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Aging and disease    2020, Vol. 11 Issue (5) : 1276-1290     DOI: 10.14336/AD.2019.1024
Review Article |
Influence of Frailty on Outcome in Older Patients Undergoing Non-Cardiac Surgery - A Systematic Review and Meta-Analysis
Elke K.M Tjeertes1, Joris M.K van Fessem1, Francesco U.S Mattace-Raso2, Anton G.M Hoofwijk3, Robert Jan Stolker1, Sanne E Hoeks1,*
1Department of Anesthesiology, Erasmus MC University Medical Center, Rotterdam, the Netherlands
2Department of Internal Medicine, Division of Geriatric Medicine, Erasmus MC University Medical Center, Rotterdam, the Netherlands
3Department of Surgery, Zuyderland Medical Center, Geleen, the Netherlands
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Abstract  

Frailty is increasingly recognized as a better predictor of adverse postoperative events than chronological age. The objective of this review was to systematically evaluate the effect of frailty on postoperative morbidity and mortality. Studies were included if patients underwent non-cardiac surgery and if frailty was measured by a validated instrument using physical, cognitive and functional domains. A systematic search was performed using EMBASE, MEDLINE, Web of Science, CENTRAL and PubMed from 1990 - 2017. Methodological quality was assessed using an assessment tool for prognosis studies. Outcomes were 30-day mortality and complications, one-year mortality, postoperative delirium and discharge location. Meta-analyses using random effect models were performed and presented as pooled risk ratios with confidence intervals and prediction intervals. We included 56 studies involving 1.106.653 patients. Eleven frailty assessment tools were used. Frailty increases risk of 30-day mortality (31 studies, 673.387 patients, risk ratio 3.71 [95% CI 2.89-4.77] (PI 1.38-9.97; I2=95%) and 30-day complications (37 studies, 627.991 patients, RR 2.39 [95% CI 2.02-2.83). Risk of 1-year mortality was threefold higher (six studies, 341.769 patients, RR 3.40 [95% CI 2.42-4.77]). Four studies (N=438) reported on postoperative delirium. Meta-analysis showed a significant increased risk (RR 2.13 [95% CI 1.23-3.67). Finally, frail patients had a higher risk of institutionalization (10 studies, RR 2.30 [95% CI 1.81- 2.92]). Frailty is strongly associated with risk of postoperative complications, delirium, institutionalization and mortality. Preoperative assessment of frailty can be used as a tool for patients and doctors to decide who benefits from surgery and who doesn’t.

Keywords frailty      surgery      outcome      older patients      non-cardiac surgery     
Corresponding Authors: Hoeks Sanne E   
About author:

These authors contributed equally to this work.

Just Accepted Date: 26 November 2019   Issue Date: 21 September 2020
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Tjeertes Elke K.M
van Fessem Joris M.K
Mattace-Raso Francesco U.S
Hoofwijk Anton G.M
Stolker Robert Jan
Hoeks Sanne E
Cite this article:   
Tjeertes Elke K.M,van Fessem Joris M.K,Mattace-Raso Francesco U.S, et al. Influence of Frailty on Outcome in Older Patients Undergoing Non-Cardiac Surgery - A Systematic Review and Meta-Analysis[J]. Aging and disease, 2020, 11(5): 1276-1290.
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http://www.aginganddisease.org/EN/10.14336/AD.2019.1024     OR
Figure 1.  PRISMA flowchart for study selection. This flowchart depicts the flow of information trough different phases of the systematic research.
Figure 2.  Forest plot 30-day mortality per frailty score. The number of events (deaths) and the total number of patients are shown for both frail and non-frail patients, stratified per frailty assessment tool.
Figure 3.  Forest plot postoperative complications per frailty score. The number of events (complications) and the total number of patients are shown for both frail and non-frail patients, stratified per frailty assessment tool.
AuthorNSettingPeriodDesignType of surgeryFrailty scoreDefinition of complicationQuality
Abt1193Multicenter cohort study (NSQIP)2006-2013ProspectiveHead and neck cancer surgeryModified frailty indexCD 4Good
Adams6727Multicenter cohort study (NSQIP)2005-2010ProspectiveHead and neck cancer surgeryModified frailty indexCD 4 or 5Good
Arya23027Multicenter cohort study (NSQIP)2005-2012ProspectiveVascular surgery (Open or EVAR)Modified frailty indexCD 4Good
Augustin13020Multicenter cohort study (NSQIP)2005-2010ProspectivePancreatic resectionsModified frailty indexCD 4Good
Brahmbhatt24645Multicenter cohort study (NSQIP)2005-2012ProspectiveInfrainguinal vascular surgeryModified frailty indexCD 4Good
Bras90Single-center cohort study2008-2013RetrospectiveSurgery for head and neck cancerGroningen frailty indicatorCD ≥ 2Fair
Chappidi2679Multicenter cohort study (NSQIP)2011-2013ProspectiveRadical cystectomyModified frailty indexCD 4 or 5Good
Chimukangara885Multicenter cohort study (NSQIP)2011-2013ProspectiveParaesofageal hernia repairModified frailty indexCD ≥ 3Fair
Cloney243Multicenter cohort study (NSQIP)2000-2012ProspectiveGlioblastoma surgeryModified frailty indexComplications (Glioma Outcomes Project System)Fair
Cooper415Multicenter cohort study2010-2013ProspectiveGeneral and orthopedic surgeryFrailty phenotype; frailty indexMajor complicationsFair
Courtney-Brooks37Single-center cohort study2011ProspectiveSurgery for gynecologic cancerFried frailty criteriaSurgical complications (NSQIP)Fair
Dale76Single-center cohort study2007-2011ProspectivePancreaticoduodenectomy4 (of 5) components of Fried frailty criteria; VES-13CD ≥ 3Fair
Dasgupta125Single-center cohort study2002-2003ProspectiveElective noncardiac surgery (82%) orthopedic)Edmonton frail scaleCardiac - / pulmonary comlications, PODFair
Farhat35334Multicenter cohort study (NSQIP)2005-2009ProspectiveEmergency general surgeryModified frailty indexAny complication (not mortality)Fair
Flexman52671Multicenter cohort study (NSQIP)2006-2012ProspectiveSpine surgeryModified frailty indexMajor complicationsGood
Hewitt102Multicenter cohort study2013ProspectiveEmergency general surgeryRockwood clinical frailty scaleNot reportedFair
Huisman328Multicenter cohort study2008-2012ProspectiveSurgery for solid tumorsGroningen frailty indicator; VES-13CD ≥ 3Good
Joseph220Single-center cohort study2012-2014ProspectiveEmergency general surgeryRockwood clinical frailty scaleSurgical complications (NSQIP)Fair
Kenig184Single-center cohort study2013-2014ProspectiveEmergency abdominal surgeryVES-13, GFI; Rockwood; Balducci; TRST; Geriatric-8Any complication (CD)Fair
Kim197Single-center cohort study2012-2014ProspectiveElective noncardiac surgeryFried frailty criteriaSurgical complications (NSQIP)Good
Kim275Single-center cohort study2011-2012ProspectiveElective intermediate-risk or high-risk surgeryMultidimensional frailty scoreSurgical complications (NSQIP)Good
Krishnan178Single-center cohort study2011ProspectiveLow trauma hip fracture surgeryFrailty indexNot reportedPoor
Kristjansson178Multicenter cohort study2008-2011ProspectiveElective surgery for colorectal cancerComprehensive geriatric assessmentCD ≥ 2Good
Kua82Single-center cohort study2013ProspectiveHip fracture surgeryEdmonton frail scale; (modified) Fried frailty criteriaAny complicationFair
Lascano41681Multicenter cohort study (NSQIP)2005-2013ProspectiveSurgery for urologic cancerModified frailty indexCD 4Good
Lasithiotakis57Single-center cohort study2008-2011ProspectiveElective laparoscopic cholecystectomyComprehensive geriatric assessmentAny complicationPoor
Leung63Single-center cohort study2007ProspectiveNoncardiac surgeryFried frailty criteriaNot reportedFair
Levy23104Multicenter cohort study (NSQIP)2008 to 2014ProspectiveRobot-assisted radical prostatectomyModified frailty indexCD 4Good
Li189Single-center cohort studyNot reportedProspectiveMajor intra-abdominal surgeryFried frailty criteriaCDFair
Louwers10300Multicenter cohort study (NSQIP)2005-2011ProspectiveHepatectomyModified frailty indexCD 4Good
Makary594Single-center cohort study2005-2006ProspectiveElective surgeryFried frailty criteriaSurgical complications (NSQIP)Good
McAdams-DeMarco537Single-center cohort study2008-2013ProspectiveKidney transplant surgeryFried frailty criteriaNot reportedFair
McIsaac202811Single-center cohort study2002-2012RetrospectiveMajor elective noncardiac surgeryACG frailty-defining diagnoses indicatorNot reportedGood
McIsaac125163Single-center cohort study2003-2012RetrospectiveTotal joint arthroplastyACG frailty-defining diagnoses indicatorICU-admissionGood
Melin44832Multicenter cohort study (NSQIP)2005-2011ProspectiveCarotid endarterectomyFrailty-based bedside Risk Analysis IndexNot reportedFair
Mogal9986Multicenter cohort study (NSQIP)2005-2012ProspectivePancreaticoduodenectomyModified frailty indexCD 3 or 4Good
Mosquera232352Multicenter cohort study (NSQIP)2005-2012Prospectiveelective high-risk surgeryModified frailty indexMajor and minor complicationsFair
Neuman12979Single-center cohort study1992-2005RetrospectiveElective colorectal cancer surgeryACG frailty-defining diagnoses indicatorReadmission within 30 daysFair
Obeid58448Multicenter cohort study (NSQIP)2005-2009ProspectiveLaparoscopic and open colectomyModified frailty indexCD 4 or 5Fair
Partridge125Single-center cohort study2011ProspectiveArterial vascular surgeryEdmonton frail scaleComposite postoperative complicationsFair
Pearl4330Multicenter cohort study (NSQIP)2011-2014ProspectiveRadical cystectomyModified frailty indexMajor in-hospital complicationsGood
Phan3920Multicenter cohort study (NSQIP)2010-2014ProspectiveElective anterior lumbar interbody fusion (ALIF) surgeryModified frailty indexAny complicationGood
Reisinger159Single-center cohort study2010-2012ProspectiveColorectal surgeryGroningen frailty indicatorSepsisGood
Revenig351Single-center cohort studyNot reportedProspectiveMajor intra-abdominal surgeryFried frailty criteriaCD 1-4Fair
Revenig80Single-center cohort studyNot reportedProspectiveIntra-abdominal minimally invasive surgeryFried frailty criteriaCD 1-4Fair
Revenig189Single-center cohort studyNot reportedProspectiveMajor intra-abdominal surgeryFried frailty criteriaAny complicationGood
Robinson72Single-center cohort study2007-2010ProspectiveColorectal surgeryRockwood clinical frailty scaleAny postoperative complication (VASQIP)Fair
Shin6148 ACDF; 817 PCFMulticenter cohort study (NSQIP)2005-2012ProspectiveCervical spine fusion; anterior cervical discectomy and fusion or posterior cervical fusionModified frailty indexCD 4Good
Shin14583 THA; 25223 TKAMulticenter cohort study (NSQIP)2005-2012ProspectiveTotal hip and knee arthroplastyModified frailty indexCD 4Good
Suskind95108Multicenter cohort study (NSQIP)2007-2013ProspectiveCommon urological surgeryModified frailty indexMajor and minor complicationsGood
Suskind20794Multicenter cohort study (NSQIP)2011-2013ProspectiveInpatient urological surgeryModified frailty indexNot reportedGood
Tan83Multicenter cohort study2008-2010ProspectiveColorectal surgeryFried frailty criteriaCD ≥ 2Fair
Tegels127Single-center cohort study2005-2012RetrospectiveSurgery for gastric cancerGroningen frailty indicatorCD ≥ 3Fair
Tsiouris1940Multicenter cohort study (NSQIP)2005-2010ProspectiveOpen lobectomyModified frailty indexCD 4Good
Ugolini46Single-center cohort study2009-2012ProspectiveElective colorectal cancer surgeryGroningen frailty indicator; VES-13Not reportedPoor
Uppal6551Multicenter cohort study (NSQIP)2008-2011ProspectiveSurgery for gynecologic cancerModified frailty indexCD 4 and 5Good
Table 1  Study demographics and method of determining frailty.
Figure 4.  Forest plot 1-year mortality. The number of events (one-year mortality) and the total number of patients are depicted for frail and non-frail patients.
Figure 5.  Forest plot postoperative delirium. The number of events (delirium) and the total number of patients are depicted for frail and non-frail patients.
Figure 6.  Forest plot discharge to specialized facility. The number of events (discharge to a specialized facility) and the total number of patients are depicted for frail and non-frail patients.
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