| A 30-second Sit-T0-Stand to Objectively Assess for Frailty and A Reconditioning Program to Improve Discharge Functional StatusBackground: There is an increase in the number of seniors undergoing surgery. Frailty, an age-associated decline in physiologic reserve and increased vulnerability, has been linked to poor outcomes following surgery. Hospitalized patients spend over 80% of their time in bed, resulting in early and rapid muscle wasting, leading to functional decline. Hence, it is important to develop an easily applicable reconditioning program to help elders to maintain functional independence following hospitalization for acute abdominal surgery.
Objectives: An independent bedside reconditioning program in older patients following emergency surgery will improve functional ability at discharge.
Methods: This was an uncontrolled before and after study of 66 elderly patients (≥65 years) undergoing acute abdominal surgery. Frailty was assessed using 9-point Clinical Frailty Scale (CFS). Patients were subjected to three levels of independent bedside in-hospital reconditioning program (BeFIT) based on their CFS. A 30 seconds Sit-To- Stand (STS) test, a functional lower extremity strength test, was assessed on post-operative day 2 (POD2) and prior to discharge, and Time up & Go (TUG) at 6-week follow up. Relationship between STS and frailty was examined.
Results: A total of 66 patients (33 control; 33 reconditioning) were enrolled aged 76 ± 9 years old (mean ± SD). There were 44 (66.7%) females. Patients were classified as Very fit-Well 21(31.8%), Managing well-Vulnerable 34(51.5%) Mildly -Moderately frail 11(16.7%). There was 87.8% (29) adherence to the BeFIT program. There was a significant improvement in the change of STS scores (POD discharge – POD2) in Very fit-Well and Mildly -Moderately frail BeFIT compared to their respective control groups (BeFIT very fit-well = 7 ± 1; control very fit-well = 3 ± 1; P < 0.04) and (BeFIT mildly-moderate frail = 7 ± 1; control mildly-moderate frail = 0 ± 3; P= 0.03). After adjusting for age, gender and total STS, the STS with arms was significantly associated with frailty (OR: 0.8 95% CI : 0.6-1; P<0.046).
Conclusions: An independent bedside reconditioning program is a feasible following emergency surgery. This is a cost effective way to improve elderly patients’ physical performance after hospitalization for acute abdominal surgery. University of Alberta | Specialized Publication | 2017-04-23 | "Mahmoud Alghamdi", "Alyssa McComb", Saad Salim, "Lindsey Warkentin", "Thomas Churchill", Rachel Khadaroo |
| Paradoxical relationship of muscle fibre cross-sectional area in older emergency surgery patients.Background: The number and cross sectional area (CSA) of individual fibers within a muscle determine the muscle's capacity to generate force, and both lessen with age. Muscle fibre area is normally positively associated with strength. A variety of indices of frailty and function are available for older patients, however the corresponding muscle morphology is limited.
Methods: Rectus abdominis (RA) muscle biopsies were collected during surgery from n=24 female patients 65-94 y of age undergoing emergency surgery. Frozen muscle samples were mounted in cross section and immunostained for muscle fiber area (µm2). Muscle cross sectional area (CSA; cm2) was calculated from CT images at lumbar 3 obtained from medical records of patients. Correlations were determined using IBM SPSS software.
Results: Mean RA muscle fibre cross sectional area was 3437 µm² (range 1452-6705 µm²), however this was not correlated with age (p=0.928), BMI (p=0.109) or frailty (p=0.540). Patients with larger muscle fibers performed more poorly in sit-to-stand tests (p=0.030) and had increased intramuscular adipose tissue (p=0.036).
Conclusions: Larger muscle fibre area is associated significantly with lower sit-to-stand performance. Further research is required to understand why larger muscle fibres in older adults are not associated with better strength and function.
University of Alberta | Specialized Publication | 2018-09-20 | Gauhar Ali, "Abah Dunichand-Hoedl", "Vera Mazurak", Vickie Baracos, Rachel Khadaroo |
| The role of body composition in predicting outcomes in the elderly following acuteBackground:
As the elderly population are increasing, their need for emergency surgery is expected to rise.
With aging, there is a decrease in skeletal muscle mass and an increase in visceral fat. To date,
the role of age-associated changes in body composition with outcome is unclear. We aimed to
examine the association of body composition identified by computed tomography (CT) scan with
in-hospital mortality and postoperative complications.
Methods:
A retrospective cohort of 215 patients aged ≥ 65 years underwent acute abdominal surgery
between 2008 and 2010 at the University of Alberta Hospital was analysed. CT scan at L3 was
used to measure height-adjusted surface area (cm/m 2 ) of muscularity, visceral fat, and
subcutaneous fat, and, their radiodensities in Hounsfield Units (HU). Logistic regression was
used to assess the relationship between body composition and in-hospital mortality and
postoperative complications.
Results:
Multivariate analysis identified muscularity (aOR: 0.922, 95% CI: 0.863-0.985, p-value= 0.016)
was a strong predictor of in-hospital mortality while subcutaneous fat radiodensity was not
(aOR: 1.028, 95% CI: 0.999-1.058, p-value= 0.055). Muscularity (aOR: 0.977, 95% CI: 0.935-
1.021, p-value= 0.307) and subcutaneous fat radiodensity (aOR: 1.013, 95% CI: 0.990-1.036, p-
value= 0.272) were not significantly associated with postoperative complications.
Conclusion:
Muscularity was an independent predictor of in-hospital mortality. CT-identified body
composition measurements can be used for risk stratification and as a potential modifiable risk
factor for intervention. University of Alberta | Specialized Publication | 2018-09-20 | "Mahmoud Alghamdi", Vickie Baracos, "Constantine Karvellas", "Thomas Churchill", Rachel Khadaroo |
| Perioperative factors predicting poor outcome in elderly patients following emergency general surgery: a multivariate regression analysis.BACKGROUND:
Older adults (≥ 65 yr) are the fastest growing population and are presenting in increasing numbers for acute surgical care. Emergency surgery is frequently life threatening for older patients. Our objective was to identify predictors of mortality and poor outcome among elderly patients undergoing emergency general surgery.
METHODS:
We conducted a retrospective cohort study of patients aged 65-80 years undergoing emergency general surgery between 2009 and 2010 at a tertiary care centre. Demographics, comorbidities, in-hospital complications, mortality and disposition characteristics of patients were collected. Logistic regression analysis was used to identify covariate-adjusted predictors of in-hospital mortality and discharge of patients home.
RESULTS:
Our analysis included 257 patients with a mean age of 72 years; 52% were men. In-hospital mortality was 12%. Mortality was associated with patients who had higher American Society of Anesthesiologists (ASA) class (odds ratio [OR] 3.85, 95% confidence interval [CI] 1.43-10.33, p = 0.008) and in-hospital complications (OR 1.93, 95% CI 1.32-2.83, p = 0.001). Nearly two-thirds of patients discharged home were younger (OR 0.92, 95% CI 0.85-0.99, p = 0.036), had lower ASA class (OR 0.45, 95% CI 0.27-0.74, p = 0.002) and fewer in-hospital complications (OR 0.69, 95% CI 0.53-0.90, p = 0.007).
CONCLUSION:
American Society of Anesthesiologists class and in-hospital complications are perioperative predictors of mortality and disposition in the older surgical population. Understanding the predictors of poor outcome and the importance of preventing in-hospital complications in older patients will have important clinical utility in terms of preoperative counselling, improving health care and discharging patients home. University of Alberta | Publication | 2016-04-28 | "Lees, M", "Merani S", "Tauh, K", Rachel Khadaroo |
| Self-Reported Outcomes in Individuals Aged 65 and Older Admitted for Treatment to an Acute Care Surgical Service: A 6-Month Prospective Cohort Study.Abstract
OBJECTIVES:
To examine health-related quality of life (HRQL) and cognitive and functional status before and after emergency surgical care in elderly adults.
DESIGN:
Six-month prospective cohort study.
SETTING:
Acute care and emergency surgery service at a single, academic tertiary care center, Edmonton, Alberta, Canada.
PARTICIPANTS:
Admitted individuals aged 65 and older (mean age 77.8 ± 7.9, 52% female) or their surrogates.
MEASUREMENTS:
Abbreviated Mental Test Score-4 (AMTS), Barthel Index, Vulnerable Elders Survey (VES-13), and EuroQol-5 Dimensional Scale (EQ-5D) completed by participants or their surrogates within 24 hours of admission to the hospital and 6 months after discharge. Paired t-tests and McNemar tests were used to assess the difference between baseline and 6 months.
RESULTS:
One hundred fifty-five consecutive individuals (including 16 surrogates) were enrolled. Sixteen (10%) died within 6 months of discharge, and 116 (75%, including 18 surrogates) completed a follow-up assessment 6 months after discharge. Cognitive status improved substantially over 6 months, with 72 (52%) of participants having AMTS scores showing cognitive impairment at baseline and four (4%) having AMTS scores showing cognitive impairment at 6 months (P < .001). There was no statistically significant change from baseline on the Barthel Index, VES-13, or EQ-5D.
CONCLUSION:
There was significant cognitive improvement in older adults after surgical hospitalization. HRQL improved back to age-matched population norms. These results suggest that elderly adults admitted for emergency surgery have good cognitive, functional, and HRQL outcomes. Alberta Centre on Aging, University of Alberta | Publication | 2016-04-28 | "Ali, T", "Warkentin, L", "Gazala, S", Adrian Wagg, "Padwal, R", Rachel Khadaroo |
| Ultrasound as a Point-of-Care Tool for Assessing Frailty and risk of Post-Operative Complications in Elderly Emergency Surgery PatientsBackground: Computed tomography (CT) scan quantifying skeletal muscle mass has been used as the gold standard tool to identify sarcopenia. Unfortunately, high cost, limited availability, and radiation exposure limit the use of CT. We propose that ultrasound of the thigh muscle as an objective, reproducible, portable, and risk free tool that can be used as a surrogate to the CT scan to help identify high risk patients.
Methods: We recruited 72 patients over 64 years old, referred to the Acute Care Surgery service. An ultrasound of thigh muscle thickness was standardized to patient thigh length (U/Swhole/L¬). CT skeletal muscle index (SMI) was calculated using skeletal muscle surface area of the L3 region divided by height2. Frailty status was assessed using the Rockwood Clinical Frailty Scale.
Results: Forty-nine of the 72 patients had a CT scan and ultrasound. The mean age was 76 + 8 years and 34% (n=17) were males. CT-defined sarcopenia was identified in 65% (n=11) of males and 75% (n=24) of females. In general, females had longer stay in hospital than males (14 + 9 vs. 7 + 3, P=0.003). There was a significant positive correlation between thigh U/Swhole/L and CT SMI. There was an inverse correlation between thigh U/Swhole/L and frailty score; a similar relationship was observed between CT SMI and frailty. U/Swhole/L but not CT SMI was also correlated to postoperative major complications.
Conclusion: Thigh U/Swhole/L index provides both an objective tool to assess for frailty and can assist in identifying older patients who are at high risk for developing post-operative complications. University of Alberta | Publication | 2016-07-29 | Saad Salim, "Omar Al-Khathiri", "Puneeta Tandon", Vickie Baracos, "Thomas Churchill", Rachel Khadaroo |
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