Overview
Definition:
Frailty is a clinical syndrome characterized by decreased physiological reserve and increased vulnerability to stressors, leading to a higher risk of adverse outcomes, including falls, disability, hospitalization, and mortality
Pre-operative assessment aims to identify frail individuals to allow for targeted interventions to improve surgical outcomes.
Epidemiology:
The prevalence of frailty increases with age, affecting approximately 5-10% of individuals aged 65-74 years and up to 40-50% of those aged 85 years and older
Frailty is common in surgical populations, with reported rates of 10-30% in elective surgery and higher in emergency settings.
Clinical Significance:
Frail patients are at increased risk of post-operative complications such as delirium, infections, prolonged hospital stays, need for intensive care, and mortality
Identifying and optimizing frailty pre-operatively can mitigate these risks, improve recovery, and enhance patient quality of life.
Frailty Assessment Tools
Phenotype Model:
The Fried phenotype model defines frailty based on five components: unintentional weight loss, self-reported exhaustion, low physical activity, slow gait speed, and weakness
Individuals meeting 3 or more criteria are considered frail, 1-2 are pre-frail, and 0 are not frail.
Frailty Index:
The Frailty Index (FI) is a cumulative deficit model that quantifies frailty by summing the number of health deficits (e.g., symptoms, signs, lab abnormalities, diseases) present in an individual, divided by the total number of deficits assessed
Higher FI scores indicate greater frailty.
Clinical Frailty Scale:
The Clinical Frailty Scale (CFS) is a 9-point ordinal scale that assesses a patient's functional status and dependency on others
It is a simple and widely used tool for clinical practice, ranging from 1 (very fit) to 9 (terminally ill).
Other Tools:
Additional tools include the Edmonton Frail Scale (EFS), Gargle Frailty Score, and various questionnaires like the Vulnerable Elders Survey (VES-13)
The choice of tool depends on the clinical setting, available resources, and the specific population being assessed.
Preoperative Optimization
Nutritional Support:
Assess nutritional status with BMI, albumin levels, and nutritional screening tools
Provide protein and calorie-rich supplements, and address swallowing difficulties
Oral nutritional supplements or enteral feeding may be indicated.
Exercise And Rehabilitation:
Encourage pre-habilitation programs including tailored aerobic, resistance, and balance exercises
Physical therapy referrals can improve strength, mobility, and endurance, reducing post-operative decline.
Medication Review:
Review and optimize all medications, particularly those with anticholinergic effects, sedatives, and opioids, which can increase the risk of delirium and falls
Deprescribing unnecessary medications is crucial.
Multidisciplinary Team Approach:
Involve a multidisciplinary team including geriatricians, dietitians, physiotherapists, occupational therapists, and social workers
This comprehensive approach ensures holistic management of the patient's needs.
Patient And Family Education:
Educate patients and their families about frailty, its implications for surgery, and the importance of pre-operative optimization
Shared decision-making regarding surgical risks and benefits is essential.
Surgical Considerations
Risk Stratification:
Frailty assessment should be integrated into surgical risk stratification
Frail patients may require more individualized risk assessments and potentially modified surgical approaches.
Anesthesia Choice:
Consider anesthetic techniques that minimize physiological stress, such as regional anesthesia where appropriate
Careful titration of anesthetic agents is important due to altered pharmacokinetics in frail individuals.
Procedural Modifications:
For certain procedures, consider minimally invasive techniques or staged approaches to reduce surgical burden
Intraoperative fluid management and temperature control are critical.
Postoperative Planning:
Develop a detailed post-operative care plan tailored to the patient's frailty, including early mobilization protocols, pain management strategies, and plans for discharge to home or rehabilitation facilities.
Complications And Outcomes
Common Postoperative Complications:
Frail patients are at higher risk for delirium, prolonged ventilation, wound complications, venous thromboembolism, and hospital-acquired infections
Readmission rates and mortality are also higher.
Impact On Recovery:
Frailty significantly impacts recovery trajectories, leading to longer hospital stays, increased functional decline, and reduced ability to return to pre-operative baseline activities.
Improving Outcomes:
Effective pre-operative optimization can significantly reduce the incidence of complications and improve functional recovery in frail surgical patients
Early identification and intervention are key.
Key Points
Exam Focus:
Understand the definition and assessment tools for frailty (Fried phenotype, Frailty Index, CFS)
Recognize the increased risks associated with frailty in surgical patients.
Clinical Pearls:
Always consider frailty in elderly patients undergoing elective or emergency surgery
A multidisciplinary approach to pre-operative optimization is most effective
Simple interventions like nutritional support and exercise can have a significant impact.
Common Mistakes:
Failing to assess for frailty in at-risk populations
Underestimating the impact of frailty on surgical outcomes
Not implementing comprehensive pre-operative optimization strategies.