Influence of frailty in older patients undergoing emergency laparotomy: a UK-based observational study

Introduction The National Emergency Laparotomy Audit (NELA) has reported that older patients (≥65 years) form a large percentage of emergency high-risk cases with increased postoperative morbidity and mortality. With the population continuing to age rapidly, it is clear that a greater understanding of the factors affecting surgical outcomes in older patients is required. Frailty is a relatively new concept taking into account a variety of factors that increase an individual’s vulnerability to increased dependency and death. Research has suggested that high frailty scores increase postoperative complications, length of stay and mortality but the majority of these studies have been carried out on elective patients. Knowledge of how frailty affects patients in an emergency setting would aid clinicians’ and patients’ decision-making process. Methods and analysis This multicentre study will include consecutive adult patients aged 65 years and over undergoing emergency laparotomies over a 3-month period at 52 National Health Service hospitals across the UK. The primary outcome will be 90-day mortality. Secondary outcomes will include length of hospital stay, 30-day complications, change in level of independence and 30-day readmission. This study has been powered to detect a 10% change in mortality associated with frailty (n=500 patients). Ethics and dissemination This study has been approved by the National Health Service Research Ethics Committee. It has been registered centrally with HRA for English sites, NRSPCC for Scottish sites and Health and Care Research Permissions Service for sites in Wales.Dissemination will be via international and national surgical and geriatric conferences. In addition, manuscripts will be prepared following the close of the project. Trial registration number This study is also registered online at www.clinicaltrials.gov (registration number NCT02952430)

Decision-making in COVID-19 and Frailty

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Impact of surgery on older patients hospitalized with an acute abdomen : findings from the Older Persons Surgical Outcome Collaborative

Acknowledgments: We thank our collaborator (Professor Susan Moug) and data collectors listed below.Peer reviewedPublisher PD

Frailty in older patients undergoing emergency laparotomy

Objective: This study aimed to document the prevalence of frailty in older adults undergoing emergency laparotomy and to explore relationships between frailty and postoperative morbidity and mortality. Summary Background Data: The majority of adults undergoing emergency laparotomy are older adults (≥65 y) that carry the highest mortality. Improved understanding is urgently needed to allow development of targeted interventions. Methods: An observational multicenter (n=49) UK study was performed (March–June 2017). All older adults undergoing emergency laparotomy were included. Preoperative frailty score was calculated using the progressive Clinical Frailty Score (CFS): 1 (very fit) to 7 (severely frail). Primary outcome measures were the prevalence of frailty (CFS 5–7) and its association to mortality at 90 days postoperative. Secondary outcomes included 30-day mortality and morbidity, length of critical care, and overall hospital stay. Results: A total of 937 older adults underwent emergency laparotomy: frailty was present in 20%. Ninety-day mortality was 19.5%. After age and sex adjustment, the risk of 90-day mortality was directly associated with frailty: CFS 5 adjusted odds ratio (aOR) 3.18 [95% confidence interval (CI), 1.24–8.14] and CFS 6/7 aOR 6·10 (95% CI, 2.26–16.45) compared with CFS 1. Similar associations were found for 30-day mortality. Increasing frailty was also associated with increased risk of complications, length of Intensive Care Unit, and overall hospital stay. Conclusions: A fifth of older adults undergoing emergency laparotomy are frail. The presence of frailty is associated with greater risks of postoperative mortality and morbidity and is independent of age. Frailty scoring should be integrated into acute surgical assessment practice to aid decision-making and development of novel postoperative strategies

The prevalence of hyperglycaemia and its relationship with mortality, readmissions and length of stay in an older acute surgical population : a multicentre study

Funding statement This research received no specific grant from any funding agency in the public, commercial or not-for-profit sector.Peer reviewedPostprin

Prevalence of multimorbidity and its association with outcomes in older emergency general surgical patients : an observational study

Funding: This research received no specific grant from any funding agency in the public, commercial or not-for-profit sectors.Peer reviewedPublisher PD

FMALE score: combining practical risk scales to improve preoperative predictive accuracy in emergency general surgery: a multi-centre prospective cohort study

Our increasingly aging population is associated with older people being admitted to surgical wards at a rate surpassing population growth. 1 Although frailty is not exclusive to older adults, its prevalence is positively associated with age. 2 Hewitt et al. observed frailty to independently predict increased length of hospital stay (LOS), 30-day and 90-day mortality for adults aged ≥65 years admitted to emergency general surgery (EGS). 3 Recent evidence has shown that the association between frailty and poor outcomes, is not limited to older adults, but extends to all adult EGS patients. 4 Although risk stratification tools have been derived for EGS patients, none have included a measure for frailty. 5 Previously, Ablett et al. suggested the MALE score to identify older patients at risk of poorer outcomes who may benefit from comprehensive geriatric assessment based on four characteristics obtained at the point of care: Male, Anaemic, Low albumin, and age Eight-five and over. 6 We aimed to investigate whether the accuracy of MALE score could be augmented, through incorporating physical frailty defined by the Clinical Frailty Scale (CFS), and applied to all EGS adults

SHARP risk score: a predictor of poor outcomes in adults admitted for emergency general surgery: a prospective cohort study

Purpose Post-operative complications following emergency abdominal surgery are associated with significant morbidity and mortality. Despite the knowledge of prognostic factors associated with poor surgical outcomes; few have described risks of poor outcomes based on admission information in acute surgical setting. We aimed to derive a simple, point-of-care risk scale that predicts adults with increased risk of poor outcomes. Methods We used data from an international multi-centre prospective cohort study. The effect of characteristics; age, hypoalbuminaemia, anaemia, renal insufficiency and polypharmacy on 90-day mortality was examined using fully adjusted multivariable models. For our secondary outcome we aimed to test whether these characteristics could be combined to predict poor outcomes in adults undergoing emergency general surgery. Subsequently, the impact of incremental increase in derived SHARP score on outcomes was assessed. Results The cohort consisted of 419 adult patients between the ages of 16–94 years (median 52; IQR(39) consecutively admitted to five emergency general surgical units across the United Kingdom and one in Ghent, Belgium. In fully adjusted models the aforementioned characteristics; were associated with 90-day mortality. SHARP score was associated with higher odds of mortality in adults who underwent emergency general surgery, with a SHARP score of five also being associated with an increased length of hospital stay. Conclusions SHARP risk score is a simple prognostic tool, using point-of-care information to predict poor outcomes in patients undergoing emergency general surgery. This information may be used to improve management plans and aid clinicians in delivering more person-centred care. Further validation studies are required to prove its utility

Study protocol for the COPE study: COVID-19 in Older People : the influence of frailty and multimorbidity on survival. A multi-centre, European observational study

Funding: The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.Peer reviewedPublisher PD

Cognitive impairment in older patients undergoing colorectal surgery

Background: With increasing numbers of older people being referred for elective colorectal surgery, cognitive impairment is likely to be present and affect many aspects of the surgical pathway. This study is aimed to determine the prevalence of cognitive impairment and assess it against surgical outcomes. Methods: The Montreal Cognitive Assessment (MoCA) was carried out in patients aged more than 65 years. We recorded demographic information. Data were collected on length of hospital stay, complications and 30-day mortality. Results: There were 101 patients assessed, median age was 74 years (interquartile range = 68–80), 54 (53.5%) were women. In total, 58 people (57.4%) ‘failed’ the Montreal Cognitive Assessment test (score ≤ 25). There were two deaths (3.4%) within 30 days of surgery in the abnormal Montreal Cognitive Assessment group and none in the normal group. Twenty-nine (28.7%) people experienced a complication. The percentage of patients with complications was higher in the group with normal Montreal Cognitive Assessment (41.9%) than abnormal Montreal Cognitive Assessment (19.9%) (p = 0.01) and the severity of those complications were greater (chi-squared for trend p = 0.01). The length of stay was longer in people with an abnormal Montreal Cognitive Assessment (mean 8.1 days vs. 5.8 days, p = 0.03). Conclusion: Cognitive impairment was common, which has implications for informed consent. Cognitive impairment was associated with less postoperative complications but a longer length of hospital stay