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Review
. 2020 Oct 1;11(5):1276-1290.
doi: 10.14336/AD.2019.1024. eCollection 2020 Oct.

Influence of Frailty on Outcome in Older Patients Undergoing Non-Cardiac Surgery - A Systematic Review and Meta-Analysis

Elke K M Tjeertes  1 , Joris M K van Fessem  1 , Francesco U S Mattace-Raso  2 , Anton G M Hoofwijk  3 , Robert Jan Stolker  1 , Sanne E Hoeks  1
Affiliations
Review

Influence of Frailty on Outcome in Older Patients Undergoing Non-Cardiac Surgery - A Systematic Review and Meta-Analysis

Elke K M Tjeertes et al. Aging Dis. .

Abstract

Frailty is increasingly recognized as a better predictor of adverse postoperative events than chronological age. The objective of this review was to systematically evaluate the effect of frailty on postoperative morbidity and mortality. Studies were included if patients underwent non-cardiac surgery and if frailty was measured by a validated instrument using physical, cognitive and functional domains. A systematic search was performed using EMBASE, MEDLINE, Web of Science, CENTRAL and PubMed from 1990 - 2017. Methodological quality was assessed using an assessment tool for prognosis studies. Outcomes were 30-day mortality and complications, one-year mortality, postoperative delirium and discharge location. Meta-analyses using random effect models were performed and presented as pooled risk ratios with confidence intervals and prediction intervals. We included 56 studies involving 1.106.653 patients. Eleven frailty assessment tools were used. Frailty increases risk of 30-day mortality (31 studies, 673.387 patients, risk ratio 3.71 [95% CI 2.89-4.77] (PI 1.38-9.97; I2=95%) and 30-day complications (37 studies, 627.991 patients, RR 2.39 [95% CI 2.02-2.83). Risk of 1-year mortality was threefold higher (six studies, 341.769 patients, RR 3.40 [95% CI 2.42-4.77]). Four studies (N=438) reported on postoperative delirium. Meta-analysis showed a significant increased risk (RR 2.13 [95% CI 1.23-3.67). Finally, frail patients had a higher risk of institutionalization (10 studies, RR 2.30 [95% CI 1.81- 2.92]). Frailty is strongly associated with risk of postoperative complications, delirium, institutionalization and mortality. Preoperative assessment of frailty can be used as a tool for patients and doctors to decide who benefits from surgery and who doesn't.

Keywords: frailty; non-cardiac surgery; older patients; outcome; surgery.

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Figures

Figure 1.
Figure 1.
PRISMA flowchart for study selection. This flowchart depicts the flow of information trough different phases of the systematic research.
Figure 2.
Figure 2.
Forest plot 30-day mortality per frailty score. The number of events (deaths) and the total number of patients are shown for both frail and non-frail patients, stratified per frailty assessment tool.
Figure 3.
Figure 3.
Forest plot postoperative complications per frailty score. The number of events (complications) and the total number of patients are shown for both frail and non-frail patients, stratified per frailty assessment tool.
Figure 4.
Figure 4.
Forest plot 1-year mortality. The number of events (one-year mortality) and the total number of patients are depicted for frail and non-frail patients.
Figure 5.
Figure 5.
Forest plot postoperative delirium. The number of events (delirium) and the total number of patients are depicted for frail and non-frail patients.
Figure 6.
Figure 6.
Forest plot discharge to specialized facility. The number of events (discharge to a specialized facility) and the total number of patients are depicted for frail and non-frail patients.
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