Preoperative Evaluation of the Frail Patient

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

Disclosures

Anesth Analg. 2020;130(6):1493-1503. 

In This Article

Discussion

Preoperative assessment of frailty using tools validated for surgical populations is one of the first steps in identifying patients who are at high risk for poor postoperative outcomes. Across different surgical populations, frailty is associated with greater overall postoperative complications, longer hospital LOS, and higher mortality. Therefore, preoperative knowledge of frailty can help guide discussions with the patient's care team to optimize perioperative care.

There is no gold standard assessment for frailty, particularly among older individuals undergoing surgery. Assessment tools vary in the domains assessed (ie, cognition, comorbidities, and physical function), source of information (ie, direct assessment, self-report, and electronic health records), time required, and location of evaluation (ie, outpatient, inpatient, and by telephone). In considering the data presented in Table 1 and Table 2, frailty assessment tools most predictive of postoperative complications, longer LOS, and higher mortality include the mFI, CFS, PFP, and RAI-C. The mFI and RAI-C, in particular, can pull in the relevant information needed to assess frailty from a patient's electronic medical records. The PFP can also be a useful frailty assessment tool in a preoperative clinic, particularly once staff is trained on standardized measurement of grip strength and gait speed. In addition, the PFP also has a well-characterized biologic framework and animal models in which proposed interventions for frailty can be tested for efficacy.[64,65]

The feasibility of implementing frailty assessment in a preoperative clinic visit is an important consideration. Recently developed tools (mFI 11, CFS, RAI-C, and the FRAIL scale) can be completed in approximately 10 minutes without requiring physical measures (eg, hand grip or timed walk).[13] The VES has also been successfully administered over the telephone.[12] With the right tools and appropriate training, both PFP and DAI can be performed in a clinic setting.[5,66]

It is less clear what should be done once a patient is identified as frail and is scheduled to undergo an elective or emergent surgical procedure. Some strategies that can be implemented for both frail and nonfrail patients include preoperative optimization of comorbidities such as diabetes, hypertension and congestive heart failure, nutritional assessment, and closer postoperative monitoring in a stepdown unit.[67] Geriatrics comanagement and consultation can also be implemented early on in a frail patient's hospital course. In the preoperative setting, identifying a frail patient should initiate further discussions of goals of care, and more comprehensive geriatric assessment (CGA) can be performed to identify medical, physical, or socioeconomic vulnerabilities that contribute to a patient's frail status that can be targeted for intervention.

Several recent editorials describe a role for rapid frailty assessment tools with high negative predictive values to rule out frailty in surgical candidates, while allowing for patients who screen positive for frailty to undergo more rigorous preoperative assessments.[31,68] These assessments may include a CGA, an interdisciplinary approach that systematically evaluates physical, functional, cognitive, environmental, and social domains for an older adult.[69] An individualized treatment plan resulting from concerted interdisciplinary effort is the goal of a successful CGA.[70]

An example of what can be done for individuals who are identified as frail is highlighted in study by Hall et al[58] using the RAI-C and measuring the effectiveness of a "frailty screening initiative." This initiative consisted of clarifying goals of care and postoperative expectations for patients as well as informing the patient's surgeons, anesthesiologists, and critical care physicians of the patient's frailty status.[58] Overall 30-day mortality for all subjects in the frailty screening initiative arm, regardless of frailty status, decreased from 1.6% preinitiative to 0.7% following the initiative, and frail subjects had the greatest reduction in 30-day mortality compared to robust patients, decreasing from 12.2% to 3.8%.[58]

One intervention for frail surgical patients that is receiving more attention is prehabilitation. Prehabilitation is a multimodal intervention that aims to reduce vulnerability and increase resilience of patients to stressors such as surgery or nonsurgical interventions.[67] Previous literature has considered prehabilitation as an intervention to reduce disability and restore function among frail patients before development of acute illness, injury, or surgery.[71] However, there is no consensus for the optimal type of prehabilitation for frail patients, likely from the lack of robust randomized control trials at this time.

The strengths of this narrative review include a comprehensive evaluation of frailty assessment tools that were specifically validated in surgical populations as well as postoperative outcomes that have been examined among individuals who were identified as frail using these tools. Limitations of this review include focus on adults over age 65. There are studies examining frail patients who are <65, particularly in cancer, cardiac surgery, and transplant medicine fields that were excluded based on our criteria. An additional limitation is that studies looking at oncologic surgeries and those with concurrent or preceding chemotherapy were also excluded. The presence of cancer and chemotherapy can be an additional stressor to older adults, and patients with a history of cancer have significantly higher rates of frailty and vulnerability.[72] A comprehensive review focusing on frailty in the oncologic setting has been recently published.[73] We also excluded studies that focused only on preoperative sarcopenia, but a review on the topic of sarcopenia and surgical outcomes has also been published recently.[74]

Determining a patient's preoperative frailty status is critical to assessing a patient's overall perioperative risk including postoperative complications, increased mortality, longer hospital LOS, and higher level of care on discharge. Preoperative knowledge of frailty status can guide discussions among patients, their families, anesthesiologists, and surgeons to tailor perioperative care for patients to mitigate this increased risk. All the frailty assessment tools identified in this review demonstrated the ability to identify frail individuals who were at higher risk of worse postoperative outcomes compared to nonfrail individuals in different surgical settings. These assessment tools incorporate different measurements that can be done in the outpatient setting or in the hospital before surgery, demonstrating feasibility. Ongoing studies on the efficacy of preoperative interventions targeting frail patients will be instructive in providing more information about how to best improve postoperative outcomes for frail older adults.

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