FRAILTY AND COGNITION IN THE ASSESSMENT OF VASCULAR SUGERY PATIENTS WHY WHY DISCLOSURES. INDIVIDUAL None. INSTITUTIONAL Cook, Inc

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1 DISCLOSURES FRAILTY AND COGNITION IN THE ASSESSMENT OF VASCULAR SUGERY PATIENTS INDIVIDUAL None INSTITUTIONAL Cook, Inc Not discussing off-label use of anything WHY WHY Frailty increases with age Frailty increases with age Etzioni et al, Ann Surg,

2 WHY DEFINITION Frailty increases with age Fried Frailty Phenotype Unintentional weight loss Self-reported exhaustion Weakness (grip strength) Slow walking speed Low physical activity Fried et al, J Gerontology, 2001 Etzioni et al, Ann Surg, 2003 WHAT IS FRAILTY WHAT IS FRAILTY 2

3 WHAT IS FRAILTY WHAT IS FRAILTY Revenig et al, J Surg Res 2015 Hii et al, Heart, Lung and Circulation, 2014 DEFINITION FRAILTY ASSESSMENT Decreased physiologic reserve and resistance to stressors Disruption of homeostatic mechanisms leading to a vulnerable state Increased vulnerability to stressors as a result of decreased physiological reserve Single variables Psoas muscle mass (sarcopenia) Walking speed Grip strength Time to up and go (TUAG) Multi-dimensional Scales Medical co-morbidities Medication number nutrition Mental health Cognition Mood Functional status Dependence / independence Social circumstances Environment 3

4 Fried frailty phenotype Rockwood Canadian Study of Health and Aging (CSHA) Frailty Index Edmonton Frail Scale modified Frailty Index Comprehensive Assessment of Frailty Groningen Frailty Indicator Tilburgh Frailty Indicator Fried Frailty Phenotype Unintentional weight loss Self-reported exhaustion Weakness (grip strength) Slow walking speed Low physical activity FRAIL Scale Comprehensive Geriatric Assessment Jung et al, J Thorac Cardiovasc Surg, 2014 Fried Frailty Phenotype Unintentional weight loss Self-reported exhaustion Weakness (grip strength) Slow walking speed Low physical activity SURVIVAL Rockwood Canadian Study of Health and Aging (CSHA) Frailty Index Fried et al, J Gerontology, 2001 Rockwood K et al, CMAJ,

5 Rockwood Canadian Study of Health and Aging (CSHA) Frailty Index Rockwood Canadian Study of Health and Aging (CSHA) Frailty Index Rockwood K et al, CMAJ, 2005 Edmonton Frail Scale Edmonton Frail Scale Rolfson et al, Age Ageing, 2006 Rolfson et al, Age Ageing,

6 modified Frailty Index modified Frailty Index Beggs et al, Can J Anesth, 2015 Arya et al, J Vasc Surg, Karam 2015 et al, Ann Vasc Surg, Melin 2013et al, J Vasc Surg, 2015 Comprehensive Assessment of Frailty Psoas Muscle Mass General & Vascular Procedures Beggs et al, Can J Anesth, 2015 Englesbe et al, Ann Surg,

7 Psoas Muscle Mass Addenbrooke Vascular Frailty Score AAA Repair All Vascular Procedures Lee et al, J Vasc Surg, 2011 Ambler et al Brit J Surg, 2015 Addenbrooke Vascular Frailty Score Addenbrooke Vascular Frailty Score All Vascular Procedures Overall Survival Readmission Free Survival All Vascular Procedures Ambler et al Brit J Surg, 2015 Ambler et al, Brit J Surg,

8 Canadian Study of Health and Aging Frailty Index Canadian Study of Health and Aging Frailty Index All Vascular Procedures All Vascular Procedures Karam et al, Ann Vasc Surg, 2013 Karam et al, Ann Vasc Surg, 2013 Risk Analysis Index Matched to NSQIP Variables (mfi) Risk Analysis Index Matched to NSQIP Variables (mfi) Carotid Endarterectomy Carotid Endarterectomy Melin et al, J Vasc Surg, 2015 Melin et al, J Vasc Surg,

9 Functional Health Status (NSQIP) General & Vascular Functional Health Status (NSQIP) All Vascular Scarborough et al, Ann Surg, 2015 Scarborough et al, Ann Surg, 2015 Modified Frailty Index (NSQIP) IMPAIRED COGNITION Impaired cognition in vascular patients 68% 88% unrecognized 60% of the study group previously not known to have cognition issue Velanovich et al, J Surg Res, 2013 Partridge et al, J Vasc Surg,

10 IMPAIRED COGNITION IMPAIRED COGNITION Predictive preoperative variables Receives home care Lives alone On > 6 medications Diabetes Multisite vascular disease Hearing impairment Preoperative gait speed <6 m/s TUAG 20 s EFS score 6.5 Partridge et al, J Vasc Surg, 2014 Partridge et al, J Vasc Surg, 2014 CAN FRAILTY BE MODIFIED? CAN FRAILTY BE MODIFIED? Progression of the frailty syndrome Natural history is to progress to a state of greater frailty But some patients become less frail Suggesting that the frailty continuum can be modified Frailty intervention Exercise Increase in gait speed over 12 months improves 8-year survival Other forms of exercise remain controversial Nutrition Treating anemia pre-elective ortho procedures reduces morbidity & moratlity Accepted to replete iron, B12 and folate 28 days preop Possibly Vitamin D repletion Impact of improving other nutritional deficiencies is not clear 10

11 CAN FRAILTY BE MODIFIED? CAN FRAILTY BE MODIFIED? Frailty intervention Pharmacologic Growth hormone & anabolic steroids not recommended Anti-inflammatory agents (CRP, albumin, IL-6, TNF-a) Antioxidants and creatine unclear ACE inhibitors have been shown in a randomized study to improve exercise capacity and reduce falls in older patients with impaired ADLs Socioeconomic Depression 5 studies (2 RCT and 3 before/after) showed a positive impact on morbidity, mortality and LOS after just CGA Frailty intervention PREHAB Study underway Cardiac surgery patients Standard care vs standard care + 8-week exercise and education program CAN FRAILTY BE USED CLINICALLY? 11