Frailty: Challenges and perioperative outcomes
Here, Dr Shamir Karmali, anaesthetic registrar at the National Institute for Health Research, explores the evidence base behind poor perioperative outcomes in frail patients.
Frailty in the elderly is increasingly recognized as an important risk factor for poor outcome following elective and emergency surgery. It has been the subject of numerous reports  and has led to the publication of guidelines to improve peri-operative care of these patients  - particularly as elderly patients comprise an increasing demographic of the surgical population .
What is frailty?
Frailty is a term applied to individuals who, usually as a result of the cellular and metabolic changes of ageing process, have less physiological and psychosocial reserves to cope with acute stressor events. These stressors, for example elective or emergency surgery, can precipitate significant changes in health status.
Figure 1: An acute stressor event (surgery) results in poorer functional status and return to homeostasis in the frail patient (red line) compared to the non-frail patient (green line). (Adapted from )
Frailty affects all physiological systems and is distinct from the accrual of multimorbidity and disability with age.
The British Geriatric Society report Fit for Frailty estimates this afflicts ten percent of over 65 year olds and between twenty-five to fifty percent of those over the age of 85 years, with women being at higher risk . The classic example often cited is the elderly patient with a hip fracture, who despite improvements in perioperative processes and care, still has a high mortality rate of seven percent at 30 days .
Given the implications of frailty on outcome and inconsistency between subjective clinician assessments from the “end of the bed”, there are numerous scoring systems available to classify and grade frailty.
Broadly these categorise frailty into two models:
- Fried’s physical phenotype model (Table 1)
|Reduced muscle mass (sarcopenia)||Unintentional weight loss||>10lbs|
|Exhaustion||CES-D Depression Scale||Self-reported|
|Muscle weakness||Hand-grip strength||Stratified by gender and body mass index|
|Slow walking speed||Gait-speed
Timed up-and-go test
|Stratified by gender and height|
|Low physical activity||Questionnaire of physical activities, e.g. Minnesota Leisure Time Activity Scale, Dukes Activity Index.||Weekly Kcal expenditure:
Female <280 Kcal
Table 1. Fried’s frailty phenotype. Presence of >3 indicates physical frailty and 1-2 indicates pre-frailty. 
- Rockwood’s frailty index (cumulative deficit model), which describes the accumulation of sensory and cognitive deficits , . Most recommended multidimensional scales such as the Edmonton Frail Scale (recommended for patients undergoing elective surgery) to some extent incorporate elements of both models .
Frailty and perioperative outcome
Analyses of large retrospective data sets such as the National Surgical Quality Improvement Programme (NSQUIP) and The Canadian Study of Health and Ageing (CSHA) yielded an 11-item “modified frailty index” (MFI). They found that as MFI increased, morbidity and mortality increased in a stepwise fashion in elective and emergency surgery , .
More recently, a systematic review of 23 studies looking at predominantly prospective data (20 studies) across cardiac, general, vascular and emergency orthopaedic surgery, identified consistent associations between frailty and post-operative outcomes. This persisted regardless of the instrument used to define frailty.
Mortality as an outcome measure had the greatest consistent association at 30-days, 90-days and 1-year . Morbidity data however was less consistent partly due to non-standardised definitions of morbidity and highlights the need for further studies using standardised morbidity scales.
Widespread awareness, recognition and management of the frail patient has not yet found its way into mainstream practise outside of emergency orthopaedic surgery.
Mechanisms to optimise these patients, through activation of multidisciplinary teams (e.g. proactive care of older people undergoing surgery programmes; POPS), organisational processes and individualised interventions (e.g. prehabilitation) may offer a much needed opportunity to improve outcomes for an increasingly vulnerable and prevalent demographic of the surgical population.
- NCEPOD - An Age old problem: A review of the care received by elderly patients undergoing surgery
- AAGBI: Peri-operative care of the elderly
- Health & Social Care Information Centre. Hospital Episode Statistics, Admitted Patient Care - England, 2014–15: Procedures and interventions
- Clegg, A., Young, J., IIiffe, S., Rikkert, M.O., Rockwood, K. (2013). Frailty in elderly people. Lancet. Mar 2;381(9868):752-62
- British Geriatrics Society. Fit for Frailty
- National Hip Fracture Database (NHFD) Annual Report 2016
- Fried, LP.P et al (2001). Frailty in older adults: evidence for a phenotype. J Gerontol A Biol Sci Med Sci. Mar;56(3):M146-56
- Rockwood, K. et al (2005). A global clinical measure of fitness and frailty in elderly people. CMAJ. Aug 30;173(5):489-495
- Velanovich, V., Entoine, H., Swartz, A., Peters, D., Rubinfield, I. (2013). Accumulating deficits model of frailty and postoperative mortality and morbidity: its application to a national database. J Surg Res. Jul;183(1):104-10
- Farhat, J.S. et al (2012). Are the frail destined to fail? J Trauma Acute Care Surg. Jun;72(6):1526-30
- Lin, H.S., Watts, J.N., Peel, N.M., Hubbard, R.E. (2016). Frailty and post-operative outcomes in older surgical patients: a systematic review. BMC Geriatr. Aug 31;16(1):157
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