Frailty

• There are various definitions of frailty, all of which touch on themes such as reduced reserve, reduced function and increased vulnerability:

A decreased physiological reserve across multiple organ systems, with reduced capacity to compensate effectively for external stressors, leading to adverse outcomes

Frailty is a clinically recognisable state of increased vulnerability resulting from an ageing-associated decline in reserve and function across multiple physiological systems

Frailty is defined as a multidomain decline in physiological reserve and function resulting in an increased vulnerability to stressors

• Higher rates of frailty in females and those with lower socioeconomic class

• Age is not the sole predictor of frailty, and a variety of biopsychosocial factors can affect an individual's degree of frailty
• Frailty does, however, increase with age, such that:
• 26% of patients >65yrs were frail in NAP7
• It affects 50% of those >85yrs

• Frail patients are more likely to require surgery and therefore be encountered by the anaesthetist
• They are more likely to require complex or major surgery
• They are more likely to require urgent or emergency surgery, owing to:
• Decisions made earlier in the elective pathway e.g. choosing not to offer or proceed with surgery
• Co-association with conditions such as fragility fractures, vascular disease and cancer


• It's estimated 300,000 older people living with frailty undergo surgery each year
• Approximately 1 in 11 (9%) of all adult, non-obstetric surgical patients are frail
• A third of patients undergoing emergency laparotomy are frail
• Patients who are frail are more likely to have limitations on care (15%) and/or DNACPR recommendations (24%)

• There are two main models of frailty:
1. The frailty phenotype - based on aspects of physical decline
2. The frailty index - based on multiple domains


• There's some evidence linking frailty to inflammation, although it may be causal, responsive or an epi-phenomenon i.e. a marker of other processes such as oxidative stress

• Described by Fried and colleagues in 2001 as a clinical syndrome, requiring ≥3 of:
• Unintentional weight loss of 4kg in the past year
• Self-reported exhaustion
• Weakness (specifically grip strength)
• Slow walking speed
• Low physical activity


• The presence of the frailty phenotype was predictive of progressive decline, falls, hospital admissions and death

• I.e. the Rockwood Frailty Scale a.k.a. clinical frailty scale
• A deficit accumulation model, whereby a numerical frailty index is calculated from the number of deficits an individual accrues across various domains:
• Currently illnesses
• Activities of daily living
• Physical signs

• Other syndromes may also be present in ageing individuals, such as:


• Sarcopaenia
• Low muscle mass + either low muscle strength or low physical performance
• Associated with increased post-operative 30-day mortality
• Increased susceptibility to developing sepsis


• Cachexia
• A complex metabolic syndrome associated with underlying illness


• Poor nutritional status and weight loss
• Falls

• There is no standardised method for measuring frailty, however frailty leads to a reduced ability to function normally
• This renders the frail individual vulnerable to even minor environmental stresses

• Clinical first impressions of an experienced clinician; cheap but requires experience


• Edmonton Frail Scale
• Seventeen point scale validated to assess frailty
• Includes the 'get up and go' test, which can help predict perioperative morbidity and mortality


• Electronic Frailty Index
• Clinical Frailty Scale (see below)

• A simple scoring system which assigns an individual a clinical frailty score of 1-9 based on their current level of function and comorbidity

1. Very fit: People who are robust, active, energetic and motivated. These people commonly exercise regularly. They are among the fittest for their age.


2. Well: – People who have no active disease symptoms but are less fit than category 1. Often, they exercise or are very active occasionally, e.g. seasonally.


3. Managing well: People whose medical problems are well controlled, but are not regularly active beyond routine walking.


4. Vulnerable: While not dependent on others for daily help, often symptoms limit activities. A common complaint is being “slowed up”, and/or being tired during the day.


5. Mildly frail: These people often have more evident slowing, and need help in high order IADLs (finances, transportation, heavy housework, medications). Typically, mild frailty progressively impairs shopping and walking outside alone, meal preparation and housework.


6. Moderately frail: People need help with all outside activities and with keeping house. Inside, they often have problems with stairs and need help with bathing and might need minimal assistance (cuing, standby) with dressing.


7. Severely frail: Completely dependent for personal care, from whatever cause (physical or cognitive). Even so, they seem stable and not at high risk of dying (within ~ 6 months).


8. Very severely frail: Completely dependent, approaching the end of life. Typically, they could not recover even from a minor illness.


9. Terminally ill: Approaching the end of life. This category applies to people with a life expectancy <6 months, who are not otherwise evidently frail.

• The number of comorbidities increases with increasing clinical frailty score; 70% of patients with frailty live with multimorbidity

• Increasing frailty is associated with poorer outcomes after surgery

• Frail patients are more likely to undergo emergency laparotomy, but experience worse outcomes (ELF Study, 2021):
• 90-day mortality was directly associated with frailty
• Compared to a CFS of 1, there was an increased 90-day mortality with a CFS of 5 (aOR 3.18) or 6-7 (aOR 6.10)
• There was an associated increase in risk of complications, duration of ICU stay and hospital stay
• This is in keeping with the 2023 NELA report, which found mortality after emergency laparotomy is doubled in frail patients (13% vs. 5.9%)

• In two studies of outcomes for frail patients on ICU, the prevalence of frailty ranged from 29.5% to 39.4%
• Adverse outcomes include in frail patients include:
• Longer duration of mechanical ventilation
• Longer duration of ICU stay
• Higher short-term and long-term ICU mortality
• More likely to be discharged to a care facility
• Fewer days alive at home at 30 days and 365 days

• Formal assessment for frailty (e.g. Edmonton frail scale, CFS) to allow risk stratification
• Use of frailty risk instruments improves prediction of frailty-associated mortality compared to demographic data (age, gender, ASA, physical status) alone
• Recognition of frailty by formal assessment improves ability to predict post-operative complications BJA, 2022
• Comprehensive geriatric assessment for those with CFS ≥5


• Cognitive screening


• Nutritional assessment


• Current medication review

• Close MDT work including anaesthetists, intensive care team, surgeons, older persons physicians, old-age psychiatrists, nursing staff, pharmacists, physiotherapists, and dieticians
• Proactive care of Older People undergoing Surgery (POPS) model recommends early MDT input and can help reduce complications and LOS


• Consider prehabilitation or at least physiotherapy
• Nutritional optimisation with input from dieticians and community servies
• Treat depression or other mood disorders
• De-prescribing: appropriate drug discontinuation has been linked to beneficial changes, including reductions in mortality, referrals to acute care, and health costs

• Formal assessment for frailty to allow risk stratification
• Prompt senior and MDT review
• Reduce use of drugs which may precipitate delirium
• Meticulous approach to factors which may impact cognition e.g. normothermia, maintaining hydration

• Senior anaesthetic input
• Avoid the use of unnecessary urethral catheters to reduce the risk of a hospital acquired catheter related urinary tract infection
• Formulate a pharmacological strategy to avoid anticholinergic load; e.g. avoid benzodiazepines, cyclizine, tramadol, atropine


• Maintain intra-operative physiological homeostasis such as:
• Normothermia
• Normotension (± 20% of pre-operative range)


• Multi-modal opioid-sparing analgesia e.g. regional techniques
• Consider use of depth-of-anaesthesia monitoring to titrate appropriately


• Employ strategies for moving and positioning the patient living with frailty
• E.g. adapting positioning techniques which protect impaired musculoskeletal and integumentary systems
• E.g. lifting in preference to sliding
• Use of gel type pressuring relieving supports to help secure a specific posture and avoid movements outside of an individual’s normal range of motion
• Application of soft padding or cotton wool bandages to potential pressure areas

• Ensure patients have access to dentures and sensory aids in recovery
• Assess, document and treat pain utilising relevant scoring system (e.g. Abbey or PAINAD scales) for patients with cognitive impairment
• Multi-modal, opioid-sparing and NSAID-avoiding analgesic strategies