The Prognostic Performance of Frailty for Delirium and Functional Decline in Vascular Surgery Patients

Abstract

Background Frailty in older vascular surgery patients is associated with increased mortality, hospital stay, and morbidity. The association of frailty with hospital‐acquired geriatric syndromes such as delirium and functional decline has not been well studied. Objectives To investigate the association between frailty and hospital‐acquired geriatric syndromes in older hospitalized vascular surgery patients, and to evaluate the prognostic performance of the frailty index (FI) and the Clinical Frailty Scale (CFS) for delirium and functional decline. Design Prospective cohort study. Setting Acute care academic hospital. Participants Patients aged 65 years or more admitted to a tertiary vascular surgery unit (N=150). Measurements Frailty was assessed using the FI and CFS. The adjusted association of frailty status with delirium and functional decline was assessed using logistic regression analysis. The prognostic performance of FI and CFS was determined by assessing C‐statistic and positive and negative predictive values (PPV and NPV). Results Of 150 participants, FI identified 34 (23%) and CFS identified 45 (30%) as frail. Frailty was an independent predictor of delirium (FI adjusted odds ratio, odds ratio (OR) = 5.66, 95% confidence interval (CI) = 1.53–21.03; CFS adjusted OR = 4.07, 95% CI = 1.14–14.50), but not functional decline. FI and CFS showed acceptable prognostic performance for delirium (C‐statistic 0.74), but not functional decline (C‐statistic 0.63–0.64). For both outcomes, the FI and CFS had high NPV (86–96%), and low PPV (22–29%). Conclusion Frail older vascular surgery patients are more likely to develop hospital‐acquired geriatric syndromes. The FI and CFS have acceptable prognostic performance for predicting delirium but not all individuals who are identified as frail develop delirium. Ongoing research is needed to identify interventions that improve outcomes in patients who screen positive for frailty.

Incorporating Outcomes that Matter to Older Adults into Surgical Research

“…In summary, the study by Thillainadesan et al found that up to one‐third of older vascular surgery inpatients have frailty and that baseline frailty is associated with hospital‐acquired geriatric syndromes, most notably delirium 4 . This study highlights the critical need for surgical research to incorporate geriatric‐focused predictors and patient‐centered outcomes.…”

“…Data are lacking on how surgical interventions impact outcomes valued by older adults and on how baseline geriatric conditions such as frailty may influence these outcomes following surgery. The study by Thillainadesan et al in this issue addresses this knowledge gap for the burgeoning population of older adults undergoing vascular surgery 4 . The authors had two objectives: (1) to evaluate the associations between frailty and multiple hospital‐acquired geriatric syndromes and (2) to measure the utility of two validated frailty indices in predicting the hospital‐acquired geriatric syndromes of delirium and functional decline.…”

“…The authors conducted a prospective observational cohort study of 150 older adults (≥65 years) consecutively admitted to a vascular surgery service in 2019 4 . Exclusion criteria included same‐day procedures, surgery conducted while admitted to another service, or expected admission length of stay of less than 2 days.…”

“…For example, the current Centers for Medicare and Medicaid list of hospital‐acquired conditions only refers to falls and Stages III and IV pressure ulcers 15 . The current study included these as key outcomes, as well as validated measures for delirium, functional status at discharge, constipation, and high‐risk prescribing 4 . Although postoperative and posthospitalization trajectories were beyond the scope of the current study, identifying and preventing hospital‐acquired geriatric syndromes has the potential to improve longer‐term postoperative quality of life for the population of older surgical patients.…”

“…The authors conducted a prospective observational cohort study of 150 older adults (≥65 years) consecutively admitted to a vascular surgery service in 2019. 4 Exclusion criteria included same-day procedures, surgery conducted while admitted to another service, or expected admission length of stay of less than 2 days. The study cohort underwent a variety of vascular surgery procedures ranging from endovascular to open revascularizations, amputations, and debridement.…”