COMMENTARY

Frailty in the Older Adult: A Surgical Deterrent?

Margaret R. Nolan, DNP, GNP

Disclosures

March 23, 2018

Preoperative Frailty Assessments

A recent New York Times article[1] focuses on a surgeon who uses a frailty scale to help him determine the appropriateness of surgery for his elderly patients. The belief is that older adults with higher degrees of frailty do poorly postoperatively. This idea is taking hold nationally, and although many surgeons are taking frailty into account, it is not yet routine to screen elderly patients for frailty before surgical procedures. Frailty is an important consideration, however, because serious complications are higher among elderly adults with moderate to high frailty scores.

To prevent poor outcomes in the frail elderly, many surgical centers are offering rehabilitation before surgery to improve the patient's postoperative functioning. Even a few weeks of therapy can improve the elderly patient's recovery.

The heightened awareness of poor surgical outcomes among frail patients has prompted many surgeons to rethink their standard approach. Some surgeons are already counseling their older patients differently. The surgeon quoted in the New York Times article found that evaluating patients for frailty changed the surgical plan and often led to a safer alternative.

Viewpoint

As longevity increases among the population, longer lives can have negative consequences, one of which is frailty. Frailty is a geriatric syndrome that is related to multiple systems failure.[2] Many scales are available to measure frailty, incorporating such indicators as the number of medications being taken, comorbid conditions, medical interventions, psychosocial issues, cognitive impairment, weight loss, low physical activity, slow gait, weakness, and fatigue.[2] Frail older adults have high rates of adverse outcomes, institutionalization, falls, disabilities, and unexpected death, as well as lower quality of life.[3]

There is general decline in physical activity in the older adult, and less than a quarter of all seniors in a large study met the minimum recommended activity level to maintain their health.[2] But it is never too late to begin an exercise program, and the benefits are real for older adults.[2] Many symptoms of frailty—such as low physical activity, depression, and cognitive impairment—might be improved with such interventions as physical therapy, antidepressants, or cholinesterase inhibitors.[4] Frailty should routinely be assessed in all elderly patients.

It's a common practice to require elderly patients who are deemed to be at high risk to be cleared by a cardiologist before surgery. Yet this evaluation has been shown to have no impact on perioperative or postoperative outcomes and can cause delays in surgery.[5] If we begin using a frailty scale to determine surgical appropriateness, it must be acknowledged that frailty can't be resolved with a few minutes' evaluation. It requires proactive care that addresses frailty before its onset.[3] Early frailty detection programs are needed to focus on prevention and management.[6] Special postoperative management must be developed for frail patients, which might include early physical therapy and special geriatric units that enhance cognition.

Rethinking the appropriateness of surgery in frail older adults is a good idea. But frailty isn't a one-size-fits-all issue. Individual perioperative treatment plans should be tailored to each frail patient's unique needs.[6]

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