Clinical Medicine 2019 Vol 19, No 6: 485–9 PERIOPERATIVE CARE

Frailty in the perioperative setting

Authors: Jugdeep K Dhesi, A Nicholas P LeesB and Judith SL PartridgeC

The frailty syndrome is defined as a decrease in physiological infection is more likely to require external assistance with daily
ABSTRACT

reserve across multiple organ systems leading to increased activities in comparison to a non-frail person who may continue
vulnerability to external stressors. Studies across surgical sub- to work in the context of a similar illness. In the surgical setting,
specialties and in emergency and elective settings have identi- such an acquired reduction in resilience is associated with more
fied frailty as an independent predictor of adverse postopera- frequent postoperative complications, a longer length of hospital
tive clinician-reported, patient-reported and process-related stay, higher mortality rates at 30 days and 12 months after
outcomes. Although frailty is not specific to the older popula- surgery, and a greater chance of dependent living at hospital
tion, it is associated with ageing and therefore is increasingly discharge.2,3 The association between frailty and increased risk
observed in the ageing surgical population. Identifying frailty of adverse postoperative clinician-reported, patient-reported and
early in the perioperative pathway affords the opportunity to process-related outcomes has now been reported across all major
assess risk, modify the syndrome, inform shared decision mak- surgical specialties, emergency and elective settings, and following
ing and plan the surgical pathway. Multiple tools to screen critical care admission.4
and diagnose frailty exist with limited appraisal of clinometric Perioperative medicine is being established to provide optimal
properties. A pragmatic approach to these tools is advocated preoperative, intraoperative and postoperative care for all
with a future focus on collaborative approaches to modify the patients, but with a particular focus on those at high risk of
syndrome using multicomponent methodology such as com- adverse postoperative outcomes. The high-risk group is defined
prehensive geriatric assessment and adapt the pathway to the as surgical patients with an aggregate 90-day mortality rate
needs of the frail surgical patient. greater than 1/20.5,6 These high-risk patients are predominantly
those with age related physiological changes, accumulation of
KEYWORDS: Perioperative medicine, frailty, older surgical patients, multimorbidity and geriatric syndromes including frailty. With
comprehensive geriatric assessment and optimisation (CGA), the advent of this new speciality, perioperative medicine, it is no
postoperative complications surprise that there has been a focus on identifying patients with
frailty in order to modify the perioperative pathway and achieve
improved outcomes for individual patients.6

Introduction
Frailty is defined as a decrease in physiological reserve across
Models of frailty
multiple organ systems leading to increased vulnerability to even Two models of frailty have been described. The first of these, the
seemingly minor external stressors. This renders the frail individual frailty phenotype was developed through secondary analysis of
at risk of poor resolution of homeostasis after a stressor event data from the cardiovascular health study.7 The frailty phenotype
such that the threshold from independence to dependence is proposes five variables (unintentional weight loss, self-reported
often crossed.1 For example, a frail person who develops a minor exhaustion, low energy expenditure, slow gait speed and weak grip
strength) and describes individuals with three or more of these
variables as frail, those with one or two factors present as pre-frail
and those with none of the variables as ‘robust’. The frailty index
Authors: Aconsultant geriatrician, perioperative medicine for older or deficit accumulation model of frailty was derived from the
people undergoing surgery (POPS) team, Guy's and St Thomas’ Canadian study of health and ageing using 92 variables, including
NHS Foundation Trust, London, UK, honorary reader, Faculty of Life symptoms, signs, existing diagnoses and biochemical markers.8
Sciences and Medicine, King's College London, London, UK and The index uses a binary count of the absence or presence of
honorary associate professor, Division of Surgery & Interventional each variable in an individual and thus calculates the number of
Science, University College London, London, UK; Bconsultant accumulated deficits from the total possible deficit count, giving
general and colorectal surgeon, Salford Royal NHS Foundation a result on a continuous scale from 0 (least frail) to 1 (most frail).
Trust, Salford, UK; Cconsultant geriatrician, perioperative medicine The more deficits, the frailer the individual and the higher the risk
for older people undergoing surgery (POPS) team, Guy's and St of institutionalisation and death. In this original description of the
Thomas’ NHS Foundation Trust, London, UK and honorary senior frailty index, by the time the index reached about 0.67, further
lecturer, Faculty of Life Sciences and Medicine, King's College deficit accumulation seemed impossible and death resulted.
London, London, UK The index has been replicated using different sets of variables

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 Jugdeep K Dhesi, Nicholas P Lees and Judith SL Partridge

producing similar results provided the variables collected represent imaging has increased in popularity with suggestions that this
multiple domains. may represent a surrogate marker for frailty.25 Such an approach
Since the initial conceptualisation of frailty, there has been a is at odds with the definition of sarcopenia which is low muscle
recognition of the overlap between frailty and other geriatric quantity or quality combined with low muscle strength and fails
syndromes. Fried described the relationship between frailty, to recognise the differences between sarcopenia and frailty as
comorbidity and disability in 2004 and, more recently, the discrete clinical syndromes. While the brevity and ease of surrogate
shared characteristics between frailty, sarcopenia and cachexia markers is attractive, the use of these tools risks losing fidelity to
particularly in terms of pathogenesis and clinical phenotype have the multidomain nature of the frailty definition and models.
been described.9,10 In addition, frailty should be considered in the A systematic review from 2016 examining frailty assessment
context of wider determinants; modifiable life-course conditions instruments concluded that, despite the availability of numerous
including socioeconomic standing.11 These are closely linked to tools, there was limited evidence of discriminant validity, construct
the concept of resilience, defined as the ability to adapt to or validity or reliability. Furthermore, the majority of tools were
overcome stress or trauma. The World Health Organization's World being used to predict adverse outcomes as opposed to aid with
report on ageing and health refers to intrinsic capacity as the clinical decision making or provide an interventional target.26 In
composite of all physical and mental capacities that an individual the perioperative setting, a similar systematic review suggested
can draw on to promote resilience and minimise negative that despite the recognition that frailty is an independent risk
health outcomes.12 Understanding and managing frailty in all factor for adverse outcomes, the question about the best clinical
clinical settings requires an understanding of these overlapping tool for assessing frailty remains unanswered.27 Challenges
concepts and syndromes in order to deliver personalised medicine exist in accurately measuring frailty in the perioperative setting,
supported by robust clinical pathways grounded in socioeconomic, particularly in expedited or urgent surgery. Disentangling the
cultural and environmental conditions. acute pathology from underlying frailty status can be difficult and
may rely on collateral history and discussion with primary care. In
Frailty in surgical patients the absence of consensus regarding which frailty tool should be
used to either screen for, or diagnose, frailty in the perioperative
Future projections predict that by 2030, one-fifth of surgical setting, many clinicians have opted for a pragmatic approach
procedures will be conducted in patients aged over 75 years.5 By choosing CFS. This screening tool can be used by non-specialists in
the nature of surgical pathology, which is often degenerative (eg the elective and emergency surgical setting and has been shown
osteoarthritis), neoplastic (eg bladder cancer) or metabolic (eg to be strongly associated with 30- and 90-day mortality, risk of
vascular disease), it is unsurprising that the surgical population is complications and length of intensive care unit and overall hospital
ageing. While frailty is associated with ageing, it not exclusively stay after emergency laparotomy. Indeed, using CFS, even patients
observed in older people, nor are all older people frail. Numerous who are assessed as being vulnerable or pre-frail rather than frail,
studies have described the prevalence of frailty with an observed have outcomes that mark them out as high-risk. The CFS has now
variation in rates reported across surgical specialties. In those been included in the National Emergency Laparotomy Audit.2,28
undergoing elective orthopaedic surgery, 23% were frail in
comparison to emergency hip fracture surgery where 53% of Managing frailty in the perioperative pathway
patients were defined as frail.13,14 Considering cancer surgery,
studies report a prevalence of 25% of patients undergoing Identifying and managing frailty in the perioperative setting
elective cystectomy as being frail with a similarly high prevalence depends on the acuity of presentation; elective or emergency.
of frailty in emergency general surgical patients of 39% where the In the elective setting, early screening and diagnosis of frailty is
underlying pathology is often neoplastic.15,16 In vascular surgery, advocated. The benefit of frailty assessment at the start of the
aortic aneurysms and peripheral arterial disease increase with age, pathway include informing risk assessment, shared decision making
with an estimated 52% of elective vascular patients being frail.17 and potential modification of the syndrome well in advance of
potential surgery. An accurate diagnosis of frailty coupled with a
knowledge of the perioperative implications of frailty on morbidity
Identifying frailty in the perioperative setting
and mortality can promote informed discussion of the potential
Given that frailty is common with significant perioperative benefits, risks, alternatives to surgery or options if nothing is done. In
implications but is not exclusive to or universal in older people, such a situation, some patients may decide, together with healthcare
accurately identifying frailty in the context of other overlapping professionals, not to undertake surgical management electing
conditions and syndromes is vital. While comprehensive geriatric instead for conservative measures. In other cases, seemingly high-
assessment (CGA) and optimisation remains the gold standard risk patients may work with healthcare teams to modify the frailty
method for screening, diagnosing and managing frailty, it syndrome, thus altering the perioperative risk profile, allowing surgery
can be time consuming and requires specialist skills. This has to occur and improving postoperative outcomes. Furthermore,
resulted in the development of numerous frailty tools designed there is frequently more than one surgical option. For example, a
to be applicable across clinical settings and deliverable by non- patient considering surgery for rectal cancer may have options that
specialists. These tools vary from single surrogate markers of frailty include local resection, radical resection with a stoma and radical
(eg gait velocity), simple infographic tools (eg clinical frailty scale resection with restoration of bowel continuity. Each has different
(CFS)), scales or scores (eg Edmonton frailty scale or electronic oncological benefits, perioperative risks and quality-of-life outcomes.
frailty index), biomarkers (eg interleukin 6), disease specific scores Incorporating frailty assessment, preoperative optimisation,
(eg comprehensive assessment of frailty) or surgery specific scores multidisciplinary shared decision making and targeted perioperative
(eg FORECAST).18–24 Furthermore, the opportunistic evaluation interventions means that some frail patients can still benefit from
of related syndromes, such as sarcopenia, using cross sectional surgery who may have otherwise been considered too high-risk.

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 Frailty in the perioperative setting

Table 1. A multidomain approach to modifying the frailty syndrome in the perioperative setting. Adapted
from Dhesi JK, Partridge JSL, Moppett IK. Anaesthesia for the older person. In: Thompson JP, Wiles MD, Moppett IK
(eds), Smith and Aitkenhead's textbook of anaesthesia, 7th edn. Elsevier, 2019.
Domain Issue History/examination Screening or Investigation Optimisation
diagnostic tools
Medical Postural History of falls. Unified Parkinson's DaTSCAN. In established cases, proactive
hypotension Reports of slowing, disease rating Cerebral imaging plan around medications including
with visual falls, tremor, rigidity scale. with computed timings and alternative drugs or
hallucinations etc. tomography routes of administration when nil
or magnetic by mouth.
Proactive assessment
for non-motor resonance Pre-emptive advice to ward teams
symptoms if imaging (does not about non-motor complications
Parkinson's disease necessarily need to likely at time of surgery
likely. be preoperative). (constipation, delirium or falls).
Physical examination. In newly identified cases,
consider starting medications
preoperatively versus outpatient
follow-up based on symptoms and
urgency of surgery.
Exertional Smoking history but Medical Spirometry. Smoking cessation advice.
dyspnoea no prior known chronic research council CXR. Flu vaccination.
and daily lung disease. breathlessness
Inhaled therapy according to
cough History of symptoms scale.
NICE / British Thoracic Society
of chronic obstructive 6-minute walk test. guidelines.
pulmonary disease.
Pulmonary rehabilitation according
to local guidelines.
Geriatric Falls Previous history. Gait speed. Bone profile and Medical management of
syndromes History of ‘near Timed up and go. vitamin D. bone health (eg bisphosphate
misses’, suggestive Suggestion to GP and calcium-vitamin D
Fracture risk
underlying causes and about DEXA and supplementation).
assessment tool.
injuries sustained. follow-up. Medical falls review.
Bone health screening. Strength and balance training.
Cognitive Self-reported history of 4AT. Cerebral Delirium risk assessment and
impairment cognitive issues. MoCA. imaging or optimisation eg cessation of
Collateral history from recommendation anticholinergic medications,
relative/carer. to GP for this. ensuring normal electrolytes and
treating constipation.
Signposting to standardised
postoperative management of
delirium.
Communication with patient and
relatives.
Long-term vascular risk factor
management.
Referral to memory services for
long-term follow-up.
Psychological Anxiety and Self-reported history. Hospital anxiety Thyroid function Referral for psychological support
depression Collateral from family/ and depression tests. (talking services).
carer. score. Exclusion Consider pharmacological
Symptoms. of cognitive treatment.
impairment. Explanation or counselling
regarding surgery if this is
prominent trigger for symptoms.
(Continued)

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 Jugdeep K Dhesi, Nicholas P Lees and Judith SL Partridge

Table 1. (Continued).
Domain Issue History/examination Screening or Investigation Optimisation
diagnostic tools
Functional Functional Self-reported concerns. Barthel. Physical Preoperative physiotherapy.
and social dependency Collateral from family/ Nottingham examination and Occupational therapy intervention
carer. extended activities investigation of (eg home adaptations).
of daily living. pathology causing
Assessment of Social worker intervention to
disability eg
underlying cause. proactively identify barriers to
proximal myopathy
discharge.
secondary
to vitamin D Proactive communication
deficiency. regarding anticipated length of
stay and access to rehabilitation or
Prescribe analgesia
care at discharge.
for osteoarthritis.
Non- Self or family reported STOPP/START. Assessment of Liaising with community
adherence concerns. cognition and pharmacist to assist with dosette
to prescribed Clinical evidence of understanding of box and with care services or
medications non-adherence. medications. telecare to prompt medication.
Assessment of
understanding of
medications.
4AT = four ‘A's test; CXR = chest X-ray; DaTscan = dopamine transporter single photon emission computed tomography; DEXA = dual-energy X-ray absorptiometry;
GP = general practitioner; MoCA = Montreal cognitive assessment; NICE = National Institute for Health and Care Excellence; START = screening tool to alert doctors to
right treatments; STOPP = screening tool of older people's potentially inappropriate prescriptions.

In the emergency setting, the same principles apply but the and lack of convincing efficacy have limited the widespread use of these
emphasis shifts away from modifying the patients' risk profile instead medications, although research into the use of ACEi as a therapeutic
to adapting the pathway of care. For example, high-risk frail patients agent in those with sarcopenia is currently ongoing.29
undergoing emergency laparotomy will be managed by consultant- Similarly, although the use of nutritional supplementation to slow or
level staff with planned level 3 care. Early discussions with patients reverse the weight loss commonly associated with the frailty syndrome
and their families regarding ceilings of care may also be triggered by may seem therapeutically attractive, this has not yet been supported
the recognition that the patient is frail with acknowledged adverse in research studies. Exercise intuitively seems sensible in a group known
outcomes, avoiding the futility of surgery in some and the futility of to be largely sedentary, with slow gait velocity, and is known to have
escalating interventions after complications in others.6 positive physiological effects on the brain, endocrine system, immune
While screening for frailty has gained traction in perioperative system, and skeletal muscle.1 However, research examining the impact
pathways, the interpretation of frailty tool results requires a skilled of exercise on modifying frailty is mixed, with suggestion that the most
workforce. In keeping with the perioperative agenda, this requires frail patients gain the least from this intervention.30 This does not
a collaborative approach between surgeons, anaesthetics and preclude clinicians from recommending exercise programmes for other
those skilled in the management of frailty and multimorbidity. indications and positive results may emerge in future trials.
Such an approach should firstly focus on potential modifiers of Translation of this scant evidence on frailty modification into the
the frailty syndrome at an individual patient level and secondly on preoperative setting is even more problematic. While the national
modifying the perioperative pathway to achieve optimal clinician- appetite for prehabilitation exercise programmes in older, frail, surgical
reported, patient-reported and process-related outcomes. populations has been considerable, to date there is no evidence
linking these with improved postoperative outcomes. This leaves
Modifying frailty in the perioperative setting researchers and clinicians aware that frailty has an adverse impact on
outcomes in older surgical populations, able to identify the syndrome
No evidence-based single frailty modifier exists. Studies have examined
using various tools but unable to effectively treat frailty with a single
pharmacological agents, exercise, nutritional supplementation and
intervention or modifier evidenced to have benefit. In this situation the
multicomponent interventions with limited success to date. Limitations to
potential for multicomponent interventions to modify aspects of the
this body of work result from a lack of explicit frailty measures such that
frailty syndrome appear attractive. The established multicomponent
in many cases the findings are extrapolated from populations known
intervention CGA has been shown to have benefit on morbidity and
to have a high prevalence of frailty, for example care home residents,
mortality in older frailer patients in other clinical areas.
hip fracture patients, sarcopenic subjects or those with pressure ulcers,
but without frailty being explicitly defined or identified. Despite these
acknowledged issues, no pharmacological interventions are currently
Comprehensive geriatric assessment
supported by the literature, although there is support for the positive
and optimisation
effect of angiotensin converting enzyme inhibitor (ACEi) medications on CGA and optimisation is an established method for evaluating and
skeletal muscle function, testosterone on muscle strength and vitamin D managing older patients in various clinical settings. It involves a
on neuromuscular functioning. Side effects, in the case of testosterone, multidomain, interdisciplinary assessment aiming to describe both

488 © Royal College of Physicians 2019. All rights reserved.

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 Frailty in the perioperative setting

known pathology and previously undiagnosed conditions together 12 World Health Organization. World report on ageing and health.
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study. BMJ Open 2019;9:e025941.
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14 Johnson RL, Abdel MP, Frank RD et al. Impact of Frailty on
setting, addressing a multisystem condition through a multidomain
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17 Partridge JS, Fuller M, Harari D et al. Frailty and poor functional
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Discussion postoperative outcomes. Int J Surg 2015;18:57–63.
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