Domains of Frailty Predict Loss of Independence in Older Adults after Non-Cardiac Surgery

Ann Surg. 2022 Sep 20. doi: 10.1097/SLA.0000000000005720. Online ahead of print.


IMPORTANCE: Preoperative frailty has been consistently associated with death, severe complications, and loss of independence after surgery. Loss of independence is an important patient-centered outcome, but it is unclear which domains of frailty are most strongly associated with loss of independence. 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 can predict loss of independence in older adults after non cardiac surgery.

DESIGN: Retrospective Cohort Study.

SETTING: One Academic Hospital.

PARTICIPANTS: Patients aged 65 or older who were living independently and evaluated with the Edmonton Frail Scale (EFS) during a preoperative visit to the Center for Preoperative Optimization at the Johns Hopkins Hospital between June 2018 and January 2020.

MAIN OUTCOME: Loss of independence (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 prior to 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 loss of independence. Total EFS score was associated with LOI (OR 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 prediction of LOI with the final model achieving an area under the curve (AUC) 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 AUC of 0.838.

CONCLUSION AND RELEVANCE: Among domains measured by the EFS prior to a wide range of non-cardiac surgeries in older adults, functional performance, functional dependence, social support, and urinary incontinence were independently associated with and improved the prediction of loss of independence. Clinical initiatives to mitigate LOI may consider screening with the EFS and targeting abnormalities within these domains.

PMID:36124773 | DOI:10.1097/SLA.0000000000005720

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