Frailty and Surgical Outcomes in Older Patients

The September issue of the Journal of the American College of surgeons highlights a growing issue for surgeons: the frail patient. Ten to 20% of Americans 65 years of age or older are considered frail, and the problem tends to worsen with every passing year. Additionally, this age demographic has an elevated likelihood of needing surgical intervention. Trauma pursuant to falls is a special and increasing problem. For this reason, the National Institute on Aging convened a conference to address frailty.

Frailty, which both predisposes to disability and occurs in tandem with disability, is generally recognized as being associated with falls, comorbid disease, delirium, cognitive decline, iatrogenic complications, social isolation. Frail patients are particularly vulnerable to adverse health care outcomes including hospitalization, functional dependence, institutionalization, and death.

For surgeons, the basis of the concern is that preoperative frailty in older adults is closely linked to postoperative adverse surgical outcomes. Regardless, little research has been published to guide surgeons when faced with frail patients.

Experts have been unable to select a single measurement tool to assess frailty. However, a recent consensus conference on frailty suggested that healthcare providers need to screen all patients older than age 70 for physical frailty. Caught early, physical frailty can be potentially treated or prevented with specific modalities. With appropriate interventions, adverse outcomes associated with frailty can be ameliorated. The clinician must tailor his or her choice of assessment tools to the clinical situation and clinical need. This summary describes a number of suitable tools and their strengths and limitations.

The review also discusses two conditions that accelerate frailty: heart failure and end-stage renal disease.

Of great utility for surgeons are the sections describing triage, prehabilitation, anesthesia, and delirium prevention. It reminds surgeons that team-based care is critical and refers to the Acute Care for Elders model to maintain functional status during hospitalization. It also acknowledges that for some patients, palliative care is a wise choice.