Frailty in surgical patients
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.
KeywordsFrailty Post-operative outcomes Surgery Elderly
Compliance with ethical standards
Conflict of interest
The authors declare that they have no conflict of interest.
- 1.He W, Goodkind D, Kowal P (2016) An Aging World: 2015Google Scholar
- 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
- 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
- 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
- 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
- 14.Centre for Disease Control and Prevention (2010) National Hospital Discharge Survey. 2018Google Scholar
- 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.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
- 18.Saklad MDM (1941) Grading of Patients for Surgical Procedures. Anesthesiology 2:281–284Google Scholar
- 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
- 22.Minto G, Biccard B (2014) Assessment of the high-risk perioperative patient. Contin Educ Anaesth Crit Care Pain 14:12–17Google Scholar
- 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.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
- 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
- 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
- 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.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.Rockwood K, Mitnitski A (2007) Frailty in relation to the accumulation of deficits. J Gerontol A Biol Sci Med Sci 62Google Scholar
- 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.Rockwood K, Mitnitski A (2011) Frailty defined by deficit accumulation and geriatric medicine defined by frailty. Clin Geriatr Med 27:17–26Google Scholar
- 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.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
- 41.Taffett GE (2003) Physiology of aging. Geriatric medicine: an evidence-based approach. Springer New York, New York, pp 27–35Google Scholar
- 42.Clegg A, Young J, Iliffe S et al (2013) Frailty in elderly people. Lancet 381:752–762Google Scholar
- 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
- 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.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.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
- 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
- 73.Rockwood K, Song X, MacKnight C, et al. (2005) A global clinical measure of fitness and frailty in elderly people. CMAJ 173Google Scholar
- 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.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
- 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.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
- 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.Campbell S, Szoeke C (2009) Pharmacological Treatment of Frailty in the Elderly. J Pharm Pract Res 39:147–151Google Scholar