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22 (); 304-307
doi:
10.1016/j.jor.2020.05.024

Peri-operative management of frailty in the orthopedic patient

, , , ,
a UCI Center on Stress and Health, School of Medicine, University of California-Irvine, Irvine, CA, USA
b Chicago Medical School, Rosalind Franklin University of Medicine and Science, North Chicago, IL, USA
c Department of Anesthesiology and Perioperative Care, University of California-Irvine, Irvine, CA, USA
d Sue & Bill Gross School of Nursing, University of California‐Irvine, Irvine, CA, USA
e Department of Pediatric Psychology, Children's Hospital of Orange County, Orange, CA, USA
f Department of Anesthesiology, Pain Medicine, and Critical Care, Beth Israel Deaconess Medical Center, Boston, MA, USA
g Department of Pediatrics, Children's Hospital of Orange County, Orange, CA, USA
h Yale Child Study Center, Yale University School of Medicine, New Haven, CT, USA

∗Corresponding author: Zeev N. Kain. zkain@uci.edu

Received: , Accepted: ,
Professor P K Surendran Memorial Education Foundation
Disclaimer:
This article was originally published by Reed Elsevier India Pvt. Ltd. and was migrated to Scientific Scholar after the change of Publisher.

Abstract

Abstract

The purpose of this investigation was to summarize current research on diagnosis, outcomes, and management of frail patients undergoing orthopedic surgery. Because frail patients are at increased risk of negative post-operative outcomes including increased 30-day mortality and post-operative complications including infections and delirium, such a review is timely. Strategies including supervised exercise training programs before surgery, early identification of frailty, prophylactic antibiotics, regular drug chart review, regular monitoring of electrolytes, and other strategies to prevent post-operative delirium are helpful in the management of frail orthopedic patients. It is important for surgeons and anesthesiologists to take action in attempt to alleviate adverse post-operative outcomes in frail patients. Ultimately, more research is needed to identify new strategies and to evaluate whether pre-operative optimization can effectively mitigate post-operative outcomes in large-scale randomized controlled trials.

Keywords

Anesthesiology
Orthopedic surgery
Frailty
Geriatrics
Perioperative management
1

1 Introduction

With medical and technological advances, global life expectancy has increased significantly in the past few decades and by year 2030, at least 30% of the population in the United States is expected to be older than 65 years.1 To keep pace with the increasing lifespan, surgical and anesthetic services will need to be adapted to provide safe and specialized care for the older population. Accordingly, there has been heightened attention focused on the concept of frailty in the older adult surgical population in the past decade.

It was only in 2001 that Fried and colleagues defined frailty as a biological condition with its own symptoms and functional impairments that is not synonymous to advanced age,.2 An international panel in 2011 concluded that frailty is a multidimensional concept comprised of 6 domains including physical performance, gait speed, mobility, nutritional status, mental health, and cognition.3 We and others conclude that ultimately frailty is a measure of decreased physiologic reserve across multiple organ systems.4 Frailty has been reported to be associated with an increased perioperative complication rate in older adults undergoing elective and emergency surgeries4–7 and mortality rates are higher among frail patients undergoing surgery.8–11 Total Hip Arthroplasty (THA) and Total Knee Arthroplasty (TKA) surgeries are specifically associated with increased morbidity and mortality in the frail population12,13

As a direct consequence of the growing aging population, the demand for orthopedic surgical procedures is increasing. A recent study predicted the demand for THA to increase by 174%–572,000 procedures per year and the demand for TKA to increase by 673% to 3.48 million procedures per year by the year 2030. The growing number of orthopedic procedures in the older adult population, high prevalence of frailty in the surgical population, and increased risk for morbidity and mortality in frail older adult surgical patients all highlight the importance of increased focus on frailty in the orthopedic space. Accordingly, in this review we seek to summarize the current research and recommendations on frailty in patients undergoing orthopedic surgery. We incorporate the classical biomedical approach to disease that will include a discussion of risk factors, outcomes, diagnosis and management of frailty in this patient population.

2

2 How to diagnose and screen frailty?

Unfortunately, there is not one single and simple way to diagnose frailty. Rather, there have been at least 27 frailty scales developed to date14 and the screening tools that exist are either scoring systems based on physical, mental, and functional abilities or single measures of frailty based on functional capabilities.2,15–19 Each screening tool has its own advantages and disadvantages; therefore, caution must be used in selecting the optimal screening tool based on both the patient and the context.

Fried developed an early standardized phenotype for frailty using data from over 5300 adults over age 65 in the Cardiovascular Heart Study.2 This screening method is called the Frailty Phenotype (FP) and predicts falls, disability, worsening mobility, future hospitalization, and death, but it fails to account for changes in cognition and mood,20 which are crucial components to frailty (Appendix A). However, this measure has methodological flaws as diagnosis of frailty via detection of two or more characteristics has limited theoretical grounds and there is no reliability or validity data.21

Since the development of the Frailty Phenotype, researchers developed the Frailty Index (FI),22 which consists of 44 items. The FI has been found to be an effective measure for frail patients undergoing major elective orthopedic surgeries including total hip and knee replacement and lumbar, sacral, or cervical laminectomy.23 After the FI was first developed, it was revised to become the Modified Frailty Index (mFI).24 This modified scale provides an even simpler measure of frailty, as the mFI consists of only 11 items along with information about functional status from the medical record to stratify patients into risk categories and predict post-operative outcomes (Appendix B).

In terms of orthopedic surgeries, the mFI has also been proven to be an effective risk assessment tool for both THA and TKA in addition to being easier to implement.17,18,25,26 It has been shown to be a stronger predictor for readmission, post-operative complications, re-operation, and post-operative mortality.16 Throughout the past few years, the mFI has been shrunk to a 5-factor mFI (mFI-5).27 A recent study comparing the credibility of the mFI-5 compared to the original 11 factor mFI has found it an equally credible predictor of frailty in all surgical subspecialties with a correlation coefficient of above 0.9 for all surgical subspecialties except cardiac and vascular surgery.27 Several recent studies have found the 5-mFI a strong predictor of frailty and post-operative morbidity and mortality in a wide variety of surgeries including primary hip and knee arthroplasty, kyphoplasty vertebral augmentation, posterior lumbar fusion, distal radius fractures repair.28–31

The Frailty Phenotype has five domains and all domains have to be collected specifically for the purpose of the phenotype. Some domains also require the use of specialized equipment and training for the collection of data such as weakness and slow gait domains, which require the measurement of grip strength and gait speed, for example. Furthermore, the FI has its own challenges as it has 42 variables and thus requires the use of an algorithm to extract information from individual electronic medical records and administrative databases.32

Ultimately, the FP, FI, and the 5 factor mFI are all useful for assessing and screening for frailty pre-operatively for patients undergoing major elective orthopedic surgery32 but differ in the level of complicity. The mFI-5 has the benefit of simplicity with only 5 variables to measure and without the need for specialized equipment and therefore may be the most clinically useful. In the research setting, the original FI may have the most utility as it is more detailed in its inclusion of 70 clinical deficits in a wide variety of domains to more precisely stratify individuals into risk categories. However, both the mFI and mFI-5 have been proven useful in identifying frailty before surgery; therefore, selection of the optimal measure for pre-operative frailty will depend upon feasibility considerations such as available data, logistical constraints, and provider preference32.

3

3 What are the outcomes for frailty?

Previous research has reported that frailty is highly associated with post-operative mortality12,25,26,33,.34 Frailty is associated with post-operative mortality in patients undergoing surgery for pelvis and lower extremity fractures, adult spinal deformity, femoral neck fracture, primary hip arthroplasty, and primary knee arthroplasty12,25,26,33,.34 Higher mFI scores are associated with increased post-operative mortality and are shown to be a stronger predictor of post-operative mortality compared to age, obesity class, and ASA class12,25,26,33,.34 Various studies have shown different results as to increased post-operative mortality for spine surgery, orthopedic trauma, THA, TKA, and HA (Table 1).

Table 1 Percent Increase in 30-Day Mortality, Re-Operation, Readmission, Clavien-Dindo Class IV Complications and Any Complications with Increase in mFI Score by Type of Orthopedic Surgery.
Orthopedic Surgery Type 30-Day Mortality (% increase) Re-operation (% increase) Readmission (% increase) Clavien-Dindo Class IV Complications (% increase) Any Complications (% increase)
Spine 9.7% 10% N/A N/A 25%
Orthopedic Trauma 10.5% 1.3% 13.3% 9.6% 8.5%
THA 4.08% 3.19% 11.28% N/A 14.8%
TKA 1.49% N/A 9.45% N/A 11.27%
HA 11% N/A N/A 4.9% N/A

There is also an increased risk of post-operative complications, length of stay, and readmission in frail patients undergoing orthopedic surgery.12 Specifically, as can be seen in Table 1, there are a significant number of post-operative complications that are associated with frailty. There is an increased risk of Clavien-Dindo Class IV complications and hospital acquired conditions (surgical-site infections, pneumonia, venous thromboembolism, and urinary tract infections) with increased mFI score12,13,25,26,33–37 for patients undergoing spine surgery, orthopedic trauma, THA, TKA, and HA (Table 1).

Several recent studies have found an association with frailty with the occurrence of post-operative delirium.38–40 Frailty is also associated with higher delirium severity as measured by the Confusion Assessment Method (CAM).41 Furthermore, for post-operative delirium in frail patients, it has been shown that there is an association with delirium and longer length of hospitalization, lower baseline functional status, and pre-operative cognitive impairment.42–44

4

4 How to manage the orthopedic frail patient?

Excellent pain control, optimizing sleep environment, minimizing tethers, cognitive reorientation with clocks, clear communication, early mobilization, and good nutrition have been reported to improve the outcome in this group of patients.45,46 Identification and management of triggering factors such as sepsis, dehydration, electrolyte imbalance, and substance withdrawal is paramount.47 The European Society of Anesthesiology recommends implementing fast-track surgery to prevent post-operative delirium in high-risk patients such as those who are frail.45,46 Specific suggestions for anesthesia management include avoiding potentially inappropriate medications such as benzodiazepines for pre-medication and monitoring of anesthesia depth to avoid excessive depth.45,46

Optimization strategies for functional status for frail patients include referring patients to obtain formal physical therapy evaluations, obtaining assistive devices, and planning for in-hospital and post discharge rehabilitative therapy. Pre-operative exercise programs often referred to as pre-habilitation to improve strength and mobility have shown minimal to no improvement in post-operative outcomes including reduced risk of discharge to a rehabilitation facility post-discharge, improved strength, and functional ability.48 A recent systematic review by Wang et al. that included 33 studies found that only two studies reported a significant reduction in several different pain scores at 6 and 12 weeks post-operatively as a function of pre-habilitation.48 Only 25% of the studies reported significant improvement of post-operative function which was measured by various ADL scales and various ranges of motion on the operated joint.48,49 Furthermore, length of stay, cost, and quality of life were not significantly changed following these interventions.48

To prevent common post-operative infections including respiratory, wound, and urinary infections, antibiotics and standard infection protocols should be given and followed.50 Frail patients are also at increased risk for opportunistic infections such as MRSA (methicillin-resistant staph aureus) or clostridium difficile and iatrogenic problems that arise from unnecessary medication as there is a high rate of unnecessary prescribing in hospitals.50 Even when drugs are prescribed appropriately, polypharmacy and altered pharmacodynamics and kinetics can lead to systemic side effects including nausea, lethargy, confusion, anorexia, dizziness, constipation, and electrolyte imbalance. Therefore, regular drug chart review and rationalization of each medication is important.50

To prevent problems with fluid and electrolyte imbalance, regular monitoring of urea and electrolytes, weight and blood pressure (both standing and lying), and drug charts should be regularly reviewed.50 Postoperative volume overload or volume depletion is common in frail patients especially in patients with poor oral intake which can lead to exertional dyspnea, fatigue, drowsiness, and postural hypotension.50

Ultimately, there is a lack of evidence that frailty can be attenuated or reversed once established. Nevertheless, some strategies including supervised exercise training programs before surgery, early identification of frailty, prophylactic antibiotics, regular drug chart review, regular monitoring of urea and electrolytes, and strategies to prevent post-operative delirium may be helpful in the management of the frail orthopedic patient.

5

5 Conclusion

As the world population ages, the demand for surgical care in older and frail patients will continue to increase. As such, it is crucial for clinicians and researchers to tailor the peri-operative pathway for these patients as they present unique challenges. Since there is currently a lack of evidence that frailty can be attenuated or reversed, it is important for anesthesiologists and surgeons to initiate preventative action in order to counter the development of this disease. These preventive strategies include pre-operative supervised exercise programs, early identification of frailty, prophylactic antibiotics, regular drug chart review, regular monitoring of urea and creatinine, and implementing strategies to prevent post-operative delirium. Ultimately, more research is needed to identify new strategies to prevent and reduce negative post-operative outcomes in frail patients as well as to evaluate whether pre-operative optimization can effectively mitigate post-operative outcomes in large-scale randomized controlled trials.

References

  2. , , , et al . Frailty in older adults: evidence for a phenotype. J Gerontol Ser A Biol Sci Med Sci. 2001;56(3):M146-M157.
    [Google Scholar]
  3. , , , et al . Searching for an operational definition of frailty: a delphi method based consensus statement. The frailty operative definition-consensus conference project. J Gerontol Ser A. Jan. 2013;68(1):62-67.
    [Google Scholar]
  4. , , , et al . Association of frailty with failure to rescue after low-risk and high-risk inpatient surgery. JAMA Surg. May 2018;153(5)
    [Google Scholar]
  5. , , , et al . Association of patient frailty with increased morbidity after common ambulatory general surgery operations. JAMA Surg. Feb. 2018;153(2):160.
    [Google Scholar]
  6. , , , et al . Frailty predicts risk of life-threatening complications and mortality after pancreatic resections. Surgery. Oct. 2016;160(4):987-996.
    [Google Scholar]
  7. , , , et al . Emergency general surgery in the elderly: too old or too frail? J Am Coll Surg. May 2016;222(5):805-813.
    [Google Scholar]
  8. , , , et al . Addition of frailty and disability to cardiac surgery risk scores identifies elderly patients at high risk of mortality or major morbidity. Circ Cardiovasc Qual Outcomes. Mar. 2012;5(2):222-228.
    [Google Scholar]
  9. , , , et al . Comprehensive assessment of frailty for elderly high-risk patients undergoing cardiac surgery. Eur J Cardio Thorac Surg. Jan. 2011;39(1):33-37.
    [Google Scholar]
  10. , , , , , . Assessment of morbidity and mortality after esophagectomy using a modified frailty index. Ann Thorac Surg. Oct. 2013;96(4):1240-1245.
    [Google Scholar]
  11. , , , , , . Simplified frailty index to predict adverse outcomes and mortality in vascular surgery patients. Ann Vasc Surg. Oct. 2013;27(7):904-908.
    [Google Scholar]
  12. , , , , . The impact of frailty on outcomes and healthcare resource usage after total joint arthroplasty. Bone Joint Lett J.. Jun. 2016;98-B(6):799-805.
    [Google Scholar]
  13. , , , , , . Impact of frailty on outcomes in geriatric femoral neck fracture management: an analysis of national surgical quality improvement program dataset. Int J Surg. Apr. 2016;28:185-190.
    [Google Scholar]
  14. , , , et al . Measures of frailty in population-based studies: an overview. BMC Geriatr. Dec. 2013;13(1):64.
    [Google Scholar]
  15. , , , , , . Validity and reliability of the edmonton frail scale. Age Ageing. Sep. 2006;35(5):526-529.
    [Google Scholar]
  16. , , , . Frailty in the older surgical patient: a review. Age Ageing. 2012;41(2):142-147.
    [Google Scholar]
  17. , , . Frailty in relation to the accumulation of deficits. Journals Gerontol. Ser. A Biol. Sci. Med. Sci.. Jul. 2007;62(7):722-727.
    [Google Scholar]
  18. , , , , , , . Outcome instruments to measure frailty: a systematic review. Ageing Res Rev. Jan. 2011;10(1):104-114.
    [Google Scholar]
  19. , , , , , , . Development of an easy prognostic score for frailty outcomes in the aged. Age Ageing. 2008;37(2):161-166.
    [Google Scholar]
  20. , , , . Peri-operative optimisation of elderly and frail patients: a narrative review. Anaesthesia. Jan. 2019;74:80-89.
    [Google Scholar]
  21. , , , et al . Psychometric properties of multicomponent tools designed to assess frailty in older adults: a systematic review. BMC Geriatr. Dec. 2016;16(1):55.
    [Google Scholar]
  22. , , , et al . A global clinical measure of fitness and frailty in elderly people. CMAJ (Can Med Assoc J). Aug. 2005;173(5):489-495.
    [Google Scholar]
  23. , , , , , . Use of the modified frailty index to predict 30-day morbidity and mortality from spine surgery. J Neurosurg. 2016;25(537):541.
    [Google Scholar]
  24. , , , , , , . A modified frailty index to assess morbidity and mortality after lobectomy. J Surg Res. 2013;183(1):40-46.
    [Google Scholar]
  25. , , , , , , . Modified frailty index is an effective risk assessment tool in primary total knee arthroplasty. J Arthroplasty. Sep. 2017;32(9):S177-S182.
    [Google Scholar]
  26. , , , , , , . Modified frailty index is an effective risk assessment tool in primary total hip arthroplasty. J Arthroplasty. Oct. 2017;32(10):2963-2968.
    [Google Scholar]
  27. , , , , . New 5-factor modified frailty index using American college of surgeons NSQIP data. J Am Coll Surg. 2018;226(2):173-181.
    [Google Scholar]
  28. , , , , . The 5-item modified frailty index is predictive of 30-day postoperative complications in patients undergoing kyphoplasty vertebral augmentation. World Neurosurg. 2018;116:e225-e231.
    [Google Scholar]
  29. , , , , , . New 5-factor modified frailty index predicts morbidity and mortality in primary hip and knee arthroplasty. J Arthroplasty. 2019;34(1):140-144.
    [Google Scholar]
  30. , , , , , , . The modified 5-item frailty index: a concise and useful tool for assessing the impact of frailty on postoperative morbidity following elective posterior lumbar fusions. World Neurosurg. 2019;S1878-8750(19):30035-30038.
    [Google Scholar]
  31. , , , , , . Use of a 5-item modified frailty index for risk stratification in patients undergoing surgical management of distal radius fractures. J. Hand Surg. Am.. 2018;43(8):701-709.
    [Google Scholar]
  32. , , , et al . Comparison of frailty measures as predictors of outcomes after orthopedic surgery. J Am Geriatr Soc. Dec. 2016;64(12):2464-2471.
    [Google Scholar]
  33. , , , et al . Frailty index is a significant predictor of complications and mortality after surgery for adult spinal deformity. Spine Phila. Pa.. 1976;41
    [Google Scholar]
  34. , , , , . The frail fail: increased mortality and post-operative complications in orthopaedic trauma patients. Injury. 2017;48(11):2443-2450.
    [Google Scholar]
  35. , , , . The impact of frailty on short-term outcomes after elective hip and knee arthroplasty in older adults: a systematic review. Geriatr. Orthop. Surg. Rehabil.. Jan. 2019;10
    [Google Scholar]
  36. , , , , . Simplified frailty index as a predictor of adverse outcomes in total hip and knee arthroplasty. J Arthroplasty. 2016;31(11):2389-2394.
    [Google Scholar]
  37. , , , et al . Complications during hospitalization and risk factors in elderly patients with hip fracture following integrated orthogeriatric treatment. Arch Orthop Trauma Surg. 2017;137(4):507-515.
    [Google Scholar]
  38. , , , , , . Impact of frailty on post-operative outcome of major orthopaedic surgery in older Indian. J Indian Acad Geosci. 2018;14
    [Google Scholar]
  39. , , , , . Which frailty measure is a good predictor of early post-operative complications in elderly hip fracture patients? Arch Orthop Trauma Surg. May 2016;136(5):639-647.
    [Google Scholar]
  40. , , , et al . Prognostic factors of in-hospital complications after hip fracture surgery: a scoping review. Osteoporos Int Apr. 2019:1-13.
    [Google Scholar]
  41. , , , et al . Preoperative frailty is associated with higher postoperative delirium incidence and severity. Innov Aging. Nov. 2018;2(suppl_1)
    [Google Scholar]
  42. , , , , . Frailty and short-term outcomes in patients with hip fracture. Geriatr Orthop Surg Rehabil. Sep. 2015;6(3):209-214.
    [Google Scholar]
  43. , , , et al . Poor performance on a preoperative cognitive screening test predicts postoperative complications in older orthopedic surgical patients. Anesthesiology. Nov. 2017;127(5):765-774.
    [Google Scholar]
  44. , , , , , , . Risk factors for onset of delirium after neck of femur fracture surgery: a prospective observational study. SICOT-J. 2018;4:27.
    [Google Scholar]
  45. , , , et al . European Society of Anaesthesiology evidence-based and consensus-based guideline on postoperative delirium. Eur J Anaesthesiol. Apr. 2017;34(4):192-214.
    [Google Scholar]
  46. , , , . Peri-operative optimisation of elderly and frail patients: a narrative review. Anaesthesia. Jan. 2019;74:80-89.
    [Google Scholar]
  47. , , , et al . Postoperative delirium in older adults: best practice statement from the American geriatrics society. J Am Coll Surg. Feb. 2015;220(2)
    [Google Scholar]
  48. , , , , , , . Does preoperative rehabilitation for patients planning to undergo joint replacement surgery improve outcomes? A systematic review and meta-analysis of randomised controlled trials. BMJ Open. Feb. 2016;6(2)
    [Google Scholar]
  49. , , . Frailty and anesthesia. Curr Opin Anaesthesiol. Jun. 2017;30(3):409-417.
    [Google Scholar]
  50. , . Medical input, rehabilitation and discharge planning for patients with hip fracture: why traditional models are not fit for purpose and how things are changing. Curr Anaesth Crit Care. Feb. 2005;16(1):11-22.
    [Google Scholar]

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