International Journal of Colorectal Disease

, Volume 33, Issue 12, pp 1657–1666 | Cite as

Frailty in surgical patients

  • Simon J. G. RichardsEmail author
  • Frank A. Frizelle
  • John A. Geddes
  • Tim W. Eglinton
  • Mark B. Hampton
Original Article



To describe the current definitions, aetiology, assessment tools and clinical implications of frailty in modern surgical practice.


Frailty is a critical issue in modern surgical practice due to its association with adverse health events and poor post-operative outcomes. The global population is rapidly ageing resulting in more older patients presenting for surgery. With this, the number of frail patients presenting for surgery is also increasing. Despite the identification of frailty as a significant predictor of poor health outcomes, there is currently no consensus on how to define, measure and diagnose this important syndrome.


Relevant references were identified through keyword searches of the Cochran, MEDLINE and EMbase databases.


Despite the lack of a gold standard operational definition, frailty can be conceptualised as a state of increased vulnerability resulting from a decline in physiological reserve and function across multiple organ systems, such that the ability to withstand stressors is impaired. Multiple studies have shown a strong association between frailty and adverse peri-operative outcomes. Frailty may be assessed using multiple tools; however, the ideal tool for use in a clinical setting has yet to be identified. Despite the association between frailty and adverse outcomes, few interventions have been shown to improve outcomes in these patients.


Frailty encompasses a group of individuals at high risk of adverse post-operative outcomes. Further work exploring ways to optimally assess and target interventions towards these patients should be the focus of ongoing research.


Frailty Post-operative outcomes Surgery Elderly 


Compliance with ethical standards

Conflict of interest

The authors declare that they have no conflict of interest.


  1. 1.
    He W, Goodkind D, Kowal P (2016) An Aging World: 2015Google Scholar
  2. 2.
    Weiss AJ, Elixhauser A (2014) Overview of Hospital Stays in the United States, 2012: Statistical Brief #180. Healthcare Cost and Utilization Project (HCUP) Statistical Briefs. Rockville (MD), Agency for Healthcare Research and Quality (US)Google Scholar
  3. 3.
    Ambler GK, Brooks DE, Al Zuhir N et al (2015) Effect of frailty on short- and mid-term outcomes in vascular surgical patients. Br J Surg 102:638–645PubMedGoogle Scholar
  4. 4.
    Beggs T, Sepehri A, Szwajcer A et al (2015) Frailty and perioperative outcomes: a narrative review. Can J Anaesth 62:143–157PubMedGoogle Scholar
  5. 5.
    Courtney-Brooks M, Tellawi AR, Scalici J et al (2012) Frailty: an outcome predictor for elderly gynecologic oncology patients. Gynecol Oncol 126:20–24Google Scholar
  6. 6.
    De Saint-Hubert M, Schoevaerdts D, Cornette P et al (2010) Predicting functional adverse outcomes in hospitalized older patients: a systematic review of screening tools. J Nutr Health Aging 14:394–399PubMedPubMedCentralGoogle Scholar
  7. 7.
    Fagard K, Leonard S, Deschodt M et al (2016) The impact of frailty on postoperative outcomes in individuals aged 65 and over undergoing elective surgery for colorectal cancer: a systematic review. J Geriatr Oncol 7:479–491PubMedGoogle Scholar
  8. 8.
    Huisman MG, Audisio RA, Ugolini G et al (2015) Screening for predictors of adverse outcome in onco-geriatric surgical patients: a multicenter prospective cohort study. Eur J Surg Oncol 41:844–851PubMedGoogle Scholar
  9. 9.
    Keenan LG, O'Brien M, Ryan T et al (2017) Assessment of older patients with cancer: edmonton Frail Scale (EFS) as a predictor of adverse outcomes in older patients undergoing radiotherapy. J Geriatr Oncol 8:206–210PubMedGoogle Scholar
  10. 10.
    Keller SD, Bankwitz PB, Nobel PT et al (2014) Using frailty to predict who will fail early discharge after laparoscopic colorectal surgery with an established recovery pathway. Dis Colon Rectum 57:337–342Google Scholar
  11. 11.
    Lin H-S, Watts JN, Peel NM et al (2016) Frailty and post-operative outcomes in older surgical patients: a systematic review. BMC Geriatr 16:157PubMedPubMedCentralGoogle Scholar
  12. 12.
    Makary MA, Segev DL, Pronovost PJ et al (2010) Frailty as a predictor of surgical outcomes in older patients. J Am Coll Surg 210:901–908Google Scholar
  13. 13.
    Partridge JS, Harari D, Dhesi JK (2012) Frailty in the older surgical patient: a review. Age Ageing 41:142–147PubMedGoogle Scholar
  14. 14.
    Centre for Disease Control and Prevention (2010) National Hospital Discharge Survey. 2018Google Scholar
  15. 15.
    Polanczyk CA, Marcantonio E, Goldman L et al (2001) Impact of age on perioperative complications and length of stay in patients undergoing noncardiac surgery. Ann Intern Med 134:637–643Google Scholar
  16. 16.
    Hamel MB, Henderson WG, Khuri SF et al (2005) Surgical outcomes for patients aged 80 and older: morbidity and mortality from major noncardiac surgery. J Am Geriatr Soc 53:424–429Google Scholar
  17. 17.
    Torres O, Francia E, Longobardi V et al (2006) Short- and long-term outcomes of older patients in intermediate care units. Intensive Care Med 32:1052–1059PubMedGoogle Scholar
  18. 18.
    Saklad MDM (1941) Grading of Patients for Surgical Procedures. Anesthesiology 2:281–284Google Scholar
  19. 19.
    Charlson ME, Pompei P, Ales KL et al (1987) A new method of classifying prognostic comorbidity in longitudinal studies: development and validation. J Chronic Dis 40:373–383PubMedPubMedCentralGoogle Scholar
  20. 20.
    Lee TH, Marcantonio ER, Mangione CM et al (1999) Derivation and prospective validation of a simple index for prediction of cardiac risk of major noncardiac surgery. Circulation 100:1043–1049Google Scholar
  21. 21.
    Copeland GP, Jones D, Walters M (1991) POSSUM: a scoring system for surgical audit. Br J Surg 78:355–360PubMedGoogle Scholar
  22. 22.
    Minto G, Biccard B (2014) Assessment of the high-risk perioperative patient. Contin Educ Anaesth Crit Care Pain 14:12–17Google Scholar
  23. 23.
    Fried LP, Ferrucci L, Darer J et al (2004) Untangling the concepts of disability, frailty, and comorbidity: implications for improved targeting and care. J Gerontol A Biol Sci Med Sci 59:255–263Google Scholar
  24. 24.
    Dasgupta M, Rolfson DB, Stolee P et al (2009) Frailty is associated with postoperative complications in older adults with medical problems. Arch Gerontol Geriatr 48:78–83Google Scholar
  25. 25.
    Robinson TN, Walston JD, Brummel NE et al (2015) Frailty for surgeons: review of a national institute on aging conference on frailty for specialists. J Am Coll Surg 221:1083–1092PubMedPubMedCentralGoogle Scholar
  26. 26.
    Robinson TN, Eiseman B, Wallace JI et al (2009) Redefining geriatric preoperative assessment using frailty, disability and co-morbidity. Ann Surg 250:449–455Google Scholar
  27. 27.
    Morley JE, Vellas B, Abellan van Kan G et al (2013) Frailty consensus: a call to action. J Am Med Dir Assoc 14:392–397PubMedPubMedCentralGoogle Scholar
  28. 28.
    Gobbens RJ, Luijkx KG, Wijnen-Sponselee MT et al (2010) Toward a conceptual definition of frail community dwelling older people. Nurs Outlook 58:76–86PubMedGoogle Scholar
  29. 29.
    Fried LP, Tangen CM, Walston J, et al. (2001) Frailty in older adults: evidence for a phenotype. J Gerontol A Biol Sci Med Sci 56Google Scholar
  30. 30.
    Chen X, Mao G, Leng SX (2014) Frailty syndrome: an overview. Clin Interv Aging 9:433–441PubMedPubMedCentralGoogle Scholar
  31. 31.
    Fulop T, Larbi A, Witkowski J et al (2010) Aging, frailty and age-related diseases. Biogerontology 11:547–563PubMedGoogle Scholar
  32. 32.
    Fried LP, Kronmal RA, Newman AB et al (1998) Risk factors for 5-year mortality in older adults: The cardiovascular health study. JAMA 279:585–592Google Scholar
  33. 33.
    Rockwood K, Howlett SE, MacKnight C, et al. (2004) Prevalence, attributes, and outcomes of fitness and frailty in community-dwelling older adults: report from the Canadian study of health and aging. J Gerontol A Biol Sci Med Sci 59Google Scholar
  34. 34.
    Rockwood K, Mitnitski A (2007) Frailty in relation to the accumulation of deficits. J Gerontol A Biol Sci Med Sci 62Google Scholar
  35. 35.
    Rockwood K, Stolee P, McDowell I (1996) Factors associated with institutionalization of older people in Canada: testing a multifactorial definition of frailty. J Am Geriatr Soc 44:578–582PubMedGoogle Scholar
  36. 36.
    de Vries NM, Staal JB, van Ravensberg CD et al (2011) Outcome instruments to measure frailty: a systematic review. Ageing Res Rev 10:104–114Google Scholar
  37. 37.
    Rockwood K, Mitnitski A (2011) Frailty defined by deficit accumulation and geriatric medicine defined by frailty. Clin Geriatr Med 27:17–26Google Scholar
  38. 38.
    Collard RM, Boter H, Schoevers RA et al (2012) Prevalence of frailty in community-dwelling older persons: a systematic review. J Am Geriatr Soc 60:1487–1492Google Scholar
  39. 39.
    Xue Q-L, Bandeen-Roche K, Varadhan R et al (2008) Initial manifestations of frailty criteria and the development of frailty phenotype in the women's health and aging study II. J Gerontol A Biol Sci Med Sci 63:984–990Google Scholar
  40. 40.
    Gill TM, Gahbauer EA, Allore HG et al (2006) Transitions between frailty states among community-living older persons. Arch Intern Med 166:418–423PubMedGoogle Scholar
  41. 41.
    Taffett GE (2003) Physiology of aging. Geriatric medicine: an evidence-based approach. Springer New York, New York, pp 27–35Google Scholar
  42. 42.
    Clegg A, Young J, Iliffe S et al (2013) Frailty in elderly people. Lancet 381:752–762Google Scholar
  43. 43.
    Walston J, McBurnie MA, Newman A et al (2002) Frailty and activation of the inflammation and coagulation systems with and without clinical comorbidities: results from the Cardiovascular Health Study. Arch Intern Med 162:2333–2341PubMedGoogle Scholar
  44. 44.
    Li H, Manwani B, Leng SX (2011) Frailty, inflammation, and immunity. Aging Dis 2:466PubMedPubMedCentralGoogle Scholar
  45. 45.
    Wilson D, Jackson T, Sapey E et al (2017) Frailty and sarcopenia: the potential role of an aged immune system. Ageing Res Rev 36:1–10PubMedGoogle Scholar
  46. 46.
    Franceschi C, Campisi J (2014) Chronic inflammation (inflammaging) and its potential contribution to age-associated diseases. J Gerontol A Biol Sci Med Sci 69(Suppl 1):S4–S9PubMedGoogle Scholar
  47. 47.
    Hubbard R, Woodhouse K (2010) Frailty, inflammation and the elderly. Biogerontology 11:635–641PubMedGoogle Scholar
  48. 48.
    Rønning B, Wyller TB, Seljeflot I et al (2010) Frailty measures, inflammatory biomarkers and post-operative complications in older surgical patients. Age Ageing 39:758–761PubMedGoogle Scholar
  49. 49.
    Leng S, Chaves P, Koenig K et al (2002) Serum Interleukin-6 and Hemoglobin as physiological correlates in the geriatric syndrome of frailty: a Pilot Study. J Am Geriatr Soc 50:1268–1271Google Scholar
  50. 50.
    Leng SX, Xue QL, Tian J et al (2007) Inflammation and frailty in older women. J Am Geriatr Soc 55:864–871PubMedGoogle Scholar
  51. 51.
    Michelon E, Blaum C, Semba RD et al (2006) Vitamin and carotenoid status in older women: associations with the frailty syndrome. J Gerontol A Biol Sci Med Sci 61:600–607PubMedGoogle Scholar
  52. 52.
    Newman AB, Gottdiener JS, McBurnie MA et al (2001) Associations of subclinical cardiovascular disease with frailty. J Gerontol A Biol Sci Med Sci 56:M158–M166PubMedGoogle Scholar
  53. 53.
    Phan HM, Alpert JS, Fain M (2008) Frailty, inflammation, and cardiovascular disease: evidence of a connection. Am J Geriatr Cardiol 17:101–107PubMedGoogle Scholar
  54. 54.
    Gonzalez-Freire M, de Cabo R, Bernier M et al (2015) Reconsidering the Role of mitochondria in aging. J Gerontol A Biol Sci Med Sci 70:1334–1342PubMedPubMedCentralGoogle Scholar
  55. 55.
    Sun N, Youle RJ, Finkel T (2016) The mitochondrial basis of aging. Mol Cell 61:654–666PubMedPubMedCentralGoogle Scholar
  56. 56.
    Marzetti E, Calvani R, Cesari M et al (2013) Mitochondrial dysfunction and sarcopenia of aging: from signaling pathways to clinical trials. Int J Biochem Cell Biol 45:2288–2301PubMedPubMedCentralGoogle Scholar
  57. 57.
    Cappola AR, Bandeen-Roche K, Wand GS et al (2001) Association of IGF-I levels with muscle strength and mobility in older women. J Clin Endocrinol Metab 86:4139–4146PubMedGoogle Scholar
  58. 58.
    Leng SX, Cappola AR, Andersen RE et al (2004) Serum levels of insulin-like growth factor-I (IGF-I) and dehydroepiandrosterone sulfate (DHEA-S), and their relationships with serum interleukin-6, in the geriatric syndrome of frailty. Aging Clin Exp Res 16:153–157PubMedGoogle Scholar
  59. 59.
    Schmidt M, Naumann H, Weidler C et al (2006) Inflammation and sex hormone metabolism. Ann N Y Acad Sci 1069:236–246PubMedGoogle Scholar
  60. 60.
    Johar H, Emeny RT, Bidlingmaier M et al (2014) Blunted diurnal cortisol pattern is associated with frailty: a cross-sectional study of 745 participants aged 65 to 90 years. J Clin Endocrinol Metab 99:E464–E468PubMedGoogle Scholar
  61. 61.
    Varadhan R, Walston J, Cappola AR et al (2008) Higher levels and blunted diurnal variation of cortisol in frail older women. J Gerontol A Biol Sci Med Sci 63:190–195PubMedGoogle Scholar
  62. 62.
    Oakland K, Nadler R, Cresswell L et al (2016) Systematic review and meta-analysis of the association between frailty and outcome in surgical patients. Ann R Coll Surg Engl 98:80–85PubMedPubMedCentralGoogle Scholar
  63. 63.
    Rolfson DB, Majumdar SR, Tsuyuki RT et al (2006) Validity and reliability of the Edmonton Frail Scale. Age Ageing 35:526–529PubMedPubMedCentralGoogle Scholar
  64. 64.
    Pijpers E, Ferreira I, Stehouwer CDA et al (2012) The frailty dilemma. Review of the predictive accuracy of major frailty scores. Eur J Intern Med 23:118–123PubMedGoogle Scholar
  65. 65.
    de Vries NM, van Ravensberg CD, Hobbelen JS et al (2012) Effects of physical exercise therapy on mobility, physical functioning, physical activity and quality of life in community-dwelling older adults with impaired mobility, physical disability and/or multi-morbidity: a meta-analysis. Ageing Res Rev 11:136–149PubMedGoogle Scholar
  66. 66.
    Dent E, Kowal P, Hoogendijk EO (2016) Frailty measurement in research and clinical practice: a review. Eur J Intern Med 31:3–10Google Scholar
  67. 67.
    Yanagawa B, Graham MM, Afilalo J, et al. (2018) Frailty as a risk predictor in cardiac surgery: beyond the eyeball test. J Thorac Cardiovasc SurgGoogle Scholar
  68. 68.
    Schoene D, Wu SM, Mikolaizak AS et al (2013) Discriminative ability and predictive validity of the timed up and go test in identifying older people who fall: systematic review and meta-analysis. J Am Geriatr Soc 61:202–208PubMedGoogle Scholar
  69. 69.
    Robinson TN, Wu DS, Sauaia A et al (2013) Slower walking speed forecasts increased postoperative morbidity and 1-year mortality across surgical specialties. Ann Surg 258:582–588 discussion 588–90PubMedPubMedCentralGoogle Scholar
  70. 70.
    Chow WB, Rosenthal RA, Merkow RP et al (2012) Optimal preoperative assessment of the geriatric surgical patient: a best practices guideline from the American College of Surgeons National Surgical Quality Improvement Program and the American Geriatrics Society. J Am Coll Surg 215:453–466Google Scholar
  71. 71.
    Hubbard R, Ng K (2015) Australian and New Zealand Society for Geriatric Medicine: position statement - frailty in older people. Australas J Ageing 34:68–73PubMedGoogle Scholar
  72. 72.
    Morley JE, Malmstrom TK, Miller DK (2012) A simple frailty questionnaire (FRAIL) predicts outcomes in middle aged African Americans. J Nutr Health Aging 16:601–608PubMedPubMedCentralGoogle Scholar
  73. 73.
    Rockwood K, Song X, MacKnight C, et al. (2005) A global clinical measure of fitness and frailty in elderly people. CMAJ 173Google Scholar
  74. 74.
    Malmstrom TK, Miller DK, Morley JE (2014) A comparison of four frailty models. J Am Geriatr Soc 62:721–726PubMedPubMedCentralGoogle Scholar
  75. 75.
    Juma S, Taabazuing M-M, Montero-Odasso M (2016) Clinical frailty scale in an acute medicine unit: a simple tool that predicts length of stay. Can Geriatr J 19:34–39PubMedPubMedCentralGoogle Scholar
  76. 76.
    Wallis SJ, Wall J, Biram RW et al (2015) Association of the clinical frailty scale with hospital outcomes. QJM 108:943–949PubMedGoogle Scholar
  77. 77.
    Clegg AP, Barber SE, Young JB et al (2012) Do home-based exercise interventions improve outcomes for frail older people? Findings from a systematic review. Rev Clin Gerontol 22:68–78PubMedPubMedCentralGoogle Scholar
  78. 78.
    Meyers BM, Al-Shamsi HO, Rask S et al (2017) Utility of the Edmonton Frail Scale in identifying frail elderly patients during treatment of colorectal cancer. J Gastrointest Oncol 8:32PubMedPubMedCentralGoogle Scholar
  79. 79.
    Bolshinsky V, Li MH, Ismail H et al (2018) Multimodal prehabilitation programs as a bundle of care in gastrointestinal cancer surgery: a systematic review. Dis Colon Rectum 61:124–138PubMedGoogle Scholar
  80. 80.
    Hijazi Y, Gondal U, Aziz O (2017) A systematic review of prehabilitation programs in abdominal cancer surgery. Int J Surg 39:156–162PubMedGoogle Scholar
  81. 81.
    Le Roy B, Selvy M, Slim K (2016) The concept of prehabilitation: what the surgeon needs to know? J Visc Surg 153:109–112PubMedGoogle Scholar
  82. 82.
    Moran J, Guinan E, McCormick P et al (2016) The ability of prehabilitation to influence postoperative outcome after intra-abdominal operation: a systematic review and meta-analysis. Surgery 160:1189–1201PubMedGoogle Scholar
  83. 83.
    West MA, Loughney L, Lythgoe D et al (2015) Effect of prehabilitation on objectively measured physical fitness after neoadjuvant treatment in preoperative rectal cancer patients: a blinded interventional pilot study. Br J Anaesth 114:244–251PubMedGoogle Scholar
  84. 84.
    Hulzebos EH, Smit Y, Helders PP et al (2012) Preoperative physical therapy for elective cardiac surgery patients. Cochrane Database Syst Rev 11:Cd010118PubMedGoogle Scholar
  85. 85.
    Pouwels S, Stokmans RA, Willigendael EM et al (2014) Preoperative exercise therapy for elective major abdominal surgery: a systematic review. Int J Surg 12:134–140PubMedGoogle Scholar
  86. 86.
    Boden I, Skinner EH, Browning L, et al. (2018) Preoperative physiotherapy for the prevention of respiratory complications after upper abdominal surgery: pragmatic, double blinded, multicentre randomised controlled trial. BMJ 360Google Scholar
  87. 87.
    Barnes DE, Palmer RM, Kresevic DM et al (2012) Acute care for elders units produced shorter hospital stays at lower cost while maintaining patients' functional status. Health Aff (Millwood) 31:1227–1236Google Scholar
  88. 88.
    Landefeld CS, Palmer RM, Kresevic DM et al (1995) A randomized trial of care in a hospital medical unit especially designed to improve the functional outcomes of acutely ill older patients. N Engl J Med 332:1338–1344PubMedGoogle Scholar
  89. 89.
    Harari D, Hopper A, Dhesi J et al (2007) Proactive care of older people undergoing surgery ('POPS'): designing, embedding, evaluating and funding a comprehensive geriatric assessment service for older elective surgical patients. Age Ageing 36:190–196PubMedGoogle Scholar
  90. 90.
    Partridge J, Sbai M, Dhesi J (2018) Proactive care of older people undergoing surgery. Aging Clin Exp Res 30:253–257PubMedPubMedCentralGoogle Scholar
  91. 91.
    Ellis G, Whitehead MA, O'Neill D, et al. (2011) Comprehensive geriatric assessment for older adults admitted to hospital. Cochrane Database Syst RevGoogle Scholar
  92. 92.
    Eamer G, Taheri A, Chen SS, et al. (2018) Comprehensive geriatric assessment for older people admitted to a surgical service. Cochrane Database Syst RevGoogle Scholar
  93. 93.
    Braude P, Goodman A, Elias T et al (2017) Evaluation and establishment of a ward-based geriatric liaison service for older urological surgical patients: Proactive care of Older People undergoing Surgery (POPS)-Urology. BJU Int 120:123–129PubMedGoogle Scholar
  94. 94.
    Partridge JSL, Harari D, Martin FC et al (2014) The impact of pre-operative comprehensive geriatric assessment on postoperative outcomes in older patients undergoing scheduled surgery: a systematic review. Anaesthesia 69:8–16PubMedGoogle Scholar
  95. 95.
    Lorenzo-Lopez L, Maseda A, de Labra C et al (2017) Nutritional determinants of frailty in older adults: a systematic review. BMC Geriatr 17:108PubMedPubMedCentralGoogle Scholar
  96. 96.
    Cesari M, Fielding R, Benichou O et al (2015) Pharmacological Interventions in Frailty and Sarcopenia: Report by the International Conference on Frailty and Sarcopenia Research Task Force. J Frailty Aging 4:114–120PubMedPubMedCentralGoogle Scholar
  97. 97.
    Gillespie LD, Robertson MC, Gillespie WJ, et al. (2012) Interventions for preventing falls in older people living in the community. Cochrane Database Syst Rev CD007146Google Scholar
  98. 98.
    Campbell S, Szoeke C (2009) Pharmacological Treatment of Frailty in the Elderly. J Pharm Pract Res 39:147–151Google Scholar
  99. 99.
    Sumukadas D, Witham MD, Struthers AD et al (2007) Effect of perindopril on physical function in elderly people with functional impairment: a randomized controlled trial. CMAJ 177:867–874PubMedPubMedCentralGoogle Scholar

Copyright information

© Springer-Verlag GmbH Germany, part of Springer Nature 2018

Authors and Affiliations

  1. 1.University of OtagoChristchurchNew Zealand
  2. 2.Department of SurgeryChristchurch HospitalChristchurchNew Zealand

Personalised recommendations