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• W4220961779 abstract "The American Society of Colon and Rectal Surgeons (ASCRS) is dedicated to ensuring high-quality patient care by advancing the science and prevention and management of disorders and diseases of the colon, rectum, and anus. The Clinical Practice Guidelines Committee is composed of society members who are chosen because they have demonstrated expertise in the specialty of colon and rectal surgery. This committee was created to lead international efforts in defining quality care for conditions related to the colon, rectum, and anus and develop clinical practice guidelines based on the best available evidence. Although not proscriptive, these guidelines provide information on which decisions can be made and do not dictate a specific form of treatment. These guidelines are intended for the use of all practitioners, health-care workers, and patients who desire information on the management of the conditions addressed by the topics covered in these guidelines. These guidelines should not be deemed inclusive of all proper methods of care nor exclusive of methods of care reasonably directed toward obtaining the same results. The ultimate judgment regarding the propriety of any specific procedure must be made by the physician in light of all the circumstances presented by the individual patient. STATEMENT OF THE PROBLEM Aging of the population has led to increasing rates of older adults requiring surgery‚ and due to the increased rate of postoperative morbidity and mortality associated with these patients, special considerations should be made before pursuing surgical intervention in this patient population.1 Older adult patients presenting to a colorectal surgery practice often have comorbidities and impaired functional status in addition to their presenting condition that needs to be considered when recommending a care plan. Specifically, older adults with frailty could be at risk for poor surgical outcomes.2 In general, frailty can be defined as an accumulation of deficits resulting in an inability to tolerate stress. Fried’s phenotypic definition of having 3 of the following 5 traits is the basis for the objective evaluation of frailty: slow walking speed, impaired grip strength, self-reported declining activity level, unintended weight loss, or exhaustion.3,4 It is especially challenging for surgeons to fully understand the impact of a proposed surgical intervention in the context of benefit versus harm among vulnerable patients. Reliable preoperative clinical assessment is essential to stratify risk and assist with decision-making under these circumstances. Improving the care of older and/or frail surgical patients begins with acknowledging the fact that frailty is more predictive of surgical outcomes than chronological age and that currently available frailty assessment tools are reliable and useful.5–7 Accurately assessing frail older patients facilitates opportunities to identify and address vulnerabilities that can potentially improve outcomes. Four major emerging categories for quality improvement in these patients include using prehabilitation, providing multidisciplinary care in partnership with geriatricians or practitioners with geriatrics expertise, adopting programs and techniques aimed at reducing stress during and after surgery, and assessing goals of care based on a consideration of realistic outcomes. These categories are not mutually exclusive‚ and optimal perioperative care should ideally encompass aspects of each category. In the following guideline, we evaluate the evidence and provide recommendations regarding the perioperative assessment and management of frail older patients undergoing colorectal surgery. Of note, from a practice standpoint, following recommendations regarding the care and management of frail older patients may require resources from a hospital or health system organization. Understandably, limited access to support may be a barrier to adoption at the individual practitioner level. Although previous ASCRS Clinical Practice Guidelines address issues relevant to the care of frail older patients (eg, bowel preparation, prevention of thromboembolic disease, and survivorship), these topics are beyond the scope of this guideline. MATERIALS AND METHODS As no previous ASCRS Clinical Practice Guideline has specifically addressed the topic of frailty, this guideline is an original body of work and not based on a particular previous publication. A systematic literature search limited to the English language and to studies with human subjects was performed using PubMed, Medline, EMBASE, Cochrane Database of Collected Reviews, and CINAHL databases from January 1, 2014, through November 24, 2021,8 using medical subject headings and keywords outlined in Appendix A at https://links.lww.com/DCR/B899. A total of 2235 articles were identified using the defined inclusion and exclusion criteria. Directed searches using embedded references from primary articles were performed in selected circumstances and yielded an additional 189 articles (Fig. 1). After the duplicates were removed, 1978 articles were evaluated for their level of evidence favoring clinical trials, meta-analyses/systematic reviews, comparative studies, and large registry retrospective studies over single institutional series, retrospective reviews, and peer-reviewed observational studies.9,10 A final list of 166 sources was evaluated for methodologic quality; the evidence base was examined, and a treatment guideline was formulated by the subcommittee for this guideline. The final grade of recommendation and level of evidence for each statement were determined using the Grades of Recommendation, Assessment, Development, and Evaluation system (Table 1).11 When agreement was incomplete regarding the evidence base or treatment guideline, consensus from the committee chair, vice-chair, and 2 assigned reviewers determined the outcome. Members of the ASCRS clinical practice guidelines committee, other fellows of ASCRS, and 3 geriatricians worked in joint production of these guidelines from inception to final publication. Recommendations formulated by the subcommittee were reviewed by the entire clinical practice guidelines committee and members of the ASCRS geriatrics task force. The guideline was peer-reviewed by Diseases of the Colon and Rectum, and the final guideline was approved by the ASCRS executive council. In general, each ASCRS clinical practice guideline is updated every 5 years. No funding was received for preparing this guideline‚ and the authors have declared no competing interests related to this material. This guideline conforms to the appraisal of guidelines research and evaluation checklist. TABLE 1. - The GRADE system: grading recommendations Grade Description Benefit versus risk and burdens Methodologic quality of supporting evidence Implications 1A Strong recommendation, high-quality evidence Benefits clearly outweigh risks and burdens or vice versa RCTs without important limitations or overwhelming evidence from observational studies Strong recommendation; can apply to most patients in most circumstances without reservation 1B Strong recommendation, moderate-quality evidence Benefits clearly outweigh risks and burdens or vice versa RCTs with important limitations (inconsistent results, methodologic flaws, indirect or imprecise) or exceptionally strong evidence from observational studies Strong recommendation; can apply to most patients in most circumstances without reservation 1C Strong recommendation, low- or very low-quality evidence Benefits clearly outweigh risks and burdens or vice versa Observational studies or case series Strong recommendation but may change when higher-quality evidence becomes available 2A Weak recommendation, high-quality evidence Benefits closely balanced with risks and burdens RCTs without important limitations or overwhelming evidence from observational studies Weak recommendation; best action may differ depending on circumstances or patients’ or societal values 2B Weak recommendation, moderate-quality evidence Benefits closely balanced with risks and burdens RCTs with important limitations (inconsistent results, methodologic flaws, indirect or imprecise) or exceptionally strong evidence from observational studies Weak recommendation; best action may differ depending on circumstances or patients’ or societal values 2C Weak recommendation, low- or very low-quality evidence Uncertainty in the estimates of benefits, risks, and burden; benefits, risks, and burdens may be closely balanced Observational studies or case series Very weak recommendations; other alternatives may be equally reasonable Used with permission from Chest 2006;129:174–181.11GRADE = Grades of Recommendation, Assessment, Development, and Evaluation; RCT = randomized controlled trial. FIGURE 1.: PRISMA literature search flow sheet. PRISMA = preferred reporting items for systematic reviews and meta-analyses.1. Treatment recommendations regarding colorectal surgery should consider patients’ degree of frailty (ie, physiological age) rather than chronological age. Grade of recommendation: strong recommendation based on high-quality evidence, 1A. Chronological age has been one of the most widely used variables in research assessing tolerance and outcomes of treatments across a variety of settings, including surgery. Many studies compare outcomes of patients older and younger than a certain age. Because Medicare eligibility starts at 65 years of age, this age has often been chosen as the cutoff to define older patients; however, as life expectancy has increased over time, older age reference points of 70 and 75 years have been used.12–18 Studies comparing groups of patients based on chronological age have reported variable findings in terms of an association between age and outcomes.19 Age as a study variable has a significant limitation in that it is a nonmodifiable risk factor‚ and researchers have argued that age should not be the sole determinant when making treatment decisions.2,20 Geriatricians, in particular, assert that instead of relying on age, patients’ fitness or frailty should be assessed and taken into consideration when making clinical decisions.20,21 Although it is universally accepted that frail patients are more vulnerable to adverse events due to reduced reserve capacity across multiple physiologic systems, it is important to acknowledge that the concept of frailty has not been uniformly assessed in the literature. Nevertheless, results linking frailty to adverse postoperative outcomes are remarkably consistent using a variety of frailty measurement tools.22–28 In terms of the ability to assess frailty as a predictor of postoperative outcomes, a 2015 systematic review evaluated 6 prospective studies and examined whether the comprehensive geriatric assessment (CGA), which addresses multidisciplinary components related to patients’ physical, mental, and psychosocial well-being and functional capabilities, predicted surgical outcomes in 1019 patients who underwent a variety of elective oncologic operations.29 This study showed that dependency in instrumental activities of daily living (IADLs: preparing hot meals, grocery shopping, making telephone calls, taking medicines, and managing money), fatigue, and frailty were significantly associated with overall complications, and that dependency in IADL was predictive of discharge to an institutional setting (ie, not the patient’s home). Although major complications were more frequent in patients with cognitive impairment and dependency in IADL and activities of daily living (ADL: walking, dressing, bathing, eating, getting into and out of bed, and toileting), age, per se, was not associated with a higher complication rate. Similarly, a Cochrane review and meta-analysis of randomized controlled trials of patients who underwent surgery for hip fracture that included 1316 patients aged ≥65 years showed that using the CGA preoperatively and/or postoperatively compared to usual surgical care may reduce mortality (relative risk 0.85; 95% CI, 0.68–1.05). In the same Cochrane review, analysis of 941 patients who had data reporting discharge destination found that using geriatric assessment reduced the rate of discharge to a higher level of care (ie, needing care in an institutional or dependent living setting; relative risk 0.71; 95% CI, 0.55–0.92).30 Finally, multivariable analysis of a prospective study of 980 patients aged ≥75 years undergoing oncologic surgery demonstrated that frailty (stratified by the number of impairments in the geriatric assessment) was associated with 6-month mortality after surgery (OR 1.14 for each unit increase in CGA score; p = 0.01). Interestingly, the ASA Physical Status Classification System Score, a commonly used marker of preoperative functional status, and age were not associated with 6-month mortality in this study.31 Similarly, a multivariate logistic regression analysis of 7337 patients from the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) who underwent elective colorectal cancer resection (mean age 65.8 ± 13.6 years) showed that frailty, assessed using an 11-point modified frailty index (m-FI), not age, was independently associated with readmission within a month of surgery (OR 1.4; 95% CI, 1.1–1.8).32 Meanwhile, another ACS-NSQIP study of 295,490 patients who underwent colorectal surgery for any indication between 2011 and 2016 showed that frailty, as assessed using a 5-item m-FI, was associated with significantly higher risks of prolonged length of stay (OR 1.24; 95% CI, 1.20–1.27), discharge to an institutional setting (OR 2.80; 95% CI, 2.70–2.90), 30-day serious morbidity (OR 1.39; 95% CI, 1.35–1.43), and mortality (OR 2.00; 95% CI, 1.87–2.14).27 Like much of the literature regarding frailty, these studies used large databases and retrospective methodology that put more emphasis on the metrics of frailty obtained from a chart review (ie, comorbidities and reported dependence) than on objective office-based frailty measures (ie, grip strength and walking time). 2. Frailty screening in the ambulatory setting identifies vulnerable and frail older adults. Grade of recommendation: strong recommendation based on high-quality evidence, 1A. Frailty screening tools should, ideally, consider patients’ mobility, functional activity, cognitive function, comorbidities, and nutritional status. Although the CGA33 is considered the benchmark for frailty assessment and generally includes follow-up care such as geriatric-specific optimization interventions,34 it may be time-consuming to administer, and a geriatric assessment composed of questionnaires assessing different domains of well-being can often be used instead.2,35 Other frailty screening tools, developed to facilitate the timely assessment of patients’ frailty status by surgeons in the ambulatory setting, can be as effective as the CGA in predicting postoperative complications.23,36,37 In a prospective study of 460 patients older than 70 years undergoing surgery for a variety of cancers, Audisio et al36 showed that moderate/severe fatigue, dependency in IADL, and an abnormal Eastern Cooperative Oncology Group Performance Status were the most important independent predictors of postoperative complications and that disability, as assessed by dependency in ADL or IADL or an abnormal Eastern Cooperative Oncology Group Performance Status, was associated with an extended hospital stay. In a prospective, multicenter study of 263 patients aged ≥70 years undergoing surgery for solid tumors, Huisman et al reported that a simple Timed Up and Go test (ie, the time a patient requires to get out of a chair, walk 3 m, and return to the chair) predicted major postoperative complications (OR 3.43; 95% CI, 1.13–10.36), was associated with a prolonged length of stay (OR 4.21; 95% CI, 1.10–24.73), and required more than 3 specialists during the hospitalization (OR 5.39; 95% CI, 1.85–15.77). In the same study, both impaired nutritional status and ASA score greater than or equal to 3 correlated with poor postoperative outcomes.38 Jones et al,39 in a prospective cohort study, evaluated 81 patients aged >65 years undergoing elective colorectal surgery and showed that more than 1 fall in the 6 months before the operation was associated with a higher rate of postoperative complications (59% versus 25%; p = 0.04) and postoperative institutionalization (52% versus 6%; p < 0.001). Similarly, the 11-point m-FI and the Risk Analysis Index (RAI), a 14-question survey measuring frailty among surgical patients, have also been shown to predict prolonged length of stay, need for intensive care unit admission, discharge to nursing home, and short- and long-term mortality after various surgical procedures‚ including colectomy.40–46 In another study evaluating the use of RAI, Shah et al evaluated 984,550 patients from the ACS-NSQIP database who underwent a variety of inpatient operations during an 8-year period. In this study, frailty, as measured using the RAI, was associated with increased complication rates and failure to rescue (ie, mortality after a complication) after both low- and high-risk procedures.47 In terms of other ways to potentially identify vulnerable patients before and after surgery, assessing sarcopenia (ie, loss of muscle mass and strength) continues to gain traction. Loss of muscle mass48 and myosteatosis (ie, fat deposits in muscle) can be quantified by a CT scan by measuring the skeletal muscle index at the L3 vertebral body, Hounsfield unit average calculation of the psoas muscle, total psoas muscle volume, intramuscular adipose content, or the dorsal muscle group area‚ and these measures have been shown to correlate with postoperative mortality, complication rates, and unfavorable cancer-related survival.49–52 Beyond elective surgery, frailty can also be assessed in the emergency setting. Zattoni et al showed that the Flemish version of the Triage Risk Screening Tool (fTRST) can be used in the emergency setting to aid in decision-making for frail older patients. The fTRST, a simple method to estimate postoperative risk, evaluates 5 weighted factors including experiencing cognitive decline (2 points), living alone or having no help available at home (1 point), having reduced mobility or having fallen in the past 6 months (1 point), being hospitalized in the past 3 months (1 point), and requiring polypharmacy (≥5 different medications, 1 point). This prospective study evaluated 110 frail older patients undergoing emergency abdominal surgery for a variety of indications and demonstrated that an fTRST score greater than or equal to 2 was predictive of increased morbidity, mortality, and length of stay.53 Using such screening tools to assess frailty preoperatively may help patients and their caregivers decide on a personalized treatment plan that aligns with their goals of care. Although not an exhaustive list, Table 2 summarizes frailty screening tools used in patients who underwent colorectal surgery. Typically, frailty screening uses tools that are chosen based on practice patterns and health system resources in collaboration with a geriatric practitioner. TABLE 2. - Selected frailty screening tools evaluated in colorectal surgery patients Tool Acronym Range of scores Cutoff indicating frailty Population tested Geriatric-8 G8 0–17 ≤14 CRC22 Timed Up and Go test TUG n/a ≥20 s CRC23 4-m gait speed Gait speed 0–2 m/s <0.8–1.0 m/s CRC24 6-min walking distance 6MWD n/a <20 m CRSa,25 6-min walk test 6MWT n/a <20 m CRSa,25 Question about falls in past 6 months Falls n/a ≥2 CRC39 Risk analysis index RAI 0–81 ≥30 Noncardiac including CRS26 Modified frailty index (11-item) mFI 0–11 >3 CRC32 Modified frailty index (5-item) mFI 0-5 ≥2 CRS27 Multidimensional prognostic index MPI 0–1.0 >0.33 CRC28 Flemish version of the Triage Risk Screening Tool fTRST 0–6 ≥2 Emergency surgery including CRS53 CRC = colorectal cancer; CRS = colorectal surgery.aAlso used as a measure of recovery of function. 3. Treatment plans for frail older adults should align with patients’ goals of care and should be based on a discussion regarding realistic outcomes. Grade of recommendation: strong recommendation based on low-quality evidence, 1C. When contemplating the care plan for a frail patient, the goals of care should be discussed with the patient, engaged family, caregivers or advocates, and other members of the multidisciplinary team that may include representatives from surgery, geriatrics, palliative care, primary care, oncology, radiation oncology, and so on.54 Typically, these discussions address domains such as anticipated longevity, functional status, independence, and comfort.55,56 In circumstances involving potential surgical intervention, deliberating whether to proceed with surgery should consider the likely treatment outcomes (including curative versus palliative objectives) and patient and family preferences.57 A realistic picture should be presented based on the anticipated risks of morbidity, mortality, and cognitive decline for each of the proposed treatment options taking into consideration the patient’s unique presentation, degree of frailty, and functional status.58 Specifically, patients may value their functional performance and cognitive status more than other treatment-related considerations and, as a result, patients may base their decisions on the likelihood of maintaining a certain level of performance (this concept is further discussed in statement no. 11). Of note, the degree of cognitive decline associated with an individual surgery or anesthetic exposure is unknown. However, the Mayo Clinic performed a 5-year longitudinal study of 1819 patients aged ≥70 years and showed that exposure to general anesthesia and surgery was associated with subtle accelerated cognitive decline.59 On an individual patient basis, it is important to clarify what matters most to patients‚ and online resources are available to facilitate these discussions (eg, the American Geriatrics Society’s Health in Aging Foundation website, https://www.healthinaging.org/age-friendly-healthcare-you/care-what-matters-most). In practice, it may be helpful to include a geriatrician and/or the patient’s primary care physician in treatment planning discussions. When planning operative treatment, it is helpful to clarify patients’ current living situation and existing support, to communicate goals for postoperative disposition as well as code status, and to have patients designate a surrogate decision-maker. Importantly, clinicians should recognize that patients’ goals of care may change during the perioperative period.55 In the emergency setting, it may be difficult to have comprehensive goals of care discussions with patients, particularly if they are septic or unstable, have cognitive impairment, or are otherwise unable to have a meaningful discussion. An interdisciplinary, 23-member expert panel recommended a structured communication framework addressing 9 key elements to facilitate decision-making among seriously ill older patients with emergency surgical conditions.60 The difficulties with having discussions in the setting of emergency circumstances highlight the importance of taking the opportunity to engage patients and their families in early goals of care discussions, especially when patients have multiple comorbidities or a condition that may result in a subsequent emergency (eg, obstructing colorectal cancer).61,62 4. Cognitive function should be assessed preoperatively in frail older adults. Grade of recommendation: strong recommendation based on low-quality evidence, 1C. The prevalence of dementia in the United States is estimated to be 5% among 70- to 79-year-olds, 24% among 80- to 89-year-olds, and nearly 40% among people older than 90 years.63 Meanwhile, mild cognitive impairment (MCI) is distinguished from dementia in that the impairment is not severe enough to interfere with independent function. MCI is common among older adults, even those living independently, and affects up to 50% of patients older than 65 years.64 Although the American College of Surgeons (ACS) and the American Geriatrics Society (AGS) recommend routinely assessing preoperative cognitive function and advocate using cognitive assessment tools such as the Mini-Cog preoperatively to detect MCI,65 the results of studies evaluating an association between MCI and postoperative outcomes such as complications, length of stay, and mortality are mixed and studies have been underpowered.66,67 Nonetheless, the most compelling reason to evaluate for cognitive impairment preoperatively is to predict and prepare patients and caregivers for the likelihood of postoperative delirium; preoperative MCI is one of the strongest predictors of postoperative delirium.68 In patients found to have cognitive impairment, it is advisable, when feasible, to involve a geriatrician and/or psychiatrist and to implement delirium risk reduction interventions such as orientation to staff and surroundings, sleep hygiene, early mobilization, and optimization of vision and hearing.69–71 In addition, decision-making capacity may be diminished in patients with cognitive impairment or dementia, and family members, health-care surrogates, and primary care physicians should be included in the decision-making process in appropriately selected patients.72 Upon returning home postoperatively, patients with cognitive or memory impairment may benefit from close surveillance from caregivers or home care services. Culley et al studied 211 patients who underwent orthopedic surgery using the Mini-Cog‚ which includes a 3-item recall test and a clock-drawing task that tests visuospatial representation, memory, recall, and executive function. In this prospective study, 24% of the patients were identified with preoperative cognitive impairment (Mini-Cog score ≤2), which was associated with an increased postoperative incidence of delirium (21% versus 7%; OR 4.52; 95% CI, 1.30–15.68).73 Cognitive impairment, again measured using the Mini-Cog, was also observed in 21% of 1003 patients older than 70 years before undergoing major elective oncologic surgery in the prospective, multicenter Geriatric Oncology Surgical Assessment and Functional rEcovery after Surgery study.74 Another method for evaluating preoperative, baseline cognitive function is the 12-item Self-Administered Gerocognitive Examination‚ which detects MCI and early dementia among geriatric patients.75 Benefits of the Self-Administered Gerocognitive Examination include its digital format‚ which can be administered while patients are in waiting rooms or even at home‚ and its ability to trend serial results over time.76 5. Frail older adults should be screened for postoperative signs and symptoms of delirium and treated appropriately. Grade of recommendation: strong recommendation based on moderate-quality evidence, 1B. Delirium, an acute confused state with hallmarks of fluctuating inattention and global cognitive dysfunction, occurs in up to 50% of older adults postoperatively77 and may remain unrecognized in up to two-thirds of cases.78 Delirium is associated with functional and cognitive decline, increased morbidity and mortality, longer lengths of stay, higher rates of nursing home placement, and increased health-care costs.79–85 Moreover, as complications may present atypically in older adults, clinicians should recognize that postoperative delirium may be an indicator or manifestation of an underlying complication. Maintaining an appropriate index of suspicion in frail older adults experiencing postoperative delirium and initiating a broad clinical workup under these circumstances may be advised (eg, evaluating for infections, electrolyte abnormalities, and drug side effects).86 The Confusion Assessment Method screens for delirium by evaluating for 1) mental status changes with acute onset and fluctuating severity, 2) inattention, 3) disorganized thinking, and 4) an altered level of consciousness. Using the Confusion Assessment Method, the presence of 1, 2, and either 3 or 4 confirms the diagnosis of delirium.87 Patients experiencing delirium may benefit from geriatric or neuropsychiatric specialist consultation to assist with perioperative management as well as multimodal, nonpharmacologic interventions such as cognitive stimulation, early mobilization, preservation of the sleep-wake cycle, and ensuring adequate hydration.70,71,83 Importantly, delirium can be prevented in up to 50% of patients by using a delirium prevention bundle.88 Watt et al performed a meta-analysis of 8557 patients older than 60 years who underwent elective orthopedic, cardiac, or abdominal surgery and found a pooled postoperative delirium incidence rate of 18.4% (95% CI, 14.3–23.3). In this study, the strongest predictors of postoperative delirium were a personal history of delirium (OR 6.4; 95% CI, 2.2–17.9), frailty (OR 4.1; 95% CI, 1.4–11.7), and cognitive impairment (OR 2.7; 95% CI, 1.9–3.8). In this study, prognostic factors that could potentially be modified to reduce the incidence of delirium included decreasing the use of psychotropic medications, smoking cessation, and increasing caregiver support.68 Another intervention shown to decrease the incidence of delirium is avoiding or reducing the use of specific medications such as opioids, benzodiazepines, antihistamines, atropine, sedative hypnotics, and corticosteroids.89 In 2019, in an effort to reduce adverse drug events in older patients and to decrease the incidence of delirium, the AGS updated the Beers Criteria describing potentially inappropriate medication use in patients aged ≥65 years and specifically highlighted the detrimental effects related to antipsychotics, benzodiazepines, H2 receptor" @default.
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• W4220961779 date "2022-03-02" @default.
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• W4220961779 title "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" @default.
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