Age, co-morbidity and frailty   Theo WiggersBarbara van Leeuwen       Cascais, Portugal   Sunday February 13th,2011      D...
Introduction   Comorbidity   Frailty   Conclusion                        This lecture               •Introduction         ...
Introduction   Comorbidity   Frailty   Conclusion                 Ageing in The Netherlands
Introduction   Comorbidity   Frailty   Conclusion                     Life expectancy                       ♀             ...
Introduction   Comorbidity   Frailty   Conclusion                More cancers in the elderly                              ...
Introduction   Comorbidity   Frailty   Conclusion        The impact of cancer in an ageing world                          ...
Introduction   Comorbidity   Frailty   Conclusion     1-and 6 mortality after rectal cancer surgery                       ...
Introduction   Comorbidity   Frailty    Conclusion                   Age and complications                                ...
Introduction   Comorbidity   Frailty   Conclusion          No improvement in survival for elderly                         ...
Introduction   Comorbidity     Frailty   Conclusion                       Cognitive decline                               ...
Introduction   Comorbidity   Frailty    Conclusion           Post Operative Cognitive dysfunction                 1064 Pat...
Introduction   Comorbidity   Frailty   Conclusion                      Mortality and POCD                                 ...
Introduction   Comorbidity   Frailty      Conclusion     Life time risk of non communicable disease                (heart,...
Introduction   Comorbidity   Frailty    Conclusion       Comorbidity and rectal cancer treatment                          ...
Introduction   Comorbidity    Frailty     Conclusion                             Disability • Inability to perform   every...
Introduction   Comorbidity          Frailty          Conclusion                  Disability:                     Comorbidi...
Introduction   Comorbidity   Frailty   Conclusion
Introduction   Comorbidity   Frailty   Conclusion                             Frailty • Vulnerability associated with age ...
Introduction   Comorbidity     Frailty   Conclusion                             Identifying frail elderly
Introduction   Comorbidity   Frailty   Conclusion         Estimating frailty in the surgical patient •   Predict postopera...
Introduction        Comorbidity         Frailty            Conclusion                         Identifying frail elderly   ...
Introduction   Comorbidity   Frailty   Conclusion                    Identifying frail elderly    • Preoperative Assessmen...
Introduction   Comorbidity   Frailty   Conclusion                             PACE • MMS (abnormal <24): Mini Mental State...
Introduction      Comorbidity            Frailty      Conclusion               PACE and hospital stay           Component ...
Introduction   Comorbidity         Frailty      Conclusion                  PACE and complications               Component...
Introduction    Comorbidity   Frailty   Conclusion               Groningen Frailty Index (GFI)    •   15 questions    •   ...
Introduction   Comorbidity   Frailty   Conclusion                               GFI    Mobility    Physical fitness    Vis...
Introduction   Comorbidity   Frailty   Conclusion                               GFI    Mobility    Can the patient perform...
Introduction   Comorbidity   Frailty   Conclusion                               GFI    Hearing    7. Does the patient enco...
Introduction   Comorbidity   Frailty   Conclusion                                 GFI   Psychosocial   11. Does the patien...
Introduction   Comorbidity   Frailty      Conclusion                             GFI     • Currently used in national stud...
Introduction   Comorbidity   Frailty   Conclusion                Perioperative care
Introduction      Comorbidity           Frailty         Conclusion                               LIFE study   •   Multicen...
Introduction   Comorbidity   Frailty    Conclusion                         LIFE study   • Incidence of postoperative delir...
Introduction   Comorbidity   Frailty   Conclusion                         Conclusion   • The increase in postoperative mor...
Introduction   Comorbidity   Frailty   Conclusion               Co morbidity, disability, frailty               Prevent ov...
MCC 2011 - Slide 5
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MCC 2011 - Slide 5

  1. 1. Age, co-morbidity and frailty Theo WiggersBarbara van Leeuwen Cascais, Portugal Sunday February 13th,2011 Department of Surgery, University Medical Center Groningen
  2. 2. Introduction Comorbidity Frailty Conclusion This lecture •Introduction •Co morbidity/ disability •Frailty •Conclusions
  3. 3. Introduction Comorbidity Frailty Conclusion Ageing in The Netherlands
  4. 4. Introduction Comorbidity Frailty Conclusion Life expectancy ♀ ♂ Walter LC, JAMA 2001
  5. 5. Introduction Comorbidity Frailty Conclusion More cancers in the elderly Quaglia et al Int J Cancer 2007
  6. 6. Introduction Comorbidity Frailty Conclusion The impact of cancer in an ageing world WHO data 2007
  7. 7. Introduction Comorbidity Frailty Conclusion 1-and 6 mortality after rectal cancer surgery Rutten et al Lancet Oncolgy 2008
  8. 8. Introduction Comorbidity Frailty Conclusion Age and complications Janssen-Heijnen Eur J Cancer 2007
  9. 9. Introduction Comorbidity Frailty Conclusion No improvement in survival for elderly Rutten et al Eur J Cancer 2007
  10. 10. Introduction Comorbidity Frailty Conclusion Cognitive decline Mild Alzheimers Normal ageing cognitive disease decline Small et al., 2008
  11. 11. Introduction Comorbidity Frailty Conclusion Post Operative Cognitive dysfunction 1064 Patients neuropsychological tests before ,at discharge and after three months Monk et al., 2008
  12. 12. Introduction Comorbidity Frailty Conclusion Mortality and POCD Monk et al., 2008
  13. 13. Introduction Comorbidity Frailty Conclusion Life time risk of non communicable disease (heart, diabetes, stroke) From: ageing and life course WHO 2001
  14. 14. Introduction Comorbidity Frailty Conclusion Comorbidity and rectal cancer treatment Janssen-Heijnen Eur J Cancer 2007
  15. 15. Introduction Comorbidity Frailty Conclusion Disability • Inability to perform everyday task independently
  16. 16. Introduction Comorbidity Frailty Conclusion Disability: Comorbidity ≥ 1ADL 21,5% 5,7% 46,2% 26,6% Frailty Fried et al J Gerontol A Biol Sci 2004
  17. 17. Introduction Comorbidity Frailty Conclusion
  18. 18. Introduction Comorbidity Frailty Conclusion Frailty • Vulnerability associated with age • Individual measurement of the severity and speed of the aging process associated with chronic illness and functional loss • Predictive of outcome?
  19. 19. Introduction Comorbidity Frailty Conclusion Identifying frail elderly
  20. 20. Introduction Comorbidity Frailty Conclusion Estimating frailty in the surgical patient • Predict postoperative morbidity/mortality • Prevent functional decline • Need for screening tool • Few studies
  21. 21. Introduction Comorbidity Frailty Conclusion Identifying frail elderly CGA: comprehensive geriatric assessment: combination of tests used by geriatricians to estimate general wellbeing/ frailty in elderly patients. Too time consuming ( takes 2 hours on average) for surgical what tools to use? practice and not specifically tested with regards to PACE was initiated to develop a predictive value for screening tool for frailty in the elderly postoperative surgical population. It consists of complications. several tests that are easy to use and measure different aspects of wellbeing and frailty. This is the first study measuring the predictive value of these tests in a surgical population.
  22. 22. Introduction Comorbidity Frailty Conclusion Identifying frail elderly • Preoperative Assessment of Cancer in the Elderly (PACE) • Estimating frailty in surgical elderly cancer patients (GFI)
  23. 23. Introduction Comorbidity Frailty Conclusion PACE • MMS (abnormal <24): Mini Mental State examination • ADL (dependent >0) Activities of Daily Life : things like going to toilet, eating a meal • IADL( dependent <8) Instrumental Activities of Daily Life : things like handling finances, making telephone call, taking medication • GDS (depressed >4) Geriatric Depression Scale; 15 questions investigating mood • BFI (mod/severe fatigue >3) : Brief Fatigue Inventory • ASA (abnormal >1) • PS (abnormal >1) Performance Status • Satariano’s Index (1) : score for different sorts of co morbidity
  24. 24. Introduction Comorbidity Frailty Conclusion PACE and hospital stay Component of PACE RR* 95%CI MMS abnormal (<24) 1.18 0.76-1.86 ADL dependent (>0) 2.01 1.37-2.93 IADL dependent (<8) 1.58 1.11-2.24 GDS depressed (>4) 1.30 0.91-1.85 BFI mod/severe fatigue (>3) 1.29 0.90-1.84 ASA abnormal (>1) 0.85 0.60-1.20 PS abnormal (>1) 1.64 1.06-2.56 Satariano’s Index (1) 1.23 0.85-1.78 Satariano’s Index (2+) 1.36 0.70-2.65 Audisio et al. Crit Rev Oncol/Hem, 2008
  25. 25. Introduction Comorbidity Frailty Conclusion PACE and complications Component of PACE Any complication RR* 95% CI MMS abnormal (<24) 1.23 0.81-1.88 ADL dependent (>0) 1.41 0.95-2.10 IADL dependent (<8) 47015146 1.43 1.03-1.98 GDS depressed (>4) 1.30 0.93-1.81 BFI mod/severe fatigue (>3) 1.52 1.09-2.12 ASA abnormal (>1) 1.00 0.73-1.38 PS abnormal (>1) 1.64 1.07-2.52 Satariano’s Index (1) 1.11 0.78-1.59 Satariano’s Index (2+) 1.58 0.88-2.85 Audisio et al. Crit Rev Oncol/Hem, 2008
  26. 26. Introduction Comorbidity Frailty Conclusion Groningen Frailty Index (GFI) • 15 questions • Predicts morbidity • Easy to administer • GFI ≥3 is frail • 30% of patients >65 yrs are frail
  27. 27. Introduction Comorbidity Frailty Conclusion GFI Mobility Physical fitness Vision Hearing Nutrition Co-morbidity Cognition Psychosocial
  28. 28. Introduction Comorbidity Frailty Conclusion GFI Mobility Can the patient perform the following tasks without assistance from another person (walking aids such as a cane or wheelchair are allowed) 1. Grocery shopping YES/NO 2. Walk outside house (around house or to neighbours) YES/NO 3. Getting (un)dressed YES/NO 4. Visiting restroom YES/NO
  29. 29. Introduction Comorbidity Frailty Conclusion GFI Hearing 7. Does the patient encounter problems in daily life because of impaired hearing? YES/NO Nutrition 8. Has the patient unintentionally lost a lot of weight in the past 6 months (6kg in 6 months or 3 kg in a month) YES/NO
  30. 30. Introduction Comorbidity Frailty Conclusion GFI Psychosocial 11. Does the patient ever experience emptiness around him? YES/NO 12. Does the patient ever miss the presence of other people around him? YES/NO 13. Does the patient ever feel left alone? YES/NO 14. Has the patient been feeling down or depressed lately? YES/NO 15. Has the patient felt nervous or anxious lately? YES/NO
  31. 31. Introduction Comorbidity Frailty Conclusion GFI • Currently used in national study • To be tested in international setting started end 2008 • Results expected in coming years
  32. 32. Introduction Comorbidity Frailty Conclusion Perioperative care
  33. 33. Introduction Comorbidity Frailty Conclusion LIFE study • Multicenter prospective randomized clinical trial • Patients over 65 years surgery for a solid tumor • Groningen Frailty Indicator ≥ 3 • Geriatric team preoperatively and monitored during hospital stay • Primary outcome: incidence of delirium • Secondary outcome – Return to the pre-operative living situation within 3 months postoperatively – The Physical and Mental Component Summary measures of the SF-36 – Complications during hospital stay including mortality – Care Dependency Scale at discharge – Percentage of patients receiving adjuvant treatment – Direct health care and non-health care costs during hospital stay • Power/data analysis: incidence of delirium 30% expected reduction of 15 % sample sizes of 2x133
  34. 34. Introduction Comorbidity Frailty Conclusion LIFE study • Incidence of postoperative delirium was lower as expected • Less delirium in the intervention group • Co morbidity, activities in daily life, abdominal surgical procedure are major determinants in the incidence of delirium
  35. 35. Introduction Comorbidity Frailty Conclusion Conclusion • The increase in postoperative morbidity an mortality is a result of comorbidity, disability and frailty and most likely not due to the biological behavior of the cancer • Estimating frailty in elderly cancer patient of increasing importance • Search for ideal screening tool predictive of outcome ongoing • Need for tailor made treatment • Future: tailor made intervention to prevent postoperative morbidity
  36. 36. Introduction Comorbidity Frailty Conclusion Co morbidity, disability, frailty Prevent over- and undertreatment Patient tailored treatment

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