Hoe herken je kwetsbaarheid bij patiënten van ≥70 jaar in de preoperatieve setting?

Beoordeeld: 09-04-2024

Uitgangsvraag

Aanbeveling

Verricht bij alle patiënten van ≥70 jaar die een indicatie hebben voor een operatie met verwachte opnameduur ≥2 dagen preoperatief een screening naar kwetsbaarheid.

Geschikte screeningsinstrumenten zijn de CFS, G8 (oncologische patiënten), GFI, EFS en de ISAR of ISAR-HP. Ook kan een (verkort) geriatrisch assessment gebruikt worden ter screening.

Verwijs bij afwijkende screening naar de geriater/internist-ouderengeneeskunde voor een Comprehensive Geriatric Assessment.

Overwegingen

Er is literatuuronderzoek verricht naar verschillende screeningsinstrumenten die preoperatief worden ingezet om de mate van kwetsbaarheid te schatten bij oudere patiënten. De resultaten laten klinisch relevante verschillen van vergelijkbare grootte in voor de patiënt relevante uitkomstmaten zien, die in onderstaande paragrafen beschreven worden.

Kwetsbaarheid screening in relatie tot postoperatieve complicaties

Kwetsbare ouderen lopen een 2- tot 4-maal verhoogd risico op postoperatieve complicaties, waarbij de grootste verschillen te zien waren bij ouderen die als kwetsbaar werden geclassificeerd door het gebruik van de Clinical Frailty Score (CFS), Edmonton Fail Scale (EFS) of de Geriatric 8 (G8). De CFS is in 9 studies onderzocht, zowel in de electieve als acute chirurgische setting. In de gepoolde analyse hebben patiënten die kwetsbaar zijn 2x zoveel kans op postoperatieve complicaties. Hierbij moet wel opgemerkt worden dat in de studies verschillende CFS afkappunten voor frailty worden gebruikt, variërend van een score van 3 of hoger tot een score van 7 of hoger. De EFS is in 4 studies onderzocht in electieve setting. In de gepoolde analyse hebben patiënten die kwetsbaar zijn 4x zoveel kans op postoperatieve complicaties. Ook hier verschilt het afkappunt voor frailty van 4 of hoger tot 7 of hoger. De G8 werd in 8 studies onderzocht, waarbij de gepoolde analyse laat zien dat patiënten die kwetsbaar zijn 3x zoveel kans hebben op postoperatieve complicaties. De bewijskracht van de literatuur t.a.v. de CFS, EFS en G8 is laag. De Groningen Frailty Indicator (GFI) en VMS-vragen werden in respectievelijk 2 studies en 1 studie onderzocht, met lage tot zeer lage bewijskracht.

Kwetsbaarheid screening in relatie tot postoperatieve mortaliteit

De grootste verschillen in risico op postoperatieve mortaliteit waren te zien bij patiënten die geclassificeerd waren ten aanzien van hun kwetsbaarheid door CFS, EFS of de Identification of Seniors At Risk (ISAR) of ISAR-hospitalized patients (ISAR-HP). In de gepoolde analyses van de CFS studies geeft kwetsbaarheid een 2,5 keer hoger risico op postoperatieve sterfte. Voor mortaliteit was het bewijs over het algemeen van lage kwaliteit, behalve voor ISAR, waarvoor het bewijs redelijk van kwaliteit was (door het grote aantal geïncludeerde patiënten).

Kwetsbaarheid screening in relatie tot postoperatieve ontslagbestemming

Classificatie door ISAR en VMS liet de grootste verschillen zien ten aanzien van de ontslagbestemming. Kwetsbare patiënten konden minder vaak naar huis na ontslag. Het bewijs voor ISAR was van redelijke kwaliteit, voor de overige instrumenten van lage kwaliteit, en voor CFS van zeer lage kwaliteit (door de grote onzekerheid van de resultaten).

Kwetsbaarheid screening in relatie tot postoperatief fysiek functioneren.

Patiënten die als kwetsbaar werden geclassificeerd door CFS en ISAR lieten een lager niveau van fysiek functioneren zien. Het bewijs voor ISAR was redelijk van kwaliteit, voor CFS was de kwaliteit laag.

Kwetsbaarheid screening in relatie tot opnameduur

Ten aanzien van de opnameduur werd bewijs gevonden voor kwetsbaarheid geclassificeerd door EFS, G8 en ISAR-HP. De kwaliteit van het bewijs was laag.

Samenvattend lijkt kwetsbaarheid van ouderen een groter risico te geven op nadelige uitkomsten. De grootte van de risico’s verschilt tussen de verschillende screeningsinstrumenten, net als de kwaliteit van het bewijs. Het bewijs ten aanzien van het instrument ISAR heeft een redelijke kwaliteit; het verschil met het niveau van bewijs voor andere screeningsinstrumenten zit in het aantal deelnemende patiënten en daarmee een grotere precisie van de effectschattingen.

Internationale richtlijnen rondom screening op kwetsbaarheid in de preoperatieve setting

De internationale richtlijnen voor perioperatieve zorg bevelen aan om bij ouderen in de preoperatieve fase een screeningstool te gebruiken om kwetsbaarheid te identificeren, dit is gebaseerd op hoge kwaliteit bewijs (Engel et al., 2023). Ook wordt in internationale richtlijnen geadviseerd dat bij een afwijkende screening de patiënt verwezen wordt voor een CGA (review door Engel et al, 2023).

Twee internationale richtlijnen zijn verschenen nadien en niet meer meegenomen in bovenstaande review. Dit betreft:

1. De ‘Clinical Practice Guidelines for the Perioperative Evaluation and Management of Frailty Among Older Adults Undergoing Colorectal Surgery’ (Saur et al., 2022), van de American Society of Colon and Rectal Surgeons beveelt aan dat ouderen preoperatief gescreend moet worden op kwetsbaarheid (grade A, strong recommendation, high-quality evidence). De richtlijn noemt als mogelijke screeningsinstrumenten onder andere de G8, de Multidimensional Prognostic Index, de Timed Up and Go Test, loopsnelheid en de vraag naar een valincident in de afgelopen 6 maanden.

2. Een richtlijn van de Royal College of Anesthesists (2023) uit het Verenigd Koninkrijk stelt dat patiënten die kwetsbaar zijn een verhoogd risico hebben op ongunstige postoperatieve uitkomsten. Oudere patiënten die intermediair- en hoog-risico chirurgie ondergaan, moeten dan ook preoperatief gescreend moeten worden op kwetsbaarheid met een erkende screeningstool.

Waarden en voorkeuren van patiënten (en evt. hun verzorgers)

Het doel van preoperatieve screening op kwetsbaarheid is om kwetsbare ouderen een CGA te bieden waardoor de risico’s van een operatie goed in kaart worden gebracht en waar mogelijk patiënten te optimaliseren. Ook helpt een CGA om de wensen van patiënten helder te krijgen. Ouderen scoren behoud van zelfstandigheid vaak als een belangrijker behandeldoel dan zo lang mogelijk leven. Het CGA kan helpen om de kans op behoud van zelfstandigheid in te schatten en tevens om het behoud en herstel van zelfstandigheid postoperatief te bevorderen (NVKG, 2021).

Kosten (middelenbeslag)

Er zijn geen studies naar kosteneffectiviteit van screening op kwetsbaarheid in de preoperatieve setting. Screening neemt hooguit enkele minuten in beslag.

Een gerandomiseerde en dubbelblind gecontroleerde studie bij vaatchirurgische patiënten toonde dat een preoperatief uitgevoerd CGA leidde tot minder postoperatieve complicaties, minder delier, wondinfectie, en kortere opnameduur (Partridge et al., 2017). Een vervolganalyse toonde aan dat deze interventie kosteneffectief was (Partridge et al., 2021).

Aanvaardbaarheid, haalbaarheid en implementatie

Het gehele zorgpad voor (kwetsbare) ouderen die een indicatie hebben voor chirurgie dient de volgende onderdelen te bevatten: screening op kwetsbaarheid alsook op cognitieve stoornissen (zie module 2.2), een CGA op indicatie, en gezamenlijke besluitvorming in een multidisciplinair overleg (zie module 3 van deze richtlijn).

De screening kan plaatsvinden op de polikliniek van de snijdend hoofdbehandelaar of op de preoperatieve polikliniek van de anesthesiologie. De screening kan door verschillende personen worden uitgevoerd (verpleegkundige, verpleegkundig specialist, PA, arts). Vooraf dienen de personen die de screening gaan uitvoeren kort getraind te worden, dit betreft met name de cognitieve screening (zie module 2.2). Een (verkort) GA vraagt wat meer tijd en training, en kan door een verpleegkundige, verpleegkundig specialist of PA worden afgenomen. In het geval de verwijsbrief van de huisarts al vermeldt dat het om een kwetsbare patiënt gaat, kan de snijdend specialist ook direct naar de geriater/ internist ouderengeneeskunde verwijzen voor een CGA.

Een studie onder Nederlandse anesthesisten gaf aan dat 99% van de respondenten vond dat kwetsbaarheid het anesthesiologische beleid kan veranderen (Bouwhuis et al., 2021). Voor de praktische uitvoering is het belangrijk om de logistieke afspraken voor screening, en de samenwerking met snijdende specialismen enerzijds en de geriatrie/ ouderengeneeskunde anderzijds goed vorm te geven. In dezelfde studie gaf slechts 43% van de anesthesisten aan dat er een adequate samenwerking met geriaters was.

Onafhankelijk van welke werkwijze er gekozen wordt, moet er dus een specialist met geriatrische expertise betrokken zijn bij een protocol waarin de risico’s en de interventies beschreven worden. Lokaal kunnen afspraken worden gemaakt wie verantwoordelijk is voor de interventies.

Screening van de acute chirurgische patiënt

Spoedoperaties worden in de Nederlandse setting ingedeeld in 4 categorieën, namelijk een operatie moet starten: 1. binnen (30) minuten, 2. binnen uren (8 uur), 3. binnen dagen (bij voorkeur dezelfde dag), of 4. binnen 1 week (zie richtlijn ‘Beleid rondom spoedoperaties’ (NVvH 2018)). Voor categorie 3 en 4 is de werkgroep van mening dat er voldoende tijd is om bij oudere patiënten een screening uit te voeren in de klinische setting. Voor operaties die binnen uren uitgevoerd moeten worden, categorie 2, zal de screening vaker op de SEH uitgevoerd moeten worden. Hiervoor zou gebruik gemaakt kunnen worden van de APOP screener die op veel SEH’s al geïmplementeerd is en tevens de cognitieve functie screent (zie richtlijn ‘Comprehensive Geriatric Assessment’ (NVKG 2021)). Een tweede mogelijkheid is het gebruik van de Clinical Frailty Scale, ook deze is snel af te nemen. Meerdere systematische reviews beschrijven dat frailty in de acute chirurgische patiënt een sterke relatie toont met ongunstige postoperatieve uitkomsten (Fehlmann et al., 2022; Kennedy et al., 2022; Leiner et al., 2022; Ward et al., 2019).

Screening van patiënten <70 jaar

Het kan zinvol zijn om patiënten jonger dan 70 te screenen, met name als het om specifieke patiëntengroepen waarbij de biologisch leeftijd vaak ouder is dan de kalenderleeftijd. Dit betreft bijvoorbeeld patiënten met hoofd-halskanker (Bakas et al., 2023). Het is uiteraard ook mogelijk om patiënten jonger dan 70 voor een CGA te verwijzen wanneer de snijdend hoofdbehandelaar kwetsbaarheid of cognitieve problemen vermoedt.

Rationale van de aanbeveling:

Ouderen die kwetsbaar zijn hebben een 2- tot 4-maal hoger risico op nadelige postoperatieve uitkomsten en een hoger risico op postoperatieve sterfte vergeleken met ouderen die niet kwetsbaar zijn. Daarom is het belangrijk voor de operatie kwetsbare ouderen te identificeren bijvoorbeeld d.m.v. een korte screening. Voor de richtlijn is gekeken naar screeningsinstrumenten die in de Nederlandse setting gebruikt worden en ook in de literatuur onderzocht zijn. De belangrijkste screeningsinstrumenten in de preoperatieve setting zijn de Clinical Frailty Scale (CFS), de Edmonton Frail Scale (EFS), de G8, de Groningen Frailty Indicator (GFI) en de ISAR(-HP). De G8 is speciaal ontwikkeld voor de oudere kankerpatiënt en is een bruikbaar instrument gebleken voor de oncologische populatie (zie Richtijn Comprehensive Geriatric Assessment (CGA)). De grootte van de risico’s op ongunstige uitkomsten is verschillend tussen de diverse screeningsinstrumenten, net als de kwaliteit van het bewijs. De werkgroep adviseert om de screening altijd in samenwerking met de geriater/ internist ouderengeneeskunde van het ziekenhuis op te zetten, omdat een afwijkende screening een reden is om de patiënt te verwijzen voor een Comprehensive Geriatric Assessment (CGA) voor nadere diagnostiek, risico-inventarisatie en voor eventuele optimalisatie en behandeling van kwetsbaarheid. De korte screening kan door verschillende personen worden afgenomen, kost enkele minuten en is weinig belastend voor de patiënt. Daarnaast is het ook mogelijk een verkort Geriatric Assessment (GA) uit te voeren, bijvoorbeeld bestaande uit een combinatie van een screeningstest en functionele testen zoals handknijpkracht of een loopsnelheid. Het uitvoeren van een verkort GA vraagt wel enige scholing, maar kan ook door verpleegkundigen worden uitgevoerd. Screening voorkomt dat fitte ouderen ten onrechte verwezen worden voor een CGA. Tenslotte sluit de aanbeveling aan bij internationale richtlijnen voor de perioperatieve zorg bij (kwetsbare) ouderen.

Onderbouwing

Conclusies

CFS

Low GRADE	The evidence suggests that patients with frailty as classified by CFS (≥5) have a higher risk of postoperative complications compared to patients who are classified as not frail. Source: Ahola, 2022; Arteaga, 2020; Covino, 2022; Miguelena-Hycka, 2019; Niemeläinen, 2021; Sun, 2020; Tanaka, 2019; Tanaka, 2022; Yamada, 2021
Low GRADE	The evidence suggests that patients with frailty as classified by CFS have a higher risk of mortality compared to patients who are classified as not frail. Source: Arteaga, 2020; Artiles-Armas, 2021; Covino, 2022; Hill, 2020; Miguelena-Hycka, 2019; Sanchez Arteaga, 2022; Sun, 2020; Tanaka, 2019; Tanaka, 2022; Vilches-Moraga, 2020; Wu, 2021; Yamada, 2021
Very low GRADE	The evidence is very uncertain about the risk of not returning home at discharge for patients with frailty as classified by CFS compared to patients who are classified as not frail. Source: Ahola, 2022; Hill, 2020; Sun, 2020
Low GRADE	The evidence suggests that patients with frailty as classified by CFS have an impaired physical functioning after surgery compared to patients who are classified as not frail. Source: Sun, 2020
No GRADE	No studies reported on the outcome discharge destination, therefore the quality of the evidence could not be rated.
No GRADE	No studies reported on the outcome physical functioning, therefore the quality of the evidence could not be rated.

EFS

Low GRADE	The evidence suggests that patients with frailty as classified by EFS have a higher risk of postoperative complications compared to patients who are classified as not frail. Source: Amabili, 2019
Low GRADE	The evidence suggests that patients with frailty as classified by EFS have a higher risk of mortality compared to patients who are classified as not frail. Source: Dal Moro, 2017; Dasgupta, 2009; He, 2020; Nishijima, 2021
Low GRADE	The evidence suggests that patients with frailty as classified by EFS have a higher risk of not returning home at discharge compared to patients who are classified as not frail. Source: Amabili, 2019; Dasgupta, 2009
No GRADE	No studies reported on the outcome physical functioning, therefore the quality of the evidence could not be rated.
Low GRADE	The evidence suggests that patients with frailty as classified by EFS have a longer length of stay compared to patients who are classified as not frail. Source: Dasgupta, 2009
No GRADE	No studies reported on the outcome quality of life, therefore the quality of the evidence could not be rated.

Low GRADE	The evidence suggests that patients with frailty as classified by G8 have a higher risk of postoperative complications compared to patients who are classified as not frail. Source: Fagard, 2017; Kaibori, 2016; Kenig, 2020; Krenzlin, 2021; Niemeläinen, 2021; Nishijima, 2021; Souwer, 2018; Traunero, 2022
Low GRADE	The evidence suggests that patients with frailty as classified by G8 have a slightly higher risk of mortality compared to patients who are classified as not frail. Source: Kaibori, 2016; Kenig, 2020; Krenzlin, 2021; Souwer, 2018
No GRADE	No studies reported on the outcome discharge destination, therefore the quality of the evidence could not be rated.
No GRADE	No studies reported on the outcome physical functioning, therefore the quality of the evidence could not be rated.
Low GRADE	The evidence suggests that patients with frailty as classified by G8 have a longer length of stay compared to patients who are classified as not frail. Source: Kaibori, 2016; Souwer, 2018
No GRADE	No studies reported on the outcome quality of life, therefore the quality of the evidence could not be rated.

GFI

Low GRADE	The evidence suggests that patients with frailty as classified by GFI have a higher risk of postoperative complications compared to patients who are classified as not frail. Source: Kenig, 2020; Krenzlin, 2021
Very low GRADE	The evidence is very uncertain about the risk of death after surgery or during follow-up for patients with frailty as classified by GFI compared to patients who are classified as not frail. Source: Kenig, 2020; Krenzlin, 2021; Winters, 2018
No GRADE	No studies reported on the outcome discharge destination, therefore the quality of the evidence could not be rated.
No GRADE	No studies reported on the outcome physical functioning, therefore the quality of the evidence could not be rated.
No GRADE	No studies reported on the outcome discharge destination, therefore the quality of the evidence could not be rated.
No GRADE	No studies reported on the outcome physical functioning, therefore the quality of the evidence could not be rated.

ISAR and ISAR-HP

No GRADE	No studies reported on the outcome complications, therefore the quality of the evidence could not be rated.
Moderate GRADE	Patients with frailty as classified by ISAR (Knauf) or ISAR-HP (Souwer) likely have a higher risk of mortality compared to patients who are classified as not frail. Source: Knauf, 2022; Souwer, 2018
Moderate GRADE	Patients in the acute surgical setting (proximal femur fracture) with frailty as classified by ISAR likely have a higher risk of being discharged towards a healthcare facility compared to patients who are classified as not frail. Source: Knauf, 2022
Moderate GRADE	Patients in the acute surgical setting (proximal femur fracture) with frailty as classified by ISAR likely have a higher risk of being unable to walk independently or at all, compared to patients who are classified as not frail. Source: Knauf, 2022
Low GRADE	The evidence suggests that patients with frailty as classified by the ISAR-HP have a slightly longer mean length of hospital stay compared to patients who are classified as not frail. Source: Souwer, 2018
No GRADE	No studies reported on the outcome physical functioning, therefore the quality of the evidence could not be rated

Mini-Cog

Very low GRADE	The evidence is very uncertain about the risk of complications after surgery or during follow-up for patients with possible cognitive impairment as classified by Mini-Cog compared to patients who are classified as a normal cognition. Source: Heng, 2016; Korc-Grodzicki, 2015; Susano, 2020; Weiss, 2022
Low GRADE	The evidence suggests that patients with possible cognitive impairment as classified by Mini-Cog have a higher risk of mortality compared to patients who are classified as a normal cognition. Source: Heng, 2016 and Weiss, 2022
Low GRADE	The evidence suggests that patients with possible cognitive impairment as classified by Mini-Cog have a higher risk of not returning home at discharge compared to patients who are classified as a normal cognition. Source: Puustinen, 2016; Weiss, 2022
No GRADE	No studies reported on the outcome physical functioning, therefore the quality of the evidence could not be rated.
No GRADE	No studies reported on the outcome discharge destination, therefore the quality of the evidence could not be rated.
No GRADE	No studies reported on the outcome physical functioning, therefore the quality of the evidence could not be rated.

VMS

Very low GRADE	The evidence is very uncertain about the risk of complications after surgery or during follow-up for patients with frailty as classified by VMS compared to patients who are classified as not frail. Source: Van der Zanden, 2021
Low GRADE	The evidence suggests that patients with frailty as classified by VMS have a slightly higher risk of mortality compared to patients who are classified as not frail. Source: Van der Zanden, 2021; Winters, 2018
Low GRADE	The evidence suggests that patients with frailty as classified by VMS have a higher risk of not returning home at discharge compared to patients who are classified as not frail. Source: Van der Zanden, 2021
No GRADE	No studies reported on the outcome physical functioning, therefore the quality of the evidence could not be rated.
No GRADE	No studies reported on the outcome discharge destination, therefore the quality of the evidence could not be rated.
No GRADE	No studies reported on the outcome physical functioning, therefore the quality of the evidence could not be rated.

Samenvatting literatuur

Description of studies

Ahola (2022) performed a retrospective cohort study to assess the incidence of postoperative outcomes (complications, discharge destination) related to frailty according to assessment according to the CFS screening tool. 95 patients with a minimum age of 80 years were included.

Amabili (2019) performed a prospective cohort study to assess the incidence of postoperative outcomes (mortality, discharge destination) related to frailty according to preoperative assessment according to the EFS screening tool. 254 patients with a median age of 80 years were included, of whom 20% were classified as frail.

Arteaga (2020) performed a prospective cohort study to assess the incidence of postoperative outcomes (mortality, complications) related to frailty according to preoperative assessment according to the CFS screening tool. 92 patients with a mean age of 79 years were included.

Artiles-Armas (2021) performed a prospective cohort study to assess the incidence of postoperative outcomes (mortality) related to frailty according to preoperative assessment according to the CFS screening tool. 149 patients with a median age of 75 years were included, of whom 40% were classified as frail.

Covino performed a prospective cohort study to assess the incidence of postoperative outcomes (mortality, complications) related to frailty according to preoperative assessment according to the CFS screening tool. 1039 patients with a median age of 85 years were included, of whom 18% were classified as frail.

Dal Moro (2017) performed a prospective cohort study to assess the incidence of postoperative outcomes (complications) related to frailty according to preoperative assessment according to the EFS screening tool. 78 patients with a mean age of 78.5 years were included, of whom 22% were classified as frail.

Dasgupta (2009) performed a prospective cohort study to assess the incidence of postoperative outcomes (complications, discharge destination, length of stay) related to frailty according to preoperative assessment according to the EFS screening tool. 12 patients with a mean age of 77.4 years were included.

Fagard (2017) performed a retrospective cohort study to assess the incidence of postoperative outcomes (complications) related to frailty according to preoperative assessment according to the EFS screening tool. 190 patients with a median

age of 77 years were included, of whom 61% were classified as frail.

He (2020) performed a prospective cohort study to assess the incidence of postoperative outcomes (complications) related to frailty according to preoperative assessment according to the EFS screening tool. 134 patients with a mean age of 74 years were included, of whom 10% were classified as frail.

Heng (2016) performed a retrospective cohort study to assess the incidence of postoperative outcomes (mortality, complications) related to possible cognitive impairment according to preoperative assessment according to the Mini-Cog screening tool. 513 patients with a median age of 83 years were included, of whom 35% were classified as cognitive impaired.

Hill (2020) performed a prospective cohort study to assess the incidence of postoperative outcomes (mortality, complications, discharge destination) related to frailty according to preoperative assessment according to the CFS screening tool. 233 patients with a mean age of 84 years were included, of whom 44% were classified as frail.

Kaibori (2016) performed a prospective cohort study to assess the incidence of postoperative outcomes (mortality, complications, length of stay) related to frailty according to preoperative assessment according to the G8 screening tool. 71 patients with a median age of 71 years were included, of whom 55% were classified as frail.

Kenig (2020) performed a prospective cohort study to assess the incidence of postoperative outcomes (mortality, complications) related to frailty according to preoperative assessment according to the G8 and GFI screening tools. 272 patients with a median age of 272 years were included, of whom 83% (G8) and 51% (GFI) were classified as frail.

Knauf (2022) performed a retrospective cohort study to assess the incidence of postoperative outcomes (mortality, discharge destination, physical functioning) related to frailty according to preoperative assessment according to the ISAR screening tool. 15,099 patients with a median age of 85 years were included, of whom 81% were classified as frail.

Korc-Grodzicki (2015) performed a prospective retrospective cohort study to assess the incidence of postoperative outcomes (complications, i.e., delirium) related to possible cognitive impairment according to preoperative assessment according to the Mini-Cog screening tool. 416 patients with a median age of 80 years were included, of whom 31% were classified as cognitive impaired.

Krenzlin (2021) performed a retrospective cohort study to assess the incidence of postoperative outcomes (mortality, complications) related to frailty according to preoperative assessment according to the G8 and GFI screening tools. 104 patients with a mean age of 77 years were included, of whom 51% (G8) and 59% (GFI) were classified as frail.

Miguelena-Hylcka (2019) performed a prospective cohort study to assess the incidence of postoperative outcomes (mortality, complications) related to frailty according to preoperative assessment according to the CFS screening tool. 143 patients with a mean age of 78 years were included, of whom 13% were classified as frail.

Niemeläinen (2021) performed a retrospective cohort study to assess the incidence of postoperative outcomes (complications) related to frailty according to preoperative assessment according to the CFS G8 screening tool. 161 patients with a mean age of 85 years were included, of whom 47% were classified as frail.

Nishjima (2021) performed a prospective cohort study to assess the incidence of postoperative outcomes (complications) related to frailty according to preoperative assessment according to the EFS and G8 screening tools. 114 patients with a median age of 80 years were included, of whom 15% were classified as frail.

Puustinen (2016) performed a prospective cohort study to assess the incidence of postoperative outcomes (discharge destination) related to possible cognitive impairment according to preoperative assessment according to the Mini-Cog screening tool. 52 patients with a mean age of 79 years were included, of whom 32% were classified as cognitive impaired.

Sanches Arteaga (2022) performed a prospective cohort study to assess the incidence of postoperative outcomes (mortality) related to frailty according to preoperative assessment according to the CFS screening tool. 92 patients with an approximate mean age of 77 years were included, of whom 9% were classified as frail.

Souwer (2018) performed a prospective cohort study to assess the incidence of postoperative outcomes (mortality, complications) related to frailty according to preoperative assessment according to both the ISAR-HP and G8 screening tool. 139 patients with a mean age of 77.7 years were included, of whom 14% were classified as frail.

Sun (2020) performed a prospective cohort study to assess the incidence of postoperative outcomes (mortality, complications, discharge destination, physical functioning) related to frailty according to preoperative assessment according to the CFS screening tool. 82 patients with a mean age of 82 years were included, of whom 32% were classified as frail.

Susano (2020) performed a prospective cohort study to assess the incidence of postoperative outcomes (complications) related to possible cognitive impairment according to preoperative assessment according to the Mini-Cog screening tool. 229 patients with a median age of 75 years were included, with a median Mini-Cog score of 4.

Tanaka (2019) performed a retrospective cohort study to assess the incidence of postoperative outcomes (mortality, complications) related to frailty according to preoperative assessment according to the CFS screening tool. 96 patients with a median age of 82 years were included, of whom 17% were classified as frail.

Tanaka (2022) performed a retrospective cohort study to assess the incidence of postoperative outcomes (mortality, complications) related to frailty according to preoperative assessment according to the CFS screening tool. 36 patients with a median age of 77 years were included, of whom 44% were classified as frail.

Traunero (2022) performed a prospective cohort study to assess the incidence of postoperative outcomes (complications) related to frailty according to preoperative assessment according to the G8 screening tool. 162 patients with a median age of 76 years were included, of whom 56% were classified as frail.

Van der Zanden (2021) performed a retrospective cohort study to assess the incidence of postoperative outcomes (mortality, complications, discharge destination) related to frailty according to preoperative assessment according to the VMS screening tool. 157 patients with a median age of 74 years were included, of whom 39% were classified as frail.

Vilches-Moraga (2020) performed a prospective cohort study to assess the incidence of postoperative outcomes (mortality) related to frailty according to preoperative assessment according to the CFS screening tool. 113 patients with a mean age of 82 years were included, of whom 33% were classified as frail.

Weiss (2022) performed a prospective cohort study to assess the incidence of postoperative outcomes (mortality, complications, discharge destination) related to possible cognitive impairment according to preoperative assessment according to the Mini-Cog screening tool. 1,338 patients with a mean age of approximately 77 years were included, of whom 21% were classified as cognitive impaired.

Winters (2018) performed a prospective cohort study to assess the incidence of postoperative outcomes (mortality) related to frailty according to preoperative assessment according to the GFI and VMS screening tools. 286 patients with a mean age of 83 years were included, of whom 26% (VMS) and 30% (GFI) were classified as frail.

Wu (2021) performed a retrospective cohort study to assess the incidence of postoperative outcomes (mortality) related to frailty according to preoperative assessment according to the CFS screening tool. 397 patients with a mean age of 84 years were included, of whom 46% were classified as frail.

Yamada (2021) performed a prospective cohort study to assess the incidence of postoperative outcomes (mortality, complications) related to frailty according to preoperative assessment according to the CFS screening tool. 82 patients with a mean age of 80 years were included, of whom 23% were classified as frail.

No studies were found that reported on the relevant outcomes and screened for frailty using the instruments Fried frailty, Frailty index, Tilburg Frailty Indicator, 6-CIT, MMSE, and MOCA.

Results

CFS

Complications

In total, nine (9) studies reported on postoperative complications in patients classified as frail according to the CFS, compared to patients not classified as frail (Ahola, 2022; Arteaga, 2020; Covino, 2022; Miguelena-Hycka, 2019; Niemeläinen, 2021; Sun, 2020; Tanaka, 2019; Tanaka, 2022; Yamada, 2021). When we summarized the results, a pooled odds ratio of 2.17 (95% CI: 1.67 to 2.81) could be calculated, which can be interpreted as a higher risk of complications in frail patients compared to non-frail patients. (Figure 1)

Figure 1 – Pooled estimate of risk of postoperative complications according to frailty status (CFS).

Mortality

In total, twelve (12) studies reported on postoperative mortality in patients classified as frail according to the CFS, compared to patients not classified as frail (Arteaga, 2020; Artiles-Armas, 2021; Covino, 2022; Hill, 2020; Miguelena-Hycka, 2019; Sanchez Arteaga, 2022; Sun, 2020; Tanaka, 2019; Tanaka, 2022; Vilches-Moraga, 2020; Wu, 2021; Yamada, 2021).

When we summarized the results, a pooled odds ratio of 2.57 (95% CI: 1.70 to 3.90) could be calculated, which can be interpreted as a higher risk of mortality in frail patients compared to non-frail patients. (Figure 2) Studies reported mortality over different follow-up durations. We performed subgroup analyses of the results by follow-up duration.

Figure 2 – Pooled estimate of risk of postoperative mortality according to frailty status (CFS).

Discharge destination

In total, three (3) studies reported on postoperative discharge destination in patients classified as frail according to the CFS, compared to patients not classified as frail (Ahola, 2022; Hill, 2020; Sun, 2020). Ahola (2022) reported an OR of 1.17 (95% CI: 0.37 to 8.47); Hill (2020) reported 0.55 (95% CI: 0.35 to 0.95), and Sun (2020) reported 0.10 (95% CI: 0.01 to 0.95)

Physical functioning

In total, one (1) study reported on postoperative physical functioning in patients classified as frail according to the CFS, compared to patients not classified as frail (Sun, 2020). They reported an OR of 2.5 (95% CI 1.4 to 4.6) for a decline in ADL for each point increase in CFS.

Length of stay

No studies reported on the outcome length of stay.

Quality of life

No studies reported on the outcome quality of life.

EFS

Complications

In total, four (4) studies reported on postoperative complications in patients classified as frail according to the EFS, compared to patients not classified as frail (Dal Moro, 2017; Dasgupta, 2009; He, 2020; Nishijima, 2021). When we summarized the results, a pooled odds ratio of 4.32 (95% CI: 2.59 to 7.19) could be calculated, which can be interpreted as a higher risk of complications in frail patients compared to non-frail patients. (Figure 3)

Figure 3 – Pooled estimate of risk of postoperative complications according to frailty status (EFS)

Mortality

In total, one (1) study reported on postoperative mortality in patients classified as frail according to the EFS, compared to patients not classified as frail (Amabili, 2019). They reported an odds ratio of 3.90 (95% CI: 1.42 to 10.67) which can be interpreted as a higher risk of mortality in frail patients compared to non-frail patients.

Discharge destination

In total, two (2) studies reported on postoperative discharge destination in patients classified as frail according to the EFS, compared to patients not classified as frail (Amabili, 2019; Dasgupta, 2009)

Amabili (2019) reported an adjusted odds ratio for being admitted to a healthcare facility of 1.7 (95% CI, 0.8-3.8), and an adjusted odds ratio for returning home for non-frail patients compared to frail patients of 2.6; 95% CI, 1.2-5.3.

Dasgupta (2009) reported an odds ratio for returning home of 0.27 (95% CI 0.09 to 0.81) for frail patients.

Physical functioning

No studies reported on the outcome physical functioning.

Length of stay

In total, one (1) study reported on postoperative length of stay in patients classified as frail according to the EFS, compared to patients not classified as frail (Dasgupta, 2009). They reported a mean difference of 2.90 days (95% CI 1.22 to 4.58).

Quality of life

No studies reported on the outcome quality of life.

Complications

In total, nine (9) studies reported on postoperative complications in patients classified as frail according to the G8, compared to patients not classified as frail (Fagard, 2017; Kaibori, 2016; Kenig, 2020; Krenzlin, 2021; Niemeläinen, 2021; Nishijima, 2021; Souwer, 2018; Traunero, 2022)

When we summarized the results, a pooled odds ratio of 2.26 (95% CI: 1.15 to 4.45) could be calculated, which can be interpreted as a higher risk of complications in frail patients compared to non-frail patients. (Figure 4)

Figure 4 – Pooled estimate of risk of postoperative complications according to frailty status (G8)

Kenig (2020) reported a sensitivity of 94% (95% CI: 92 to 96), a specificity of 39% (24 to 52), a positive predictive value (PPV) of 80% (73 to 85), a negative predictive value (NPV) of 80% (73 to 85) and an area under the curve (AUC) of (95%CI) 0.75 (0.66 to 0.81) for complications.

Krenzlin (2021) reported an odds ratio of 3.68 (95% CI: 1.11 to 15.15).

Nishijima (2021) reported an odds ratio of 3.56 (95% CI: 0.96 to 13.21).

Traunero (2022) reported an odds ratio of 21.36 (7.98 to 74.58).

Mortality

In total, four (4) studies reported on postoperative mortality in patients classified as frail according to the G8, compared to patients not classified as frail (Kaibori, 2016; Kenig, 2020; Krenzlin, 2021; Souwer, 2018). They reported different outcome measures, therefore the results could not be pooled.

Kaibori (2016) reported an odds ratio of 8.24 (95% CI 0.43 to 159.04) for 1-year mortality.

Kenig (2020) reported a sensitivity of 98% (95% CI: 93 to 99), a specificity of 42% (27 to 55), a positive predictive value (PPV) of 34% (18 to 50), a negative predictive value (NPV) of 98% (93 to 99) and an area under the curve (AUC) of (95%CI) 0.74 (0.65 to 0.81) for 1-year mortality. They reported a sensitivity of 98% (95% CI: 93 to 99), a specificity of 49% (35 to 61), a positive predictive value (PPV) of 39% (24 to 52), a negative predictive value (NPV) of 97% (93 to 99) and an area under the curve (AUC) of (95%CI) 0.71 (0.61 to 0.78) for 30-day mortality.

Krenzlin (2021) reported a hazard ratio (HR) of 1.74 (95% CI 1.12 to 2.71).

Souwer (2018) reported an odds ratio of 1.0 (95%CI 0.2 to 5.2) for 30-day mortality and 1.4 (95% CI 0.3 to 6.4) for 6-month mortality.

Discharge destination

No studies reported on discharge destination.

Physical functioning

No studies reported on the outcome physical functioning.

Length of stay

In total, two (2) studies reported on postoperative length of stay in patients classified as frail according to the G8, compared to patients not classified as frail (Kaibori, 2016; Souwer, 2018).

Kaibori (2016) reported an odds ratio of 3.33 (95% CI 1.25 to 8.86) for the risk of a length of hospital stay of 13 days or longer.

Souwer (2018) reported a mean (SD) length of hospital stay of frail patients of 8.3 (7.0) and non-frail patients of 9.0 (6.7).

Quality of life

No studies reported on the outcome quality of life.

GFI

Complications

In total, two (2) studies reported on postoperative complications in patients classified as frail according to the GFI, compared to patients not classified as frail (Kenig, 2020; Krenzlin, 2021)

Kenig (2020) reported a sensitivity of 58% (95% CI: 45 to 68), a specificity of 60% (48 to 70), a positive predictive value (PPV) of 63% (51 to 72), a negative predictive value (NPV) of 55% (42 to 66) and an area under the curve (AUC) of 0.60 (0.48 to 0.70) for 1-year mortality.

Krenzlin (2021) reported an odds ratio of 4.0 (95% CI: 1.07 to 14.90) for complications.

Mortality

In total, three (3) studies reported on postoperative mortality in patients classified as frail according to the GFI, compared to patients not classified as frail (Kenig, 2020; Krenzlin, 2021; Winters, 2018). They reported different outcome measures, therefore the results could not be pooled.

Kenig (2020) reported a sensitivity of 75% (95% CI: 63 to 79), a specificity of 56% (43 to 66), a positive predictive value (PPV) of 28% (12 to 42), a negative predictive value (NPV) of 90% (86 to 92) and an area under the curve (AUC) of 0.65 (0.54 to 0.74) for 1-year mortality. They reported a sensitivity of 73% (95% CI: 64 to 90), a specificity of 55% (42 to 66), a positive predictive value (PPV) of 24% (10 to 39), a negative predictive value (NPV) of 91% (88 to 93) and an area under the curve (AUC) of (95%CI) 0.64 (0.53 to 0.73) for 30-day mortality.

Krenzlin (2021) reported a hazard ratio of 1.67 (95% CI 1.09 to 2.57) for mortality.

Winters (2018) reported an odds ratio of 2.3 (95% CI 1.2 to 4.1) for 3-year mortality.

Discharge destination

No studies reported on the outcome discharge destination.

Physical functioning

No studies reported on the outcome physical functioning.

Length of stay

No studies reported on the outcome length of stay.

Quality of life

No studies reported on the outcome quality of life.

ISAR and ISAR-HP

Mortality

In total, two (2) studies reported on postoperative mortality in patients classified as frail according to the ISAR (Knauf) or ISAR-HP (Souwer), compared to patients not classified as frail (Knauf, 2022; Souwer, 2018).

Knauf, 2022 reported an odds ratio of 3.45 (95% CI 2.44 to 5.03) for an increased risk of in-hospital mortality in patients with an acute proximal femoral fracture who were classified as frail according to the ISAR.

Souwer (2018) reported an odds ratio of 3.6 (95%CI 0.7 to 18.7) for 30-day mortality and 4.9 (95% CI 1.1 to 23.4) for 6-month mortality.

Complications

No studies reported on postoperative complications.

Discharge destination

Discharge destination was reported by Knauf, 2022; they reported an odds ratio of 0.42 (95% CI 0.38 to 0.47) for a decreased probability of returning home at hospital discharge for patients with an acute proximal femoral fracture who were classified as frail according to the ISAR.

Physical functioning

Physical functioning was reported by Knauf, 2022; they reported a odds ratio for walking ability 7 days postoperatively. The odds ratio for the risk of only being able to walk with walker for frail patients was 3.69 (95% CI 3.24 to 4.21), and the odds ratio for not being able to walk anymore was 12.52 (95% CI 10.13 to 15.48).

Length of stay

One (1) study reported on length of hospital stay in patients classified as frail according to the ISAR-HP, compared with patients not classified as frail (Souwer, 2018). They reported a mean (SD) length of hospital stay of frail patients of 10.3 (6.0) and non-frail patients of 8.9 (9.4).

Quality of life

No studies reported on the outcome quality of life.

Mini-Cog

Complications

In total, four (4) studies reported on postoperative complications in patients classified as having possible cognitive impairment according to the Mini-Cog, compared to patients classified as having a normal cognition (Heng, 2016; Korc-Grodzicki, 2015; Susano, 2020; Weiss, 2022). Three studies were excluded because of the inclusion criteria of age ≥65 years, instead of ≥70 years (Culley, 2017; Tiwari, 2021; Yaima 2022). When we summarized the results of the 4 included studies, a pooled odds ratio of 2.49 (95% CI: 1.24 to 4.98) could be calculated, which can be interpreted as a higher risk of complications in possibly cognitive impaired patients compared to non-impaired patients. (Figure 5). Susano 2020) only reported a p-value of 0.333 without underlying data, this study could therefore not be pooled.

Figure 5 – Pooled estimate of risk of postoperative complications according to frailty status (Mini-Cog)

Mortality

In total, two (2) studies reported on postoperative mortality in patients classified as frail according to the Mini-Cog, compared to patients not classified as frail (Heng, 2016 and Weiss, 2022).

Heng (2016) reported adjusted hazard ratios (95%CI), adjusted for age, sex, Charlson Comorbidity Index, and fracture type:

1-year mortality: 1.41 (0.88 to 2.26)
6-month: 1.81 (0.97 to 3.39)
90-day: 1.81 (95% CI 0.97 to 3.39)

Weiss (2022) reported a crude odds ratio (95%CI) 1-year mortality: 1.50 (0.69 to 3.28) and an adjusted OR of 1.3 (95% CI: 0.6 to 2.6)

Discharge destination

In total, two (2) studies reported on postoperative discharge destination in patients classified as frail according to the Mini-Cog, compared to patients not classified as frail (Puustinen, 2016; Weiss, 2022).

Puustinen (2016) reported Mini-Cog scores of 2.68 (sd 1.25) for those patients discharged home, and 3.53 (sd 1.13) for those discharged to a healthcare center. The mean difference was 0.85 (95% CI: 0.13 to 1.57)

Weiss (2022) reported an odds ratio of 1.83 (95% CI: 1.23 to 2.72) to be discharged not home.

Physical functioning

No studies reported on the outcome physical functioning.

Length of stay

No studies reported on the outcome length of stay.

Quality of life

No studies reported on the outcome quality of life.

VMS

Complications

In total, one (1) study reported on postoperative complications in patients classified as frail according to the VMS, compared to patients not classified as frail (Van der Zanden, 2021). They reported an odds ratio of 2.20 (95% CI: 1.07 to 4.54), indicating an increased risk of complications within the first 30 days after surgery for patients who were classified as frail according to VMS.

Mortality

In total, two (2) studies reported on postoperative mortality in patients classified as frail according to the VMS, compared to patients not classified as frail (Van der Zanden, 2021; Winters, 2018).

Van der Zanden (2021) reported an OR of 4.66 (95% CI: 0.19 to 116.20) for death within 90 days after surgery, indicating an increased risk of mortality for patients who were classified as frail according to VMS.

Winters (2018) presented hazard ratios (HR) for the risk of death during the 3 years after surgery. The 3-year survival HR was 3.5 (95% CI: 2.1 to 5.7), indicating an increased risk of mortality for patients who were classified as frail according to VMS.

Discharge destination

In total, one (1) study reported on postoperative complications in patients classified as frail according to the VMS, compared to patients not classified as frail (Van der Zanden, 2021). They reported an odds ratio of 2.86 (95% CI: 1.37 to 9.94), indicating an increased risk of being discharged not towards home for patients who were classified as frail according to VMS.

Physical functioning

No studies reported on the outcome physical functioning.

Length of stay

No studies reported on the outcome length of stay.

Quality of life

No studies reported on the outcome quality of life.

Level of evidence of the literature

Complications

Mortality

Discharge destination

Physical functioning

Length of stay

Quality of life

Effect size and direction

Quality of evidence

Effect size and direction

Quality of evidence

Effect size and direction

Quality of evidence

Effect size and direction

Quality of evidence

Effect size and direction

Quality of evidence

Effect size and direction

Quality of evidence

CFS

↑↑F

⊕⊕

Low GRADE

↑↑ F

⊕⊕

Low GRADE

⊕

Very Low GRADE*

↓↓ F

⊕⊕

Low GRADE

No evidence

⊕

No GRADE

No evidence

⊕

No GRADE

EFS

↑↑F

⊕⊕

Low GRADE

↑↑F

⊕⊕

Low GRADE

↑ (not home) F

⊕⊕

Low GRADE

No evidence

⊕

No GRADE

↑F

⊕⊕

Low GRADE

No evidence

⊕

No GRADE

↑↑F

⊕⊕

Low GRADE

↑F

⊕⊕

Low GRADE

No evidence

⊕

No GRADE

No evidence

⊕

No GRADE

↑↑ F

⊕⊕

Low GRADE

No evidence

⊕

No GRADE

GFI

↑F

⊕⊕

Low GRADE

↑F

⊕

Very Low GRADE*

⊕

No GRADE

⊕

No GRADE

No evidence

⊕

No GRADE

No evidence

⊕

No GRADE

No evidence

⊕

No GRADE

ISAR/ ISAR-HP

No evidence

⊕

No GRADE

↑↑ F

⊕⊕⊕

Moderate GRADE†

↑↑ (not home) F

⊕⊕⊕

Moderate GRADE†

↓↓ F

⊕⊕⊕

Moderate GRADE†

↑

⊕

Low GRADE

No evidence

⊕

No GRADE

Mini-Cog

↑F

⊕

Very Low GRADE*

↑F

⊕⊕

Low GRADE

↑ (not home) F

⊕⊕

Low GRADE

No evidence

⊕

No GRADE

No evidence

⊕

No GRADE

No evidence

⊕

No GRADE

VMS

↑F

⊕

Very Low GRADE*

↑F

⊕⊕

Low GRADE

↑↑ (not home) F

⊕⊕

Low GRADE

No evidence

⊕

No GRADE

No evidence

⊕

No GRADE

No evidence

⊕

No GRADE

* Downgraded for uncertainty (confidence interval crosses the border of clinical relevance).

† Upgraded for large effect.

Zoeken en selecteren

Question 1: Which screening instruments for frailty and/or cognitive impairment that are already used in the Netherlands predict postoperative adverse outcomes for patients aged 70 years or older?

P: Patients aged 70 years or older with an indication for surgery

I: Screening instruments for frailty and/or cognitive impairment that are already used in the Netherlands

O: Test properties (positive/negative predictive value, sensitivity, specificity) for:

Mortality: postoperative mortality, mortality at discharge, mortality at follow-up
Complications: length of stay, readmission, pulmonary-cardiac, delirium, pressure ulcers, urinary tract infection, wound infection, falling
Discharge destination: instituationalization after discharge, geriatric rehabiliation at discharge, independently living at home
Physical functioning: functionering at discharge, functional decline, mobility, falls, walking independently/with walking aid
Cognitive functioning
Quality of life
Social participation
Pain
Patient’s goal (attained?)

Relevant outcome measures

The working group considered all outcome measures relevant in the patient-centred decision-making process. Whether an outcome measure is critical or important depends on the individual patient, so the working group did not distinguish critical or important outcome measures.

A priori, the working group did not define the outcome measures listed above but used the definitions used in the studies.

Search and select (Methods)

The databases Medline (via OVID) and Embase (via Embase.com) were searched with relevant search terms until October 6, 2022. The detailed search strategy is depicted under the tab Methods. The systematic literature search resulted in 766 hits. Studies were selected based on the following criteria: systematic review of randomized controlled trials or observational studies, randomized controlled trials or observational studies, no case-control studies, no case reports or case series, written in English or Dutch, 49 studies were initially selected based on title and abstract screening. After reading the full text, sixteen (16) studies were excluded (see the table with reasons for exclusion under the tab Methods), and 33 studies were included.

Results

33 studies were included in the analysis of the literature. Important study characteristics and results are summarized in the evidence tables. The assessment of the risk of bias is summarized in the risk of bias tables.

Referenties

Bakas AT, Polinder-Bos HA, Streng F, Mattace-Raso FUS, Ziere G, de Jong RJB, Sewnaik A. Frailty in Non-geriatric Patients With Head and Neck cancer. Otolaryngol Head Neck Surg. 2023 Jun 2. doi: 10.1002/ohn.388. Epub ahead of print. PMID: 37264978.
Bouwhuis A, van den Brom CE, Loer SA, Bulte CSE. Frailty as a growing challenge for anesthesiologists - results of a Dutch national survey. BMC Anesthesiol. 2021 Dec 6;21(1):307. doi: 10.1186/s12871-021-01528-x. PMID: 34872523; PMCID: PMC8647406.
Engel JS, Tran J, Khalil N, Hladkowicz E, Lalu MM, Huang A, Wong CL, Hutton B, Dhesi JK, McIsaac DI. A systematic review of perioperative clinical practice guidelines for care of older adults living with frailty. Br J Anaesth. 2023 Mar;130(3):262-271. doi: 10.1016/j.bja.2022.12.010. Epub 2023 Jan 25. PMID: 36707368.
Fehlmann CA, Patel D, McCallum J, Perry JJ, Eagles D. Association between mortality and frailty in emergency general surgery: a systematic review and meta-analysis. Eur J Trauma Emerg Surg. 2022 Feb;48(1):141-151. doi: 10.1007/s00068-020-01578-9. Epub 2021 Jan 9. PMID: 33423069; PMCID: PMC8825621.
Kennedy CA, Shipway D, Barry K. Frailty and emergency abdominal surgery: A systematic review and meta-analysis. Surgeon. 2022 Dec;20(6):e307-e314. doi: 10.1016/j.surge.2021.11.009. Epub 2021 Dec 31. PMID: 34980559.
Leiner T, Nemeth D, Hegyi P, Ocskay K, Virag M, Kiss S, Rottler M, Vajda M, Varadi A, Molnar Z. Frailty and Emergency Surgery: Results of a Systematic Review and Meta-Analysis. Front Med (Lausanne). 2022 Mar 31;9:811524. doi: 10.3389/fmed.2022.811524. PMID: 35433739; PMCID: PMC9008569.
NVKG. Richtlijn Comprehensive Geriatric Assessment (CGA). Richtlijnendatabase; 2021. https://richtlijnendatabase.nl/richtlijn/comprehensive_geriatric_assessment_cga/startpagina_-_comprehensive_geriatric_assessment_cga.html
NVvH. Richtlijn Beleid rondom spoedoperaties. Richtlijnendatabase; 2018. https://richtlijnendatabase.nl/richtlijn/beleid_rondom_spoedoperaties/classificatiesystemen_spoedoperaties.html
Partridge JS, Harari D, Martin FC, Peacock JL, Bell R, Mohammed A, Dhesi JK. Randomized clinical trial of comprehensive geriatric assessment and optimization in vascular surgery. Br J Surg. 2017 May;104(6):679-687. doi: 10.1002/bjs.10459. Epub 2017 Feb 15. PMID: 28198997.
Partridge JSL, Healey A, Modarai B, Harari D, Martin FC, Dhesi JK. Preoperative comprehensive geriatric assessment and optimisation prior to elective arterial vascular surgery: a health economic analysis. Age Ageing. 2021 Sep 11;50(5):1770-1777. doi: 10.1093/ageing/afab094. PMID: 34120179.
Royal College of Anesthesists. Chapter 2: Guidelines for the Provision of Anaesthesia Services for the Perioperative Care of Elective and Urgent Care Patients 2023. RCOA; https://rcoa.ac.uk/gpas/chapter-2
Saur NM, Davis BR, Montroni I, Shahrokni A, Rostoft S, Russell MM, Mohile SG, Suwanabol PA, Lightner AL, Poylin V, Paquette IM, Feingold DL; 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 Apr 1;65(4):473-488. doi: 10.1097/DCR.0000000000002410. PMID: 35001046.
Ward MAR, Alenazi A, Delisle M, Logsetty S. The impact of frailty on acute care general surgery patients: A systematic review. J Trauma Acute Care Surg. 2019 Jan;86(1):148-154. doi: 10.1097/TA.0000000000002084. PMID: 30399129.

Evidence tabellen

Indicatoren

Er wordt een preoperatieve screening naar kwetsbaarheid verricht bij patiënten van ≥70 jaar die indicatie hebben voor operatie met verwachte opnameduur ≥2 dagen. Indien afwijkend, wordt de patiënt verwezen voor een CGA.

Evidence tables

Research question: Hoe herken je kwetsbaarheid bij ouderen preoperatief?

Study reference

Study characteristics

Patient characteristics

Prognostic factor(s)

Follow-up

Estimates of prognostic effect

Comments

Ahola, 2022

Type of study: retrospective cohort study

Setting and country: Department of

Gastroenterology and

Alimentary Tract Surgery,

Tampere University Hospital,

Tampere, Finland

Funding and conflicts of interest: State Research

Funding (VTR), Finland and the Sigrid Jusélius Foundation, Finland.

Funding was not involved in the study design, data collection, data

analysis, manuscript preparation, or publication decisions.

Inclusion criteria:

Patients ≥75y (measured at date of surgery) who underwent pancreatic resection 2012-2019

Exclusion criteria: none

N= 95

Mean age ± SD: not reported; 27% over age 80

Sex: 50% M / 50% F

Potential confounders or effect modifiers: not reported

Clinical Frailty Score (CFS) calculated retrospectively out of data measured preoperatively

Duration or endpoint of follow-up: 1 year or death

For how many participants were no complete outcome data available?

N (%): none reported

Reasons for incomplete outcome data described? na

(Adjusted) Odds ratios (95% confidence interval [CI])

Complications: 1.24 (0.42 to 3.85)

Discharge destination: 12 frail patients (no effect estimation)

One-year survival calculated for patients who survived at least 30 days

Amabili, 2019

Type of study: prospective observational study

Setting and country: university hospital, Belgium

Funding and conflicts of interest: not reported

Inclusion criteria: pt ≥ 75y scheduled for cardiac surgery between Feb 2014 and May 2017

Exclusion criteria: critical state, emergency surgery, inability to consent or perform the scale, institutionalization, assessor unavailable

N= 254 (202 nonfrail, 52 frail)

Median age ± IQR: 80 (77 to 82)

Sex: 62% M / 38% F

EuroSCORE II: Nonfrail: 3.4 (2.1-5.5)

Frail: 4.5 (2.9-8.7)

Edmonton Frail Score (EFS), a 9-domain 8-item multidimensional scale assessed one day preoperatively by a senior anesthesiologist

Duration or endpoint of follow-up: 30 days

For how many participants were no complete outcome data available?

N (%): not reported

Reasons for incomplete outcome data described? na

(Adjusted) Factor-outcome associations (include SEs or 95%CI and p-value if available):

Mortality

30-day 3.90 (95% CI, 1.42-10.67)

Adjusted for EuroSCORE: 3.20 (95% CI: 1.12 to 9.10)

30-day for moderate/severe frailty: aOR = 4.6 (95% CI, 1.0-20.5)

Discharge destination home: aOR 1.7 (95% CI, 0.8-3.8)

Discharge destination healthcare facility: aOR = 2.6; 95% CI, 1.2-5.3

Well-performed study, not all raw data provided for secondary outcomes

Arteaga, 2020

Type of study: prospective observational study

Setting and country: University hospital, Spain

Funding and conflicts of interest: none reported

Inclusion criteria: pt ≥70y undergoing abdominal surgery

Exclusion criteria: life expectancy >6m, moderate to severe cognitive deterioration

N=92

Mean age ± SD: 78.7 SD 6.3

Sex: 46.7% M / 53.3% F

Potential confounders or effect modifiers:

CFS assessed preoperatively

Duration or endpoint of follow-up: 30d

For how many participants were no complete outcome data available?

N (%): 0

Reasons for incomplete outcome data described? na

(Adjusted) OR (95%CI) and p-value if available):

Mortality

30-day: OR 5.7 (95% CI: 1.5–22.6, p=0.013)

Complications OR 3.4 (95% CI: 1.2–9.8, p= 0.024)

No raw data to pool

Artiles-Armas, 2021

Type of study: prospective observational study

Setting and country: tertiary hospital, Spain

Funding and conflicts of interest: none reported

Inclusion criteria: pt ≥70y, consecutive, undergoing elective colorectal surgery for cancer between Jan 2013 and Dec 2015

Exclusion criteria: none reported

N= 149

Median age ± IQR: 75 (72-80)

Sex: 64.4% M / 35.6% F

Potential confounders or effect modifiers: 59 (39.6%) frail; 90 (60.4% nonfrail)

CFS, preoperatively assessed by a surgeon and an anaesthesiologist

Duration or endpoint of follow-up: >5y

For how many participants were no complete outcome data available?

N (%): 0

Reasons for incomplete outcome data described? na

(Adjusted) ORs (95%CI):

Mortality

1-year 1.44 (95% CI: 0.55 to 3.79)

90-day 2.29 (95% CI: 0.69 to 7.59)

30-day 18.27 (95% CI: 0.99 to 336.82)

Covino, 2022

Type of study: prospective cohort

Setting and country: urban teaching hospital, Italy

Funding and conflicts of interest: none reported

Inclusion criteria: pt ≥80y admitted to emergency department form Jan 2018 to Sep 2021 who were hospitalized and undergoing major urgent surgery

Exclusion criteria: pt undergoing minor surgery, refused to participate, incomplete baseline data, or refused surgery

N= 1039

Median age: 85 (IQR 82-89)

Sex: 42.8% M / 57.2% F

Potential confounders or effect modifiers: 190 frail, 849 nonfrail

CFS

Duration or endpoint of follow-up: till discharge or death

For how many participants were no complete outcome data available?

N (%): 0

Reasons for incomplete outcome data described? na

(Adjusted) HRs (95%CI):

Mortality

In-hospital

Severe frailty: 12.55 (95% CI: 2.96 to 53.21)

Mild frailty: 6.93 (95% CI: 1.69 to 28.27)

Complications

Severe frailty: 2.65 (95% CI: 1.12 to 6.23)

Mild frailty: 1.18 (95% CI: 0.51 to 2.75)

Dal Moro, 2017

Type of study: prospective cohort

Setting and country: surgery department, hospital, Italy

Funding and conflicts of interest: none reported

Inclusion criteria: pt ≥70y, undergoing major urological surgery (radical cystectomy, nephrectomy, prostatectomy, or resection of bladder neoplasms)

Exclusion criteria: refuse to participate

N= 78

Mean age ± SD: 78.5 (3.9)

Sex: 85.9% M / 14.1% F

Potential confounders or effect modifiers: 21.8% frail (n=17, vs 61 nonfrail)

EFS

Duration or endpoint of follow-up: 3 months

For how many participants were no complete outcome data available?

N (%): not reported

Reasons for incomplete outcome data described? na

(Adjusted) OR (95%CI):

Complications 7.45 (95% CI: 2.23 to 24.95)

Dasgupta, 2009

Type of study: prospective cohort

Setting and country: tertiary teaching hospital, Canada

Funding and conflicts of interest: none reported

Inclusion criteria: pt ≥70y, referred for elective non-cardiac surgery and referred for preoperative screening for medical clearance

Exclusion criteria: day surgical procedures, active cancer, surgery uncertain, not English speaking, not cleared for surgery, participating in clinical trials for pharmacological treatment

N=12

Mean age: 77.4 (range 70-92)

Sex: 42% M / 58% F

Potential confounders or effect modifiers: mean EFS 4.4 (range 0–11)

EFS, administered by the main investigator

Duration or endpoint of follow-up: up till hospital discharge

For how many participants were no complete outcome data available?

N (%): 0

Reasons for incomplete outcome data described? na

(Adjusted) OR (95%CI):

Complications: unadjusted OR 5.08 (1.70 to 15.17)

Age-adjusted OR: 5.02 (1.55–16.25)

Discharge destination home (frail vs nonfrail: 0.27 (95% CI 0.09 to 0.81)

Length of stay (mean difference frail vs nonfrail): 2.90 (95% CI 1.22 to 4.58)

Fagard, 2017

Type of study: retrospective study using data from three subsequent, prospective,

observational, multicenter cohort studies

Setting and country: surgery department, university hospital, Belgium

Funding and conflicts of interest: supported by a grant from ‘Kom op tegen Kanker’ (B32220096771) and

‘Cancer Plan Belgium’ (NKP_24_005 (B32220096854); KPC_24_A_025

(B322201215495). Hans Wildiers is a recipient of the ‘Fonds voor

Wetenschappelijk Onderzoek – Vlaanderen’ (FWO).

Inclusion criteria: consecutive pt ≥ 70y scheduled for colorectal cancer surgery between October 2009

and February 2015

Exclusion criteria: patients receiving neo-adjuvant therapy, transanal or endoscopic surgery,

N= 190

Median age (range): 77 (70 to 97)

Sex: 55.3 % M / 44.7 % F

Potential confounders or effect modifiers:

115 patients had an abnormal result on the G8

G8, no information about the moment of assessment

Duration or endpoint of follow-up: 30 days

For how many participants were no complete outcome data available?

N (%): not reported

Reasons for incomplete outcome data described? na

(Adjusted) ORs (95%CI):

Complications: 2.07 (95% CI 1.12 to 3.82)

He, 2020

Type of study: prospective observational study

Setting and country: tertiary public hospital in Singapore

Funding and conflicts of interest: none declared

Inclusion criteria: pt ≥70y undergoing major abdominal surgery between Dec 2017 and Sep 2018

Exclusion criteria: surgery cancelled or declined

N= 134

Mean age ± SD: Fit: 74.2 (4.2) Vulnerable: 76.8 (4.9) Mildly frail: 77.5 (6.2) Moderately frail: 77.7 (5.7) Severely frail: 78.3 (6.9)

Sex: 50% M / 50% F

Potential confounders or effect modifiers:

9.7% severe frailty

EFS assessed by blinded trained nurses

Duration or endpoint of follow-up: 30d

For how many participants were no complete outcome data available?

N (%): not reported

Reasons for incomplete outcome data described? na

(Adjusted) OR (95%CI):

Complications: 4.24 (95% CI 1.83 to 9.82)

Heng, 2016

Type of study: retrospective observational cohort

Setting and country: orthopaedic trauma centre hospital, USA

Funding and conflicts of interest: Dr. Javedan reports grants from RX Foundation, Hadley, MA 01305, during the conduct of the study; .; Jennifer Kodela reports grant from AFAR MSTAR, during the conduct of the study; .

Inclusion criteria: consecutive elderly patients (≥70y) admitted at the geriatric trauma unit from Nov 2011 to Nov 2012

Exclusion criteria: no orthopaedic fracture, unable to complete Mini-Cog

N= 513

Median age (IQR) 83.0 (70 to 102)

Sex: 26.7% M / 73.3% F

Potential confounders or effect modifiers: 333 normal Mini-Cog, 180 Abnormal Mini-Cog

Mini-Cog assessed preoperatively

Duration or endpoint of follow-up: 12m

For how many participants were no complete outcome data available?

N (%): not reported

Reasons for incomplete outcome data described? Not reported

Adjusted HR (95%CI), adjusted for age, sex, Charlson Comorbidity Index, and fracture type:

Mortality

1-year: 1.41 (0.88 to 2.26)

6-month: 1.81 (0.97 to 3.39)

90-day: 1.81 (95% CI 0.97 to 3.39)

Complications: OR, 2.16 (95% CI,

1.42 to 3.31)

Hill, 2020

Type of study: multicenter prospective observational cohort

Setting and country: 24 ICUs in Canada

Funding and conflicts of interest: R.C.A has

received a restricted educational grant from Pfizer Canada Inc., and honoraria from Mallickrodt

Pharmaceuticals, Abbott Nutrition and Edwards Lifesciences for work unrelated to this manuscript.

Inclusion criteria: pt ≥80y who stayed at the ICU for ≥24h after cardiac surgery

Exclusion criteria: non-residence of Canada, no family member available for data collection, no family member visited in first 96h after ICU admission, family member not speaking English or French, family member being paid for care, family member younger than 18 years, no consent, dying acutely

N=184 (general surgery), 49 (cardiac surgery)

Mean age ± SD: 84.4 ± 3.4 (general surgery) 83.8 ± 3.1 (cardiac surgery)

Sex: 54% M / 46% F (general surgery) 57% M / 43% F (cardiac surgery)

Potential confounders or effect modifiers: Frailty: 44% (general surgery), 43% (cardiac surgery)

CFS, initially completed with the closest family member or, if possible, by collecting the

data directly from the patient later after they recovered

Duration or endpoint of follow-up: 12m

For how many participants were no complete outcome data available?

N (%):

Reasons for incomplete outcome data described?

(Adjusted) ORs (95%CI):

Mortality

1-year: 1.98 (95% CI: 1.12 to 3.49)

In-hospital: 1.51 (95% CI 0.77 to 2.96)

Discharge destination (independent): 0.55 (95% CI 0.32 to 0.95)

Moderate risk of bias due to design of the study

Kaibori, 2016

Type of study: prospective observational cohort

Setting and country: hospital, Japan

Funding and conflicts of interest: supported by the

Practical Research for Innovative Cancer Control from Japan Agency

for Medical Research and Development, AMED

Inclusion criteria: pt ≥70y undergoing elective hepatectomy with adequate cardiopulmonary and renal function, and able to give consent

Exclusion criteria: not reported

N= 71

Median age (range): 77 (70 to 89)

Sex: 73% M / 27% F

Potential confounders or effect modifiers: 55% frail

G8 assessed preoperatively

Duration or endpoint of follow-up: 1 year

For how many participants were no complete outcome data available?

N (%): not reported

Reasons for incomplete outcome data described? Not reported

ORs (95%CI):

Mortality

1-year: 8.24 (95% CI 0.43 to 159.04)

Complications: 23.95 (95% CI 2.96 to 193.57)

Length of stay ≥13d: 3.33 (95% CI 1.25 to 8.86)

Kenig, 2020

Type of study: prospective cohort

Setting and country: surgery department, hospital, Poland

Funding and conflicts of interest: none reported

Inclusion criteria: pt ≥70y with solid abdominal tumors undergoing elective surgery between Jun 2012 and Dec 2018, and who gave informed consent

Exclusion criteria: Patients

who underwent emergency laparotomy within 24 h of admission,

had distant metastases, peritoneal carcinomatosis, or only underwent

explorative laparoscopy /laparotomy

N=272

Median age (range): 78 (70 to 94)

Sex: 55.8% M / 44.2% F

83% frail (according to G8)

51%) frail (according to GFI)

G8, Groningen Frailty Index (GFI) assessed preoperatively

Duration or endpoint of follow-up: 12 months

For how many participants were no complete outcome data available?

N (%): 3

Reasons for incomplete outcome data described? No

Sensitivity, specificity, PPV, NPV, and AUC (95%CI):

Mortality

1-year

Sensitivity 98 (93 to 99)

Specificity 42 (27 to 55)

PPV 34 (18 to 50)

NPV 98 (93 to 99)

AUC (95%CI) 0.74 (0.65 to 0.81)

30-day

Sensitivity 98 (93 to 99)

Specificity 49 (35 to 61)

PPV 39 (24 to 52)

NPV 97 (93 to 99)

AUC ( 95%CI) 0.71 (0.61 to 0.78)

Complications

Sensitivity 94 (92 to 96)

Specificity 39 (24 to 52)

PPV 80 (73 to 85)

NPV 80 (73e85)

AUC (95%CI) 0.75 (0.66 to 0.81)

GFI

Mortality

1-year

Sensitivity 72 (63 to 79)

Specificity 56 (43 to 66)

PPV 28 (12 to 42)

NPV 90 (86 to 92)

AUC (95%CI) 0.65 (0.54 to 0.74)

30-day

Sensitivity 73 (64 to 80)

Specificity 55 (42 to 66)

PPV 24 (10 to 39)

NPV 91 (88 to 93)

AUC ( 95%CI) 0.64 (0.53 to 0.73)

Complications

Sensitivity 58 (45 to 68)

Specificity 60 (48 to 70)

PPV 63 (51 to 72)

NPV 55 (42 to 66)

AUC (95%CI) 0.60 (0.48 to 0.70)

Knauf, 2022

Type of study: retrospective registry study

Setting and country: Trauma surgery units, 84 hospitals, Germany and Switzerland

Funding and conflicts of interest: none

Inclusion criteria:

Pt ≥70y undergoing surgery for hip fracture between 2016 and 2018

Exclusion criteria: Periprosthetic or peri-implant fractures were excluded

N= 15,099

Median age ± IQR: 85 (80 to 89)

Sex: 28.1% M / 71.9% F

Frailty: 80.6% (n=8,142) classified as frail of those with an ISAR (Identification of

Seniors at Risk) assessment (n=11,473)

ISAR, assessed at time of admission to hospital

Duration or endpoint of follow-up: 120 days

For how many participants were no complete outcome data available?

N (%): 1,412

Reasons for incomplete outcome data described? This was a registry study

(Adjusted) ORs (95%CI):

Mortality

In-hospital: 3.45 (95% CI 2.44 to 5.03)

Discharge destination home: 0.42 (95% CI 0.38 to 0.47)

Physical functioning (walking ability 7 days postoperatively): with walker: 3.69 (95% CI 3.24 to 4.21)

No walking possible: 12.52 (95% CI 10.13 to 15.48)

souersoursoiu

Korc-Grodzicki, 2015

Type of study: retrospective cohort study

Setting and country: Cancer hospital, USA

Funding and conflicts of interest: none

Inclusion criteria: pt ≥75y who underwent surgery between Sep 2010 and Dec 2011 and were admitted to the study hospital.

Exclusion criteria: Non-English speakers who were unable to perform the Mini-Cog, patients who were admitted to the ICU

N=416

Median age ± range: 80 (75-98)

Sex: 45.9% M / 54.1% F

Frailty: 123 (31%)

Mini-Cog assessed preoperatively

Duration or endpoint of follow-up: 6 months

For how many participants were no complete outcome data available?

N (%): not reported

Reasons for incomplete outcome data described? na

ORs and HRs (95%CI):

Complications (delirium)

1.69 [1.01, 2.83]

Krenzlin, 2021

Type of study: retrospective study

Setting and country: hospital, Germany

Funding and conflicts of interest: none

Inclusion criteria: pt ≥70y with newly diagnosed glioblastoma who received stereotactic biopsy or tumor resection between Jan 2015 and Dec 2019

Exclusion criteria: none reported

N= 104

Mean age ± SD: 76.6 ± 4.4

Sex: 53% M / 47% F

Frailty (G8): 51%

Frailty (GFI) 59%

G8, GFI assessed preoperatively

Duration or endpoint of follow-up: radiological progression or death

For how many participants were no complete outcome data available?

N (%): not reported

Reasons for incomplete outcome data described? na

HR or OR (95%CI):

Mortality

HR: 1.74 (95% CI 1.12 to 2.71)

Complications

3.68 (95% CI: 1.11 to 15.15

GFI

Mortality

HR: 1.67 (95% CI 1.09 to 2.57)

Complications

OR: 4.0 (95% CI: 1.07 to 14.90)

No pooling possible because of missing raw numbers

Miguelena-Hycka, 2019

Type of study: multicenter prospective cohort study

Setting and country: three university hospitals in Spain

Funding and conflicts of interest:

Not reported

Inclusion criteria: pt ≥70y scheduled for cardiac surgery including cardiopulmonary bypass

Exclusion criteria: Urgent, emergent and off-pump surgery. Pt with important motor or cognitive capabilities

N=143

Mean age ± SD: 78.4 -±4.2

Sex: 52.5% M / 47.5% F

Frail (CFS): 18 (13.1%), Prefrail: 100 (73.0%), Robust: 19 (13.9%)

CFS assessed preoperatively

Duration or endpoint of follow-up: 6 months

For how many participants were no complete outcome data available?

N (%): 6 (for in-hospital outcomes)

Additionally: 28 (for 6-month QoL)

Reasons for incomplete outcome data described?

3 withdrew consent
3 incomplete data
12 deceased
16 lost to follow-up

OR (95%CI)

Mortality (

6-month): 2.18 (95% CI 0.54 to 8.83)

Complications (

6-month): 2.40 (95% CI 0.88 to 6.55)

Niemeläinen, 2021

Type of study: retrospective cohort

Setting and country: University hospital, Finland

Funding and conflicts of interest: Competitive State Research Financing of

the Expert Responsibility area of Tampere

University Hospital partly supported this

study financially. The Cancer Foundation

Finland obtained external funding by

awarding a grant, but they did not have

any role in designing the study, collection,

analysis or interpretation of the data or

writing the manuscript.

Inclusion criteria: pt aged ≥80y diagnosed with Stage I-III colon cancer and referred to surgery unit for possible resection.

Exclusion criteria: pt with metastatic disease, emergency operations, or life expectancy >6m, treated nonoperatively, pt having benign disease

N= 161

Mean age: 84.5 range 80-97

Sex: 40% M 60%F

Frail (CFS≥5): 47%

CFS, G8 assessed preoperatively

Duration or endpoint of follow-up: 30d

For how many participants were no complete outcome data available?

N (%): 0

Reasons for incomplete outcome data described? na

ORs (95%CI):

Complications

30d (CFS): 1.39 (95% CI 0.69 to 2.82)

30d (G8): 1.62 (95% CI 0.48 to 5.51)

Nishijima, 2021

Type of study: prospective cohort

Setting and country: hospital, Japan

Funding and conflicts of interest: None declared

Inclusion criteria: consecutive oncologic patients ≥75y undergoing oncologic surgery between Sep 2018 and Dec 2019 and having undergone geriatric assessment.

Exclusion criteria: Pt receiving neo-adjuvant therapy

N=114

Median age ± range: 80 ± 72 to 96

Sex: 58% M / 42% F

Frailty:

EFS: 17 (15%)

G8: 97 (85%)

EFS, G8 assessed preoperatively

Duration or endpoint of follow-up: 30d

For how many participants were no complete outcome data available?

N (%): 0

Reasons for incomplete outcome data described? na

ORs (95%CI):

Complications

30-day (EFS): 2.53 (95% CI: 0.88 to 7.24)

30-day (G8): 3.56 (95% CI: 0.96 to 13.21)

Puustinen, 2016

Type of study: prospective cohort

Setting and country: outpatient clinic, Finland

Funding and conflicts of interest: the authors received a

research grant for the research from the employer Pa¨ija¨t-Ha¨meen

sosiaali-ja terveysyhtyma¨ (Hospital)

Inclusion criteria: pt waiting for hip or knee replacement surgery between March 17, 2009, and

March 26, 2010

Exclusion criteria: not reported

N= 52

Mean age: 79 (range 74 to 87)

Sex: not reported

Abnormal Mini-Cog: 16 (32%)

Mini-Cog assessed preoperatively

Duration or endpoint of follow-up: 5 years

For how many participants were no complete outcome data available?

N (%): 2

Reasons for incomplete outcome data described? Did not complete preoperative tests

Discharge destination home versus healthcare centers: Mini-Cog score 1 versus 3.53±1.13

Sanchez Arteaga, 2022

Type of study: prospective cohort

Setting and country: emergency surgery Hospital in Spain

Funding and conflicts of interest: no funding reported

Inclusion criteria: consecutive pt aged >70y undergoing emergency surgery from Sep 2017 to Jun 2020

Exclusion criteria: moderate to severe cognitive impairment; no consent, unable to complete frailty questionnaires

N=92

Mean age ± SD: not reported, but probably ~77

Sex: not reported

CFS: 8 patients

severely frail, 13 patients moderately frail, and 61 patients

non-frail

CFS assessed preoperatively

Duration or endpoint of follow-up: 18m

For how many participants were no complete outcome data available?

N (%): not reported

Reasons for incomplete outcome data described? na

ORs/HRs (95%CI a):

Mortality

18-month: HR 2.08 (95% CI 0.87 to 4.99) NOTE: moderately frail patients were not analysed

6-month: OR 3.81 (95% CI 1.25 to 11.63) NOTE: moderately frail patients were not analysed

Difficult to follow design and results, and unsure about methodology and patient flow

Souwer, 2018

Type of study: prospective cohort

Setting and country: two teaching hospitals in the Netherlands

Funding and conflicts of interest:

none

Inclusion criteria: patients >70 years with surgical treatment for colorectal cancer from May 2014 to Aug 2016

Exclusion criteria: non-elective surgery, Transanal Endoscopic

Microsurgery (TEM), metastatic disease (stage IV), another synchronous cancer

N=139

Mean age (IQR): 77.7 (75.0-82.8)

Sex: 45 F

Frailty:

68 G8-frail, 32 ISAR-HP-frail. 48 G8-frail but not ISAR-HP-frail, 11 ISAR-HP-frail but not G8-frail, 20 both G8-frail and ISAR-HP-frail

ISAR-HP and G8 assessed in the diagnostic workup prior to surgery

Duration or endpoint of follow-up: at least 183 days.

For how many participants were no complete outcome data available?

N (%): 2 (1.4%) only ISAR-HP available

Reasons for incomplete outcome data described? No

ISAR-HP

OR (95%CI)

30-day complication: 2.4 (95% CI 1.1 to 5.4)

Surgical complication: 2.3 (95% CI 0.9 to 5.9)

Anastomotic leakage: 1.4 (95% CI 0.3 to 7.6)

Non-surgical complication: 1.6 (95% CI 0.6 to 4.2)

Cardiopulmonary complications: 5.9 (95% CI 1.6 to 22.6)

Delirium: 2.7 (95% CI 0.6 to 12.9)

30-day mortality: 3.6 (95%CI 0.7 to 18.7)

6-month mortality: 4.9 (95% CI 1.1 to 23.4)

Mean (SD):

Length of hospital stay: frail 10.3 (6.0) vs non-frail 8.9 (9.4)

OR (95% CI)

30-day complication: 1.2 (95% CI 0.6 to 2.4)

Surgical complication: 0.7 (95% CI 0.3 to 1.6)

Anastomotic leakage: 2.7 (95% CI 0.5 to 14.2)

Non-surgical complication: 1.8 (95% CI 0.8 to 4.3)

Cardiopulmonary complications: 1.3 (95% CI 0.3 to 5.0)

Delirium: 1.4 (95% CI 0.3 to 6.4)

30-day mortality: 1.0 (95%CI 0.2 to 5.2)

6-month mortality: 1.4 (95% CI 0.3 to 6.4)

Mean (SD):

Length of hospital stay: frail 8.3 (7.0) vs non-frail 9.0 (6.7)

Sun, 2020

Type of study: prospective observational study

Setting and country: university hospital, Taiwan

Funding and conflicts of interest: funded by the National Cheng Kung University Hospital

(NCKUH-10606023) and theChi-Mei Medical Center (CMNCKU-10702). All

statements in the manuscript, including its results and conclusions, do not necessarily represent

the official views of the funding agencies.

Inclusion criteria: pt aged ≥75y who were admitted to the surgery department for elective urologic surgery between Jan and Dec 2017.

Exclusion criteria: patients with severe cognitive impairment, or terminal malignancy with distant metastasis, did not consent, did not undergo surgery, no baseline measurements, had a benign lesion or had a delay in geriatric assessment after surgery

N=82

Mean age ± SD: 81.6 (5.2)

Sex: 50 % M / 50 % F

Frailty:

26 patients severely frail, 35 patients moderately frail, 21 patients non-frail

CFS assessed before surgery

Duration or endpoint of follow-up: 90 days

For how many participants were no complete outcome data available?

N (%): 0

Reasons for incomplete outcome data described? na

OR (95%CI):

Mortality

90-day 11.53 (95% CI 0.53 to 249.18)

Complications 2.27 (95% CI 0.88 to 5.87)

Discharge destination home: 0.10 (95% CI 0.01 to 0.95)

Physical functioning (90-day ADL decline): adjusted OR per point increase in CFS: 2.5 (95% CI 1.4 to 4.6)

Susano, 2020

Type of study: prospective cohort

Setting and country: hospital, USA

Funding and conflicts of interest: National Institutes of Health AG048522 and AG055833 (DJC) and the Department of Anesthesiology, Perioperative, and Pain Medicine, Brigham and Women’s Hospital, Boston, MA

Inclusion criteria: pt ≥ 70y undergoing elective spine surgery and expected to have inpatient admission after surgery

Exclusion criteria: planned outpatient surgery; history of overt stroke or brain tumor; uncorrected vision or hearing impairment (unable to see pictures or read or hear instructions); limited use of the dominant hand (limited ability to draw); and/or inability to speak, read or understand English

N=229

Median age ± IQR: 75y (73, 79)

Sex: 57 % M / 43% F

Mini-Cog median (IQR): 4 (3, 5)

Mini-Cog assessed preoperatively

Duration or endpoint of follow-up: until discharge or 3 days

For how many participants were no complete outcome data available?

N (%): 10

Reasons for incomplete outcome data described? Yes; 5 no procedure, 4 asked to be unenrolled

MD (95%CI):

Complications (delirium): p=0.333

Tanaka, 2019

Type of study: retrospective cohort

Setting and country: department of surgery, university hospital, Japan

Funding and conflicts of interest: none

Inclusion criteria: pt ≥ 80 who underwent gastrectomy

Exclusion criteria: none reported

N= 96

Median age and range: 82 (80-92)

Sex: 73% M / 27% F

Frailty: CFS<5: 79; CFS ≥5: 17

CFS assessed preoperatively

Duration or endpoint of follow-up: 5y

For how many participants were no complete outcome data available?

N (%): not reported

Reasons for incomplete outcome data described? no

OR (95%CI)

Overall survival 5y 3.14 (1.39 to 7.10)

Complications: 3.01 (1.02 to 8.94)

No underlying numbers reported

Tanaka, 2022

Type of study: retrospective cohort

Setting and country: department of surgery, university hospital, Japan

Funding and conflicts of interest: none

Inclusion criteria: pt ≥75y with esophageal squamous cell carcinoma with tumor depths of

m3 and deeper

Exclusion criteria: not reported

N=36

Age Median (range): 77 (75-90)

Sex: 82% M / 18% F

Frailty: CFS<5: 20; CFS ≥5: 16

CFS assessed preoperatively

Duration or endpoint of follow-up: 5y

For how many participants were no complete outcome data available?

N (%): not reported

Reasons for incomplete outcome data described? na

OR (95%CI)

Mortality

1y 10.63 (0.51 to 222.61)

Complications 0.69 (0.18 to 2.67)

Traunero, 2022

Type of study: prosprective cohort

Setting and country: dept of urology, hospital, Italy

Funding and conflicts of interest: none reported

Inclusion criteria: patients ≥70y who underwent kidney surgery for clinical-localized renal masses

Exclusion criteria: patients who were candidates for other ablative treatment

(Radiofrequency, Cryoablation) or who had any previously active surveillance and/or

other ablative treatment

N= 162

Median age ± IQR: 76 (72-80)

Sex: 57% M / 43% F

Frailty (G8≤ 14): 91 (56%)

G8 assessed preoperatively

Duration or endpoint of follow-up (months), median (IQR) 36 (16–60)

For how many participants were no complete outcome data available?

N (%): not reported

Reasons for incomplete outcome data described? na

OR (95% CI)

Complications 21.36 (7.98 to 74.58)

Van der Zanden, 2021

Type of study: retrospective cohort

Setting and country: two general teaching hospitals, the Netherlands

Funding and conflicts of interest: none

Inclusion criteria: women who were 70 years or

older and had been admitted to the gynecology ward for

any kind of gynecological surgical treatment if they

had been admitted for 24 h or longer

Exclusion criteria: all VMS

screening tool data were missing

N= 157

Median age ± IQR: 74 (71 to 78)

Sex: 0 % M / 100 % F

Frailty (VMS≥1): 62 (39%)

VMS assessed preoperatively

Duration or endpoint of follow-up: 6m

For how many participants were no complete outcome data available?

N (%): not reported

Reasons for incomplete outcome data described? na

OR (95% CI):

Mortality

90-day: 4.66 (0.19, 116.20)

Complications (30d): 2.20 (1.07 to 4.54)

Discharge destination (direction unclear): 2.86 1.37–3.94

Vilches-Moraga, 2020

Type of study: prospective cohort

Setting and country: urban teaching hospital, UK

Funding and conflicts of interest: no conflict of interest.

Inclusion criteria: All patients aged 75 years or older undergoing emergency

laparotomy at an urban teaching hospital between 8th September

2014 and 30th March 2017

Exclusion criteria: pt who remained

an inpatient > 90 days prior to the final date of data collection

N=113

Mean age ± SD: 81.9 ± 4.7

Sex: 47% M / 53% F

Frail (CFS ≥5): 37 (32.7%)

CFS assessed preoperatively

Duration or endpoint of follow-up: 12m

For how many participants were no complete outcome data available?

N (%): not reported

Reasons for incomplete outcome data described? na

OR (95% CI):

Mortality

1-year 1.67 (0.74 to 3.81)

Weiss, 2022

Type of study: prospective cohort

Setting and country: hospital, Israel

Funding and conflicts of interest: not reported

Inclusion criteria: patients 70 years or older having elective non-cardiac, non-cranial surgery in the Tel-Aviv

Medical Center between January and December 2020

Exclusion criteria: patients having urgent or

emergent surgery, ambulatory surgery or procedural sedation/anesthesia outside the operating

room, pre-existing dementia, patients that were unable to sign informed consent for surgery or

anesthesia, and patients who remained mechanically ventilated after surgery or were directly

admitted to an intensive care unit (ICU); severe preoperative

cognitive impairment (MiniCog = 0) who failed all their postoperative delirium assessments, due

to the possibility that their delirium diagnosis is a misinterpretation of severe baseline

impairment

N= 1338

Mean age ± SD: no CI: 77(6); CI: 78 (6)

Sex: 53% M / 47% F

Frailty (Mini-Cog≤2): 279 (20.9%)

Mini-Cog assessed preoperatively

Duration or endpoint of follow-up: 1y

For how many participants were no complete outcome data available?

N (%): not reported

Reasons for incomplete outcome data described? na

OR (95% CI):

Mortality

1-year 1.50 [0.69, 3.28] (adjueste: 1.3 (0.6-2.6))

Complications (delirium): 3.44 [2.50, 4.75] (adjusted: 3.3 (2.3-4.7))

Discharge destination (non-home) 1.83 [1.23, 2.72] (adjusted: 1.7 (1.1-2.6))

Winters, 2018

Type of study: prospective cohort

Setting and country: hospital, the Netherlands

Funding and conflicts of interest: none reported

Inclusion criteria: All patients at the age of 70 years or older, who were admitted to the hospital with a primary proximal hip fracture and underwent surgery between November 2014 and December 2015

Exclusion criteria: fractures distal from subtrochanteric fracture, periprosthetic fractures, pathological fractures, and admission to another department than the orthopedics/surgical or internal medicine/geriatric department

N= 286

Mean age ± SD: 83.0 (6.6)

Sex: 25% M / 75% F

Frailty

VMS: 75 (26%)

GFI: 85 (30%)

VMS, GFI assessed preoperatively

Duration or endpoint of follow-up: 3y

For how many participants were no complete outcome data available?

N (%): not reported

Reasons for incomplete outcome data described? na

VMS:

OR (95% CI):

Mortality

3-year 3.5; 95% CI =2.1–5.7

‼ Numbers don’t add up‼

GFI:

OR (95% CI):

Mortality

3-year 2.3; 95% CI =1.2–4.1,

‼ Numbers don’t add up‼

Wu, 2021

Type of study: retrospective cohort

Setting and country: teaching hospital, UK

Funding and conflicts of interest: A.C. Nixon reports a grant from Kidney Research

UK outside of this submitted work

Inclusion criteria: Patients with non-dialysis and dialysis-dependent CKD

(G3b-5D) admitted with hip fracture between June 2013 and December

2019

Exclusion criteria: none

N= 397

Mean age ± SD: 83.5 ± 9.2

Sex: 37% M / 63% F

One hundred and

eighty-three patients (46%) had a CFS 7–9 score.

CFS assessed preoperatively

Duration or endpoint of follow-up: at least 1y

For how many participants were no complete outcome data available?

N (%): not rpoerted

Reasons for incomplete outcome data described? na

OR (95% CI):

Mortality

1-year 0.93 (0.87–1.00)

30-day 0.91 (0.84–0.97)

Yamada, 2021

Type of study: prospective cohort

Setting and country: University Hospital, Japan

Funding and conflicts of interest: not reported

Inclusion criteria: patients (a) over 75 years old, (b) without a history

of previous treatment prior to the surgery and without

extrahepatic metastasis, and (c) with pathologically proved

HCC who underwent hepatectomy

from

April 2007 to August 2019,

Exclusion criteria: not reported

N= 82

Mean age ± SD: not frail (n=71): 79.7 ± 4.2

Frail: (n=21) 81.5 ± 5.3

Sex: 62% M / 38% F

Frail: 21 (23%) (CFS≥4)

CFS assessed preoperatively

Duration or endpoint of follow-up: 8y max 2.6y median

For how many participants were no complete outcome data available? Not reported

Reasons for incomplete outcome data described? na

OR (95% CI):

Mortality

3y: 0.35 [0.02, 6.74]

In-hospital: 13.80 [2.53, 75.16]

Complications: 2.23 [0.75, 6.63]

Table of quality assessment – prognostic factor (PF) studies

Based on: QUIPS^A (Haydn, 2006; Haydn 2013)

Research question: Hoe herken je kwetsbaarheid bij ouderen preoperatief?

Study reference (first author, year of publication)	Study participation Study sample represents the population of interest on key characteristics? (high/moderate/low risk of selection bias)	Study Attrition Loss to follow-up not associated with key characteristics (i.e., the study data adequately represent the sample)? (high/moderate/low risk of attrition bias)	Prognostic factor measurement Was the PF of interest defined and adequately measured? (high/moderate/low risk of measurement bias related to PF)	Outcome measurement Was the outcome of interest defined and adequately measured? (high/moderate/low risk of measurement bias related to outcome)	Study confounding Important potential confounders are appropriately accounted for? (high/moderate/low risk of bias due to confounding)	Statistical Analysis and Reporting Statistical analysis appropriate for the design of the study? (high/moderate/low risk of bias due to statistical analysis)
Ahola, 2022	Low risk Consecutive patients	Low risk No loss to follow-up reported	Moderate risk Score calculated retrospectively	Low risk Hospital records were used	Low risk	Low risk
Amabili, 2019	Low risk Consecutive patients	Low risk No loss to follow-up reported	Low risk	Low risk	Low risk	Low risk
Arteaga, 2020	Low risk Consecutive patients	Low risk No loss to follow-up reported	Low risk	Low risk	Low risk	Low risk
Artiles-Armas, 2021	Low risk Consecutive patients	Low risk No loss to follow-up reported	Low risk	Low risk	Low risk	Low risk
Covino, 2022	Low risk Consecutive patients	Low risk No loss to follow-up reported	Low risk	Low risk	Low risk	Low risk
Dal Moro, 2017	Low risk Consecutive patients	Low risk No loss to follow-up reported	Low risk	Low risk	Low risk	Low risk
Dasgupta, 2009	Low risk Consecutive patients	Low risk No loss to follow-up reported	Low risk	Low risk	Low risk	Low risk
Fagard, 2017	Low risk Consecutive patients	Low risk No loss to follow-up reported	Low risk	Low risk	Low risk	Low risk
Geiss, 2021	Low risk Consecutive patients	Moderate risk 24% loss to follow-up reported, without provision of reasons	Low risk	Low risk	Moderate risk Unclear what the role of geriatric assessment has been.	High risk Numbers don’t add up
He, 2020	Low risk	Moderate risk 8/142 patients excluded because of cancelled or declined surgery, leading to risk of bias	Low risk Blinded assessment	Low risk Hospital records used	Low risk	Low risk
Heng, 2016	Low risk Consecutive patients	Moderate risk Not reported	Low risk	Low risk	Low risk (appropriate adjustment)	Low risk
Hill, 2020	Moderate risk Only patients who stayed at the ICU for 24 hours or more were included, which may introduce survivorship bias.	Moderate risk Not reported	Moderate risk CFS potentially collected after recovery	Low risk Family member follow-up	Moderate risk
Kaibori, 2016	Low risk	Moderate risk Not reported	Low risk	Low risk	Low risk (prognostic research)	Low risk
Kenig, 2020	Low risk	Low risk Low proportion loss to follow-up	Low risk	Low risk	Low risk	Low risk
Knauf, 2022	Low risk	Moderate risk High proportion of loss to follow-up	Low risk	Low risk	Low risk	Low risk
Korc-Grodzicki, 2015	Low risk	Low risk	Low risk	Low risk	Low risk	Low risk
Krenzlin, 2021	Low risk	Low risk	Low risk	Low risk	Low risk	Low risk
Miguelena-Hycka, 2019	Low risk	Moderate risk High proportion of loss to follow-up	Low risk	Low risk	Low risk	Low risk
Niemeläinen, 2021	Low risk	Low risk	Low risk	Low risk	Low risk	Low risk
Nishijima, 2021	Moderate risk Large number of excluded patients, unclear	Low risk	Low risk	Low risk
Puustinen, 2016	Low risk	Low risk	Low risk	Low risk	Low risk	Low risk
Sanchez Arteaga, 2022	High risk Patient flow unclear for large proportion of patients	Moderate risk Outcomes unclear for large proportion of patients	Low risk	Low risk		High risk Unclear which patients were analysed
Souwer, 2018	Low risk	Low risk Low proportion loss to follow-up	Low risk	Low risk Hospital records were used	Low risk	Low risk
Sun, 2020	Moderate risk Exclusion criteria not clear, more patients excluded due to not having certain characteristics	Low risk	Low risk	Low risk	Low risk	Low risk
Susano, 2020	Low risk Consecutive patients	Low risk	Low risk	Low risk	Low risk	Low risk
Tanaka, 2019	Moderate risk Retrospective analysis	Low risk	Low risk	Low risk	Low risk	Low risk
Tanaka, 2022	Moderate risk Retrospective analysis	Low risk	Low risk	Low risk	Low risk	Low risk
Traunero, 2022	Low risk Consecutive patients	Low risk	Low risk	Low risk	Low risk	Low risk
Van der Zanden, 2021	Moderate risk Retrospective analysis	Low risk	Low risk	Low risk	Low risk	Low risk
Vilches-Moraga, 2020	Low risk Consecutive patients	Low risk	Low risk	Low risk	Low risk	Low risk
Weiss, 2022	Moderate risk Retrospective analysis	Low risk	Low risk	Low risk	Low risk	Low risk
Winters, 2018	Moderate risk Retrospective analysis	Low risk	Low risk	Low risk	Low risk	Low risk
Wu, 2021	Low risk Consecutive patients	Low risk	Low risk	Low risk	Low risk	Low risk
Yamada, 2021	Low risk Consecutive patients	Low risk	Low risk	Low risk	Low risk	Low risk

Table of excluded studies

Reference	Reason for exclusion
Geiss (2021)	Numbers don’t add up
Mezera (2022)	Wrong I (postoperative asessement)
Bessems (2021)	Wrong I
Abdullahi (2021)	Wrong P
Gronewold (2017)	Wrong I
Kaibori (2021)	Wrong I
Kenig (2015)	Wrong I
Mima (2021)	Wrong P
Rajeev (2019)	No comparison
Ruiz de Gopegui (2022)	Wrong I
Ruiz de Gopegui (2021)	Wrong I
Wang (2020)	Wrong P
Yajima (2022)	Wrong P
Aitken (2021)	Wrong P
Aucoin (2020)	Wrong P
Campi (2022)	Wrong P

Verantwoording

Autorisatiedatum en geldigheid

Laatst beoordeeld : 09-04-2024

Laatst geautoriseerd : 09-04-2024

Geplande herbeoordeling : 09-04-2028

Initiatief en autorisatie

Initiatief:

Nederlandse Vereniging voor Klinische Geriatrie

Geautoriseerd door:

Nederlandse Internisten Vereniging
Nederlandse Orthopaedische Vereniging
Nederlandse Vereniging voor Anesthesiologie
Nederlandse Vereniging voor Heelkunde
Nederlandse Vereniging voor Klinische Geriatrie

Algemene gegevens

In samenwerking met : bovenstaande partijen, Verenso, Verpleegkundigen en Verzorgenden Nederland – Verpleegkundig Specialisten en Genero

De ontwikkeling van deze richtlijn werd ondersteund door het Kennisinstituut van de Federatie Medisch Specialisten (www.demedischspecialist.nl/kennisinstituut) en werd gefinancierd uit de Kwaliteitsgelden Medisch Specialisten (SKMS).

De financier heeft geen enkele invloed gehad op de inhoud van de richtlijn.

Samenstelling werkgroep

Voor het ontwikkelen van de richtlijn is in 2021 een multidisciplinaire werkgroep ingesteld, bestaande uit vertegenwoordigers van alle relevante specialismen (zie hiervoor de Samenstelling van de werkgroep) die betrokken zijn bij chirurgie bij kwetsbare ouderen.

Werkgroep

Dr. D.E. (Didy) Jacobsen (voorzitter), Nederlandse Vereniging voor Klinische Geriatrie

Dr. H.A. (Harmke) Polinder-Bos, Nederlandse Vereniging voor Klinische Geriatrie

Dr. S. (Suzanne) Festen, Nederlandse Internisten Vereniging

N.S. (Niamh) Landa-Hoogerbrugge, MSc Verpleegkundigen en Verzorgenden Nederland en Verpleegkundigen en Verzorgenden Nederland – Verpleegkundig Specialisten

Dr. H.P.A. (Eric) van Dongen, Nederlandse Vereniging voor Anesthesiologie

Dr. J. (Juul) Tegels, Nederlandse Vereniging voor Heelkunde

Drs. P.E. (Petra) Flikweert, Nederlandse Orthopaedische Vereniging

Drs. H.P.P.R. (Heike) de Wever, Verenso

Patiëntvertegenwoordiger

M.R. (Marike) Abel- van Nieuwamerongen, Genero

Met ondersteuning van

Drs. E.A. (Emma) Gans, adviseur Kennisinstituut van de Federatie Medisch Specialisten

Drs. L.A.M. (Liza) van Mun, junior adviseur Kennisinstituut van de Federatie Medisch Specialisten

Dr. T. (Tim) Christen, adviseur Kennisinstituut van de Federatie Medisch Specialisten

Dr. J.F. (Janke) de Groot, senior adviseur Kennisinstituut van de Federatie Medisch Specialisten

Y. (Yvonne) van Kempen, projectsecretaresse, Kennisinstituut van de Federatie Medisch Specialisten

Belangenverklaringen

De Code ter voorkoming van oneigenlijke beïnvloeding door belangenverstrengeling is gevolgd. Alle werkgroepleden hebben schriftelijk verklaard of zij in de laatste drie jaar directe financiële belangen (betrekking bij een commercieel bedrijf, persoonlijke financiële belangen, onderzoeksfinanciering) of indirecte belangen (persoonlijke relaties, reputatiemanagement) hebben gehad. Gedurende de ontwikkeling of herziening van een module worden wijzigingen in belangen aan de voorzitter doorgegeven. De belangenverklaring wordt opnieuw bevestigd tijdens de commentaarfase.

Een overzicht van de belangen van werkgroepleden en het oordeel over het omgaan met eventuele belangen vindt u in onderstaande tabel. De ondertekende belangenverklaringen zijn op te vragen bij het secretariaat van het Kennisinstituut van de Federatie Medisch Specialisten.

Naam	Hoofdfunctie	Nevenwerkzaamheden	Persoonlijke Financiële Belangen	Persoonlijke Relaties	Extern gefinancierd onderzoek	Intellectuele belangen en reputatie	Overige belangen	Datum	Actie
Didy Jacobsen (voorzitter)	Internist-ouderengeneeskunde, academisch medisch specialist, Radboudumc afdeling geriatrie gedetacheerd naar Sint Maartenskliniek, Nijmegen (3 middagen per week > geriatrische diagnostiek en behandeling van orthopedische patiënten)	Geen	Geen	Geen	-	Niet aanwezig.	Nieuwe onderzoeksvoorstel op het gebied van zorgpadoptimalisatie/zorgpadontwikkeling voor ouderen met hoogrisico plaveiselcelcarcinoom. Vanuit dermatologie (Radboudumc) wordt dit opgezet. Ik denk mee voor geriatrisch perspectief.	30-09-2021	Geen restricties
Heike de Wever	Specialist ouderengeneeskunde, kaderarts geriatrische revalidatie bij de stichting TanteLouise	Lid van kerngroep kaderartsen geriatrische revalidatie van Verenso (onbetaald)	Geen	Neen	Neen	Neen	Neen	1-12-2021	Geen restricties
Suzanne Festen	Internist ouderengeneeskunde	Nvt	Geen belangenverstrengeling	Geen belangenverstrengeling	Betrokken bij ZIN subsidie en KWF subsidie	Behoudens dat de inhoud raakt aan mijn expertise in klinisch werk en onderzoek geen belangen.	Nvt	11-11-2021	Geen restricties
Eric van Dongen	Anesthesioloog maatschap anesthesiologie, ic en pijnbestrijding	Bestuur E infuse, vacatiegelden	Geen	Geen	Geen	Co-founder AGE MDO, ketenzorg perioperatief proces kwetsbare oudere	Geen	11-10-2021	Geen restricties
Harmke Polinder- Bos	Klinisch Geriater, Erasmus MC, Rotterdam	Niet van toepassing	Niet van toepassing	Niet van toepassing	2021: COOP-studie	Behoudens dat de inhoud raakt aan mijn expertise in klinisch werk en onderzoek geen belangen.	Geen	4-10-2021	Geen restricties
Niamh Landa - Hoogerbruggen	Verpleegkundig specialist GE-chirurgie/klinische geriatrie Maasstad ziekenhuis beoordelen kwetsbare ouderen die voor colorectale chirurgie gaan zowel poliklinisch als klinisch, tevens (regie)behandelaar van deze patiëntengroep	Bestuurslid V&VN geriatrie en gerontologie Voorzitter werkgroep GE-oncologie subgroep CRC V&VN oncologie Voorzitten bestuur alumnivereniging HRO-VPK Kernlid werkgroep Samen beslissen met Topics-SF van Vilans	Nee	Nee	Nee	Neveneffect kan zijn meer expertise ontwikkelen op dit gebied en zodoende integreren in huidig zorgpad dieontwikkeld is	Nee	29-09-2021	Geen restricties
Juul Tegels	Lid richtlijnwerkgroep	Traumachirurg, fellow	Geen	Geen	Geen		Geen	18-3-2022	Geen restricties
Petra Flikweert	Orthopedisch chirurg, Reinier haga orthopedisch centrum, zoetermeer. Vanuit de NOV gemandateerde voor de werkgroep.	Commissie kwaliteit - Haga ziekenhuis - onbetaald Commissie kwaliteit - NOV - onbetaald Onderwijscommissie NOV - onbetaald	Geen	Geen	Geen	Geen	Geen	3-9-2023	Geen restricties
Marike Abel- van Nieuwamerongen	Lid ouderen- en mantelzorgforum; Genero (onbezoldigd> onkostenvergoeding)	Lid RvT landelijke medezeggenschapsorganisatie cliënten Lid Cliëntenraad ziekenhuis in Tilburg Lid Cliëntenraad 1e lijnsorganisatie in Etten-Leur (onbetaalde functies, wel onkostenvergoeding)	Geen	Geen	Geen	Geen	Geen	6-9-2023	Geen restricties

Inbreng patiëntenperspectief

Er werd aandacht besteed aan het patiëntenperspectief door het uitnodigen van de Patiëntenfederatie Nederland en KBO-PCOB voor de schriftelijke knelpuntenanalyse. De verkregen input is meegenomen bij het opstellen van de uitgangsvragen, de keuze voor de uitkomstmaten en bij het opstellen van de overwegingen. De conceptrichtlijn is tevens voor commentaar voorgelegd aan Genero, KBO-PCOB en Patiëntenfederatie Nederland en de eventueel aangeleverde commentaren zijn bekeken en verwerkt.

Kwalitatieve raming van mogelijke financiële gevolgen in het kader van de Wkkgz

Bij de richtlijn is conform de Wet kwaliteit, klachten en geschillen zorg (Wkkgz) een kwalitatieve raming uitgevoerd of de aanbevelingen mogelijk leiden tot substantiële financiële gevolgen. Bij het uitvoeren van deze beoordeling zijn richtlijnmodules op verschillende domeinen getoetst (zie het stroomschema op de Richtlijnendatabase).

Uit de kwalitatieve raming blijkt dat er [waarschijnlijk geen/ mogelijk] substantiële financiële gevolgen zijn, zie onderstaande tabel.

Module	Uitkomst kwalitatieve raming	Toelichting
Module Preoperatieve herkenning van kwetsbaarheid	geen substantiële financiële gevolgen	Hoewel uit de toetsing volgt dat de aanbeveling(en) breed toepasbaar zijn (>40.000 patiënten), volgt ook uit de toetsing dat het geen nieuwe manier van zorgverlening of andere organisatie van zorgverlening betreft, het geen toename in het aantal in te zetten voltijdsequivalenten aan zorgverleners betreft en het geen wijziging in het opleidingsniveau van zorgpersoneel betreft. Er worden daarom geen substantiële financiële gevolgen verwacht.

Werkwijze

AGREE

Deze richtlijnmodule is opgesteld conform de eisen vermeld in het rapport Medisch Specialistische Richtlijnen 2.0 van de adviescommissie Richtlijnen van de Raad Kwaliteit. Dit rapport is gebaseerd op het AGREE II instrument (Appraisal of Guidelines for Research & Evaluation II; Brouwers, 2010).

Knelpuntenanalyse en uitgangsvragen

Tijdens de voorbereidende fase inventariseerden de werkgroep de knelpunten in de chirurgische zorg voor kwetsbare ouderen. De werkgroep beoordeelde de aanbevelingen uit de eerdere richtlijnmodule (NVKG, 2016) op noodzaak tot revisie. Tevens zijn er knelpunten aangedragen door betrokken partijen via een schriftelijke knelpuntenanalyse.

Op basis van de uitkomsten van de knelpuntenanalyse zijn door de werkgroep concept-uitgangsvragen opgesteld en definitief vastgesteld.

Uitkomstmaten

Na het opstellen van de zoekvraag behorende bij de uitgangsvraag inventariseerde de werkgroep welke uitkomstmaten voor de patiënt relevant zijn, waarbij zowel naar gewenste als ongewenste effecten werd gekeken. De werkgroep waardeerde deze uitkomstmaten volgens hun relatieve belang bij de besluitvorming rondom aanbevelingen, als cruciaal (kritiek voor de besluitvorming), belangrijk (maar niet cruciaal) en onbelangrijk. Tevens definieerde de werkgroep tenminste voor de cruciale uitkomstmaten welke verschillen zij klinisch (patiënt) relevant vonden.

Methode literatuursamenvatting

Een uitgebreide beschrijving van de strategie voor zoeken en selecteren van literatuur en de beoordeling van de risk-of-bias van de individuele studies is te vinden onder ‘Zoeken en selecteren’ onder Onderbouwing. De beoordeling van de kracht van het wetenschappelijke bewijs wordt hieronder toegelicht.

Beoordelen van de kracht van het wetenschappelijke bewijs

De kracht van het wetenschappelijke bewijs werd bepaald volgens de GRADE-methode. GRADE staat voor ‘Grading Recommendations Assessment, Development and Evaluation’ (zie http://www.gradeworkinggroup.org). De basisprincipes van de GRADE-methodiek zijn: het benoemen en prioriteren van de klinisch (patiënt) relevante uitkomstmaten, een systematische review per uitkomstmaat, en een beoordeling van de bewijskracht per uitkomstmaat op basis van de acht GRADE-domeinen (domeinen voor downgraden: risk of bias, inconsistentie, indirectheid, imprecisie, en publicatiebias; domeinen voor upgraden: dosis-effect relatie, groot effect, en residuele plausibele confounding).

GRADE onderscheidt vier gradaties voor de kwaliteit van het wetenschappelijk bewijs: hoog, redelijk, laag en zeer laag. Deze gradaties verwijzen naar de mate van zekerheid die er bestaat over de literatuurconclusie, in het bijzonder de mate van zekerheid dat de literatuurconclusie de aanbeveling adequaat ondersteunt (Schünemann, 2013; Hultcrantz, 2017).

GRADE	Definitie
Hoog	er is hoge zekerheid dat het ware effect van behandeling dichtbij het geschatte effect van behandeling ligt; het is zeer onwaarschijnlijk dat de literatuurconclusie klinisch relevant verandert wanneer er resultaten van nieuw grootschalig onderzoek aan de literatuuranalyse worden toegevoegd.
Redelijk	er is redelijke zekerheid dat het ware effect van behandeling dichtbij het geschatte effect van behandeling ligt; het is mogelijk dat de conclusie klinisch relevant verandert wanneer er resultaten van nieuw grootschalig onderzoek aan de literatuuranalyse worden toegevoegd.
Laag	er is lage zekerheid dat het ware effect van behandeling dichtbij het geschatte effect van behandeling ligt; er is een reële kans dat de conclusie klinisch relevant verandert wanneer er resultaten van nieuw grootschalig onderzoek aan de literatuuranalyse worden toegevoegd.
Zeer laag	er is zeer lage zekerheid dat het ware effect van behandeling dichtbij het geschatte effect van behandeling ligt; de literatuurconclusie is zeer onzeker.

Bij het beoordelen (graderen) van de kracht van het wetenschappelijk bewijs in richtlijnen volgens de GRADE-methodiek spelen grenzen voor klinische besluitvorming een belangrijke rol (Hultcrantz, 2017). Dit zijn de grenzen die bij overschrijding aanleiding zouden geven tot een aanpassing van de aanbeveling. Om de grenzen voor klinische besluitvorming te bepalen moeten alle relevante uitkomstmaten en overwegingen worden meegewogen. De grenzen voor klinische besluitvorming zijn daarmee niet één op één vergelijkbaar met het minimaal klinisch relevant verschil (Minimal Clinically Important Difference, MCID). Met name in situaties waarin een interventie geen belangrijke nadelen heeft en de kosten relatief laag zijn, kan de grens voor klinische besluitvorming met betrekking tot de effectiviteit van de interventie bij een lagere waarde (dichter bij het nuleffect) liggen dan de MCID (Hultcrantz, 2017).

Overwegingen (van bewijs naar aanbeveling)

Om te komen tot een aanbeveling zijn naast (de kwaliteit van) het wetenschappelijke bewijs ook andere aspecten belangrijk en worden meegewogen, zoals aanvullende argumenten uit bijvoorbeeld de biomechanica of fysiologie, waarden en voorkeuren van patiënten, kosten (middelenbeslag), aanvaardbaarheid, haalbaarheid en implementatie. Deze aspecten zijn systematisch vermeld en beoordeeld (gewogen) onder het kopje ‘Overwegingen’ en kunnen (mede) gebaseerd zijn op expert opinion. Hierbij is gebruik gemaakt van een gestructureerd format gebaseerd op het evidence-to-decision framework van de internationale GRADE Working Group (Alonso-Coello, 2016a; Alonso-Coello 2016b). Dit evidence-to-decision framework is een integraal onderdeel van de GRADE-methodiek.

Formuleren van aanbevelingen

De aanbevelingen geven antwoord op de uitgangsvraag en zijn gebaseerd op het beschikbare wetenschappelijke bewijs en de belangrijkste overwegingen, en een weging van de gunstige en ongunstige effecten van de relevante interventies. De kracht van het wetenschappelijk bewijs en het gewicht dat door de werkgroep wordt toegekend aan de overwegingen, bepalen samen de sterkte van de aanbeveling. Conform de GRADE-methodiek sluit een lage bewijskracht van conclusies in de systematische literatuuranalyse een sterke aanbeveling niet a priori uit, en zijn bij een hoge bewijskracht ook zwakke aanbevelingen mogelijk (Agoritsas, 2017; Neumann, 2016). De sterkte van de aanbeveling wordt altijd bepaald door weging van alle relevante argumenten tezamen. De werkgroep heeft bij elke aanbeveling opgenomen hoe zij tot de richting en sterkte van de aanbeveling zijn gekomen.

In de GRADE-methodiek wordt onderscheid gemaakt tussen sterke en zwakke (of conditionele) aanbevelingen. De sterkte van een aanbeveling verwijst naar de mate van zekerheid dat de voordelen van de interventie opwegen tegen de nadelen (of vice versa), gezien over het hele spectrum van patiënten waarvoor de aanbeveling is bedoeld. De sterkte van een aanbeveling heeft duidelijke implicaties voor patiënten, behandelaars en beleidsmakers (zie onderstaande tabel). Een aanbeveling is geen dictaat, zelfs een sterke aanbeveling gebaseerd op bewijs van hoge kwaliteit (GRADE gradering HOOG) zal niet altijd van toepassing zijn, onder alle mogelijke omstandigheden en voor elke individuele patiënt.

Implicaties van sterke en zwakke aanbevelingen voor verschillende richtlijngebruikers
	Sterke aanbeveling	Zwakke (conditionele) aanbeveling
Voor patiënten	De meeste patiënten zouden de aanbevolen interventie of aanpak kiezen en slechts een klein aantal niet.	Een aanzienlijk deel van de patiënten zou de aanbevolen interventie of aanpak kiezen, maar veel patiënten ook niet.
Voor behandelaars	De meeste patiënten zouden de aanbevolen interventie of aanpak moeten ontvangen.	Er zijn meerdere geschikte interventies of aanpakken. De patiënt moet worden ondersteund bij de keuze voor de interventie of aanpak die het beste aansluit bij zijn of haar waarden en voorkeuren.
Voor beleidsmakers	De aanbevolen interventie of aanpak kan worden gezien als standaardbeleid.	Beleidsbepaling vereist uitvoerige discussie met betrokkenheid van veel stakeholders. Er is een grotere kans op lokale beleidsverschillen.

Organisatie van zorg

In de knelpuntenanalyse en bij de ontwikkeling van de richtlijnmodule is expliciet aandacht geweest voor de organisatie van zorg: alle aspecten die randvoorwaardelijk zijn voor het verlenen van zorg (zoals coördinatie, communicatie, (financiële) middelen, mankracht en infrastructuur). Randvoorwaarden die relevant zijn voor het beantwoorden van deze specifieke uitgangsvraag zijn genoemd bij de overwegingen. Meer algemene, overkoepelende, of bijkomende aspecten van de organisatie van zorg worden behandeld in de module Organisatie van zorg.

Commentaar- en autorisatiefase

De conceptrichtlijnmodule werd aan de betrokken (wetenschappelijke) verenigingen en (patiënt) organisaties voorgelegd ter commentaar. De commentaren werden verzameld en besproken met de werkgroep. Naar aanleiding van de commentaren werd de conceptrichtlijnmodule aangepast en definitief vastgesteld door de werkgroep. De definitieve richtlijnmodule werd aan de deelnemende (wetenschappelijke) verenigingen en (patiënt) organisaties voorgelegd voor autorisatie en door hen geautoriseerd dan wel geaccordeerd.

Referenties

Agoritsas T, Merglen A, Heen AF, Kristiansen A, Neumann I, Brito JP, Brignardello-Petersen R, Alexander PE, Rind DM, Vandvik PO, Guyatt GH. UpToDate adherence to GRADE criteria for strong recommendations: an analytical survey. BMJ Open. 2017 Nov 16;7(11):e018593. doi: 10.1136/bmjopen-2017-018593. PubMed PMID: 29150475; PubMed Central PMCID: PMC5701989.

Alonso-Coello P, Schünemann HJ, Moberg J, Brignardello-Petersen R, Akl EA, Davoli M, Treweek S, Mustafa RA, Rada G, Rosenbaum S, Morelli A, Guyatt GH, Oxman AD; GRADE Working Group. GRADE Evidence to Decision (EtD) frameworks: a systematic and transparent approach to making well informed healthcare choices. 1: Introduction. BMJ. 2016 Jun 28;353:i2016. doi: 10.1136/bmj.i2016. PubMed PMID: 27353417.

Alonso-Coello P, Oxman AD, Moberg J, Brignardello-Petersen R, Akl EA, Davoli M, Treweek S, Mustafa RA, Vandvik PO, Meerpohl J, Guyatt GH, Schünemann HJ; GRADE Working Group. GRADE Evidence to Decision (EtD) frameworks: a systematic and transparent approach to making well informed healthcare choices. 2: Clinical practice guidelines. BMJ. 2016 Jun 30;353:i2089. doi: 10.1136/bmj.i2089. PubMed PMID: 27365494.

Brouwers MC, Kho ME, Browman GP, Burgers JS, Cluzeau F, Feder G, Fervers B, Graham ID, Grimshaw J, Hanna SE, Littlejohns P, Makarski J, Zitzelsberger L; AGREE Next Steps Consortium. AGREE II: advancing guideline development, reporting and evaluation in health care. CMAJ. 2010 Dec 14;182(18):E839-42. doi: 10.1503/cmaj.090449. Epub 2010 Jul 5. Review. PubMed PMID: 20603348; PubMed Central PMCID: PMC3001530.

Hultcrantz M, Rind D, Akl EA, Treweek S, Mustafa RA, Iorio A, Alper BS, Meerpohl JJ, Murad MH, Ansari MT, Katikireddi SV, Östlund P, Tranæus S, Christensen R, Gartlehner G, Brozek J, Izcovich A, Schünemann H, Guyatt G. The GRADE Working Group clarifies the construct of certainty of evidence. J Clin Epidemiol. 2017 Jul;87:4-13. doi: 10.1016/j.jclinepi.2017.05.006. Epub 2017 May 18. PubMed PMID: 28529184; PubMed Central PMCID: PMC6542664.

Medisch Specialistische Richtlijnen 2.0 (2012). Adviescommissie Richtlijnen van de Raad Kwalitieit. http://richtlijnendatabase.nl/over_deze_site/over_richtlijnontwikkeling.html

Neumann I, Santesso N, Akl EA, Rind DM, Vandvik PO, Alonso-Coello P, Agoritsas T, Mustafa RA, Alexander PE, Schünemann H, Guyatt GH. A guide for health professionals to interpret and use recommendations in guidelines developed with the GRADE approach. J Clin Epidemiol. 2016 Apr;72:45-55. doi: 10.1016/j.jclinepi.2015.11.017. Epub 2016 Jan 6. Review. PubMed PMID: 26772609.

NVKG. Richtlijn Behandeling kwetsbare ouderen bij chirurgie. 2016. https://richtlijnendatabase.nl/richtlijn/behandeling_kwetsbare_ouderen_bij_chirurgie/generieke_zorgpad.html

Schünemann H, Brożek J, Guyatt G, et al. GRADE handbook for grading quality of evidence and strength of recommendations. Updated October 2013. The GRADE Working Group, 2013. Available from http://gdt.guidelinedevelopment.org/central_prod/_design/client/handbook/handbook.html.

Schünemann HJ, Oxman AD, Brozek J, Glasziou P, Jaeschke R, Vist GE, Williams JW Jr, Kunz R, Craig J, Montori VM, Bossuyt P, Guyatt GH; GRADE Working Group. Grading quality of evidence and strength of recommendations for diagnostic tests and strategies. BMJ. 2008 May 17;336(7653):1106-10. doi: 10.1136/bmj.39500.677199.AE. Erratum in: BMJ. 2008 May 24;336(7654). doi: 10.1136/bmj.a139.

Schünemann, A Holger J [corrected to Schünemann, Holger J]. PubMed PMID: 18483053; PubMed Central PMCID: PMC2386626.

Wessels M, Hielkema L, van der Weijden T. How to identify existing literature on patients' knowledge, views, and values: the development of a validated search filter. J Med Libr Assoc. 2016 Oct;104(4):320-324. PubMed PMID: 27822157; PubMed Central PMCID: PMC5079497.

Zoekverantwoording

Zoekacties zijn opvraagbaar. Neem hiervoor contact op met de Richtlijnendatabase.

Richtlijnendatabase

Chirurgie bij kwetsbare ouderen

Chirurgie bij kwetsbare ouderen

Hoe herken je kwetsbaarheid bij patiënten van ≥70 jaar in de preoperatieve setting?

Uitgangsvraag

Aanbeveling

Overwegingen

Onderbouwing

Conclusies

Samenvatting literatuur

Zoeken en selecteren

Referenties

Evidence tabellen

Verantwoording

Autorisatiedatum en geldigheid

Initiatief en autorisatie

Algemene gegevens

Samenstelling werkgroep

Belangenverklaringen

Inbreng patiëntenperspectief

Werkwijze

Referenties

Zoekverantwoording

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