January/February 2021

Frailty: Make Frailty Part of Discussions About Surgery 
By Lindsey Getz
Today’s Geriatric Medicine
Vol. 14 No. 1 P. 6

To help prevent poor outcomes, review the patient’s frailty risk.

It’s been said that having surgery is like running a 5K, and that major surgery is like running a marathon. Not surprisingly then, even a minor surgical procedure can take a toll on a frail patient. And frailty can negatively influence outcomes of any type of operation.

According to Ronnie Rosenthal, MD, a surgeon at the Yale School of Medicine, frailty is an age-related syndrome of decreased functional reserve across numerous physiologic systems, leading to increased vulnerability to stressors and negative health outcomes.

There are several methods for categorizing frailty. “The one used most in research is the Frail Phenotype [Fried], which has five characteristics—slow gait speed, decreased activity, unintentional weight loss, weakness, and self-reported exhaustion,” Rosenthal says. “The other most common model is the accumulation of deficits model based on comorbidities. And there are also many simple tools that can be used to measure frailty, such as the Edmonton Frail Scale or the FRAIL Scale, that are easy to use in the office setting.”

A study published in JAMA Surgery in November 2019 found that frail older adults are more likely than other patients to die after surgery, even if the operation went well and there were no complications. According to Daniel E. Hall, MD, MDiV, MHSc, FACS, an associate professor of surgery and staff surgeon at the VA Pittsburgh Healthcare System, and a researcher in that study, “frail patients suffer death and complications an order of magnitude greater than their robust counterparts—even after minor procedures. Many patients and doctors will still choose to pursue surgery because the potential benefit is seen as justifying even the elevated risks. But frail patients should not expect the outcomes typical of any procedure, and this deserves at least a discussion before agreeing to pursue surgical treatment.”

 According to Claire Isbell, MD, MSCI, FACS, a general surgeon at Baylor Scott & White Medical Center in Temple, Texas, and a lead investigator on a frailty study published in the Journal of the American College of Surgeons, frailty is an important risk factor that influences surgical outcomes in the geriatric population—and some younger patients as well, according to her study findings.

“Accessing a patient’s frailty risk well in advance of the need for surgery is the best way to prevent or mitigate complications from a surgery,” she says. “Through a multidisciplinary approach to care, it’s important that surgeons work in close collaboration with geriatricians and, if possible, their primary care doctors. Developing appropriate screening and evaluation methods can be beneficial in helping to determine what resources are needed to prepare the patient and provides the care team information on how best to treat and decrease the potential for complications after surgery."

Having Conversations About Frailty
This is a conversation that should be happening across the board. Since the patient might first present with a problem to their primary care physician (PCP), upon the PCP’s referral to a surgeon, this discussion should ideally already be taking place.

“I think the earlier upstream we’re talking about frailty, the better,” Hall says. “It’s important that PCPs are setting the right expectations in the patients’ minds from the onset. For instance, while it’s true the patient might have hernia, a condition for which surgery would typically be indicated, if the patient is higher risk for surgery because of frailty, it’s valuable that the PCP gives pause and doesn’t set the wrong expectation for what’s going to happen next.”

Hall says that frailty tests should not mean PCPs do not send their patients to specialists or surgeons; it just means that they should play a role in beginning a realistic conversation about expectations.

Rosenthal agrees. “It’s not prudent to just label a patient as ‘frail’ and then deny surgery because of it,” she says. “It’s important to evaluate each older adult for the components of frailty that might be modifiable, such as undernutrition or impaired mobility, and then try to address them. That way, a frail older adult potentially in need of surgery can be prepared and the risks may be lessened.”

Clifford Ko, MD, MS, MSHS, FACS, director of the division of research and optimal patient care for the American College of Surgeons, says having “goals of care” discussions is important. Some patients may care more about their quality of life than about their quantity of years, and that can influence surgical decisions.
Ko, who’s a colon surgeon, uses an example from his specialty. “For instance, finding a small section of colon cancer which would be curable after removing part of the colon,” he says. “If the patient is 87 years old and frail, their recovery might be a lot more difficult than it is for the patient who is 45 and healthy. This is something that must be discussed ahead of time.”

Weighing the Long-Term Benefits
To help facilitate that conversation, the American College of Surgeons has introduced a new standardized program for hospitals devoted to high-quality surgical care for older adults. According to Ko, the Geriatric Surgery Verification (GSV) program introduces 30 new surgical standards designed to systematically improve surgical care and outcomes for the aging adult population. “Unfortunately, right now the mindset is usually just focused on getting patients through the surgery itself,” he says. “While the patient might do fine on the table, it’s what happens during the recovery that we need to be talking more about. We can’t just say, ‘We’ll face things as they come.’ The GSV program puts the recovery conversation at the forefront to evaluate the long-term impact of surgery.”

In some cases, Ko says, surgery can be put off in order to help get the patient more “fit” for surgery. Using his example about colon cancer—which is traditionally slow-growing—it might be more beneficial to delay surgery and spend a month doing “prehabilitation,” a new term for a proactive approach to rehabilitation that prepares patients before surgery.

Ko circles back to the race analogy. “You wouldn’t just go run a 5K or a marathon without any training,” he says. “Having the patients take in purposeful nutrition and have them on their feet and walking around more ahead of surgery are things that can be done to attempt to improve their level of frailty.”

An increasing amount of evidence suggests that some patients may be able to “train” for surgery, Hall says, adding that preliminary research has indicated that in as little as three to four weeks patients can increase pulmonary function or present with better peak airway pressures by adopting some of these “prehabilitation” measures.

That being said, not every patient can overcome frailty, he says. Even with enhanced nutrition and activity, some patients have advanced syndrome of frailty in which they are in a persistent catabolic state. The bottom line is that some patients simply may be too frail for surgery with or without an attempt at prehabilitation.

Aligning Expectations, Goals, and Realistic Outcomes
Having conversations about frailty is not always easy, but it’s important. Framing the risks in ways that patients find helpful is challenging, Hall explains.

“If you simply say, ‘We have a surgery that might fix that, but I think it is a bad idea because of your increased frailty-associated risk,’ we don’t serve our patients well because it forces a false choice between the promise of a ‘fix’ and ‘nothing.’ Americans do not like doing nothing. Rather, we need to become more fluent at phrasing the choice between two competing management strategies—like ‘surgery vs supportive care’ or ‘surgery vs watchful waiting,’” he says.

As doctors describe these two options, Hall says, they need to use storytelling to describe what life would look like under each treatment option—what would it look like in the best, worst, and most likely scenarios. “Each option will have different trade-offs,” he explains. “Some patients may consider only the best case for surgery at first. But when they learn of what the worst case might look like, they may prefer the not-quite-as-good best case of supportive care that does not risk the worst case of disability and death associated with surgery. Different patients will value the options differently, but if we don’t expose for them what is at stake in the decision, their decision for or against either option is uninformed.”

Each case is unique and must be evaluated along with the patient’s goals. “For example, a frail older man with a very symptomatic inguinal hernia that’s limiting his ability to ambulate and participate in the pastimes that bring him joy may choose to have surgery even if the risks of mortality are higher because of his frailty,” Rosenthal says.

But in all cases, patients will be better prepared when they are fully informed. This, Ko says, will ultimately lead to better outcomes. “The better we can prepare a patient not only for surgery but for recovery—both in the hospital and after they’re discharged—the better chance we have at a positive outcome,” he concludes. “It all comes down to preparing them for the entire journey, not just getting through the operation itself. When we start to focus on that end game, the better off our patients and our system will be.”

— Lindsey Getz is an award-winning freelance writer in Royersford, Pennsylvania.