1. FRAILTY AND THE PREOPERATIVE ASSESSMENT Thomas Robinson, MD Associate Professor, Surgery University of Colorado August 5th, 2009 THE AMERICAN GERIATRICS SOCIETY Geriatrics Health Professionals. Leading change. Improving care for older adults. AGS

2. TRADITIONAL PREOPERATIVE EVALUATION Single end-organ function assessment does not capture all the information required to predict adverse outcomes for the geriatric patient Slide 2

3. Frailty is an excess vulnerability to stressors, with reduced ability to maintain or regain homeostasis after a destabilizing event A non-specific state of increasing risk… measured by the accumulation of frailty traits JAGS. (2006) 54:991. JAGS. (2007) 7:722. Slide 3 DEFINITION OF FRAILTY

4. FRAILTY Depressed Mood Functional Impairment Geriatric Syndromes Low Albumin FRAILTY CHARACTERISTICS Impaired Cognition Burden Chronic Disease Slide 4 Depressed Mood Functional Impairment Geriatric Syndromes Low Albumin Impaired Cognition Burden of Chronic Disease

5. ACCUMULATION OF FRAILTY CHARACTERISTICS AVERAGE OUTCOMES POOR OUTCOMES Slide 5 FRAILTY

6. Functional Impairment Normal Mood Slide 6 AVERAGE OUTCOMES POOR OUTCOMES FRAILTY ACCUMULATION OF FRAILTY CHARACTERISTICS

7. Impaired Cognition Functional Impairment No Geriatric Syndromes Normal Mood Slide 7 AVERAGE OUTCOMES POOR OUTCOMES FRAILTY ACCUMULATION OF FRAILTY CHARACTERISTICS

8. Impaired Cognition Functional Impairment No Geriatric Syndromes Normal Mood Low Burden of Chronic Disease Normal Albumin Slide 8 AVERAGE OUTCOMES POOR OUTCOMES FRAILTY ACCUMULATION OF FRAILTY CHARACTERISTICS

9. High Burden of Chronic Disease Impaired Cognition Functional Impairment Low Albumin No Geriatric Syndromes Normal Mood Slide 9 AVERAGE OUTCOMES POOR OUTCOMES FRAILTY ACCUMULATION OF FRAILTY CHARACTERISTICS

10. FRAILTY AND POSTOPERATIVE COMPLICATIONS Long-Term Hospital Course OPERATION Slide 10

11. Patients age 70 years undergoing inpatient operations (n = 125) underwent baseline frailty assessment Increased frailty score was associated with: Increased post-op complications (P =.02) Longer hospital stay (P <.01) Arch Gerontol Geriatr (2009) 48:78. Crit Rev Onc/Heme. (2009) epub. Slide 11 FRAILTY AND POSTOPERATIVE COMPLICATIONS Long-Term Hospital Course OPERATION

12. Patients age 65 years undergoing inpatient operations (n = 110) underwent baseline frailty assessment Four or more frailty markers predicted 6-month mortality: Sensitivity 81% Specificity 86% Ann Surg. (2009) 250:449. Slide 12 FRAILTY AND POSTOPERATIVE COMPLICATIONS Long-Term Hospital Course OPERATION

13. FRAILTY Depressed Mood Functional Impairment Geriatric Syndromes Low Albumin FRAILTY CHARACTERISTICS Impaired Cognition Burden Chronic Disease Slide 13 Depressed Mood Functional Impairment Geriatric Syndromes Low Albumin Impaired Cognition Burden of Chronic Disease

14. FRAILTY Depressed Mood Functional Impairment Geriatric Syndromes Low Albumin FRAILTY CHARACTERISTICS Impaired Cognition Burden Chronic Disease Slide 14 Depressed Mood Functional Impairment Geriatric Syndromes Low Albumin Impaired Cognition Burden Chronic Disease

15. FRAILTY CHARACTERISTIC: FUNCTION JACS. (2010) 210:503. Slide 15

16. FRAILTY CHARACTERISTIC: FUNCTION JACS. (2010) 210:503. Slide 16

17. FRAILTY Depressed Mood Functional Impairment Geriatric Syndromes Low Albumin FRAILTY CHARACTERISTICS Impaired Cognition Burden Chronic Disease Slide 17 Depressed Mood Functional Impairment Geriatric Syndromes Low Albumin Impaired Cognition Burden of Chronic Disease

18. FRAILTY CHARACTERISTIC: HYPOALBUMINEMIA Arch Surg. (1999) 134:36. J Am Coll Surg. (1997) 185:315. Slide 18 Lower albumin is related to increased thirty-day morbidity and mortality across multiple surgical specialties in a dose response fashion. Low serum albumin level was found to be most closely related to 30-day post- operative mortality from more than 30 pre- operative variables.

19. FRAILTY Depressed Mood Functional Impairment Geriatric Syndromes Low Albumin FRAILTY CHARACTERISTICS Impaired Cognition Burden Chronic Disease Slide 19 Depressed Mood Functional Impairment Geriatric Syndromes Low Albumin Impaired Cognition Burden of Chronic Disease

20. FRAILTY CHARACTERISTIC: GERIATRIC SYNDROMES ASA score of III or IV is closely related to 1-year mortality following hip fracture (P <.001) Pre-existing burden of chronic disease predicts 1-year mortality following hip fracture J Bone Joint Surg. (1995) 77:1551. J Bone Min Res. (2005) 20:494. Slide 20

21. FRAILTY Depressed Mood Functional Impairment Geriatric Syndromes Low Albumin FRAILTY CHARACTERISTICS Impaired Cognition Burden Chronic Disease Slide 21 Depressed Mood Functional Impairment Geriatric Syndromes Low Albumin Impaired Cognition Burden of Chronic Disease

22. FRAILTY CHARACTERISTIC: COGNITION Dan Wu, Tom Robinson. American College of Surgeons Surgical Forum (2010). Slide 22

23. FRAILTY Depressed Mood Functional Impairment Geriatric Syndromes Low Albumin FRAILTY CHARACTERISTICS Impaired Cognition Burden Chronic Disease Slide 23 Depressed Mood Functional Impairment Geriatric Syndromes Low Albumin Impaired Cognition Burden of Chronic Disease

24. FRAILTY CHARACTERISTIC: MOOD Ann Thor Surg. (2005) 79:1255. Slide 24

25. FRAILTY Depressed Mood Functional Impairment Geriatric Syndromes Low Albumin FRAILTY CHARACTERISTICS Impaired Cognition Burden Chronic Disease Slide 25 Depressed Mood Functional Impairment Geriatric Syndromes Low Albumin Impaired Cognition Burden of Chronic Disease

26. FRAILTY CHARACTERISTIC: GERIATRIC SYNDROMES Ann Surg. (2009) 250:449. Slide 26

27. High Burden of Chronic Disease Impaired Cognition Functional Impairment Low Albumin No Geriatric Syndromes Normal Mood Slide 27 AVERAGE OUTCOMES POOR OUTCOMES FRAILTY ACCUMULATION OF FRAILTY CHARACTERISTICS

28. Visit us at: Facebook.com/AmericanGeriatricsSociety Twitter.com/AmerGeriatrics www.americangeriatrics.org THANK YOU FOR YOUR TIME! linkedin.com/company/american-geriatrics- society Slide 28