Frailty Underrecognized in Older Surgical Patients

By Jamie Santa Cruz

Identifying patients who are frail or prefrail prior to surgery and offering frailty reduction interventions could improve outcomes for many geriatric patients.

Frailty is associated with a variety of negative outcomes for surgical patients, including an increased surgical complication rate, increased hospital length of stay, increased likelihood of being discharged to an institution, and increased mortality.1-3 Despite the relevance of frailty to surgical outcomes, new research suggests that frailty may be significantly underrecognized in surgical patients.4 The researchers also suggest that identifying patients who are frail or prefrail and offering frailty reduction interventions could improve outcomes for many geriatric patients.

For the study, published in The Annals of Thoracic Surgery, the researchers screened 125 patients in a thoracic surgery clinic who were considered candidates for major thoracic surgery. Using the well-known Fried physical frailty scoring method, they evaluated each patient according to five criteria, including gait, hand grip, weight loss, level of activity, and exhaustion. Per the Fried methodology, those with abnormalities in three to five categories were considered frail, while those with abnormalities in one to two categories were considered prefrail. Using this method, almost 70% of the patients in the study were found to be either frail (12%) or prefrail (57%).4

"That's considerably higher than what we would expect in a normal community-based sample," says Angela K. Beckert, an assistant professor of geriatrics and gerontology at the Medical College of Wisconsin and lead author of the study.

In Fried's original study developing the phenotypic frailty criteria, only 7% of participants were found to be frail and 47% prefrail.1 A previous study specifically of surgical patients using Fried's frailty criteria likewise found comparatively lower prevalence of frailty, with 10% of participants demonstrating frailty and 31% prefrailty, for a total of 41% in both categories.2 The high prevalence in the new study, Beckert says, is likely a reflection of the kind of patients seen in thoracic surgery clinics, many of whom have many comorbidities.

Although previous research has found a higher prevalence of frailty in women,1 Beckert and colleagues did not find a statistically significant gender difference in frailty prevalence. In their sample as a whole, the most common abnormality was exhaustion (as gauged by self-report), whereas abnormality with respect to gait was the least common. According to Mark Ferguson, MD, a professor of surgery at the University of Chicago School of Medicine and the senior author of the study, the findings regarding the relative prevalence of each type of abnormality are the reverse of what prior research has found in other patient populations, particularly in orthopedic patient populations, where gait tends to be the most common abnormality.

Frailty status did not significantly correlate with Eastern Cooperative Oncology Group (ECOG) performance status, which is a general measure of overall vigor. Specifically, many more patients were frail/prefrail (68.8%) than had low performance status. Although frailty and performance status have both been associated with poorer surgical outcomes,5 the higher prevalence of frailty and prefrailty suggests that frailty status may be a better marker for surgical risk than ECOG status alone.

Importance of Identifying Frailty Status
Given the prevalence of frailty and the negative outcomes associated with frailty following surgery, the next question is whether the potential exists for altering frailty status. According to Beckert, there are little data available on frailty mitigation specifically in presurgical patients. However, some research from nonsurgical patients suggests that it is indeed possible to alter frailty status and improve physical performance. Certain exercise interventions, for example, have been shown to improve measures of frailty in a matter of weeks, suggesting that short presurgical interventions may be feasible.6,7

It is significant that a much higher percentage of patients in the new study were prefrail as opposed to frail, since prefrail patients typically have a better response to intervention. "It's harder to improve physical performance and frailty status in patients who are already frail," Beckert says. "I think that actually provides a good window of opportunity for intervention in this group."

Even when it may not be possible to alter frailty status, recognition of a patient's physical capacity is useful prior to surgery, especially in consenting a patient. "Knowledge of level of frailty gives the surgeon opportunity to discuss things in a very informed way with the patient and with the patient's family" so that all involved are aware of the patient's increased risk, Ferguson says.

In some cases, frailty status may motivate the surgeon to consider alternatives, such as a smaller operation or, for a tumor, radiation or chemotherapy. "I do think that sometimes the outcomes in frail patients are bad enough that it might change the conversation about whether or not to proceed with surgery," Beckert says.

If the surgeon recommends moving ahead with the original surgery as planned, knowing that a patient is frail can help both surgeon and patient plan appropriately for the perioperative and postoperative periods. Frail patients are at greater risk for postoperative dementia, for example, so Ferguson suggests planning for these patients to be placed in nonacute beds and having family members around them to reduce the risk. Similarly, frail patients will probably need more physical and occupational therapy than normal following surgery, and family members may wish to arrange time off in advance to care for the patient.

"Knowing that a patient is more likely to have a longer hospital length of stay, they're more likely to be discharged to an institution—it's good to prepare them for those things," Beckert says.

Identifying Frailty in a Clinical Setting
In theory, a formal frailty assessment can be done simply and cost effectively, according to Ferguson. Training in how to conduct a formal assessment takes only five to 10 minutes, and the only equipment required is a dynamometer (to measure hand-grip strength) and a stopwatch or smartphone to time gait. Other than that, screening simply involves an assessment of weight loss, levels of fatigue, and a physical activity questionnaire. "It's not equipment intensive, and it's quite easy to calculate the results," Ferguson says.

On the other hand, Beckert says, conducting a formal frailty screening using Fried's criteria on every geriatric patient in a general clinician visit may not be realistic, partly because of the requirement of using the dynamometer for the grip-strength assessment. "That's probably not going to happen," she says.

Beckert adds, however, that physicians can easily conduct a more basic informal screening on all patients. "Just look at general things—does a patient walk in slowly? Have they been losing weight? Do they feel exhausted? Are they active in their lives or are they mostly bed bound or chair bound?" To test weakness, the Fried methodology relies on a dynamometer, but Beckert suggests it is possible to gauge weakness on a more basic level by, for example, asking patients whether they have trouble opening jars. She adds that if an informal assessment along these lines produces concerns about a patient who seems frail, then physicians may wish to conduct a full formal screening.

Ferguson agrees that a full formal screening for every patient is unnecessary. "It's very easy to get a quick assessment of a patient—for example, by having the patient walk from a chair to climb up one low step onto the exam table, then turn around and sit down. That process can be extremely informative. One person might do it in less than a second, and the next person it might take them eight to 10 seconds to get their balance, figure out how to turn around, make sure that they're seated accurately."

If a patient appears vigorous in this simple exercise, Ferguson says, there is no need for additional screening. "It's the ones who are in a gray area or who are clearly impaired that I think are important to do the formal assessment for."

Frailty Reduction Interventions
As mentioned above, no prior research has focused specifically on frailty reduction in preoperative patients, but prior studies in nonsurgical patients have found exercise to be beneficial in mitigating frailty status. "We know from studies of other patient populations that a fairly short course of frequent resistance training does improve muscle mass and muscle strength, and those are the kinds of things that can help reduce frailty," Ferguson says.

By contrast, Beckert says, interventions focusing on nutrition alone (with the prescription of nutrition supplements, for example) and those involving pharmacologic agents such as steroids have been less successful. In some cases, a focus on both exercise and nutrition may be beneficial, since one of the frailty criteria is weight loss. Generally, however, Beckert says, interventions involving exercise alone tend to be as effective as those that involve both nutrition and exercise.

Regarding methods for constructing a frailty reduction intervention prior to surgery, Ferguson and his colleagues are involved in ongoing research to determine the effectiveness of specific presurgical interventions. They are examining not only how interventions improve frailty risk scores, but also how those improved scores impact patients' incidence of complications and their resilience in recovering from such complications. Although results from that research are still pending, Ferguson speculates that an intervention lasting three to four weeks and involving a variety of forms of exercise, including strength training, endurance training, and balance training, will produce meaningful results, especially for patients in the prefrail category.

"We think that even a short course of exercise […] can perhaps reverse a prefrail patient to a nonfrail or bring a frail patient to prefrail," Ferguson says.

— Jamie Santa Cruz is a freelance writer based in Englewood, Colorado.

References
1. Fried LP, Tangen CM, Walston J, et al. Frailty in older adults: evidence for a phenotype. J Gerontol A Biol Sci Med Sci. 2001;56(3):M146-M156.

2. Makary MA, Segev DL, Pronovost PJ, et al. Frailty as a predictor of surgical outcomes in older patients. J Am Coll Surg. 2010;210(6):901-908.

3. Robinson TN, Eiseman B, Wallace JI, et al. Redefining geriatric preoperative assessment using frailty, disability and co-morbidity. Ann Surg. 2009;250(3):449-455.

4. Beckert AK, Huisingh-Scheetz M, Thompson K, et al. Screening for frailty in thoracic surgical patients [published online October 4, 2016]. Ann Thorac Surg. doi: 10.1016/j.athoracsur.2016.08.078.

5. PACE participants, Audisio RA, Pope D, et al. Shall we operate? Preoperative assessment in elderly cancer patients (PACE) can help. A SIOG surgical task force prospective study. Crit Rev Oncol Hematol. 2008;65(2):156-163.

6. Marsh AP, Chmelo EA, Katula JA, Mihalko SL, Rejeski WJ. Should physical activity programs be tailored when older adults have compromised function? J Aging Phys Act. 2009;17(3):294-306.

7. Drey M, Zech A, Freiberger E, et al. Effects of strength training versus power training on physical performance in prefrail community-dwelling older adults. Gerontology. 2012;58(3):197-204.