Preoperative Frailty Assessment

Frailty can be described as occurring secondary to an age-related decline in multiple physiological systems rendering affected individuals susceptible to sudden health deterioration; often precipitated by minor stressor events unlikely to affect non-frail individuals.

The prevalence of frailty in the perioperative setting has been found to be as high as 28% in patients > 65 years, with affected patients having a threefold increase in risk of death within 90 days of surgery. Frail patients also have an in increased risk of non-fatal complications, prolonged hospital stay and long term institutionalised care following discharge from hospital.

There are multiple assessment tools for frailty described within the literature, the majority of which require training, space and time to administer. This makes assessment and recognition of frailty challenging in the preoperative setting. In our practice we use the Clinical Frailty Scale which is 9-point summary derived from the Canadian Study on Health and Ageing (see downloadable summary sheet for more information).

Comprehensive Geriatric Assessment (CGA) is the internationally established method to clinically assess older people, consisting of a multidisciplinary process to determine medical, psychological and functional capacity. It has been shown that when combined with proactive interventions in the elective surgical population, CGA can have a significant impact on the postoperative outcome of frail patients reducing length of stay and morbidity.

General Recommendations

• Implementation of simple screening tools or 4-m walk test should be considered for older patients during preoperative assessment allowing identification of high-risk patients and referral for specialist CGA.
• Close collaboration between preoperative clinics, Geriatricians and Surgeons in patients with frailty to facilitate shared decision-making with regards to appropriateness of surgery.
• Where surgery is deemed appropriate, proactive optimisation and management of frail patients should be undertaken, ideally through Geriatricians, to facilitate improved outcomes and reduced length of stay. This should include discharge planning in collaboration with family members.
• Where balance of perioperative risks is considered excessive, consideration should be given to non-operative management of frail patients.