Preoperative Evaluation of the Frail Patient

Lolita S. Nidadavolu, MD, PhD; April L. Ehrlich, MD; Frederick E. Sieber, MD; Esther S. Oh, MD, PhD


Anesth Analg. 2020;130(6):1493-1503. 

In This Article

Abstract and Introduction


Perioperative management of older adults is a complex field that is heavily influenced by the clinical heterogeneity of older adults. Frailty—a geriatric syndrome in which a patient is more vulnerable to stressors due to decreases in physical function and reserve—has been indicative of adverse postoperative outcomes. Many tools have been developed to measure frailty that incorporate a variety of factors including physical and cognitive function, comorbidities, self-reported measures of health, and clinical judgment. Most of these frailty assessment tools are able to identify a subset of patients at risk of adverse outcomes including postoperative complications, longer hospital length of stay, discharge to a higher level of care, and mortality. Frailty assessment before surgical interventions can also guide discussions among patients, their families, anesthesiologists, and surgeons to tailor operative plans for patients to mitigate this increased risk. Studies are ongoing to identify interventions in frail patients that can improve postoperative outcomes, but high-quality data in the form of randomized controlled trials are lacking at this time.


In the United States, approximately one-third of all operating room–based procedures are performed on adults ≥65 years.[1] Rates of surgical complications increase with age; in 1 study of adults >80 years, 20% developed postoperative complications including pneumonia, prolonged (>48 hours) ventilator support, and cardiac arrest.[2] This has implications on the practice of anesthesia as the geriatric population has a unique physiology that affects their surgical outcomes. One such challenge is frailty. Frailty is a biologic syndrome characterized by decreased homeostatic reserve and diminished resistance to stressors due to cumulative declines across multiple physiologic systems that result in vulnerability to adverse outcomes.[3]

Approximately 1 in 6 community-dwelling individuals >60 years may be frail, representing a significant portion of older individuals presenting for surgery.[4] A prospective cohort study comparing 2 frailty assessment tools demonstrated that between 35% and 41% of patients were frail, and these frail patients were more likely to have adverse outcomes including more postoperative complications, increased length of stay (LOS), and higher 30-day readmission rates.[5] Other studies showed that higher frailty scores were associated with higher risk of postoperative 30-day mortality after adjusting for age and American Society of Anesthesiology (ASA) classification.[6,7] These studies demonstrate the importance of identifying frail older individuals who are planned for elective and emergent surgeries.

This narrative review will discuss different frailty assessment tools that have been validated in surgical populations and examine the association of preoperative frailty with postoperative outcomes. Although there are younger adults who are frail, this review will focus on older adults because frailty is strongly associated with increasing age and most of the validated tools have been extensively studied in older populations.[8]