Different Frailty Scores to Incidence of Post-operative Delirium and Cognitive Dysfunction

Study Overview
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Brief Summary
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Patients who are frail will have higher rate for post-operative morbidities, mortality, prolonged hospital stays, loss of independence, increase in institutionalization, post-operative cognitive dysfunction (POCD) and delirium (POD). So, it is crucial to find a suitable frailty assessment tool that can be incorporated into a guideline and reference for our local setting in geriatric peri-operative management. In the mean time, create awareness regarding the frailty elderly population with POD, POCD and other associated poor outcomes among our clinicians.

Detailed Description
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Increasing life expectancy has led to increase in elderly populations, thus the elderly patients amounting for greater proportion of surgical cases. But, most of them are frail with multiple co-morbidities and are exposed to adverse outcome post-operatively. The commonest adverse outcomes is post-operative delirium (POD) in which clinicians often miss and often take lightly. If it is not treated, it will progress to post-operative cognitive dysfunction (POCD). So, it is crucial to identify the risk factors pre-operatively to minimize the risk of POD and POCD. The frail patients are more likely to have pre-existing cognitive impairment with reduced cognitive reserve, hence, they are the most vulnerable to POCD and POD. One of the most commonly used frailty screening tools is Fried Frailty criteria which is an easily accessible tool that mainly screens and scores the patients physically. However, the investigators propose to use the Groningen Frailty scale as it can assess the patients in a more holistic approach, not only in physical, but also vision, heating, nutritional, co-morbidities, cognition, psychosocial and mobility of the patients. Method: Elderly patients >65 years old undergoing elective surgery under general or local anaesthesia in University Malaya Medical Centre will be recruited for this study, over a 6 months period from August 2019 to January 2020. Patients will be assessed with baseline cognitive assessment, nutritional status, psychological status, and frailty scores prior to the surgery. After the operation, patients will be assessed using 4AT and CAM for at least 5 days or until patients discharged. Cognitive functions will be assessed on post-operative 7th day, 1 month and 3 months with T-MOCA via phone. All data will be analyzed using SPSS. Impact of research: A suitable frailty assessment tool will be identified to be used pre-operatively for elderly patients undergoing elective surgery. This tool will then be incorporated into a guideline and reference in our local setting for geriatric peri-operative management protocol. Moreover, with the results, investigators hope to create awareness within our multidisciplinary care of elderly surgical population on frailty assessment and its correlation to post-operative delirium, cognitive dysfunction and associated poor outcomes.

Official Title
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Comparing the Association of Different Frailty Scores to the Incidence of Post-operative Delirium and Cognitive Dysfunction

Conditions
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Frail Elderly Syndrome, Postoperative Delirium, Postoperative Cognitive Dysfunction

Intervention / Treatment
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* Diagnostic Test: Frailty Screening Tools


Participation Criteria
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Eligibility Criteria
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Inclusion Criteria: Age 65 years old and above ASA 1 - 3 Full GCS Elective surgery Able to communicate well Consented Extubated at the end of surgery Exclusion Criteria: Cardiac and neurosurgery On drugs affecting the central nervous system Admission to ICU intubated to continue ventilation. Refusal of consent Severe hearing loss Unable to use telephone/ mobile phone for communication

Ages Eligible for Study
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Minimum Age: 65 Years

Sexes Eligible for Study
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All

Accepts Healthy Volunteers
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No

Study Plan
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How is the study designed?
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Arms and Interventions

| Participant Group/Arm | Intervention/Treatment |
| --- | --- |
| Fried Frailty Phenotype<br>This group of patients will be assess by using 5 characteristics of Frailty which are weight loss, weakness, exhaustion, low activity and physical fitness of the patients. Patients classify as frail will have more than 3 criteria, intermediate or pre-frail will be 1 or 2 criteria present and robust will not have criteria. | Diagnostic Test: Frailty Screening Tools<br>* This is an observational and prospective study of patients who are going for elective surgery, thus no intervention will be given.<br>|
| Groningen Frailty Index<br>GFI is a simple questionnaire consisting of 15 items which are classified into 8 groups, consistent of 4 domains of functioning. A score of 4 or more indicates a higher risk for frailty and possible delirium. | Diagnostic Test: Frailty Screening Tools<br>* This is an observational and prospective study of patients who are going for elective surgery, thus no intervention will be given.<br>|

What is the study measuring?
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Primary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Occurence of confusion using Confusion Assessment Method (CAM) scores | Delirium is present if the following are present: Feature 1-Acute Change or/and Fluctuation (any symptom) AND Feature 2-Inattention AND EITHER Feature 3-Disorganized Thinking OR Feature 4-Altered Level of Consciousness | Within 5 days after surgery | 
| Change in cognitive function using Telephone-Montreal Cognitive Assessment (T-MOCA) | Cognitive function of the patients will be assessed after discharged and must achieved post-operative day 7 with T-MOCA via phone, subsequently assessed at 1 month and 3 month later. | Within 1 month | 
| Occurence of delirium using 4AT scores | A score of 4 or more suggests delirium but is not diagnostic: more detailed assessment of mental status may be required to reach a diagnosis. A score of 1-3 suggests cognitive impairment and more detailed cognitive testing and informant history-taking are required. A score of 0 does not definitively exclude delirium or cognitive impairment: more detailed testing may be required depending on the clinical context. | Within 5 days after surgery | 

 Terms related to the study
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Keywords Provided by Centre Hospitalier Valida
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post-operative delirium, post-operative cognitive dysfunction, frailty, nutritional status, depression