It's that Frailty Thing Again!

Every year for the past 10 years, the mean age of patients undergoing coronary artery surgery in the UK has gone up . There is a feeling now that we are possibly reaching the biological limits of the bodies that we subject to surgical trauma. Evidence for this perception is the increase in interest in using an index of frailty for pre operative risk assessment. At the recent joint annual meeting of the Society for Cardiothoracic Surgery and the Association of Cardiothoracic Anaesthetists in Manchester UK, a whole session was dedicated to the subject. I have been interested in this subject for a number of years and have posted about it on a number of occasions.

It is therefore not surprising that I feel the need to comment in this paper published recently in Circulation.

In this paper, researchers describe how the addition of various known scores of frailty to existing cardiac surgical risk scores improved the discriminatory power (the area under the curve for the Receiver Operating Characteristic or ROC curve) of the surgical risk score to predict death after a heart operation. Now prediction of early death after surgery is all well and good. What I think is even more important is the ability to predict whether a heart operation can improve the quality of life of these very elderly patients. What's the point of increasing the life years of 86 year old Ethel, who is suffering with critical left main stem stenosis, if she lives them in discomfort from her chest wounds attached to a VAC pump treating her wound infection. The good news is that PROMS or Patient Reported Outcome Measures may help us with the quality of life issue. They have been used routinely in the English NHS to measure quality of life after hip and knee surgery, and varicose vein and hernia surgery . There is now a pilot project looking at PROMS after coronary revascularisation and I get the feeling the findings form these could prove to be very interesting .

The 'Surgicalisation' of Old Age.

This is a republishing of a post I originally wrote in December 2010. It's a point that needs to be re-emphasised every so often!

Surgeons’ Decisions and the Financial and Human Costs of Medical Care

A good piece by an anaesthesiologist in the NEJM. What I found interesting was the fact that there used to be a chapter on surgical judgement instructing surgeons when not to operate in the 1960 edition of a major surgical textbook. The chapter had disappeared by 1972. As surgical and anaesthetic techniques improved, the scope for surgical intervention was extended to sicker and older patients. Now the emphasis on cost containment in a world that is broke and on patient reported outcomes,  is beginning to apply the brakes on that hubristic approach. It is however that kind of approach that frequently plays an important part in the advancement of medicine. With much greater scrutiny on doctors' performance, that kind of approach has now become increasingly socially and some might say morally unacceptable.

Frailty and Cardiovascular Disease.

Another paper looking at interaction of old age and frailty, and outcomes in cardiovascular disease. We need more of these papers. Demographics suggest that the number of people reaching their 80s or higher will increase exponentially. Dementia has quite rightly grabbed all the headlines as a consequence of this demographic change. Cardiovascular disease including aortic valve stenosis and its often invasive treatments must also be considered when we study old age and its effects.

STUDY SHOWS THAT OLD FRAIL PEOPLE DIE SOONER !!

Publication of this paper is good in one sense  - it is I hope the first of many studies examining and highlighting  the effect of frailty on outcomes after cardiac surgery.