Aim of our study is to identify patients at moderate/severe geriatric risk in order to create an appropriate clinical pathway, using the following tools:
1) Definition of a clinical and functional prognosis, before and after urological surgery using the Multidimensional Prognostic Index (MPI);
2) Modification of existing clinical risk conditions before and after surgery;
3) Early initiation of an appropriate social-assistential path for elderly patients undergoing urological surgery
At the Galliera Hospital in Genoa we have developed a Urological-Geriatric Integrated Diagnostic-Therapeutic Pathway (PDTA) for patiens aged ≥65 years affected by urogenital pathologies requiring major laparoscopic or open surgery: radical cystectomy, radical or partial nephrectomy, radical prostatectomy. These patients, in a presurgical outpatient context, receive a Selfy_MPI, which is a validated self-assessment questionnaire of multi-dimensional risk for negative outcomes validated for≥65 years patients.1
In case of Selfy_MPI class 2 (moderate risk) or 3 (high risk) the patient is addressed to the urogeriatric team, which consists of various professional figures who cooperate together (urologist, geriatrician, anesthesiologist, nurse, social worker). In particular, the geriatrician evaluate the patient for clinical history, functional assessment and calculation of MPI.
Compared to other frailty measurements, MPI shows an higher positive predictive value of adverse outcomes in hospitalized older patients.2
When the MPI score identifies a patient in a class risk 2 or 3 a specific assessment of the risk areas is required, in order to improve clinical and functional parameters, follow patient after surgery during hospitalization, plan specific postoperative geriatric and urologic follow-up after 3 or 6 months.
The PDTA started on February 2019 and until October 2019 it has included 54 patients aged from 66 to 92 years old. All patients performed the Selfy_MPI. 46 patients showed a Selfy_MPI at a risk class 1; 8 patients resulted into the risk class 2, so they were evaluated by geriatricians that performed full MPI, confirming the risk class (MPI 2). 2 patients had an ASA score 4 and the anesthesiologist excluded surgery, 1 patient developed metastasis and began chemotherapy ; 2 patients refused surgery and 3 patients were considered able to be operated. 49 patients underwent open or laparoscopic surgery: 17 patients were submitted to radical prostatectomy (15 laparoscopic, 2 open surgery), 12 to radical cystectomy (2 laparoscopic, 10 open), 15 to radical nephrectmy or nephroureterectomy (7 laparoscopic, 8 open), 3 to laparoscopic partial nephrectomy, 1 to synchronous bilateral laparoscopic radical partial nephrectomy for synchronous renal cancer, 1 to open radical cystectomy with concomitant nephroureterectomy.
Several sudies reported the effects of frailty on falls, hospitalization and mortality, but only few focused on surgical patients and frailty is not included in the traditional surgical risk scales.3
The most common definition of frailty is an age-associated, biological syndrome characterized by decreased biological reserve, due to dysregulation of several physiological systems, and poor outcomes.4
Frail patients have an higher risk of adverse outomes including prolonged hospitalization, mortality and disability. 4,5
The prevalence of frailty increases with age: in people older than 65 years ranging from 7 to 16.3%, reaching 30% of people aged 85 years. 6,7
Literature shows an improvement of clinical outcomes of elderly people urdergoing surgery when they undergo an evaluation of frailty with multidimensional assessment. 8
In our PDTA we used the MPI score for patients at risk of negative outcomes. MPI is a widely accepted prognostic tool, based on a standard Comprehensive Geriatric Assessment (CGA): multicenter studies demonstrated that MPI was a significantly more accurate predictor of all-cause mortality than other frailty index.9
The European Medicines Agency (EMA), in 2018 reported that the MPI is able to extract information from CGA to categorized frailty in three subgroups with excellent prognostic value.
The objective of our PDTA is to create for elderly patients an individual treatment plann based on frailty degree. The creation of PDTA provides a better customization of the clinical /diagnostic pathway and prognostic classification of the patients. The results we have obtained so far are still preliminary, however, the possibility of extend the PDTA to patients requiring endoscopic surgery will be evaluated.
1. Development and Validation of a Self-Administered Multidimensional Prognostic Index to Predict Negative Health Outcomes in Community-Dwelling Persons. Pilotto A1, Veronese N1, Quispe Guerrero KL1, Zora S1, Boone ALD2, Puntoni M3, Giorgeschi A1, Cella A1, Rey Hidalgo I2, Pers YM4, Ferri A1, Fernandez JRH5, Pisano Gonzalez M6; EFFICHRONIC Consortium. Rejuvenation Res. 2019 Aug;22(4):299-305. doi: 10.1089/rej.2018.2103. Epub 2018 Dec 28
2. On behalf of the MPI_AGE Investigators Using the Multidimensional Prognostic Index to predict Clinical Outcomes of Hospitalizated Older Persons: a Prospective Multicentre. Pilotto A, Veronese N, Darajati J, et al. International Study. J Gerontol A Biol Sci Med 2018 (Epub ahead of print).
3.Redefining geriatric preoperative assessment using frailty, disability and co-morbidity.Robinson TN1, Eiseman B, Wallace JI, Church SD, McFann KK, Pfister SM, Sharp TJ, Moss M. . Ann Surg. 2009 Sep;250(3):449-55.
4. Frailty in elderly people.Clegg A1, Young J, Iliffe S, Rikkert MO, Rockwood K. Lancet. 2013 Mar 2;381(9868):752-62. doi: 10.1016/S0140-6736(12)62167-9.
5. Importance of frailty in patients with cardiovascular disease. Singh M1, Stewart R2, White H2. Eur Heart J. 2014 Jul;35(26):1726-31
6. Frailty in older adults: evidence for a phenotype.
Fried LP, Tangen CM, Walston J, Newman AB, Hirsch C, Gottdiener J, Seeman T, Tracy R, Kop WJ, Burke G, McBurnie MA; Cardiovascular Health Study Collaborative Research Group.
J Gerontol A Biol Sci Med Sci. 2001 Mar;56(3):M146-56.
7. Older women are frailer, but less often die then men: a prospective study of older hospitalized people. Veronese N, Siri G, Cella A, Daragjati J, Cruz-Jentoft AJ, Polidori MC, Mattace-Raso F, Paccalin M, Topinkova E, Greco A, Mangoni AA, Maggi S, Ferrucci L, Pilotto A; MPI AGE Investigators. Maturitas. 2019 Oct;128:81-86
8. Frailty as a predictor of surgical outcomes in older patients. Makary MA, Segev DL, Pronovost PJ, Syin D, Bandeen-Roche K, Patel P, Takenaga R, Devgan L, Holzmueller CG, Tian J, Fried LP. J Am Coll Surg. 2010 Jun;210(6):901-8.
9. Comparing the prognostic accuracy for all-cause mortality of frailty instruments: a multicentre 1-year follow-up in hospitalized older patients. Pilotto A1, Rengo F, Marchionni N, Sancarlo D, Fontana A, Panza F, Ferrucci L; FIRI-SIGG Study Group. PLoS One. 2012;7(1):e29090
10. Change in the Multidimensional Prognostic Index Score During Hospitalization in Older Patients. Volpato S, Daragjati J, Simonato M, Fontana A, Ferrucci L, Pilotto A. Rejuvenation Res. 2016 Jun;19(3):244-51