Indicators of frailty are excellent predictors of complications in a variety of surgical settings (see list of our prior columns on frailty and surgery at the end of today’s column). In fact, we’ve often stressed that assessment for frailty is probably the most important pre-op consideration in the geriatric patient undergoing surgery.
Two studies from the University of Arizona Medical Center have now focused on use of frailty indices in geriatric trauma patients. The first (Joseph 2014a) was a 2-year prospective study at their level I trauma center of 250 trauma patients aged 65 years and older. The frailty index they used consisted of 50 variables that could be assessed for preadmission status. Frailty was present in 40% of the total geriatric trauma population. The frailty score was an independent predictor of both inhospital complications and adverse discharge disposition. Urinary tract infections and pneumonia were the most common complications among the patients with frailty.
Patients with frailty also had longer hospital lengths of stay (LOS) and ICU lengths of stay and, thus, higher hospital costs. Adverse discharge dispositions (death or discharge to a nursing home) were also significantly more common among patients with frailty (37.3% vs. 12.9%). All 5 deaths in their study occurred in patients with frailty. The frailty score was better than patient age as a predictor of complications and adverse discharge disposition. In their study the frailty score was also a better predictor of adverse discharge disposition than the Injury Severity Score.
The authors note that geriatric patients are becoming an increasing portion of the trauma population and that they have been historically underrepresented in academic studies of trauma patients.
Use of a frailty index could thus help identify trauma patients at greatest risk of complications and help us identify patients in need of additional resources. It should also help us be realistic when discussing long-term plans with patients’ families and caretakers.
And the frailty index might also be important in stratifying patient risk. From their results, it would be predictable that use of mortality rates and complication rates to compare trauma centers could be very misleading if the proportion of frail patients differs considerably across centers.
The above study utilized the frailty index developed by Searle et al (Searle 2008), also known by some as the Rockwood index (named for the senior author of that paper). That index has 50 variables, most of which can be dichotomized (i.e. yes or no response), allowing for a summated score. It does, however, utilize variables that measure a patient’s performance status before their trauma occurred. While it is unlikely that trauma surgeons would be administering this frailty index themselves on their patients, it would be very easy to train other members of the multidisciplinary trauma team to administer it.
Our regular readers know we favor simpler screening for frailty (see prior columns listed below). The Timed-Up-and-Go Test works remarkably well as a simple, easy, brief predictor of frailty and can be easily performed in a physician’s office prior to surgery. However, it’s obvious that you don’t have that opportunity in the trauma patient.
The University of Arizona Medical Center researchers (Joseph 2014b), cognizant of the challenges in using a 50-variable frailty index, have developed their own modified 15-variable Trauma-Specific Frailty Index (TSFI). They performed a 2-year prospective analysis of all geriatric trauma patients (n = 200) presenting to their Level I trauma center and showed the TSFI score was an independent predictor of unfavorable discharge disposition, whereas age was not. The authors conclude that the Trauma-Specific Frailty Index is an effective tool that can aid clinicians in planning discharge disposition of geriatric trauma patients.
It should really come as no surprise that frail patients fare worse after trauma. But the University of Arizona studies increase our awareness of the magnitude of this problem in the trauma population and provide use with some very useful tools to help manage such patients.
Some of our prior columns on preoperative assessment and frailty:
Joseph B, Pandit V, Zangbar B, et al. Superiority of Frailty Over Age in Predicting Outcomes Among Geriatric Trauma Patients: A Prospective Analysis. JAMA Surg 2014; 149(8): 766-772
Searle SD, Mitnitski A, Gahbauer EA, et al. A standard procedure for creating a frailty index. BMC Geriatr 2008; 8: 24
Joseph B, Pandit V, Zangbar B, et al. Validating Trauma-Specific Frailty Index for Geriatric Trauma Patients: A Prospective Analysis. J Amer Coll Surg 2014; 219(1): 10–17, July 2014
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