Who Thrives After Surgery?

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Martin A. Makary, a surgeon and public health researcher at Johns Hopkins Hospital in Baltimore, had a long talk with a patient last week. The man had a tumor in his pancreas that was probably benign but might not be. Should Dr. Makary remove it? Or should the man have regular scans to see whether it grew?

“If you’re 25, the decision is easy — get rid of that risk,” Dr. Makary told me afterward. But this patient was 89.

Let’s pause for a moment to consider the changing surgical landscape. When Dr. Makary was in training, he recalled, surgeons were just starting to offer elective procedures to patients in their 70s. Now, with better techniques, safer anesthesia and, of course, more old people — half of all operations in the United States are performed on those over age 65.

“It’s become acceptable to do major procedures on very old patients,” he said. “We routinely do elective surgery on people in their 80s and 90s.”

That doesn’t mean it’s always a good idea, or that it’s easy to calculate the costs and benefits. How very old patients respond to surgery has proved unpredictable. “There are some people you worry won’t do well, and then they fly,” Dr. Makary said. “And some people you are confident will do well have a cascade of symptoms that lead to their demise or permanent disability — and everybody is shocked.”

Surgeons eyeball their patients all the time to try to evaluate whether they can recover well from the stress of an operation, but it’s an inexact science. “You can be thrown off by hair or teeth or wrinkles, things that don’t have much to do with physiologic reserve,” Dr. Makary said.

The usual tests surgeons use to try to predict how older patients will fare are crude, Dr. Makary added, mostly based on cardiovascular strength. And standard estimates of mortality and length of hospitalization for specific operations are all but useless for patients who might be 30 or 40 years older than the norm.

But thanks to a rather elegant piece of research by a Johns Hopkins team, recently published in The Journal of the American College of Surgeons, surgeons can give more informative answers when elderly patients in this situation, or their families, wonder what to do.

For years, the geriatrician and gerontologist Linda P. Fried, now dean of the Mailman School of Public Health at Columbia University, has been talking and writing about frailty. We laypeople tend to use the word imprecisely to allude to fragility or vulnerability in old people, but for physicians and researchers, frailty is a specific medical syndrome with measurable criteria.

They look for a series of declines that include weight loss (specifically, an unintentional loss of 10 pounds or more in the past year), a weaker grip, exhaustion and lack of physical activity, and a slower gait. The assessment takes perhaps 15 minutes to conduct in an office. Then the doctors assign a score: 0 to 1 for those who aren’t frail, 2 to 3 for the intermediately frail.

Patients who score 4 to 5 are frail. “They tend to have much less reserve, a decreased ability to bounce back” from physiological stress, said Dr. Fried, who previously taught at Johns Hopkins.

Might frailty scores be better at predicting how patients fare after surgery than the existing methods? For a year, Dr. Makary, Dr. Fried and their colleagues at Johns Hopkins tracked nearly 600 patients over age 65 who had elective surgery in that hospital – from minor gallbladder removal to joint replacement and major abdominal surgery. All lived independently.

The researchers assessed patients’ frailty before their operations: slightly more than 10 percent were adjudged frail (average age 76.3), and more than 58 percent weren’t frail at all (average age 71.3). The remainder were classified as intermediately frail.

“The data are quite persuasive,” Dr. Fried said. “People who are frail before surgery are at higher risk for poor outcomes afterwards.” This is the way careful researchers talk; they say results are “persuasive.”

A layperson like, say, me would say: Yow. The frailty index did a superior job of predicting how seniors will do after surgery, and just look at the extent of the differences.

Those who were intermediately frail faced twice the odds of complications after surgery, compared to patients who were not frail, according to the study; frail patients had more than two and a half times the complication rate. Hospital stays were 44 percent to 53 percent longer for those intermediately frail, and 65 percent to 89 percent longer for the frail.

And after operation, the odds of a patient being discharged to a nursing home or to assisted living, instead of her own home, rose in proportion to her frailty. The intermediately frail were more than three times as likely to have to enter such a facility, compared with those who were not frail. The frail were 20 times (not a typo) as likely to go to a nursing home or assisted living — from which they may or may not have emerged.

“If the risks are likely to be higher, it changes the equation as to whether the surgery has benefit,” Dr. Fried said.

That 89-year-old patient, for example, turned out to be intermediately frail when Dr. Makary evaluated him using the frailty index. “I thought he was stronger,” he acknowledged. After considerable discussion, doctor and patient agreed not to remove the tumor, but to track it with annual scans.

Surgeons at Johns Hopkins have widely adopted the index to help make such pre-op decisions, and Dr. Makary says he has heard from surgeons at about a dozen other major medical centers who are also using it. In some cases, patients may decline surgery. In many, they and their families will have a more realistic idea of how long recovery may take and how much help they will need.

This is a question, Dr. Makary suggested, that older patients and their families ought to routinely ask their surgeons in fairly blunt terms: You want to operate on my father? You think he’s too old for surgery? What’s his frailty score?


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December 28, 2010, 11:04 am
By PAULA SPAN

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SOURCE: http://www.journalacs.org/article/S1072-7515%2810%2900059-1/abstract

Makary MA, Segev DL, Pronovost PJ, Syin D, Bandeen-roche K, Patel P, Takenaga R, Devgan L, Holzmueller CG, Tian J, Fried LP. Frailty as a Predictor of Surgical Outcomes in Older Patients. J Am College Surgeons 2010;210(6):901-908

Department of Surgery, John Hopkins University School of Medicine, Johns Hopkins Medical Institutions, 1550 Orleans Street, Baltimore, MD 21231, USA. mmakary1@jhmi.edu

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 designed a study to determine if frailty predicts surgical complications and enhances current perioperative risk models.

Study Design

We prospectively 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 validated 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 standardized definition can help patients and physicians make more informed decisions.