Frailty for Perioperative Clinicians: A Narrative Review

Daniel I. McIsaac, MD, MPH, FRCPC; David B. MacDonald, MD, FRCPC; Sylvie D. Aucoin, MD, MSc, FRCPC

Disclosures

Anesth Analg. 2020;130(6):1450-1460. 

In This Article

Abstract and Introduction

Introduction

Frailty is a multidimensional syndrome characterized by decreased reserve and diminished resistance to stressors. People with frailty are vulnerable to stressors, and exposure to the stress of surgery is associated with increased risk of adverse outcomes and higher levels of resource use. As Western populations age rapidly, older people with frailty are presenting for surgery with increasing frequency. This means that anesthesiologists and other perioperative clinicians need to be familiar with frailty, its assessment, manifestations, and strategies for optimization. We present a narrative review of frailty aimed at perioperative clinicians. The review will familiarize readers with the concept of frailty, will discuss common and feasible approaches to frailty assessment before surgery, and will describe the relative and absolute associations of frailty with commonly measured adverse outcomes, including morbidity and mortality, as well as patient-centered and reported outcomes related to function, disability, and quality of life. A proposed approach to optimization before surgery is presented, which includes frailty assessment followed by recommendations for identification of underlying physical disability, malnutrition, cognitive dysfunction, and mental health diagnoses. Overall, 30%–50% of older patients presenting for major surgery will be living with frailty, which results in a more than 2-fold increase in risk of morbidity, mortality, and development of new patient-reported disability. The Clinical Frailty Scale appears to be the most feasible frailty instrument for use before surgery; however, evidence suggests that predictive accuracy does not differ significantly between frailty instruments such as the Fried Phenotype, Edmonton Frail Scale, and Frailty Index. Identification of physical dysfunction may allow for optimization via exercise prehabilitation, while nutritional supplementation could be considered with a positive screen for malnutrition. The Hospital Elder Life Program shows promise for delirium prevention, while individuals with mental health and or other psychosocial stressors may derive particular benefit from multidisciplinary care and preadmission discharge planning. Robust trials are still required to provide definitive evidence supporting these interventions and minimal data are available to guide management during the intra- and postoperative phases. Improving the care and outcomes of older people with frailty represents a key opportunity for anesthesiologists and perioperative scientists.

Introduction

Western populations are aging rapidly. Current census data suggest that by the year 2050, the number of people aged 65 years or older in the United States will double relative to this decade;[1] these data are closely mirrored in other jurisdictions such as Canada and Western Europe.[2,3] While rapid growth in the older age demographic has major impacts on all areas of medicine, it is especially relevant in the perioperative setting. Advanced age predicts a 2- to 4-fold increase in rates of morbidity and mortality,[4,5] and over 50% of people having major surgery are >65 years of age.[6,7]

Despite the increased relative risk associated with older age, however, most older people survive surgery without experiencing a serious complication (>95% survival and >75% without a major complication).[8,9] This suggests that identification of a high-risk stratum within the older surgical population may allow for more targeted application of scarce health care resources to achieve value from perioperative enhanced care pathways and processes. While many risk stratification tools exist to help identify high-risk patients, few have been routinely operationalized in clinical practice.[10]

Over the past 10 years, frailty has emerged as a robust and clinically relevant entity that is commonly present in older people who experience adverse outcomes after surgery. As a multidimensional geriatric syndrome, the concept of frailty has been translated from geriatric medicine practice across many areas of acute care medicine. Interest in frailty in the perioperative setting has increased exponentially. However, many challenges exist regarding conceptualization of frailty, routine identification, and application of targeted interventions to improve outcomes. The objective of this review is to provide an overview of frailty relevant to perioperative clinicians, including defining frailty, reviewing techniques to operationalize frailty assessment before surgery, exploring pathways that may lead from frailty to adverse postoperative outcomes and discussing established and emerging interventions that may target these pathways to meaningfully improve outcomes for the growing number of older people with frailty who undergo surgery each year.

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