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September/October 2024
September/October 2024 Issue Frailty: Understanding Frailty and Procedure Risk Frailty can have a significant impact on older adults, but understanding how it influences recovery can help both providers and patients. There can be many reasons why an older person feels weak or tired. Some of it is simply age. As individuals grow older, natural changes within their bodies, such as those occurring to hormones, muscles, metabolism, and more, can cause them to feel weaker and less energized than they did at their peak. However, just because it’s somewhat expected does not mean it should be ignored, particularly when signs of aging become symptoms of something more. There’s a difference between someone not feeling as strong and active as they were at 35 and experiencing significant changes in well-being. Weakness and tiredness can be symptoms of frailty, for example. “Frailty is classically defined as an aging-related syndrome of physiological decline and poor physiologic reserve associated with adverse health outcomes. The common signs and symptoms of frailty include weak grip strength, low energy, slow walking speed, low physical activity, and unintentional weight loss,” says Raul Coimbra, MD, PhD, FACS, research director at the Comparative Effectiveness and Clinical Outcomes Research Center at Riverside University Health System and a professor of surgery at Loma Linda University. Dae Hyun Kim, MD, ScD, an associate professor of medicine at Harvard Medical School and associate scientist at the Hebrew SeniorLife Marcus Institute for Aging Research, further notes that “It is a spectrum from robust or fit to advanced frailty, rather than presence or absence.” However, he says, it’s important to identify whether an older adult is experiencing frailty or another underlying condition, such as anemia, hormone issues, heart disease, inflammation, depression, or a medication side effect. “If an older adult feels weak and fatigued, a medical workup is needed to rule out other medical reasons for the symptoms,” he explains. When individuals are diagnosed with frailty, their providers need to take this into account. Frailty, like all medical conditions, not only affects older individuals’ well-being but also how they are able to handle illnesses and medical interventions. The Impact of Frailty Frailty also can affect the way an individual recovers or experiences what others may consider a minor illness. The Canadian Frailty Network explains that “When you are frail, your body does not have the ability to cope with minor illnesses that would normally have minimal impact if you were healthy. With frailty, these minor stressors may trigger rapid and dramatic deterioration.”1 Such events can lead to hospitalization and additional complications. In that same vein, an older adult with frailty who needs a medical procedure—minor or major—may face additional complications when recovering. “Almost all older adults experience some degree of physical limitations following major surgery. People living with frailty need a longer time to recover their baseline function, frequently requiring more rehabilitation therapy than those without frailty. They may experience more complications and functional decline after minor surgical procedures,” says Kim, pointing to a retrospective analysis he took part in about the impact of frailty on postdischarge mortality and readmission, published in May 2024. “Those with severe frailty may not recover their baseline function despite technically successful surgery. In other words, a surgery may fix a problem yet add little to the overall quality of life of an older person,” he explains. Frailty can also influence an individual’s mental state when they are recovering from a procedure. Kim states that delirium is more likely to develop after surgery in older adults with frailty, for example. “Delirium can increase the length of stay and impair the person’s ability to participate in necessary postoperative care and rehabilitation after surgery. Postoperative delirium can lead to long-term cognitive impairment. Moreover, protracted recovery after surgery in older people with frailty may have negative effects on their emotional well-being. These multiple negative effects of frailty in older surgical patients necessitate a more comprehensive preoperative assessment,” he says. However, Coimbra cautions that frailty should not be a reason to unnecessarily delay a procedure. Doing so can lead to other negative effects, including the need for emergency medical care as opposed to well-planned and prepared interventions. “We believe that certain elderly patients are not being offered surgical procedures for chronic conditions due to frailty, as it is commonly associated with postoperative adverse outcomes. Ideally, those patients should undergo a period of physiologic optimization to be eventually ready for surgery under strict medical supervision. Not offering this optimization and, ultimately, the opportunity to undergo an operation makes them more vulnerable to complications of the initial disease that went untreated. Some of those patients present to emergency departments with acute complications of the same disease, requiring immediate surgical intervention,” he says. Thus, while it’s important that frailty be taken into account, providers need to do so with a full understanding of the role frailty may play in recovery, as well as the other factors that can and will affect outcomes. Procedure Risk vs Frailty They analyzed data from more than 59,000 older adult patients. Their frailty levels were classified using the Modified 5-Item Frailty Index (mFI-5). “The mFI-5 assigns one point for each of the following: 1. Presence of congestive heart failure; The final score is the sum of all points, and frailty is stratified according to the final score in three categories—No Frailty (mFI05 = 0), Moderate Frailty (MFI-5 = 1) and Significant Frailty mFI-5 ≥ 2), Coimbra explains. Procedure risk was classified as either low or high risk. The researchers found, as hypothesized, that procedure risk was more strongly connected to adverse outcomes than frailty. Patients who were not classified as frail had a 7.1% mortality rate in high-risk procedures. In low-risk procedures, their mortality rate was 0.2%. Patients deemed severely frail, similarly, had higher rates of mortality with high-risk procedures (25.8%) as opposed to low-risk (4.1%). “Our study showed that high-risk procedures are associated with many serious complications and death. We also have shown that compared to frailty, high-risk procedures are associated with a threefold increase in the risk of death and need for reoperation compared to frailty alone,” Coimbra adds. That’s not to say that frailty isn’t an important risk factor when assessing a patient prior to surgery. However, it’s not the only and not necessarily the most impactful factor. The researchers concluded that “Assessing frailty in the elderly EGS patient population without adjusting for the type of procedure or procedure risk ultimately presents an incomplete representation of how frailty impacts patient-related outcomes.”2 Decision Making Frailty is an important part of understanding how a patient will cope with the stressors of a medical intervention. It can be a risk factor for a number of adverse outcomes and, as Kim stresses, should be considered in preoperative assessment. However, as Coimbra’s analysis shows, it should be taken into account as one piece of the puzzle, not the whole. — Sue Coyle, MSW, is a freelance writer in the Philadelphia suburbs.
References 2. Zakhary B. Coimbra BC, Kwon J, Allison-Aipa T, Firek M, Coimbra R. Procedure risk vs. frailty in outcomes for elderly emergency general surgery patients: results of a national analysis [published online April 25, 2024]. J Am Coll Surg. doi: 10.1097/XCS.0000000000001079. |
