Frailty as a Growing Challenge for Anesthesiologists

Results of a Dutch National Survey

A. Bouwhuis; C. E. van den Brom; S. A. Loer; C. S. E. Bulte


BMC Anesthesiol. 2021;21(307) 

In This Article


Frailty is a multidimensional condition characterized by loss of functional reserve, loss of homeostatic mechanisms and increased vulnerability to adverse outcomes following stressors such as surgery.[1] The number of frail elderly is growing as the population is aging. Worldwide, the population over 60 years of age will nearly double from 12 to 22% between 2015 and 2050.[2] As a consequence, the number of frail patients presenting for specialized medical care and hospital admission will even further increase. The prevalence of frail individuals in society is estimated at 4,1–8,5% while frailty is present in 10–37% of patients in a general surgery population.[3,4] The aging population is paralleled by increased health care costs and in the Netherlands, it is expected that in 2030 58% of the national health care budget is spent on patients over 65 years of age.[5,6]

Aging decreases physiological reserve and increases incidence of disease, resulting in numerous comorbidities and polypharmacy.[7] While it is generally accepted that frailty prevalence increases at higher age, it is not an inevitable consequence of aging. In general, surgery in elderly patients has higher complication rates than in younger subjects. Adverse outcomes are mainly related to comorbidity, polypharmacy, impaired functional status, cognitive and sensorial disabilities rather than to chronological age. The preexisting presence of a geriatric syndrome is of importance since interventions might be available for preoperative optimization. Specifically in case of frailty, it is known to be a better predictor of health than separate comorbidities.[1] Frailty increases the odds of perioperative adverse outcome, such as increased morbidity, mortality, readmission rates, length of hospital stay and decreased self-reliance and quality of life.[3,8] Adverse outcomes can be reduced when risk factors are recognized early, especially when dedicated care pathways are in place tailored at avoiding major adverse events during critical time points before and after interventions.[9] Of major importance is that these pathways should include frequent risk assessments by dedicated personnel, allowing patients to be transferred to a different pathway if necessary. Early recognition of frailty is of key importance in which anesthesiologists could play a crucial role.

Frailty is a modifiable risk factor for the recovery of patients after surgery. A variety of studies confirm improved outcomes after initiation of multimodal interventions including prehabilitation programs in frail subjects.[10] However, optimization can only occur when patients at risk are identified early and treated accordingly.[11] Traditional risk assessment is predominantly organ-system based and applying a similar method in elderly individuals will insufficiently identify those at high risk of frailty. Patients with frailty require a comprehensive perioperative approach. The focus should shift from handling disease to preserving performance and quality of life should be centralized.[12]

The anesthesiologist beholds a key role in early identification of risk factors for frailty and preoperative optimization. It is, however, unknown whether anesthesiologists are familiar with the frailty syndrome and how they incorporate this knowledge into daily practice. We therefore investigated the perspective on the aging population, familiarity with the frailty syndrome and the current organization of perioperative care for elderly patients by conducting a survey among anesthesiologists and residents in the Netherlands.