Kirsch, Gelband, & Stone, PC

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Thursday, December 30, 2010

New York Times: Does old age and frailty preclude surgery?

"But thanks to a rather elegant piece of research by a Johns Hopkins team, recently published in The Journal of the American College of Surgeons, surgeons can give more informative answers when elderly patients in this situation, or their families, wonder what to do.

...frailty is a specific medical syndrome with measurable criteria.
They look for a series of declines that include weight loss (specifically, an unintentional loss of 10 pounds or more in the past year), a weaker grip, exhaustion and lack of physical activity, and a slower gait. The assessment takes perhaps 15 minutes to conduct in an office. Then the doctors assign a score: 0 to 1 for those who aren’t frail, 2 to 3 for the intermediately frail.
Patients who score 4 to 5 are frail. “They tend to have much less reserve, a decreased ability to bounce back” from physiological stress, said Dr. Fried, who previously taught at Johns Hopkins.
Might frailty scores be better at predicting how patients fare after surgery than the existing methods?
“The data are quite persuasive,” Dr. Fried said. “People who are frail before surgery are at higher risk for poor outcomes afterwards.”...
“If the risks are likely to be higher, it changes the equation as to whether the surgery has benefit,” Dr. Fried said.
That 89-year-old patient, for example, turned out to be intermediately frail when Dr. Makary evaluated him using the frailty index. “I thought he was stronger,” he acknowledged. After considerable discussion, doctor and patient agreed not to remove the tumor, but to track it with annual scans.
Surgeons at Johns Hopkins have widely adopted the index to help make such pre-op decisions, and Dr. Makary says he has heard from surgeons at about a dozen other major medical centers who are also using it. In some cases, patients may decline surgery. In many, they and their families will have a more realistic idea of how long recovery may take and how much help they will need.
This is a question, Dr. Makary suggested, that older patients and their families ought to routinely ask their surgeons in fairly blunt terms: You want to operate on my father? You think he’s too old for surgery? What’s his frailty score?"  (Click on above title for complete article in December 2010 NY Times).   (source: NY Times December 2010).

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