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MCC 2011 - Slide 5
1. Age, co-morbidity and frailty
Theo Wiggers
Barbara van Leeuwen
Cascais, Portugal
Sunday February 13th,2011
Department of Surgery, University Medical Center Groningen
3. Introduction Comorbidity Frailty Conclusion
Ageing in The Netherlands
4. Introduction Comorbidity Frailty Conclusion
Life expectancy
♀
♂
Walter LC, JAMA 2001
5. Introduction Comorbidity Frailty Conclusion
More cancers in the elderly
Quaglia et al Int J Cancer 2007
6. Introduction Comorbidity Frailty Conclusion
The impact of cancer in an ageing world
WHO data 2007
7. Introduction Comorbidity Frailty Conclusion
1-and 6 mortality after rectal cancer surgery
Rutten et al Lancet Oncolgy 2008
8. Introduction Comorbidity Frailty Conclusion
Age and complications
Janssen-Heijnen Eur J Cancer 2007
9. Introduction Comorbidity Frailty Conclusion
No improvement in survival for elderly
Rutten et al Eur J Cancer 2007
10. Introduction Comorbidity Frailty Conclusion
Cognitive decline
Mild Alzheimer's
Normal ageing
cognitive disease
decline
Small et al., 2008
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. Introduction Comorbidity Frailty Conclusion
Mortality and POCD
Monk et al., 2008
13. Introduction Comorbidity Frailty Conclusion
Life time risk of non communicable disease
(heart, diabetes, stroke)
From: ageing and life course WHO 2001
14. Introduction Comorbidity Frailty Conclusion
Comorbidity and rectal cancer treatment
Janssen-Heijnen Eur J Cancer 2007
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?
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. 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. Introduction Comorbidity Frailty Conclusion
Identifying frail elderly
• Preoperative Assessment of Cancer in the
Elderly (PACE)
• Estimating frailty in surgical elderly cancer
patients (GFI)
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. 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. 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. 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
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. 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. 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. 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. Introduction Comorbidity Frailty Conclusion
Perioperative care
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. 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. 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. Introduction Comorbidity Frailty Conclusion
Co morbidity, disability, frailty
Prevent over- and undertreatment
Patient tailored treatment
