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INDIAN WELLS, CALIF. -- Elderly patients with at least four of six markers of frailty before elective major surgery were significantly more likely to die within 6 months after their procedure, a prospective study of 110 subjects showed.

The six markers were a score of less than 4 on the Mini-Cog test, an albumin level of less than 3.4 g/dL, one or more falls in the previous 6 months, a hematocrit of less than 35%, a Katz Index of Independence in Activities of Daily Living score of less than 6, and a Charlson Comorbidity Index score of 3 or greater, Dr. Thomas N. Robinson reported at the annual meeting of the American Surgical Association.

The presence of at least four markers with the cutoff values that were assigned by Dr. Robinson and his fellow researchers predicted 6-month mortality with a sensitivity of 81% and a specificity of 86%.

The researchers also found that the same six factors were associated with an increased likelihood of being discharged to an institutional care facility.

More than half of all operations in the United States are performed on patients older than 65 years. Including the six frailty markers in preoperative assessments of elderly patients can help to predict postoperative mortality as well as the probability of a patient needing transfer into institutional care after discharge, Dr. Robinson said.

Use of frailty markers for preoperative assessment "represents a paradigm shift from the traditional preoperative evaluation techniques," which typically assign risk based on a single organ system assessment, said Dr. Robinson of the University of Colorado, Denver.

Discussant Dr. Michael E. Zenilman concurred. "We used to only look at comorbidities, urgency of procedure, and cardiac risk stratification to determine risk. Only recently have we recognized that frailty, disability, and alterations in serum markers like albumin and hematocrit can affect the outcome," said Dr. Zenilman, professor and chair of surgery at the State University of New York Downstate Medical Center, Brooklyn, N.Y.

The six preoperative frailty markers that were significantly associated with a higher risk of 6-month mortality were:

P Impairment on the Mini-Cog test. This simple and validated way to test for impaired cognition or dementia uses a three-item recall test and a clock-drawing test.

P Low albumin level. Values averaged 2.93 g/dL in patients who died, compared with 3.69 g/dL in patients who survived 6 months after surgery.

P Increased falls. Patients who died within 6 months after surgery averaged 1.6 falls in the 6 months before surgery. Those who survived averaged 0.7 falls.

P Low hematocrit. Values averaged 35% in patients who died and 41% in those who were alive at 6 months after surgery.

P Katz Index score. The Katz Index of Independence in Activities of Daily Living averaged 3.2 among patients who died and 4.8 among survivors.

P Charlson Comorbidty Index. The average Charlson Index score was 5.1, among patients who died as compared with 3.1 among survivors.

The investigators initially chose 12 out of the more than 70 frailty markers that have been described in the medical literature. The investigators chose the 12 frailty markers for the study because they are ones that could be marked on a dashboard sheet by a nurse taking vital signs in a clinic. A surgeon looking at the dashboard sheet during a clinic visit would then be able to "risk stratify the patient in an improved fashion," Dr. Robinson said.

The 12 measures were part of assessments performed within 30 days before elective major surgery at the Denver Veterans Affairs Medical Center. The patients underwent either general, thoracic, vascular, or urologic surgery, had an average age of 74 years, and 95% were men.

Assessments covered age, cognition as measured by the Mini-Cog test, the number of falls in the past 6 months, a history of depression, the presence of anemia as reflected by hematocrit, and disability as measured by the Katz Index of Independence in Activities of Daily Living score, which measures patient independence in bathing, grooming, and dressing.

The investigators also used three assessments of undernutrition: weight loss of 10 pounds or more in the prior 6 months, body mass index, and albumin level. Three measures assessed comorbidity level: the Charlson Index, the number of outpatient medications being used, and the American Society of Anesthesiologists (ASA) score.

All patients survived surgery and postoperative care in the ICU. A total of 15% of patients died within 6 months of undergoing surgery, and 26% required institutionalization in nursing homes or other care institutions upon discharge, Dr. Robinson reported.

Dr. Robinson and his associates stated that they have no conflicts of interest related to this study.

In an interview, Dr. Ali AbuRahma, called the presentation "an interesting study with great clinical implications.

"The analysis was multifactorial, combining both clinical and laboratory parameters, some of which have been known for quite some time to impact surgical outcome. It was surprising to me that a hematocrit level of 35% was associated with a higher mortality than patients with a hematocrit level of 41%, since a significant number of patients undergoing major surgery would have a hematocrit level of less than or equal to 35%," observed Dr. AbuRahma, professor of surgery, chief of vascular and endovascular surgery and medical director, Vascular Laboratory, West Virginia University, Charleston.

"Other factors, specifically patients with a higher number of falls were significantly more likely to die sooner than other patients. I wonder if this might reflect underlying disorders which may explain the increased number of falls.

"Would these patients be more likely to have cerebrovascular disease (carotid and/or vertebrobasilar insufficiency) or a cardiac disease such as cardiac arrythmias, etc.? If that's the case, this would be expected in these patients.

"Also, could cognitive impairment have any connection to underlying cerebrovascular ischemia? As expected, a greater burden of comorbidities are known to increase mortality in most surgical patients.

"This study adds other parameters to our knowledge to use when deciding whether to offer major surgical procedures, specifically open vascular procedures," Dr. AbuRhama concluded.

Dr. AbuRhama is an associate medical editor for Vascular Specialist.