Frailty in the Surgical Patient

Esam Aboutaleb and Ria Mehta

 Importance

• Elderly patients are being considered more and more for surgical intervention
• Conventional tools used to predict surgical outcome in these patients have limitations
• ‘Frailty’ may be an excellent predictor of post-operative morbidity and mortality, more so than chronological age

What is frailty?
How can it be quantified?
What is its impact on surgical outcomes?
 What is Frailty?

• No single agreed definition

• Not synonymous with being ‘elderly’

= A syndrome of physiological decline in late life, characterized by marked vulnerability to adverse health outcomes
= A lack of physiological reserve

“the new epidemic and how to manage it”

 Frailty is Common

• English Longitudinal Study of Aging, ELSA

• 14% (5,450 participants)
• Prevalence increases with age
• 6.5% >60 years
• 30% >80 years
• 65% >90 years
• Estimated 1.8 million people >60 years living with frailty in England
•  Based on UK population growth statistics
• % of population > 80 years living with frailty will increase by 70%
• Higher rates in women
 How Can Frailty Be Assessed?

• one of two concepts: "physical" or "phenotypic" frailty versus "deficit accumulation" or "index" frailty

‘Frailty Phenotype’ ‘Frailty Index’

Signs + symptoms Diseases, ADLs, results of clinical evaluation

Before clinical assessment; ‘screening tool’ Only after thorough assessment

As a pre-disability syndrome as an accumulation of deficits

 Frailty Phenotype

1. Weight loss (≥5 percent of body weight in last year)

2. Exhaustion (positive response to questions regarding effort required for activity)
3. Weakness (decreased grip strength)
4. Slow walking speed (gait speed) (>6 to 7 seconds to walk 15 feet)
5. Decreased physical activity (Kcals spent per week: males expending <383 Kcals and females <270 Kcal)

Frail = 3+
Pre-frail = 1-2
Not frail = 0
Frailty Index
 Utility

• A tool to assess frailty may be useful clinically to:

• Identify elderly patients who are fit for surgery
• Improve the process of informed consent
• Potentially optimize health factors pre-operatively
• Nutrition
• Exercise (resistance training)
• Drug therapies (anabolic steroids, GH, anti-cytokine agents)
• Plan post-operative care in advance e.g. ITU, assisted-living facility etc
 Differentials

Depression Thyroid disease, DM

Vascular dementia, Parkinsons HTN, CHF, Coronary heart disease

Malignancy Renal failure

PMR, Vasculitides Anaemia

Are the Frail destined to Fail?
Type of study: cross-sectional and prospective cohort study

Journal: Journal of the American Geriatrics Society 2007 Vol 55, Issue 8

Research team: Osteoporotic Fractures in Men Research Group

Aim: To describe the association between frailty and health status, the progression of frailty, and the relationship between frailty
and mortality in older men.
Study Design: 5593 male participants >65yo from 6 US clinical centres. Frailty defined as 3+ of sarcopenia, grip strength
weakness, self-reported exhaustion, low activity level and slow walking speed.

Results: Frail men were ~2x as likely to die as robust men (HR=2.05, 95% CI1.55–2.72). 

Conclusions: Frailty in older men is associated with poorer health and greater mortality. Frail men tend to remain frail over time,
whereas robust men tend to remain robust over time. Unlike in female studies, BMI was not a risk factor for frailty.
Type of study: prospective cohort study

Journal: Journal of the American Geriatrics Society, 2005

Aim: to define frailty using simple indicators; to identify risk factors for frailty as targets for prevention and to investigate frailty
as a predictor of poor outcomes

Study Design: 40,657 female participants aged 65-79 from 40 clinical centres in US. Exclusion criteria: Parkinsons disease,
depression. Follow up: 6 years

Results: Frailty is strongly and independently associated with incidents of death (HR 1.71; 95% CI 1.48-1.97), hospitalization
HR 1.95; 95% CI 1.72–2.22), hip fractures (HR 1.57 95%CI 1.11–2.20) and disability (HR 3.15 95% CI 2.47-4.02). In women
who were non-frail at baseline, smokers were 2.9x more likely to become frail than non-smokers. A strong relationship between
depressive symptoms and incident frailty Women with high and extremely low BMI had a greater risk of baseline and incident
frailty.

Conclusions: The results support the robustness of the concept of frailty as a geriatric syndrome that predicts several poor
outcomes in older women. Underweight, obesity, smoking, and depressive symptoms are strongly associated with the
development of frailty and represent important targets for prevention.
What about in Surgical patients?
Type of study: prospective cohort study

Journal: Journal of American College of Surgeons 2010

Impact factor: 5.1

Research team: Surgery, Medicine and Epidemiology departments of John Hopkins University School of Medicine

Background: Pre-operative risk assessment is important yet difficult in older patients because physiologic reserves are difficult to
measure. Frailty is thought to estimate physiologic reserves, although its use as a predictive tool has not been evaluated in
surgical patients.

Aim: To determine if frailty predicts surgical complications and enhances current perioperative risk models e.g. ASA scoring

Hypothesis: Frailty may predict surgical complications.

Study Design: Frailty was classified by a 5 point scale. Main outcomes measured were: 30-day surgical complications, length of
stay and discharge to an assisted care facility.

Results: Pre-op frailty was associated with an increased risk of all adverse surgical outcomes listed above (p<0.05). Frailty
improved the predictive power of all perioperative risk models studied (ASA, Lee and Eagle scores) (p<0.01).

Conclusions: Frailty is an independent predictor of post-operative complications, length of stay in hospital and discharge
disposition; and successfully enhances existing risk models.
Type of study: Systematic review and meta-analysis

Journal: Royal College of Surgeons

Impact factor: ?

Research team: of Cambridge University

Background: Elderly patients are being considered more and more for surgical intervention. The impact of frailty on surgical
related outcomes remains unclear.

Aim: to estimate the association between frailty and adverse patient events in surgical patients using meta-analysis

Study Design: 385 relevant articles identified of which 12 met the inclusion requirements (7960 patients in total).

Results: Shows that following surgical intervention, frailty is associated with higher in-hospital and one-year mortality, longer
length of hospital stay and increased requirement for step-down care to rehabilitation facilities or nursing homes – unanimous
across all papers.

Conclusions: There is no widely accepted definition of frailty yet, but the idea that it leads to poor outcome in surgery still
stands. Further research is needed to ascertain which specific aspects of frailty bring about such poor outcome. This may
differ depending on the specific surgical population and pathology operated on. Identification of potentially reversible
components of frailty may further improve surgical outcome.
 Can We Optimize Frailty Pre-op?

Reversible Factors Non-reversible Factors

Weight Age
Strength Disease
Nutrition
Low mood
Polypharmacy

New drug therapies?

 Elderly Care Team Support

• Advice
• Joint clinics
• Joint rounds
• Involvement in MDT meetings
 Conclusion

• Frail patients have poorer surgical outcomes compared to non-frail patients

• A tool to assess frailty may be useful clinically
• Further work is needed to:
• Define the term
• Identify which tool/biomarker/functional assessment would be most clinically applicable
• Identify what, if any, aspects of ’frailty’ are amenable to treatment
• If so – what should these interventions be? And when should they be implemented?
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