Frailty als Herausforderung im klinischen Alltag

Jeden Tag stehen wir vor neuen Herausforderungen – die Betreuung von älteren Menschen mit Frailty-Syndrom gehört dazu. Durch eine gute interdisziplinäre Zusammenarbeit können wir im Sinne der Patienten Lebensqualität erhalten und Morbidität und Mortalität reduzieren. Die Möglichkeiten im perioperativen Setting für Therapie und Begleitung von Patienten mit Frailty-Syndrom werden nachfolgend näher betrachtet.

Abstract

In order to prevent short-term complication, patients with frailty syndrome require special attention and care in the perioperative context. The implementation of a frailty screening and if possible, an advanced geriatric assessment in the clinical routine should take into account the clinical setting, the patient population as well as time and human resources. Individual treatment pathways must allow for a multidisciplinary exchange and a multimodal approach when dealing with these challenging patients. Key aspects of such pathways include physiotherapeutic interventions, nutritional counselling, adequate pain medication, delirium prevention, patient blood management and extended perioperative monitoring. An interdisciplinary shared decision-making process together with patients can help develop realistic and individual treatment concepts to improve safety and outcome of frail patients.

Kernaussagen

• Die Wahl des Frailty Assessments sollte sich an pragmatischen Gesichtspunkten und der Zielsetzung orientieren.

• Der Fried Frailty Index und die Clinical Frailty Scale erlauben eine einfache Risikostratifizierung und sind daher auch für die Intensivstation und Notaufnahme geeignet.

• Individuelle Behandlungspfade für Patienten mit Frailty sollten interdisziplinär, multiprofessionell und sektorenübergreifend erarbeitet werden.

• Partizipative Entscheidungsprozesse zusammen mit den Patienten helfen bei der Individualisierung der Versorgung.

• Im präoperativen Setting sollten die eigenen Ressourcen der Patienten gestärkt werden, insbesondere Mobilität (Muskelkraft und Ausdauer).

• Im perioperativen Setting sind neben den chirurgischen Maßnahmen auch die Narkoseführung (z. B. erweitertes Monitoring, Volumenmanagement, angepasste Schmerztherapie, Delirprävention) und die stationäre postoperative Behandlung entscheidend, um Komplikationen zu vermeiden.

• „Frailty“ sollte ein fester Bestandteil der Prognosebewertung auf der Intensivstation sein.

Schlüsselwörter

Delir - Prähabilitation - Gebrechlichkeit - Behandlungspfad

Keywords

delirium - prehabilitation - frailty - elderly

Publikationsverlauf

Artikel online veröffentlicht:
29. November 2022

• Literatur

• 1 Statistisches Bundesamt. Fallpauschalenbezogene Krankenhausstatistik (DRG-Statistik) – Operationen und Prozeduren der vollstationären Patientinnen und Patienten der Krankenhäuser (4-Steller) – 2020. Zugriff am 20. Oktober 2022 unter: https://www.destatis.de/DE/Themen/Gesellschaft-Umwelt/Gesundheit/Krankenhaeuser/Publikationen/Downloads-Krankenhaeuser/operationen-prozeduren-5231401207014.html
• 2 Benzinger P, Eidam A, Bauer JM. Clinical importance of the detection of frailty. Z Gerontol Geriatr 2021; 54: 285-296
• 3 Brijoux T, Woopen C, Zank S. Multimorbidity in old age and its impact on life results. Z Gerontol Geriatr 2021; 54: 108-113
• 4 Amrock LG, Deiner S. The implication of frailty on preoperative risk assessment. Curr Opin Anaesthesiol 2014; 27: 330-335
• 5 Apostolo J, Cooke R, Bobrowicz-Campos E. et al. Effectiveness of interventions to prevent pre-frailty and frailty progression in older adults: a systematic review. JBI Database System Rev Implement Rep 2018; 16: 140-232
• 6 Luring C, Grifka J, Kirschner S. Clinical pathway “total knee arthroplasty”. Orthopade 2010; 39: 758-763
• 7 Lawal AK, Rotter T, Kinsman L. et al. What is a clinical pathway? Refinement of an operational definition to identify clinical pathway studies for a Cochrane systematic review. BMC Med 2016; 14: 35
• 8 Rotter T, Kinsman L, James E. et al. Clinical pathways: effects on professional practice, patient outcomes, length of stay and hospital costs. Cochrane Database Syst Rev 2010; (03) CD006632
• 9 Schaller SJ, Kiselev J, Loidl V. et al. Prehabilitation of elderly frail or pre-frail patients prior to elective surgery (PRAEP-GO): study protocol for a randomized, controlled, outcome assessor-blinded trial. Trials 2022; 23: 468
• 10 Drewniok N, Mörgeli R, Eckardt-Felmberg R. Frailty-Diagnostik in verschiedenen AINS-Settings. Anasthesiol Intensivmed Notfallmed Schmerzther 2022; 57: 682-696
• 11 Birkelbach O, Morgeli R, Balzer F. et al. Why and How Should I Assess Frailty? A Guide for the Preoperative Anesthesia Clinic. Anasthesiol Intensivmed Notfallmed Schmerzther 2017; 52: 765-776
• 12 Schmid S, Heissner K, Schlosser S. et al. Geriatric patients in the intensive care unit. Gastroenterologe 2021; 16: 361-368
• 13 O’Neill BR, Batterham AM, Hollingsworth AC. et al. Do first impressions count? Frailty judged by initial clinical impression predicts medium-term mortality in vascular surgical patients. Anaesthesia 2016; 71: 684-691
• 14 Fried LP, Tangen CM, Walston J. et al. Frailty in older adults: evidence for a phenotype. J Gerontol A Biol Sci Med Sci 2001; 56: M146-M156
• 15 Mitnitski AB, Mogilner AJ, Rockwood K. Accumulation of deficits as a proxy measure of aging. ScientificWorldJournal 2001; 1: 323-336
• 16 Church S, Rogers E, Rockwood K. et al. A scoping review of the Clinical Frailty Scale. BMC Geriatr 2020; 20: 393
• 17 Rockwood K, Song X, MacKnight C. et al. A global clinical measure of fitness and frailty in elderly people. CMAJ 2005; 173: 489-495
• 18 Mende A, Riegel AK, Plumer L. et al. Determinants of Perioperative Outcome in Frail Older Patients. Dtsch Arztebl Int 2019; 116: 73-82
• 19 Treacy D, Hassett L, Schurr K. et al. Mobility training for increasing mobility and functioning in older people with frailty. Cochrane Database Syst Rev 2022; (06) CD010494
• 20 Bush K, Kivlahan DR, McDonell MB. et al. The AUDIT alcohol consumption questions (AUDIT-C): an effective brief screening test for problem drinking. Ambulatory Care Quality Improvement Project (ACQUIP). Alcohol Use Disorders Identification Test. Arch Intern Med 1998; 158: 1789-1795
• 21 Heatherton TF, Kozlowski LT, Frecker RC. et al. Measuring the heaviness of smoking: using self-reported time to the first cigarette of the day and number of cigarettes smoked per day. Br J Addict 1989; 84: 791-799
• 22 Kroenke K, Strine TW, Spitzer RL. et al. The PHQ-8 as a measure of current depression in the general population. J Affect Disord 2009; 114: 163-173
• 23 Nikolaus T, Specht-Leible N, Bach M. et al. Social aspects in diagnosis and therapy of very elderly patients. Initial experiences with a newly developed questionnaire within the scope of geriatric assessment. Z Gerontol 1994; 27: 240-245
• 24 Saeed S, Skaar E, Romarheim A. et al. Shared Decision-Making and Patient-Reported Outcome Measures in Valvular Heart Disease. Front Cardiovasc Med 2022; 9: 863040
• 25 Gustin jr. AN. Shared Decision-Making. Anesthesiol Clin 2019; 37: 573-580
• 26 Esser T, Zimmer P, Schier R. Preoperative exercise and prehabilitation. Curr Opin Anaesthesiol 2022;
• 27 Kiselev J, Schaller SJ, Schmidt K. et al. Prähabilitation als OP-Vorbereitung bei Patienten mit Frailty. Anasthesiol Intensivmed Notfallmed Schmerzther 2022; 57: 697-708
• 28 Daum N, Kiselev J, Schaller SJ. Der fraile Patient: fiktives Fallbeispiel. Anasthesiol Intensivmed Notfallmed Schmerzther 2022; 57: 674-681
• 29 Prestmo A, Hagen G, Sletvold O. et al. Comprehensive geriatric care for patients with hip fractures: a prospective, randomised, controlled trial. Lancet 2015; 385: 1623-1633
• 30 Salini S, Giovannini S, Covino M. et al. Frailty Network in an Acute Care Setting: The New Perspective for Frail Older People. Diagnostics (Basel) 2022; 12: 1228
• 31 Lorenzo-Lopez L, Maseda A, de Labra C. et al. Nutritional determinants of frailty in older adults: A systematic review. BMC Geriatr 2017; 17: 108
• 32 Rubenstein LZ, Harker JO, Salva A. et al. Screening for undernutrition in geriatric practice: developing the short-form mini-nutritional assessment (MNA-SF). J Gerontol A Biol Sci Med Sci 2001; 56: M366-M372
• 33 Gado K, Khodier M, Virag A. et al. Anemia of geriatric patients. Physiol Int 2022; 109: 119-134
• 34 Olotu C, Lebherz L, Harter M. et al. Improvement of perioperative care of the elderly patient (PeriAge): protocol of a controlled interventional feasibility study. BMJ Open 2019; 9: e031837
• 35 Ijaz N, Buta B, Xue QL. et al. Interventions for Frailty Among Older Adults With Cardiovascular Disease: JACC State-of-the-Art Review. J Am Coll Cardiol 2022; 79: 482-503
• 36 Morgeli R, Wollersheim T, Spies C. et al. How to Reduce the Rate of Postoperative Complications in Frail Patients?. Anasthesiol Intensivmed Notfallmed Schmerzther 2017; 52: 785-797
• 37 Aldecoa C, Bettelli G, Bilotta F. et al. European Society of Anaesthesiology evidence-based and consensus-based guideline on postoperative delirium. Eur J Anaesthesiol 2017; 34: 192-214
• 38 Leitliniengruppe. Analgesie, Sedierung und Delirmanagement in der Intensivmedizin (DAS-Leitlinie 2020). AWMF-Registernummer: 001/012. Zugriff am 20. Oktober 2022 unter: https://www.awmf.org/uploads/tx_szleitlinien/001–012l_S3_Analgesie-Sedierung-Delirmanagement-in-der-Intensivmedizin-DAS_2021–08.pdf
• 39 Schuler M. Pain and old age. Schmerz 2015; 29: 337-338
• 40 Kramer J, Nolte K, Zupanc L. et al. Structured Delirium Management in the Hospital. Dtsch Arztebl Int 2022; 119: 188-194
• 41 Michels G, Sieber CC, Marx G. et al. Geriatric intensive care: Consensus paper of DGIIN, DIVI, DGAI, DGGG, OGGG, OGIAIN, DGP, DGEM, DGD, DGNI, DGIM, DGKliPha and DGG. Z Gerontol Geriatr 2019; 52: 440-456
• 42 Muscedere J, Waters B, Varambally A. et al. The impact of frailty on intensive care unit outcomes: a systematic review and meta-analysis. Intensive Care Med 2017; 43: 1105-1122
• 43 De Biasio JC, Mittel AM, Mueller AL. et al. Frailty in Critical Care Medicine: A Review. Anesth Analg 2020; 130: 1462-1473
• 44 Singler K, Gosch M, Antwerpen L. Klinische Frailty Skala (CFS). 2020 Zugriff am 20. Oktober 2022 unter: https://www.divi.de/images/Dokumente/200331_DGG_Plakat_A4_Clinical_Frailty_Scale_CFS.pdf
• 45 Rottler M, Ocskay K, Sipos Z. et al. Clinical Frailty Scale (CFS) indicated frailty is associated with increased in-hospital and 30-day mortality in COVID-19 patients: a systematic review and meta-analysis. Ann Intensive Care 2022; 12: 17
• 46 Joseph B, Jehan FS. The Mobility and Impact of Frailty in the Intensive Care Unit. Surg Clin North Am 2017; 97: 1199-1213
• 47 De Silva T, Ahip S, Theou O. et al. Frailty in nursing home residents: a scoping review protocol. JBI Database System Rev Implement Rep 2017; 15: 2040-2046
• 48 Scherer M, Luhmann D, Kazek A. et al. Patients Attending Emergency Departments. Dtsch Arztebl Int 2017; 114: 645-652
• 49 De Hert S, Staender S, Fritsch G. et al. Pre-operative evaluation of adults undergoing elective noncardiac surgery: Updated guideline from the European Society of Anaesthesiology. Eur J Anaesthesiol 2018; 35: 407-465