Cardiac surgery as a stressor and the response of the vulnerable older adult

Abstract

In an aging population, recovery and restoration of function are critical to maintaining independence. Over the past 50 years, there have been dramatic improvements made in cardiac surgery processes and outcomes that allow for procedures to be performed on an increasingly older population with the goal of improving function. Although improved function is possible, major surgical procedures are associated with substantial stress, which can severely impact outcomes. Past literature has identified that frail patients, who are vulnerable to the stress of surgery, are more likely to have postoperative major adverse cardiac and cerebrovascular events (OR 4.9, 95% confidence interval 1.6, 14.6). The objective of this manuscript is to examine preoperative frailty in biological, psychological, and social domains using cardiac surgery to induce stress. We systematically searched PubMed for keywords including “cardiac surgery, frailty, and aged” in addition to the biological, psychological, and social keywords. In the biological domain, we examine the association of physiological and physical vulnerabilities, as well as, the impact of comorbidities and inflammation on negative surgical outcomes. In the psychological domain, the impact of cognitive impairment, depression, and anxiety as vulnerabilities were examined. In the social domain, social structure, coping, disparities, and addiction as vulnerabilities are described. Importantly, there is substantial overlap in the domains of vulnerability. While frailty research has largely focused on discrete physical vulnerability criteria, a broader definition of frailty demonstrates that vulnerabilities in biological, psychological, and social domains can limit recovery after the stress of cardiac surgery. Identification of vulnerability in these domains can allow better understanding of the risks of cardiac surgery and tailoring of interventions to improve outcomes.

Multidimensional Approach to Frailty

“…Meta-analytic data based on nine prospective studies showed that an improvement in gait rate by 0.1 m/s leads to a 10% improvement in survival (Afilalo et al, 2014). Patients' dependence with respect to basic vital functions or the use of auxiliary devices are independent predictors of test results after cardiac surgeries (Neupane et al, 2017).…”

Frailty as a risk predictor in cardiac surgery: Beyond the eyeball test

“…The literature has largely focused on the biological or physical aspects of frailty as a risk factor; however, more recently there is greater appreciation for the psychologic and social aspects of frailty, which may also result in negative postoperative outcomes. 7,8 Chronologic age is inextricably linked to frailty but should not be the sole determinant in determining operative vulnerability or assignment of treatment futility. Younger patients can also be frail.…”

Cognitive Impairment and Overall Survival in Frail Surgical Patients

“…Many of the previous studies conducted on physical frailty and cognitive impairment focus only on adults aged 65 years and older. 9,12,27,28 More than half (69.2%) of the physically frail and cognitively impaired patients in our cohort were aged 65 years or older. This is consistent with previous literature that the risk of cognitive and physical decline increases exponentially with age.…”

“…However, surgery is a complex process that is not only a physical stressor, but also a mental stressor. 9 Many recent studies have considered incorporating the concept of cognition in the definition of frailty, 10–12 and a definition for cognitive frailty has emerged. In 2013, an International Consensus Group 13 on cognitive frailty was organized to propose a heterogeneous clinical manifestation characterized by the simultaneous presence of both physical frailty and cognitive impairment in the elderly.…”