Elder Care Interprofessional Provider Sheets

Frailty in Patients Undergoing Elective and Emergency Surgery

Bellal Joseph, M.D., Zaid Haddadin, M.D., Bardiya Zangbar, M.D., Mindy Fain, M.D., University of Arizona College of Medicine

May 2019

TIPS FOR DEALING WITH FRAILTY
  • When older adults are being considered for elective surgery, use a validated assessment tool (see Table) to evaluate them for frailty. 
  • If frailty is present and surgery can be delayed, recommend interventions to lessen frailty prior to scheduling surgery. Interventions can include exercise programs, addressing nutritional deficiencies, and dealing with psychosocial factors. 
  • When emergency surgery is necessary, a frailty assessment should still be performed, when possible, as interventions to address frailty may still be useful as part of post-operative care.

The number of older adults undergoing surgery is increasing rapidly as the population ages. Studies have shown that frailty, independent of age, is an important risk factor for poor outcomes after surgery. National Surgical Quality Improvement Guidelines call for pre-surgery frailty assessments for adults 65 years of age and older.

Frailty is a general state of increased vulnerability due to decreases in physiological reserve, physical activity, and social and cognitive skills. Although frailty may overlap with conditions such as sarcopenia and malnourishment, it is usually considered as a stand-alone condition referred to as the "frailty syndrome."

Risk Assessment Prior To Surgery

Risk stratification of older surgical patients is not standardized and often based only on limited data and subjective impressions of a patient's condition. However, a formal assessment of frailty in geriatric patients can provide professionals, patients, and their families a better understanding of the risks of undergoing surgery.

Frailty assessments can predict in-hospital complications and mortality rates, as well as long-term outcomes including the need for institutionalization. Frail patients are at a higher risk of institutionalization after surgery, and for a longer period of time. Patients and families can be informed of these risks in a more objective fashion by pre-operative frailty assessment.

A variety of assessment tools are available to aid in identifying frailty in older adults (see table on reverse side). These tools can be particularly useful for evaluating "young" older adults, in whom frailty might not be apparent based on a patient's general appearance or gait, thus answering the question "Is this a 68-year old going on 90?" Use of these tools can provide surgeons, and primary care clinicians referring patients to surgeons, with a systematic way to identify frailty, and thus include frailty in the consideration of surgical risks.

Preoperative Optimization

When possible, modifiable factors should be optimized if frailty is identified prior to elective surgery to improve the likelihood of favorable outcomes. Preoperative optimization can include attention to prehabilitation, nutrition, psychosocial factors, and possibly drug therapy.

Prehabilitation can improve frailty, and may be particularly important for frail patients with cardiac disorders. Improving nutritional deficiencies, including attention to vitamin replacement, protein supplementation, and iron supplement when indicated, may also be of value though more research is needed to explore the benefit of these interventions. Screening with a depression instrument such as the PHQ-9, and dealing with other psychosocial factors, including social support, and "will to improve" should also be addressed. Finally, although the safety, benefit, and mechanism of action of "performance-enhancing drugs" (e.g. anabolic steroids) are unclear, it is thought that they may be helpful.

Frailty in Elective Surgery

Many pre-operative assessment instruments and scoring systems are available for evaluating patients prior to elective surgery. However, most of these assessment and scoring systems focus on risk-reduction interventions related to specific procedures or organ systems, or on individual risk factors or interventions (e.g., interventions to reduce morbidity and mortality following cardiac surgery).

In contrast, frailty assessments are pertinent to a wide variety of elective surgeries, and studies have shown their superiority in predicting outcomes, compared to other assessment methods. Moreover, frailty assessment tools take into account the physiological changes in older adults that make them less resistant to stressors. Indeed, frailty scores can predict complications in patients undergoing procedures ranging from cardiac interventions to colorectal surgeries.

Patients undergoing elective surgery usually have the ability to perform the physical tests required for some of the frailty assessments. As a result, surgeons and clinicians referring patients to surgeons should use these assessment tools to aid in identifying frailty. The diversity of instruments provides options to choose the appropriate assessment, tailored to the patient's specific circumstances.

Frailty in Emergency Surgery

In recent years, studies have validated the use of simple bedside frailty assessment tools to independently predict postoperative complications, mortality, and failure to rescue in older emergency general surgery patients. Frailty assessment thus helps in the decision-making process. It predicts the hospital course of the patients and will allow for early intervention and more efficient allocation of resources for patients in need. It is also helpful in guiding post-operative care, and in providing patients and families with realistic expectations of the post-operative course.

Frailty and Patient Reported Outcomes

Subjective experiences of patients as well as patient-centered outcomes have gained increased attention. Frailty has been shown to negatively effect quality of life and functional independence. Frailty is thus an important metric and a major predictor of outcomes and post discharge quality-of-life in geriatric patients. Early identification of frailty in patients being considered for surgery can steer us into tailored special interventions to improve the functional status and quality of life.

Frailty Assessment Instruments
 Instrument  Variables Assessed  Pros  Cons
  •  70 variables
  •  Cognitive
  •  Comorbidities
  •  Daily activity
  •  Self-Assessment
  • Has few objective items, making it easy to use in emergency/trauma situations

  • Predicts length of hospital stay, complications, discharge disposition, and mortality

  • Has few objective components, raising possibility of incorrect assessments
  • Involves a lengthy questionnaire
  • 15 variables
  • Comorbidities
  • Daily activities
  • Health attitude
  • Function
  • Nutrition
  • Validated for emergency settings
  • Quick/Simple
  • Can be obtained from relatives/proxy
  • Superior to traditionally used predictors
  • Has subjective variables
  • Includes variables that only the patient can provide accurately
  •  Weight loss
  •  Grip strength
  •  Walking speed
  •  Physical activity
  •  Exhaustion
  • Widely used in research
  • Measures frailty both objectively and subjectively
  • Requires measurements (e.g., grip strength) not always available in routine practice settings
  • Acceleration
  • Balance
  • Angular velocity
  • Delay
  • Range of motion
  • Speed/Swing
  • Quick
  • Objective
  • Technology-based
  • Can be performed on upper or lower extremities
  • Evaluates only limb motion
  • Must be individualized and tailored for each patient
  • Ability to rise from chair five times without using arms
  • Weight loss
  • Validated
  • Simple
  • Depending on surgical condition, it may not be possible to assess rising from chair

References and Resources

  • American College of Surgeons Trauma Quality Improvement Program
  • Hamidi M, Zeeshan M, O'Keeffe T, Nisbet B, Northcutt A, Nikolich-Zugich J, Khan M, Kulvatunyou N, Fain M, Joseph B. Prospective evaluation of frailty and functional independence in older adult trauma patients. Am J Surg. 2018; 216:1070-5.
  • Joseph B, Pandit V, Zangbar B, Kulvatunyou N, Hashmi A, Green DJ, O'keeffe T, Tang A, Vercruysse G, Fain MJ, Friese RS. Superiority of frailty over age in predicting outcomes among geriatric trauma patients: a prospective analysis. JAMA Surgery. 2014;149:766-72.
  • Khan M, Jehan F, Zeeshan M, Kulvatunyou N, Fain MJ, Saljuqi AT, O'Keeffe T, Joseph B. Failure to rescue after emergency general surgery in geriatric patients: does frailty matter? J Surg Res. 2019; 233:397-402.
  • Kim SW, Han HS, Jung HW, et al. Multidimensional frailty score for the prediction of postoperative mortality risk. JAMA Surg. 2014. 149:633-640.