of the individual components of the CBC . Results There were 2448 patients admitted over the 5 years included in the analysis . When adjusting for age , gender and ISS the relative risk of death was elevated with a persistent leukocytosis ( 2.501 ( 95 % CI = 1.477 - 4.235 ) ) or failure to normalize lymphopenia ( 1.639 ( 95 % CI = 10.17 - 2.643 ) ) within the first 4 days following admission . Similar results were seen when Kaplan-Meier curves were created . Persistent lymphopenia was associated with shortest time to death . Paradoxically in survivors persistent lymphopenia was associated with the shortest time to discharge . Conclusions Persistently abnormal CBC responses are associated with a higher mortality following trauma . This is the first report noting that a failure to normalize lymphopenia in severely injured patients is associated with significantly higher mortality BACKGROUND The National Veterans Affairs Surgical Risk Study was design ed to collect reliable , valid data on patient risk and outcomes for major surgery in the Veterans Health Administration and to report comparative risk-adjusted postoperative mortality and morbidity rates for surgical services in the Veterans Health Administration . STUDY DESIGN This was a cohort study conducted at 44 Veterans Affairs Medical Centers closely affiliated with university medical centers . Included were 87,078 major noncardiac operations performed under general , spinal , or epidural anesthesia between October 1 , 1991 , and December 31 , 1993 . The main outcomes measures in this report are 21 postoperative adverse events ( morbidities ) occurring within 30 days after the index procedure . Multivariable logistic regression risk-adjustment models for all operations and for eight surgical subspecialties were developed . RESULTS Patient risk factors predictive of postoperative morbidity included serum albumin level , American Society of Anesthesia class , the complexity of the operation , and 17 other preoperative risk variables . Wide variation in the unadjusted rates of one or more postoperative morbidities for all operations was observed across the 44 hospitals ( 7.4 - 28.4 % ) . Risk-adjusted observed-to-expected ratios ranged from 0.49 to 1.46 . The Spearman rank order correlation between the ranking of the hospitals based on unadjusted morbidity rates and risk-adjusted observed-to-expected ratios for all operations was 0.87 . There was little or no correlation between the rank order of the hospitals by risk-adjusted morbidity and risk-adjusted mortality . CONCLUSIONS The Department of Veterans Affairs has successfully implemented a system for the prospect i ve collection and comparative reporting of postoperative mortality and morbidity rates after major noncardiac operations . Risk adjustment had only a modest effect on the rank order of the hospitals BACKGROUND The use of surgical outcome in the comparative assessment of the quality of surgical care is predicted on the development of proper models that adjust for the severity of the preoperative risk factors of the patient . The National Veterans Administration Surgical Risk Study was design ed to collect reliable , valid data about patient risk and outcome for major surgery in the Veterans Health Administration ( VHA ) and to report comparative risk-adjusted surgical morbidity and mortality rates for surgical services in VHA . This study describes the rationale and methods used in the Risk Study and reports on the frequency distribution of the data elements that will be used in the development of risk-adjusted reporting of surgical outcome . STUDY DESIGN This study was a prospect i ve observational study in which dedicated nurses collected preoperative , intraoperative , and outcome data on patients undergoing noncardiac operations using general , spinal , and epidural anesthesia in 44 Veterans Administration Medical Centers . Outcome measures included all cause mortality within the 30 days after the index procedure and 21 major morbidities . RESULTS Eighty-three thous and nine hundred fifty-eight cases meeting inclusion criteria were entered in the study between October 1 , 1991 and December 31 , 1993 . Ninety-seven percent of patients were men , with a mean age of 60.1 + /- 13.6 ( st and ard deviation ) years . The most common preoperative risk factors were smoking ( 40.7 percent ) and hypertension ( 36.1 percent ) . Of the patients , 84.6 percent had one or more risk factors . The most common procedures were transurethral resection of the prostate gl and ( 6.7 percent ) , total knee replacement ( 3.1 percent ) , thromboendarterectomy ( 2.4 percent ) , partial colectomy ( 2.2 percent ) , and total hip replacement ( 2 percent ) . The unadjusted mortality rate was 3.1 percent at 30 days . The most common postoperative morbidities were pneumonia ( 3.6 percent ) , urinary tract infection ( 3.5 percent ) , and failure to wean from the ventilator at 48 hours postoperatively ( 3.2 percent ) . Seventeen percent of the patients have one or more major complications . CONCLUSIONS The Veterans Health Administration has successfully implemented an outcome reporting system for major surgery that prospect ively collects patient risk and outcome information reliably and validly . Risk adjustment models and comparative hospital-specific rates of risk-adjusted outcomes are currently being developed OBJECTIVE Risk scores have become an important tool in patient assessment , as age , severity of heart disease , and comorbidity in patients undergoing heart surgery have considerably increased . Various risk scores have been developed to predict mortality after heart surgery . However , there are significant differences between scores with regard to score design and the initial patient population on which score development was based . It was the purpose of our study to compare six commonly used risk scores with regard to their validity in our patient population . METHODS Between September 1 , 1998 and February 28 , 1999 , all adult patients undergoing heart surgery with cardiopulmonary bypass in our institution were preoperatively scored using the initial Parsonnet , Clevel and Clinic , French , Euro , Pons , and Ontario Province Risk ( OPR ) scores . Postoperatively , we registered 30-day mortality , use of mechanical assist devices , renal failure requiring hemodialysis or hemofiltration , stroke , myocardial infa rct ion , and duration of ventilation and intensive care stay . Score validity was assessed by calculating the area under the ROC curve . Odds ratios were calculated to investigate the predictive relevance of risk factors . RESULTS Follow-up was able to be completed in 504 prospect ively scored patients .  Receiver operating characteristics ( ROC ) curve analysis for mortality showed the best predictive value for the Euro score . Predictive values for morbidity were considerably lower than predictive values for mortality in all of the investigated score systems . For most risk factors , odds ratios for mortality were substantially different from ratios for morbidity . CONCLUSIONS Among the investigated scores , the Euro score yielded the highest predictive value in our patient population . For most risk factors , predictive values for morbidity were substantially different from predictive values for mortality . Therefore , development of specific morbidity risk scores may improve prediction of outcome and hospital cost . Due to the heterogeneity of morbidity events , future score systems may have to generate separate predictions for mortality and major morbidity events OBJECTIVES This study sought to evaluate the impact of frailty in older adults undergoing transcatheter aortic valve replacement ( TAVR ) for symptomatic aortic stenosis . BACKGROUND Frailty status impacts prognosis in older adults with heart disease ; however , the impact of frailty on prognosis after TAVR is unknown . METHODS Gait speed , grip strength , serum albumin , and activities of daily living status were collected at baseline and used to derive a frailty score  among patients who underwent TAVR procedures at a single large-volume institution . The cohort was dichotomized on the basis of median frailty score into frail and not frail groups . The impact of frailty on procedural outcomes ( stroke , bleeding , vascular complications , acute kidney injury , and mortality at 30 days ) and 1-year mortality was evaluated . RESULTS Frailty status was assessed in 159 subjects who underwent TAVR ( age 86 ± 8 years , Society of Thoracic Surgery Risk Score 12 ± 4 ) .  Baseline frailty score was not associated with conventionally ascertained clinical variables or Society of Thoracic Surgery score . Although high frailty score was associated with a longer post-TAVR hospital stay when compared with lower frailty score ( 9 ± 6 days vs. 6 ± 5 days , respectively , p = 0.004 ) , there were no significant crude associations between frailty status and procedural outcomes , suggesting adequacy of the st and ard selection process for identifying patients at risk for periprocedural complications after TAVR . Frailty status was independently associated with increased 1-year mortality ( hazard ratio : 3.5 , 95 % confidence interval : 1.4 to 8.5 , p = 0.007 ) after TAVR . CONCLUSIONS Frailty was not associated with increased periprocedural complications in patients selected as c and i date s to undergo TAVR but was associated with increased 1-year mortality after TAVR . Further studies will evaluate the independent value of this frailty composite in older adults with aortic stenosis OBJECTIVE To examine the association between the outcomes of a pre-operative comprehensive geriatric assessment ( CGA ) and the risk of severe post-operative complications in elderly patients electively operated for colorectal cancer . METHODS One hundred seventy-eight consecutive patients ≥ 70 years electively operated for all stages of colorectal cancer were prospect ively examined . A pre-operative CGA was performed , and patients were categorized as fit , intermediate , or frail . The main outcome measure was severe complications within 30 days of surgery . RESULTS Twenty-one patients ( 12 % ) were categorized as fit , 81 ( 46 % ) as intermediate , and 76 ( 43 % ) as frail . Eighty-three patients experienced severe complications , including three deaths ; 7/21 ( 33 % ) of fit patients , 29/81 ( 36 % ) of intermediate patients and 47/76 ( 62 % ) of frail patients ( p=0.002 ) . Increasing age and ASA classification were not associated with complications in this series . CONCLUSION CGA can identify frail patients who have a significantly increased risk of severe complications after elective surgery for colorectal cancer BACKGROUND The role of nutritional status in the disablement process is still unclear . The objective of this study was to assess whether low concentrations of nutrients predict the development and course of disability . METHODS Longitudinal study including community-dwelling women 65 years or older enrolled in the Women 's Health and Aging Study I. In total , 643 women were assessed prospect ively at 6-month intervals from 1992 to 1995 . RESULTS Incidence rates of disability in activities of daily living ( ADLs ) during 3 years of follow-up . Incidence rates in the lowest quartile of each selected nutrient were compared with those in the upper quartiles . The hazard ratios were estimated from Cox models adjusted for potential confounders . Women in the lowest quartile of serum concentrations of vitamin B(6 ) ( hazard ratio [ HR ] , 1.31 ; 95 % confidence interval [ CI ] , 1.03 - 1.67 ) , vitamin B(12 ) ( HR , 1.40 ; 95 % CI , 1.12 - 1.74 ) , and selenium ( HR , 1.38 ; 95 % CI , 1.12 - 1.71 ) had significantly higher risk of disability in ADLs during 3 years of follow-up compared with women in the upper 3 quartiles . CONCLUSIONS Low serum concentrations of vitamins B(6 ) and B(12 ) and selenium predict subsequent disability in ADLs in older women living in the community .  Nutritional status is one of the key factors to be considered in the development of strategies aim ed at preventing or delaying the disablement process BACKGROUND The National Veterans Affairs Surgical Risk Study was design ed to collect reliable , valid data on patient risk and outcomes for major surgery in the Veterans Health Administration and to report comparative risk-adjusted postoperative mortality rates for surgical services in Veterans Health Administration . STUDY DESIGN This cohort study was conducted in 44 Veterans Affairs Medical Centers . Included were 87,078 major noncardiac operations performed under general , spinal , or epidural anesthesia between October 1 , 1991 , and December 31 , 1993 . The main outcomes measure was all-cause mortality within 30 days after the index procedure . Multivariable logistic regression risk-adjustment models for all operations and for eight surgical subspecialties were developed . Risk-adjusted surgical mortality rates were expressed as observed-to-expected ratios and were compared with unadjusted 30-day postoperative mortality rates . RESULTS Patient risk factors predictive of postoperative mortality included serum albumin level , American Society of Anesthesia class , emergency operation , and 31 additional preoperative variables . Considerable variability in unadjusted mortality rates for all operations was observed across the 44 hospitals ( 1.2 - 5.4 % ) . After risk adjustment , observed-to-expected ratios ranged from 0.49 to 1.53 . Rank order correlation of the hospitals by unadjusted and risk-adjusted mortality rates for all operations was 0.64 . Ninety-three percent of the hospitals changed rank after risk adjustment , 50 % by more than 5 and 25 % by more than 10 . CONCLUSIONS The Department of Veterans Affairs has successfully implemented a system for the prospect i ve collection and comparative reporting of risk-adjusted postoperative mortality rates after major noncardiac operations . Risk adjustment had an appreciable impact on the rank ordering of the hospitals and provided a means for monitoring and potentially improving the quality of surgical care IMPORTANCE The increasing number of elderly and comorbid patients undergoing surgical procedures raises interest in better identifying patients at increased risk of morbidity and mortality , independent of age . Frailty has been identified as a predictor of surgical complications . OBJECTIVE To establish the implication s of frailty as a predictor of morbidity and mortality in inpatient otolaryngologic operations . DESIGN Retrospective review of medical records . SETTING National Surgical Quality Improvement Program ( NSQIP ) participating hospitals . PATIENTS NSQIP participant use files were used to identify 6727 in patients who underwent operations performed by surgeons specializing in otolaryngology between 2005 and 2010 . The study sample was 50.3 % male and 10.2 % African American , with a mean ( range ) age of 54.7 ( 16 - 90 ) years . MAIN OUTCOMES AND MEASURES A previously described modified frailty index ( mFI ) was calculated on the basis of NSQIP variables . The effect of increasing frailty on morbidity and mortality was evaluated using univariate analysis . Multivariate logistic regression was used to compare mFI with age , ASA , and wound classification . RESULTS The mean ( range ) mFI was 0.07 ( 0 - 0.73 ) . As the mFI increased from 0 ( no frailty-associated variables ) to 0.45 ( 5 of 11 ) or higher , mortality risk increased from 0.2 % to 11.9 % . The risk of Clavien-Dindo grade IV complications increased from 1.2 % to 26.2 % . The risk of all complications increased from 9.5 % to 40.5 % . All results were significant at P < .001 . In a multivariate logistic regression model to predict mortality or serious complication , mFI became the dominant significant predictor . CONCLUSIONS AND RELEVANCE The mFI is significantly associated with morbidity and mortality in this retrospective survey . Additional study with prospect i ve analysis and external validation is needed . The mFI may provide an improved underst and ing of preoperative risk , which would facilitate perioperative optimization , risk stratification , and counseling related to outcomes The ability to predict outcomes following a kidney transplant is limited by the complex physiologic decline of kidney failure , a latent factor that is difficult to capture using conventional comorbidity assessment . The frailty phenotype is a recently described inflammatory state of increased vulnerability to stressors result ing from decreased physiologic reserve and dysregulation of multiple physiologic systems . We hypothesized that frailty would be associated with delayed graft function , based on putative associations between inflammatory cytokines and graft dysfunction . We prospect ively measured  frailty  in 183 kidney transplant recipients between December 2008 and April 2010 . Independent associations between frailty and delayed graft function were analyzed using modified Poisson regression . Preoperative frailty was independently associated with a 1.94-fold increased risk for delayed graft function ( 95 % CI , 1.13 - 3.36 ; P = .02 ) . The assessment of frailty may provide further insights into the pathophysiology of allograft dysfunction and may improve our ability to preoperatively risk-stratify kidney transplant recipients Background Individuals ≥80 years of age represent an increasing proportion of colon cancer diagnoses . Selecting these patients for elective surgery is challenging because of diminished overall health , functional decline , and limited data to guide decisions . The objective was to identify overall health measures that are predictive of poor survival after elective surgery in these oldest-old colon cancer patients . Methods Medicare beneficiaries ≥80 years who underwent elective colectomy for stage I – III colon cancer from 1992–2005 were identified from the Surveillance , Epidemiology and End Results (SEER)-Medicare data base . Kaplan – Meier survival analysis determined 90-day and 1-year overall survival . Multivariable logistic regression assessed factors associated with short-term postoperative survival . Results Overall survival for the 12,979 oldest-old patients undergoing elective colectomy for colon cancer was 93.4 and 85.7 % , at 90 days and 1 year . Older age , male gender , frailty , increased hospitalizations in prior year , and dementia were most strongly associated with decreased survival . In addition , AJCC stage III ( vs stage I ) disease and widowed ( vs married ) were highly associated with decreased survival at 1 year . Although only 4.4 % of patients were considered frail , this had the strongest association with mortality , with an odds ratio of 8.4 ( 95 % confidence interval , 6.4–11.1 ) . Conclusions Although most oldest-old colon cancer patients do well after elective colectomy , a significant proportion ( 6.6 % ) die by postoperative day 90 and frailty is the strongest predictor . The ability to identify frailty through billing cl aims is intriguing and suggests the potential to prospect ively identify , through the electronic medical record , patients at highest risk of decreased survival Background Frailty is a phenotype characterized by complex and challenging medical problems and higher susceptibility to adverse health outcomes . It can be derived at by a multidimensional process known as comprehensive geriatric assessment ( CGA ) , which assesses the functional reserves of the elderly . In this study we report for the first time on a prospect i ve evaluation of the association between CGA and postoperative complications after elective laparoscopic cholecystectomy for biliary disease . Methods Fifty-seven patients older than 65 years who were to undergo elective laparoscopic cholecystectomy for uncomplicated biliary disease were prospect ively examined .  Preoperative CGA was performed and the patients were categorized as fit or frail . The main outcome of the study was the rate of any postoperative complication within 30 days of surgery . Results There were 29 women ( 50.9 % ) and the median ( interquartile range ) age of the cohort was 73 ( 8.8 ) years . Thirty-two patients ( 56.1 % ) were categorized as frail and 25 ( 43.9 % ) as fit . The overall incidence of postoperative complications was 23.7 % , most of which were grade I and II ( 18.8 % ) . Frail patients , according to the CGA assessment , experienced a significantly higher incidence of postoperative complications compared to their fit counterparts ( 84.6 vs. 15.4 % , p = 0.023 ) . Frail patients experienced a significantly higher frequency of prolonged ( more than 2 days ) postoperative hospital stay compared with their fit counterparts ( p = 0.023 ) . Conclusions Preoperative CGA may predict postoperative complications and prolonged postoperative hospital stay of elderly patients who undergo elective laparoscopic cholecystectomy . Larger-scale studies independently assessing this association are warranted Objective : To prospect ively evaluate the additional value of geriatric assessment ( GA ) for predicting surgical outcomes in a cohort of older patients undergoing a pancreaticoduodenectomy ( PD ) for pancreatic tumors . Background : Older patients are less often referred for possible PD . St and ard preoperative assessment s may underestimate the likelihood of significant adverse outcomes . The prospect i ve utility of vali date d GA has not been studied in this group . Methods : PD-eligible patients were enrolled in a prospect i ve outcome study . St and ard preoperative assessment s were recorded . Elements of vali date d GA were also measured , including components of Fried 's model of frailty , the Vulnerable Elders Survey ( VES-13 ) , and the Short Physical Performance Battery ( SPPB ) . All postoperative adverse events were recorded , systematic ally review ed , and grade d using the Clavien-Dindo system by a surgeon blinded to the GA results . Multivariate regression analyses were conducted . Results : Seventy-six older patients underwent a PD . Significant unrecognized vulnerability was identified at the baseline : Fried 's “ exhaustion ” ( 37.3 % ) , SPPB < 10 ( 28.5 % ) , and VES-13 > 3 ( 15.4 % ) . Within 30 days of PD , 46 % experienced a severe complication ( Clavien-Dindo grade ≥III ) . In regression analyses controlling for age , the body mass index , the American Society of Anesthesiologists score , and comorbidity burden , Fried 's “ exhaustion ” predicted major complications [ odds ratio ( OR ) = 4.06 ; P = 0.01 ] , longer hospital stays ( & bgr ; = 0.27 ; P = 0.02 ) , and surgical intensive care unit admissions ( OR = 4.30 ; P = 0.01 ) . Both SPPB ( OR = 0.61 ; P = 0.04 ) and older age predicted discharge to a rehabilitation facility ( OR = 1.1 ; P < 0.05 ) and age correlated with a lower likelihood of hospital readmission ( OR = 0.94 ; P = 0.02 ) . Conclusions : Controlling for st and ard preoperative assessment s , worse scores on GA prospect ively and independently predicted important adverse outcomes  . Geriatric assessment may help identify older patients at high risk for complications from PD BACKGROUND The clinical syndrome of frailty identified through the assessment of weight loss , gait speed , grip strength , physical activity , and physical exhaustion has been used to identify patients with reduced reserves . We hypothesized that frailty is useful in predicting adverse outcomes in optimized elective elderly colorectal surgery patients . METHODS A prospect i ve study was conducted at 2 centers ( Singapore and Japan ) . All patients over 75 years of age undergoing colorectal resection were assessed for the presence of the syndrome of frailty .  All these patients had already had their comorbidities optimized for surgery . The outcome measure was postoperative major complications ( defined as Clavien-Dindo type II and above complications ) . RESULTS Eighty-three patients were studied from February 2008 to April 2010 . The mean age was 81.5 years ( range 75 - 93 years ) . The mean comorbidity index was 3.37 ( range 0 - 11 ) . Twenty-six ( 31.3 % ) patients were an American Society of Anesthesiologists ( ASA ) score of 3 and above . Chi-square analysis revealed that the odds ratio of postoperative major complications was 4.083 ( 95 % confidence interval , 1.433 - 11.638 ) when the patient satisfied the criteria for frailty . Albumin < 35 , ASA > 3 , comorbidity index > 5 , and Physiologic and Operative Severity Score for the enUmeration of Mortality and Morbidity ( POSSUM ) scores were not predictive of postoperative major complications . CONCLUSIONS Preliminary findings show that frailty is a potent adjunctive tool of predicting postoperative morbidity . Frailty can be used to identify elderly patients needing further optimization before major surgery
target: RESULTS Severity of frailty syndrome significantly correlated with post-surgical mortality rates and with many although not all post-surgical complications .
  These relationships emerge in different type of surgical procedures and patients ' features .
background: BACKGROUND Frailty is a geriatric syndrome characterized by the clinical presentation of identifiable physical alterations and decreased physiological reserve .
  The assessment of frailty syndrome has been recently related with post-surgical outcomes and overall mortality in older individuals .