1 UCSF Vascular & Endovascular Symposium 2015 UCSF - - PowerPoint PPT Presentation

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UCSF Vascular & Endovascular Symposium 2015

Frailty in Vascular Surgery Patients

UCSF

FRAILTY AND COGNITION IN THE ASSESSMENT OF VASCULAR SUGERY PATIENTS

UCSF Vascular & Endovascular Symposium 2015

Frailty in Vascular Surgery Patients

UCSF

DISCLOSURES INDIVIDUAL None INSTITUTIONAL Cook, Inc Not discussing off-label use of anything

UCSF Vascular & Endovascular Symposium 2015

Frailty in Vascular Surgery Patients

UCSF

WHY

Frailty increases with age

UCSF Vascular & Endovascular Symposium 2015

Frailty in Vascular Surgery Patients

UCSF

WHY

Frailty increases with age Etzioni et al, Ann Surg, 2003

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UCSF Vascular & Endovascular Symposium 2015

Frailty in Vascular Surgery Patients

UCSF

WHY

Frailty increases with age Etzioni et al, Ann Surg, 2003

UCSF Vascular & Endovascular Symposium 2015

Frailty in Vascular Surgery Patients

UCSF

DEFINITION

Fried Frailty Phenotype

Unintentional weight loss Self-reported exhaustion Weakness (grip strength) Slow walking speed Low physical activity Fried et al, J Gerontology, 2001

UCSF Vascular & Endovascular Symposium 2015

Frailty in Vascular Surgery Patients

UCSF

WHAT IS FRAILTY

UCSF Vascular & Endovascular Symposium 2015

Frailty in Vascular Surgery Patients

UCSF

WHAT IS FRAILTY

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UCSF Vascular & Endovascular Symposium 2015

Frailty in Vascular Surgery Patients

UCSF

WHAT IS FRAILTY

Revenig et al, J Surg Res 2015

UCSF Vascular & Endovascular Symposium 2015

Frailty in Vascular Surgery Patients

UCSF

WHAT IS FRAILTY

Hii et al, Heart, Lung and Circulation, 2014

UCSF Vascular & Endovascular Symposium 2015

Frailty in Vascular Surgery Patients

UCSF

DEFINITION

Decreased physiologic reserve and resistance

to stressors

Disruption of homeostatic mechanisms leading

to a vulnerable state

Increased vulnerability to stressors as a result

• f decreased physiological reserve

UCSF Vascular & Endovascular Symposium 2015

Frailty in Vascular Surgery Patients

UCSF

FRAILTY ASSESSMENT

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

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UCSF Vascular & Endovascular Symposium 2015

Frailty in Vascular Surgery Patients

UCSF

SCALES

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 FRAIL Scale Comprehensive Geriatric Assessment

UCSF Vascular & Endovascular Symposium 2015

Frailty in Vascular Surgery Patients

UCSF

SCALES

Fried Frailty Phenotype

Unintentional weight loss Self-reported exhaustion Weakness (grip strength) Slow walking speed Low physical activity Jung et al, J Thorac Cardiovasc Surg, 2014

UCSF Vascular & Endovascular Symposium 2015

Frailty in Vascular Surgery Patients

UCSF

SCALES

Fried Frailty Phenotype

Unintentional weight loss Self-reported exhaustion Weakness (grip strength) Slow walking speed Low physical activity Fried et al, J Gerontology, 2001

SURVIVAL

UCSF Vascular & Endovascular Symposium 2015

Frailty in Vascular Surgery Patients

UCSF

SCALES

Rockwood—Canadian Study of Health and Aging (CSHA) Frailty Index

Rockwood K et al, CMAJ, 2005

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UCSF Vascular & Endovascular Symposium 2015

Frailty in Vascular Surgery Patients

UCSF

SCALES

Rockwood—Canadian Study of Health and Aging (CSHA) Frailty Index

UCSF Vascular & Endovascular Symposium 2015

Frailty in Vascular Surgery Patients

UCSF

SCALES

Rockwood—Canadian Study of Health and Aging (CSHA) Frailty Index

Rockwood K et al, CMAJ, 2005

UCSF Vascular & Endovascular Symposium 2015

Frailty in Vascular Surgery Patients

UCSF

SCALES

Edmonton Frail Scale

Rolfson et al, Age Ageing, 2006

UCSF Vascular & Endovascular Symposium 2015

Frailty in Vascular Surgery Patients

UCSF

SCALES

Edmonton Frail Scale

Rolfson et al, Age Ageing, 2006

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UCSF Vascular & Endovascular Symposium 2015

Frailty in Vascular Surgery Patients

UCSF

SCALES

modified Frailty Index

Beggs et al, Can J Anesth, 2015

UCSF Vascular & Endovascular Symposium 2015

Frailty in Vascular Surgery Patients

UCSF

SCALES

modified Frailty Index

Arya et al, J Vasc Surg, 2015 Karam et al, Ann Vasc Surg, 2013 Melin et al, J Vasc Surg, 2015 UCSF Vascular & Endovascular Symposium 2015

Frailty in Vascular Surgery Patients

UCSF

SCALES

Comprehensive Assessment of Frailty

Beggs et al, Can J Anesth, 2015

UCSF Vascular & Endovascular Symposium 2015

Frailty in Vascular Surgery Patients

UCSF

FRAILTY AND VASCULAR SURGERY OUTCOMES

Englesbe et al, Ann Surg, 2012

Psoas Muscle Mass

General & Vascular Procedures

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UCSF Vascular & Endovascular Symposium 2015

Frailty in Vascular Surgery Patients

UCSF

FRAILTY AND VASCULAR SURGERY OUTCOMES

Lee et al, J Vasc Surg, 2011

Psoas Muscle Mass

AAA Repair

UCSF Vascular & Endovascular Symposium 2015

Frailty in Vascular Surgery Patients

UCSF

FRAILTY AND VASCULAR SURGERY OUTCOMES

Ambler et al Brit J Surg, 2015

Addenbrooke Vascular Frailty Score

All Vascular Procedures

UCSF Vascular & Endovascular Symposium 2015

Frailty in Vascular Surgery Patients

UCSF

FRAILTY AND VASCULAR SURGERY OUTCOMES

Ambler et al Brit J Surg, 2015

Addenbrooke Vascular Frailty Score

All Vascular Procedures

UCSF Vascular & Endovascular Symposium 2015

Frailty in Vascular Surgery Patients

UCSF

FRAILTY AND VASCULAR SURGERY OUTCOMES

Overall Survival Readmission – Free Survival

Ambler et al, Brit J Surg, 2015

Addenbrooke Vascular Frailty Score

All Vascular Procedures

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UCSF Vascular & Endovascular Symposium 2015

Frailty in Vascular Surgery Patients

UCSF

FRAILTY AND VASCULAR SURGERY OUTCOMES

Karam et al, Ann Vasc Surg, 2013

Canadian Study of Health and Aging Frailty Index All Vascular Procedures

UCSF Vascular & Endovascular Symposium 2015

Frailty in Vascular Surgery Patients

UCSF

FRAILTY AND VASCULAR SURGERY OUTCOMES

Karam et al, Ann Vasc Surg, 2013

Canadian Study of Health and Aging Frailty Index All Vascular Procedures

UCSF Vascular & Endovascular Symposium 2015

Frailty in Vascular Surgery Patients

UCSF

FRAILTY AND VASCULAR SURGERY OUTCOMES

Melin et al, J Vasc Surg, 2015

Risk Analysis Index Matched to NSQIP Variables (mFI) Carotid Endarterectomy

UCSF Vascular & Endovascular Symposium 2015

Frailty in Vascular Surgery Patients

UCSF

FRAILTY AND VASCULAR SURGERY OUTCOMES

Melin et al, J Vasc Surg, 2015

Risk Analysis Index Matched to NSQIP Variables (mFI) Carotid Endarterectomy

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UCSF Vascular & Endovascular Symposium 2015

Frailty in Vascular Surgery Patients

UCSF

FRAILTY AND VASCULAR SURGERY OUTCOMES

Scarborough et al, Ann Surg, 2015

Functional Health Status (NSQIP) General & Vascular

UCSF Vascular & Endovascular Symposium 2015

Frailty in Vascular Surgery Patients

UCSF

FRAILTY AND VASCULAR SURGERY OUTCOMES

Scarborough et al, Ann Surg, 2015

Functional Health Status (NSQIP) All Vascular

UCSF Vascular & Endovascular Symposium 2015

Frailty in Vascular Surgery Patients

UCSF

FRAILTY AND VASCULAR SURGERY OUTCOMES

Velanovich et al, J Surg Res, 2013

Modified Frailty Index (NSQIP)

UCSF Vascular & Endovascular Symposium 2015

Frailty in Vascular Surgery Patients

UCSF

IMPAIRED COGNITION

Partridge et al, J Vasc Surg, 2014

Impaired cognition in vascular patients

68% 88% unrecognized 60% of the study group previously

not known to have cognition issue

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UCSF Vascular & Endovascular Symposium 2015

Frailty in Vascular Surgery Patients

UCSF

IMPAIRED COGNITION

Partridge et al, J Vasc Surg, 2014

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

UCSF Vascular & Endovascular Symposium 2015

Frailty in Vascular Surgery Patients

UCSF

IMPAIRED COGNITION

Partridge et al, J Vasc Surg, 2014

UCSF Vascular & Endovascular Symposium 2015

Frailty in Vascular Surgery Patients

UCSF

CAN FRAILTY BE MODIFIED?

Progression of the frailty syndrome

• Natural history is to progress to a state
• f greater frailty
• But some patients become less frail
• Suggesting that the frailty continuum can

be modified

UCSF Vascular & Endovascular Symposium 2015

Frailty in Vascular Surgery Patients

UCSF

CAN FRAILTY 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

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UCSF Vascular & Endovascular Symposium 2015

Frailty in Vascular Surgery Patients

UCSF

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

• lder 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

UCSF Vascular & Endovascular Symposium 2015

Frailty in Vascular Surgery Patients

UCSF

CAN FRAILTY BE MODIFIED?

Frailty intervention

• PREHAB Study underway

Cardiac surgery patients Standard care vs standard care + 8-week exercise and education program

UCSF Vascular & Endovascular Symposium 2015

Frailty in Vascular Surgery Patients

UCSF

CAN FRAILTY BE USED CLINICALLY?

UCSF Vascular & Endovascular Symposium 2015

Frailty in Vascular Surgery Patients

UCSF