Preoperative Frailty Screening, Assessment, and Management

Introduction

The major population of people undergoing surgery is older patients who are above the age of 60. They also have a higher percentage of complications than others. Frailty helps to influence the outcome of surgery and faster healing postoperatively. Frailty must be included in the preoperative evaluation to identify the patients for complications and effectively manage them.

What Is Frailty?

Frailty is a condition of increased susceptibility to stressful situations like injury or illness that can result in poor control of bleeding and other risks of complications. Frailty occurs from advanced loss of functional reserve which is related to aging. Frailty is a complicated and multidimensional group of complaints involving various organ systems and as a result, multiple phenotypes of frailty are formed. They should be differentiated from other co-existing diseases and other dysfunctions even though the three of them are related to each other.

What Are the Tools to Assess Frailty?

Frailty is related to the increase in the number of falls, lack of movement, frequency of hospital admission, poor life quality, stress, a decline in mental health, and leading a lonely life. There are few tools to assess frailty among elderly patients requiring surgery, evaluated preoperatively.

1. FRAIL Test:

• This tool determines five components namely fatigue, resistance, aerobics, illnesses, and loss of weight.

• It is five short-form questions self-reported by the patient with yes or no answers.

• The advantages of this tool are ease of use, quickness, and does not require any special equipment or machine.

2. Clinical Frailty Scale (CFS):

• This scale evaluates different stages of frailty as very fit, well, well with the resolved coexisted disease, seemingly vulnerable, mil frailty, moderate frailty, severe frailty, very severe frailty, and terminally ill.

• The advantages are that this scale accurately classifies the patients and powerful scale of frailty.

• It determines the physical, social, and mental health of patients. It evaluates for any bone pathology like osteoporosis, anemia, cognitive impairment, chronic inflammation, and depression.

• The cons are it is time-consuming and difficult to use in a clinical setup.

3. Rockwood Mitnitski Frailty Index:

• It is a tool that uses a formula to calculate the frailty index.

• The frailty index is the aggregated deficiencies measures against a reference of pre-listed deficiencies.

• Frailty index = Number of existing health deficiencies / Number of measured health deficiencies.

  • Fit: 0-<0.1

  • Pre-frail: 0.1-<0.2

  • Nearing Frail: 0.2-<0.25

  • Frail: >0.25

• The advantages are its reliability and validity, no special equipment required, and assessment of outcome.

4.Reported Edmonton Frail Scale (REFS):

• It is a combination of the frailty index and cardiovascular health study Frailty test.

• It measures a total of nine clinical signs that is general health, functional independence, cognition, social support, functional performance, nutritional status, use of medication, mood, and continence.

• The scale has a total score of 17 and based on scoring there are five categories starting from not being frail to having severe frailty.

  • 0-5: Not being frail

  • 6-7: Susceptible

  • 8-9: Mild frailty

  • 10-11: Moderate frailty

  • 12-18: Severe frailty

• The advantages are that the tool is very easy to use, so people who do not have any prior training in geriatric evaluation can do it.

• The scale identifies patients at the starting stage of frailty and predicts the prognosis.

• But it has the disadvantages of being time-consuming and difficult to use on patients who are not fluent in the English language or have a vision or hearing difficulty.

5. Cardiovascular Health Study (Fried’s Frailty Phenotype Approach):

• This assessment tool measures five deficiencies namely weight loss, physical activity, speed of walking, strength in muscles, and tiredness.

• It categorizes patients on the number of deficiencies present out of the total number of deficiencies.

  • Robust: The patient will have no problem with the five above-mentioned physical deficiencies.

  • Pre-Frail: There will be a deficiency of one or two physical domains.

  • Frail: There will be a deficiency of three or more physical domains.

• This scale has validity and reliability and requires special equipment for assessment.

• It evaluates patients based on their health status before 2 weeks so it measures the result of acute illness.

• It also uses pictures to show frailty depending on the judgment made clinically by the health professional.

How Does Frailty Assessment Help in Managing Patients?

1. When frailty testing has is carried out on elderly patients perioperatively, the potential risks of complications and the chances of death are identified. So it helps surgeons and others to be well prepared and also disapproves surgery or a specific surgical technique for very frail patients.

2. They can calculate the percentage of benefits against the risks with the help of the frailty score and conclude. Frailty assessment has more advantages like identification of a patient who is prefrail and attempting surgery to reverse and restore their health condition.

3. Their health can be improved by a prehabilitation plan to make them tolerate the surgery better. Alternatively, the prefrail patients can be put under a rehabilitation plan to improvise their prognosis after surgery.

4. The rehabilitation plan mainly focuses on making it easy for the patients to recover their cardiac, and pulmonary function after surgery. Different areas of physical deficits are determined and suitable prehabilitation and rehabilitation therapies are planned.

5. Preoperative management is done according to the patient’s requirements like nutritional plan, physical activity, psychological counseling, and social support.

How Is Frailty Managed?

1. The four main steps of frailty management are first identifying frailty, then determining the incidence and distribution of frailty, assessment through frailty scales, and applying appropriate and individualized interventions for reducing frailty.

2. Comprehensive geriatric assessment is an effective way to decrease the frailty level. A few management techniques are providing proper nutrition in form of healthy food, multivitamin supplements, and Vitamin D, and making patients perform physical exercises and brain training with mental exercises can help to reduce their frailty.

Conclusion

Frailty assessment preoperatively has shown great success and positive outcomes of surgery in geriatric patients. The incidence of frailty increases with increasing age. With appropriate interventions, patients are managed efficiently based on their specific areas of frailty, and the rate of risk of developing complications following surgery is reduced.