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While assessing a 76-year-old female scheduled for an upcoming total knee replacement, the patient and her daughter express concerns about the risk of post-operative cognitive changes. The patient’s husband, now deceased, had experienced delirium after a bowel resection, and the family felt that he had never recovered his pre-operative level of cognitive function.
Question: How could frailty assessment help to address this patient’s concerns?
Answer: Systematic reviews demonstrate that, with the exception of a prior history of delirium for the individual patient, the presence of frailty is the strongest risk factor for developing postoperative delirium in older people having surgery (an approximately fourfold increase in the odds of delirium [odds ratio (OR) 4.1, 95%CI 1.4 to 11.7]). Systematic reviews also demonstrate that delirium is associated with subsequent long-term cognitive decline.
By performing a frailty assessment, you could provide the patient and her family with important and relevant information about how likely she was to experience delirium after surgery. For example, if the average risk of delirium in older surgical patients is 20 percent, the presence of frailty would suggest that this patient had at least a 50 percent risk of developing delirium after surgery, whereas the absence of frailty would suggest a risk of 5 percent or less. Further information about delirium prevention, especially related to orientation, availability of glasses and hearing aids, maintenance of normal homeostasis, and avoidance of deliriogenic medications, could be discussed and considered.
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The next patient in your anesthesia pre-assessment unit is a 79-year-old female who is scheduled for a right hemicolectomy for a primary colorectal cancer.
In addition to her colorectal cancer, her past medical history is significant for Type 2 diabetes and hypertension. She has had previous general and neuraxial anesthetics, including for fixation of a femoral neck fracture 2 years ago, without any adverse outcomes. However, when asked, she reports having unintentional weight loss over the past six months and feels that she has slowed down noticeably. Although she still prepares her own meals and goes out to shop, she feels much more tired by day’s end and is concerned that after surgery she will no longer be able to keep up the same level of independence.
Question 1: What is your initial impression of this patient’s frailty status based on the Clinical Frailty Scale?
Answer: Based on this initial assessment, this patient is likely a Clinical Frailty Scale 4 (Vulnerable). She states that she is independent but has slowed down and is more easily tired.
Question 2: Your patient asks how likely it is that she will not be able to go home independently after surgery. How can frailty assessment inform this discussion?
Answer: Approximately 50 percent of older people report losing some independence one month after surgery (e.g., less able to ambulate independently or take care of activities of daily living [such as meal preparation, self care, housework]). However, the presence of frailty provides important information beyond age in determining risk. After elective non-cardiac surgery, 15-20 percent of older people who lived at home before surgery are discharged to an institution (like a skilled nursing facility). Identifying frailty (e.g., Clinical Frailty Scale 4 or higher) increases the odds of not being discharged home approximately fivefold.
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To support its new, fast-track minimally invasive cardiac surgery initiative, your hospital has asked your Department of Anesthesiology to help guide patient assessment and selection. Their goal is to identify patients who will be able to benefit from their procedure (e.g., transcatheter aortic valve insertions) and successfully transition home with a hospitalization of <48 hours. As the target population is mainly older adults, a consultant has recommended frailty assessment using grip strength as part of the patient selection criteria.
Question: How do single item frailty proxy assessments compare to multicomponent assessment?
Answer: “Frailty” has been defined in many ways by many people and little consensus on the best or gold standard definition. However, international consensus has been reached on frailty being a multidimensional state or condition. This means that single item assessments (e.g., grip strength, presence of a frailty defining diagnosis) does not represent a true assessment of frailty. Research also demonstrates that single item frailty proxies, or frailty definitions that only focus on one main area (such as comorbidity), are inferior to multidimensional assessments when trying to accurately predict patients’ risk of morbidity, mortality, and resource use. Therefore, your institution would likely be best served by considering a well validated, multidimensional assessment (e.g., frailty index, Clinical Frailty Scale, Frailty Phenotype, or Edmonton Frail Scale, although the best choice among these may depend on your environment and resources).
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You are about to anesthetize a 71-year-old male for a lower limb bypass vascular surgery. He tells you that in his preoperative assessment by an internal medicine physician, he was told that he had frailty. He mentioned this to his daughter, who had done some online research. She told him that his likelihood of a bad outcome was much higher because of the frailty he had. He asks you whether he is, “crazy to be having this big surgery? Is there any chance that my outcome will be okay?”.
Question: What could you tell this patient in response to his query about his frailty status?
Answer: Frailty is consistently associated with a higher risk of poor outcomes after surgery. However, even with frailty, the large majority of older people survive surgery and get back home safely. Unfortunately, longer term outcomes (e.g., beyond one to three months after surgery) are not well described for older surgical patients. Promisingly, there is evidence that many older patients do have positive long-term outcomes after surgery, and in one multicenter cohort study, older people with frailty had a greater improvement in their self-reported disability status than people without frailty 1 year after elective non-cardiac surgery. This may be because the surgical diagnosis may also contribute to a person’s frailty status, and safe and successful surgical treatment could lead to benefit if an individual is safely able to transition through the perioperative period. However, there are no studies that have randomized older people with frailty to a surgical vs. non-surgical course of treatment, so no data are available to directly inform the question of how surgery impacts frailty and related outcomes long-term.
Ultimately, though, research does suggest that just identifying frailty and communicating its presence to the perioperative team may support better outcomes. This may be due to changes that are then made to the overall approach to care. However, at the end of the day the decision to have surgery is always an individual and autonomous decision for each patient, where frailty assessment can add important information to informed consent and care planning.
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You do not have to make a payment at this time, but you can reach out to your practice/group leader to find out when they plan to pay your dues. Email or call the ASA Support team for assistance: (630) 912-2552 or info@asahq.org.
