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Frailty can help predict complications in trauma patients

Sunday June 15, 2014
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Measuring frailty can help predict in-hospital complications, the need for discharge to a skilled nursing facility or in-hospital death in older patients who are hospitalized after physical trauma, according to a new study.

According to the study background, current guidelines for managing elderly patients who have suffered trauma do not address the role frailty plays in the recovery process. Frail patients often have a low physiological reserve and an altered response to injury, the authors wrote.

The study, led by Bellal Joseph, MD, of the University of Arizona Medical Center in Tucson, and colleagues, explored whether the Frailty Index could help identify patients at risk of complications or in-hospital deaths, as well as those who need to go to a skilled nursing facility after discharge.

Their findings were published June 11 on the website of the journal JAMA Surgery.

From June 2011 to February 2013, researchers measured frailty in trauma patients ages 65 and older admitted at a level 1 trauma center at the University of Arizona. A total of 250 patients with an average age of 77.9 years were enrolled in the study; 69.2% were male.

The researchers defined frailty as a syndrome of decreased physiological reserve and resistance to stressors, which results in increase vulnerability to poor health outcomes, worsening mobility and disability, hospitalizations and death.

The Frailty Index, from the Canadian Study of Health and Aging, collects information including age, medication history, comorbidities, social activity, activities of daily living, nutritional status and general mood. FI scores range from zero, which represents nonfrail status, to one, which represents severely frail status. For the study, scores higher than 0.25 were considered frail.

The researchers found 44% (110) of the patients qualified as frail. The study showed no significant differences in age, mechanism of injury, systolic blood pressure and Glasgow Coma Scale score between patients with and without frailty. Patients with frailty were more likely to have a higher injury severity, the results showed.

For the entire group, 28.4% (71 patients) developed in-hospital complications. Frail patients were more likely to develop complications than nonfrail patients (37.3% vs. 21.4%), the findings showed. The most common complications for patients with frailty were urinary tract infections (12) and pneumonia (10). Researchers did not find a difference in the rates of additional surgeries for patients with and without frailty.

When investigators looked at outcomes, patients with frailty had a longer overall length of stay and a longer ICU length of stay than those without frailty. Fifty-nine patients (23.6%) were either discharged to a skilled nursing facility (54 patients) or died in the hospital (5 patients), according to the study. The overall mortality rate was 2%, and all the patients who died had frailty.

After controlling for age, sex and other factors, the FI score was an independent predictor of patients’ outcomes and complications, the researchers found.

“Using age as the sole reference for clinical decision making is inadequate and misleading in geriatric patients,” the authors wrote. “The FI should be used as a clinical tool for risk stratification among geriatric trauma patients.”

The study limitations include not evaluating the effect of frailty on long-term functional outcomes and quality of life, the authors wrote. Because the data was collected at a single medical center, they note the results might not be able to be generalized.

In a related commentary, Thomas N. Robinson, MD, MS, of the University of Colorado School of Medicine, Aurora, and Emily Finlayson, MD, MS, of the University of California, San Francisco, praise the study authors for showing the effects of chronological and physiological age on trauma outcomes.

“Although the best frailty tool for trauma cases has yet to be determined, this study should trigger further research and quality improvement efforts targeting the growing population of trauma patients with frailty,” Robinson and Finlayson wrote in the commentary.

Study abstract: http://archsurg.jamanetwork.com/article.aspx?articleid=1879845


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