衰弱对老年外科患者出院后结局的影响：一项前瞻性队列研究。
Impact of frailty on outcomes after discharge in older surgical patients: a prospective cohort study.
作者信息
Li Yibo, Pederson Jenelle L, Churchill Thomas A, Wagg Adrian S, Holroyd-Leduc Jayna M, Alagiakrishnan Kannayiram, Padwal Raj S, Khadaroo Rachel G
机构信息
Departments of Surgery (Li, Pederson, Churchill, Khadaroo), Medicine (Wagg, Alagiakrishnan, Padwal) and Critical Care Medicine (Khadaroo), University of Alberta; Alberta Seniors Health Strategic Clinical Network (Wagg, Alagiakrishnan), Alberta; Departments of Medicine (Holroyd-Leduc) and Community Health Sciences (Holroyd-Leduc), University of Calgary, Calgary, Alta.; Alberta Diabetes Institute (Padwal), Edmonton, Alta.
出版信息
CMAJ. 2018 Feb 20;190(7):E184-E190. doi: 10.1503/cmaj.161403.
BACKGROUND
Frailty is a state of vulnerability to diverse stressors. We assessed the impact of frailty on outcomes after discharge in older surgical patients.
METHODS
We prospectively followed patients 65 years of age or older who underwent emergency abdominal surgery at either of 2 tertiary care centres and who needed assistance with fewer than 3 activities of daily living. Preadmission frailty was defined according to the Canadian Study of Health and Aging Clinical Frailty Scale as "well" (score 1 or 2), "vulnerable" (score 3 or 4) or "frail" (score 5 or 6). We assessed composite end points of 30-day and 6-month all-cause readmission or death by multivariable logistic regression.
RESULTS
Of 308 patients (median age 75 [range 65-94] yr, median Clinical Frailty Score 3 [range 1-6]), 168 (54.5%) were classified as vulnerable and 68 (22.1%) as frail. Ten (4.2%) of those classified as vulnerable or frail received a geriatric consultation. At 30 days after discharge, the proportions of patients who were readmitted or had died were greater among vulnerable patients ( = 27 [16.1%]; adjusted odds ratio [OR] 4.60, 95% confidence interval [CI] 1.29-16.45) and frail patients ( = 12 [17.6%]; adjusted OR 4.51, 95% CI 1.13-17.94) than among patients who were well ( = 3 [4.2%]). By 6 months, the degree of frailty independently and dose-dependently predicted readmission or death: 56 (33.3%) of the vulnerable patients (adjusted OR 2.15, 95% CI 1.01-4.55) and 37 (54.4%) of the frail patients (adjusted OR 3.27, 95% CI 1.32-8.12) were readmitted or had died, compared with 11 (15.3%) of the patients who were well.
INTERPRETATION
Vulnerability and frailty were prevalent in older patients undergoing surgery and unlikely to trigger specialized geriatric assessment, yet remained independently associated with greater risk of readmission for as long as 6 months after discharge. Therefore, the degree of frailty has important prognostic value for readmission.
TRIAL REGISTRATION FOR PRIMARY STUDY
ClinicalTrials.gov, no. NCT02233153.
背景
衰弱是一种易受多种应激源影响的状态。我们评估了衰弱对老年外科患者出院后结局的影响。
方法
我们前瞻性地随访了65岁及以上在两家三级医疗中心之一接受急诊腹部手术且日常生活活动需要少于3项协助的患者。入院前衰弱根据加拿大健康与老龄化临床衰弱量表定义为“健康”（评分1或2）、“脆弱”（评分3或4）或“衰弱”（评分5或6）。我们通过多变量逻辑回归评估30天和6个月全因再入院或死亡的复合终点。
结果
在308例患者中（中位年龄75岁[范围65 - 94岁]，中位临床衰弱评分为3[范围1 - 6]），168例（54.5%）被分类为脆弱，68例（22.1%）为衰弱。在被分类为脆弱或衰弱的患者中，有10例（4.2%）接受了老年病咨询。出院后30天，脆弱患者（n = 27[16.1%]；调整后的优势比[OR]为4.60，95%置信区间[CI]为1.29 - 16.45）和衰弱患者（n = 12[17.6%]；调整后的OR为4.51，95% CI为1.13 - 17.94）的再入院或死亡比例高于健康患者（n = 3[4.2%]）。到6个月时，衰弱程度独立且呈剂量依赖性地预测再入院或死亡：56例（33.3%）脆弱患者（调整后的OR为2.15，95% CI为1.01 - 4.55）和37例（54.4%）衰弱患者（调整后的OR为3.27，95% CI为1.32 - 8.12）再入院或死亡，而健康患者为11例（15.3%）。
解读
脆弱和衰弱在接受手术的老年患者中普遍存在，不太可能引发专门的老年病评估，但在出院后长达6个月的时间里，仍与再入院的更高风险独立相关。因此，衰弱程度对再入院具有重要的预后价值。
主要研究的试验注册
ClinicalTrials.gov，编号NCT02233153。
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