Redefining Geriatric Pre-Operative Assessment Using Frailty, Disability And Co-Morbidity
*Thomas N Robinson1, Ben Eiseman1, *Jeffrey I Wallace1, *Skotti D Church1, *Kim K McFann1, *Shirley M Pfister2, *Terra J Sharp2, *Marc Moss1
1University of Colorado, Aurora, CO;2Denver VA Medical Center, Denver, CO
Geriatric surgery patients have unique physiologic vulnerability requiring pre-operative assessment beyond the traditional evaluation of older adults. The constellation of frailty, disability and co-morbidity predict poor outcomes in elderly hospitalized patients.
OBJECTIVES: (1) Determine the relationship of geriatric markers to six-month post-operative mortality in elderly patients. (2) Create a clinical prediction rule using geriatric markers for pre-operative assessment.
METHODS: Prospectively, subjects ≥65 years undergoing a major operation requiring post-operative ICU admission were enrolled. Pre-operative geriatric markers included: Mini-Cog Test (cognition), having fallen within past 6 months, albumin, Katz Score (function) and Charlson Index (co-morbidities). Outcome measures included six-month mortality (primary) and post-discharge institutionalization (secondary). Univariate and multivariate analyses were performed.
RESULTS: 110 subjects (age 74±6 years) were studied. Six-month mortality was 15% (16/110). Pre-operative markers related to six-month mortality included: greater cognitive dysfunction (p<0.01), having fallen in past six months (p<0.01), lower albumin (p<0.01), functional dependence (p<0.01) and increased co-morbidities (p<0.01). Similar statistical significance was found for all five markers and post-discharge institutionalization. Logistic regression identified any functional dependence (Odds Ratio 13) as the strongest predictor of six-month mortality. Four or more markers in any one patient predicted six-month mortality with a sensitivity of 75% (12/16) and specificity of 90% (85/94).
CONCLUSIONS: Geriatric-specific markers for frailty, disability and co-morbidity predict six-month post-operative mortality and post-discharge institutionalization. The preoperative presence of ≥4 geriatric-specific markers has high sensitivity and specificity for six-month mortality. Pre-operative assessment using geriatric-specific markers is a substantial paradigm shift from the traditional pre-operative evaluation of older adults.