Frailty Assessment and Prehabilitation as Part of a PeRioperative Evaluation and Planning (PREP) Program for Patients Undergoing Colorectal Surgery

Abstract

Frailty assessment and prehabilitation can be incrementally implemented in a multidisciplinary, multiphase pathway to improve patient care. To start, modifications can be made to a surgeon's practice with existing resources while adapting standard pathways for frail patients. Frailty screening can identify patients in need of additional assessment and optimization. Personalized utilization of frailty data for optimization through prehabilitation can improve postoperative outcomes and identify patients who would benefit from adapted care. Additional utilization of the multidisciplinary team can lead to improved outcomes and a strong business case to add additional members of the team.

Keywords

frailty - prehabilitation - geriatric assessment - functional recovery - optimization

Publication History

Article published online:
03 February 2023

• References

• 1 Montroni I, Saur NM, Shahrokni A, Suwanabol PA, Chesney TR. Surgical considerations for older adults with cancer: a multidimensional, multiphase pathway to improve care. J Clin Oncol 2021; 39 (19) 2090-2101
• 2 DuMontier C, Loh KP, Bain PA. et al. Defining undertreatment and overtreatment in older adults with cancer: a scoping literature review. J Clin Oncol 2020; 38 (22) 2558-2569
• 3 Shahrokni A, Alexander K. The age of talking about age alone is over. Ann Surg Oncol 2019; 26 (01) 12-14
• 4 Korc-Grodzicki B, Downey RJ, Shahrokni A, Kingham TP, Patel SG, Audisio RA. Surgical considerations in older adults with cancer. J Clin Oncol 2014; 32 (24) 2647-2653
• 5 Saur NM, Montroni I. Geriatric comanagement: a secret ingredient of the elusive recipe. JAMA Netw Open 2020; 3 (08) e209460
• 6 Soto-Perez-de-Celis E, Li D, Yuan Y, Lau YM, Hurria A. Functional versus chronological age: geriatric assessments to guide decision making in older patients with cancer. Lancet Oncol 2018; 19 (06) e305-e316
• 7 Faye AS, Wen T, Soroush A. et al. Increasing prevalence of frailty and its association with readmission and mortality among hospitalized patients with IBD. Dig Dis Sci 2021; 66 (12) 4178-4190
• 8 Saur NM, Davis BR, Montroni I. et al; Clinical Practice Guidelines Committee of the American Society of Colon and Rectal Surgeons. The American Society of Colon and Rectal Surgeons Clinical Practice Guidelines for the perioperative evaluation and management of frailty among older adults undergoing colorectal surgery. Dis Colon Rectum 2022; 65 (04) 473-488
• 9 Rockwood K, Mitnitski A. Frailty defined by deficit accumulation and geriatric medicine defined by frailty. Clin Geriatr Med 2011; 27 (01) 17-26
• 10 Robinson TN, Walston JD, Brummel NE. et al. Frailty for surgeons: Review of a National Institute on Aging Conference on Frailty for Specialists. J Am Coll Surg 2015; 221 (06) 1083-1092
• 11 Berian JR, Wolf JH, Kunitake H. Much to do about frailty. Dis Colon Rectum 2022; 65 (04) 457-460
• 12 van Walree IC, Scheepers E, van Huis-Tanja L. et al. A systematic review on the association of the G8 with geriatric assessment, prognosis and course of treatment in older patients with cancer. J Geriatr Oncol 2019; 10 (06) 847-858
• 13 Huisman MG, Audisio RA, Ugolini G. et al. Screening for predictors of adverse outcome in onco-geriatric surgical patients: a multicenter prospective cohort study. Eur J Surg Oncol 2015; 41 (07) 844-851
• 14 Bessems SAM, Konsten JLM, Vogelaar JFJ. et al. Frailty screening by Geriatric-8 and 4-meter gait speed test is feasible and predicts postoperative complications in elderly colorectal cancer patients. J Geriatr Oncol 2021; 12 (04) 592-598
• 15 Moriello C, Mayo NE, Feldman L, Carli F. Validating the six-minute walk test as a measure of recovery after elective colon resection surgery. Arch Phys Med Rehabil 2008; 89 (06) 1083-1089
• 16 George EL, Hall DE, Youk A. et al. Association between patient frailty and postoperative mortality across multiple noncardiac surgical specialties. JAMA Surg 2021; 156 (01) e205152
• 17 Al-Khamis A, Warner C, Park J. et al. Modified frailty index predicts early outcomes after colorectal surgery: an ACS-NSQIP study. Colorectal Dis 2019; 21 (10) 1192-1205
• 18 Pata G, Bianchetti L, Rota M. et al. Multidimensional Prognostic Index (MPI) score has the major impact on outcome prediction in elderly surgical patients with colorectal cancer: The FRAGIS study. J Surg Oncol 2021; 123 (02) 667-675
• 19 Saur NM, Montroni I, Shahrokni A. et al. Care of the geriatric colorectal surgical patient and framework for creating a geriatric program: a compendium from the 2019 American Society of Colon and Rectal Surgeons Annual Meeting. Dis Colon Rectum 2020; 63 (11) 1489-1495
• 20 Seishima R, Okabayashi K, Hasegawa H. et al. Is laparoscopic colorectal surgery beneficial for elderly patients? A systematic review and meta-analysis. J Gastrointest Surg 2015; 19 (04) 756-765
• 21 Antoniou SA, Antoniou GA, Koch OO, Pointner R, Granderath FA. Laparoscopic colorectal surgery confers lower mortality in the elderly: a systematic review and meta-analysis of 66,483 patients. Surg Endosc 2015; 29 (02) 322-333
• 22 Vallribera Valls F, Landi F, Espín Basany E. et al. Laparoscopy-assisted versus open colectomy for treatment of colon cancer in the elderly: morbidity and mortality outcomes in 545 patients. Surg Endosc 2014; 28 (12) 3373-3378
• 23 Chesney TR, Quereshy HA, Draginov A, Chadi SA, Quereshy FA. Benefits of minimally-invasive surgery for sigmoid and rectal cancer in older adults compared with younger adults: do older adults have the most to gain?. J Geriatr Oncol 2020; 11 (05) 860-865
• 24 Panel AGSBCUE. By the 2019 American Geriatrics Society Beers Criteria® Update Expert Panel. American Geriatrics Society 2019 Updated AGS Beers Criteria® for potentially inappropriate medication use in older adults. J Am Geriatr Soc 2019; 67 (04) 674-694
• 25 Fleet JL, Dixon SN, Kuwornu PJ. et al. Gabapentin dose and the 30-day risk of altered mental status in older adults: a retrospective population-based study. PLoS One 2018; 13 (03) e0193134
• 26 Tejedor P, Pastor C, Gonzalez-Ayora S, Ortega-Lopez M, Guadalajara H, Garcia-Olmo D. Short-term outcomes and benefits of ERAS program in elderly patients undergoing colorectal surgery: a case-matched study compared to conventional care. Int J Colorectal Dis 2018; 33 (09) 1251-1258
• 27 Gonzalez-Ayora S, Pastor C, Guadalajara H. et al. Enhanced recovery care after colorectal surgery in elderly patients. Compliance and outcomes of a multicenter study from the Spanish working group on ERAS. Int J Colorectal Dis 2016; 31 (09) 1625-1631
• 28 Wang Q, Suo J, Jiang J, Wang C, Zhao YQ, Cao X. Effectiveness of fast-track rehabilitation vs conventional care in laparoscopic colorectal resection for elderly patients: a randomized trial. Colorectal Dis 2012; 14 (08) 1009-1013
• 29 Forsmo HM, Erichsen C, Rasdal A, Körner H, Pfeffer F. Enhanced Recovery After Colorectal Surgery (ERAS) in elderly patients is feasible and achieves similar results as in younger patients. Gerontol Geriatr Med 2017; 3: 2333721417706299
• 30 Jia Y, Jin G, Guo S. et al. Fast-track surgery decreases the incidence of postoperative delirium and other complications in elderly patients with colorectal carcinoma. Langenbecks Arch Surg 2014; 399 (01) 77-84
• 31 Ostermann S, Morel P, Chalé JJ. et al. Randomized controlled trial of enhanced recovery program dedicated to elderly patients after colorectal surgery. Dis Colon Rectum 2019; 62 (09) 1105-1116
• 32 National Institutes of Health Consensus Development Conference Statement: geriatric assessment methods for clinical decision-making. J Am Geriatr Soc 1988; 36 (04) 342-347
• 33 Puts MTE, Alibhai SMH. Fighting back against the dilution of the comprehensive geriatric assessment. J Geriatr Oncol 2018; 9 (01) 3-5
• 34 Audisio RA, Pope D, Ramesh HS. et al; PACE participants. Shall we operate? Preoperative assessment in elderly cancer patients (PACE) can help. A SIOG surgical task force prospective study. Crit Rev Oncol Hematol 2008; 65 (02) 156-163
• 35 Katlic MR, Coleman J, Khan K, Wozniak SE, Abraham JH. Sinai abbreviated geriatric evaluation: development and validation of a practical test. Ann Surg 2019; 269 (01) 177-183
• 36 Huisman MG, van Leeuwen BL, Ugolini G. et al. “Timed Up & Go”: a screening tool for predicting 30-day morbidity in onco-geriatric surgical patients? A multicenter cohort study. PLoS One 2014; 9 (01) e86863
• 37 Jones TS, Dunn CL, Wu DS, Cleveland Jr JC, Kile D, Robinson TN. Relationship between asking an older adult about falls and surgical outcomes. JAMA Surg 2013; 148 (12) 1132-1138
• 38 Hall DE, Arya S, Schmid KK. et al. Development and initial validation of the Risk Analysis Index for measuring frailty in surgical populations. JAMA Surg 2017; 152 (02) 175-182
• 39 Hall DE, Arya S, Schmid KK. et al. Association of a frailty screening initiative with postoperative survival at 30, 180, and 365 days. JAMA Surg 2017; 152 (03) 233-240
• 40 Dirks RC, Edwards BL, Tong E. et al. Sarcopenia in emergency abdominal surgery. J Surg Res 2017; 207: 13-21
• 41 van der Windt DJ, Bou-Samra P, Dadashzadeh ER, Chen X, Varley PR, Tsung A. Preoperative Risk Analysis Index for frailty predicts short-term outcomes after hepatopancreatobiliary surgery. HPB (Oxford) 2018; 20 (12) 1181-1188
• 42 Keller DS, Bankwitz B, Nobel T, Delaney CP. Using frailty to predict who will fail early discharge after laparoscopic colorectal surgery with an established recovery pathway. Dis Colon Rectum 2014; 57 (03) 337-342
• 43 Panayi AC, Orkaby AR, Sakthivel D. et al. Impact of frailty on outcomes in surgical patients: a systematic review and meta-analysis. Am J Surg 2019; 218 (02) 393-400
• 44 Wahl TS, Graham LA, Hawn MT. et al. Association of the modified frailty index with 30-day surgical readmission. JAMA Surg 2017; 152 (08) 749-757
• 45 Culley DJ, Flaherty D, Fahey MC. et al. Poor performance on a preoperative cognitive screening test predicts postoperative complications in older orthopedic surgical patients. Anesthesiology 2017; 127 (05) 765-774
• 46 Montroni I, Rostoft S, Spinelli A. et al; SIOG surgical task force/ESSO GOSAFE study group. GOSAFE: Geriatric Oncology Surgical Assessment and Functional rEcovery after Surgery—early analysis on 977 patients. J Geriatr Oncol 2020; 11 (02) 244-255
• 47 Watt J, Tricco AC, Talbot-Hamon C. et al. Identifying older adults at risk of delirium following elective surgery: a systematic review and meta-analysis. J Gen Intern Med 2018; 33 (04) 500-509
• 48 Siddiqi N, Harrison JK, Clegg A. et al. Interventions for preventing delirium in hospitalised non-ICU patients. Cochrane Database Syst Rev 2016; 3: CD005563
• 49 Zattoni D, Montroni I, Saur NM. et al. A simple screening tool to predict outcomes in older adults undergoing emergency general surgery. J Am Geriatr Soc 2019; 67 (02) 309-316
• 50 Williams GRWK, Weaver KE, Lesser GJ. et al. Capacity to provide geriatric specialty care for older adults in community oncology practices. Oncologist 2020; 25 (12) 1032-1038
• 51 Shahrokni A, Tin AL, Sarraf S. et al. Association of geriatric comanagement and 90-day postoperative mortality among patients aged 75 years and older with cancer. JAMA Netw Open 2020; 3 (08) e209265
• 52 Tarazona-Santabalbina FJ, Llabata-Broseta J, Belenguer-Varea Á, Álvarez-Martínez D, Cuesta-Peredo D, Avellana-Zaragoza JA. A daily multidisciplinary assessment of older adults undergoing elective colorectal cancer surgery is associated with reduced delirium and geriatric syndromes. J Geriatr Oncol 2019; 10 (02) 298-303
• 53 Dent E, Morley JE, Cruz-Jentoft AJ. et al. Physical frailty: ICFSR International Clinical Practice Guidelines for Identification and Management. J Nutr Health Aging 2019; 23 (09) 771-787
• 54 Hawkins AT, Pallangyo AJ, Herman AM. et al. The effect of social integration on outcomes after major lower extremity amputation. J Vasc Surg 2016; 63 (01) 154-162
• 55 Gonzalez-Saenz de Tejada M, Bilbao A, Baré M. et al. Association of social support, functional status, and psychological variables with changes in health-related quality of life outcomes in patients with colorectal cancer. Psychooncology 2016; 25 (08) 891-897
• 56 Gardner B, Jovicic A, Belk C. et al. Specifying the content of home-based health behaviour change interventions for older people with frailty or at risk of frailty: an exploratory systematic review. BMJ Open 2017; 7 (02) e014127
• 57 Minnella EM, Carli F. Prehabilitation and functional recovery for colorectal cancer patients. Eur J Surg Oncol 2018; 44 (07) 919-926
• 58 Waite I, Deshpande R, Baghai M, Massey T, Wendler O, Greenwood S. Home-based preoperative rehabilitation (prehab) to improve physical function and reduce hospital length of stay for frail patients undergoing coronary artery bypass graft and valve surgery. J Cardiothorac Surg 2017; 12 (01) 91
• 59 Chia CLKMS, Mantoo SK, Tan KY. “Start to finish trans-institutional transdisciplinary care”: a novel approach improves colorectal surgical results in frail elderly patients. Colorectal Dis 2016; 18 (01) O43-O50
• 60 Mazzola M, Bertoglio C, Boniardi M. et al. Frailty in major oncologic surgery of upper gastrointestinal tract: How to improve postoperative outcomes. Eur J Surg Oncol 2017; 43 (08) 1566-1571
• 61 Hoogeboom TJ, Dronkers JJ, van den Ende CH, Oosting E, van Meeteren NL. Preoperative therapeutic exercise in frail elderly scheduled for total hip replacement: a randomized pilot trial. Clin Rehabil 2010; 24 (10) 901-910
• 62 Oosting E, Jans MP, Dronkers JJ. et al. Preoperative home-based physical therapy versus usual care to improve functional health of frail older adults scheduled for elective total hip arthroplasty: a pilot randomized controlled trial. Arch Phys Med Rehabil 2012; 93 (04) 610-616
• 63 Kamarajah SK, Bundred J, Weblin J, Tan BHL. Critical appraisal on the impact of preoperative rehabilitation and outcomes after major abdominal and cardiothoracic surgery: a systematic review and meta-analysis. Surgery 2020; 167 (03) 540-549
• 64 Carli F, Bessissow A, Awasthi R, Liberman S. Prehabilitation: finally utilizing frailty screening data. Eur J Surg Oncol 2020; 46 (03) 321-325
• 65 Hedrick TL, Hassinger TE, Myers E. et al. Wearable technology in the perioperative period: predicting risk of postoperative complications in patients undergoing elective colorectal surgery. Dis Colon Rectum 2020; 63 (04) 538-544
• 66 Kane WJ, Hassinger TE, Myers EL. et al. Wearable technology and the association of perioperative activity level with 30-day readmission among patients undergoing major colorectal surgery. Surg Endosc 2022; 36 (02) 1584-1592
• 67 Hamaker ME, Oosterlaan F, van Huis LH, Thielen N, Vondeling A, van den Bos F. Nutritional status and interventions for patients with cancer: a systematic review. J Geriatr Oncol 2020; 20: S1879-S4068
• 68 Kamel HK. Sarcopenia and aging. Nutr Rev 2003; 61 (5, Pt 1): 157-167
• 69 Hargreaves M. Pre-exercise nutritional strategies: effects on metabolism and performance. Can J Appl Physiol 2001; 26 (Suppl): S64-S70
• 70 Leung JM, Sands LP, Mullen EA, Wang Y, Vaurio L. Are preoperative depressive symptoms associated with postoperative delirium in geriatric surgical patients?. J Gerontol A Biol Sci Med Sci 2005; 60 (12) 1563-1568
• 71 Kristjansson Sr JM, Nesbakken A, Skovlund E, Bakka A, Johannessen H, Wyller TB. Which elements of a comprehensive geriatric assessment (CGA) predict post-operative complications and early mortality after colorectal cancer surgery?. J Geriatr Oncol 2010; 1 (02) 57-65
• 72 Parker PA, Pettaway CA, Babaian RJ. et al. The effects of a presurgical stress management intervention for men with prostate cancer undergoing radical prostatectomy. J Clin Oncol 2009; 27 (19) 3169-3176
• 73 Carli F, Bousquet-Dion G, Awasthi R. et al. Effect of multimodal prehabilitation vs postoperative rehabilitation on 30-day postoperative complications for frail patients undergoing resection of colorectal cancer: a randomized clinical trial. JAMA Surg 2020; 155 (03) 233-242
• 74 Gillis C, Fenton TR, Gramlich L. et al. Older frail prehabilitated patients who cannot attain a 400 m 6-min walking distance before colorectal surgery suffer more postoperative complications. Eur J Surg Oncol 2021; 47 (04) 874-881
• 75 Montroni I, Ugolini G, Saur NM. et al; SIOG Surgical Task Force/ESSO GOSAFE Study Group. Quality of life in older adults after major cancer surgery: the GOSAFE international study. J Natl Cancer Inst 2022; 114 (07) 969-978
• 76 Carli F, Baldini G, Feldman LS. Redesigning the preoperative clinic: from risk stratification to risk modification. JAMA Surg 2021; 156 (02) 191-192
• 77 Tatar C, Benlice C, Delaney CP. et al. Modified frailty index predicts high-risk patients for readmission after colorectal surgery for cancer. Am J Surg 2020; 220 (01) 187-190