More than half of all surgeries performed in the US are thought to be for patients over 65 years of age (Dall et al., 2013). For some types of surgical patients, the prevalence of frailty approaches 50%. Frailty therefore represents an increasingly important aspect of planning for optimal surgical care, as the share of the US population over age 65 is continuing to expand (Vespa et al., 2020; Braude et al., 2016). Frailty is recognized as an independent predictor of poor outcomes following surgery, which means assessing frailty with an adequate tool is increasing recognized as a key part of perioperative risk stratification for older surgical patients (Partridge et al., 2012). The goal of including frailty assessment in surgical decision-making is ultimately to develop techniques to mitigate the negative effects on surgical outcomes among older, vulnerable patients.
Impact of frailty on surgery (and surgical outcomes) in older patients:
Frailty is a well-validated predictor of poor postoperative outcomes such as a greater incidence of serious morbidity and mortality, extended length of hospital stay, increased dependency, and frequent readmissions to an acute care facility (Dall et al., 2013; Braude et al., 2016; Partridge et al., 2012). A recent meta-analysis of 56 studies with over 1 million patients following non-cardiac surgeries demonstrated a 3.4-fold increased risk in mortality, 2.1-fold increased risk for developing postoperative delirium, and a 2.3-fold increased risk for requiring a specialty facility upon discharge in frail patients as compared to non-frail patients (Tjeertes et al., 2020). Not only does failure to recognizing the needs of older adults result in poor outcomes, but also failure to consider their goals of care. Frail patients often experience a loss of independence following major surgery, with long-lasting effects on quality of life and subsequent health (Gearhart et al., 2020; De Roo et al., 2020). These outcomes are increasing recognized as important, perhaps even more than more traditional measures. For example, although disease-free survival from the time of diagnosis is the most commonly used indicator of successful cancer treatment, older patients have preferred to focus on long-term functional status, physical performance, and maintenance of independence (Fried et al., 2002). A similar shift in focus may also be applicable to surgical decision making informed by frailty assessments.
Applying knowledge of frailty to the treatment of older surgical patients:
In 2013, the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP), in collaboration with the American Geriatrics Society (AGS), issued best practices guidelines recommending the incorporation of pre-operative frailty assessment into clinical practice to address the trend of a rapidly aging U.S. population (Mohanty et al., 2016). Over the course of the past seven years, the ACS and AGS have partnered to develop 32 standards which are recognized as necessary to provide appropriate care for our older patients. Please see the Geriatric Surgery Verification website at https://www.facs.org/quality-programs/geriatric-surgery for more information. Hospitals implementing these standards can now undergo a verification process through the American College of Surgeons which recognizes their excellence in care of older surgical patients.
Identifying and routinizing best practices can improve care by ensuring that uniformly recognized protocols are followed. Enhanced Recovery After Surgery (ERAS) is an established program for all surgical patients that utilizes evidence-based practices to minimize the physiologic stress of surgery and reduce variability in care through a multidisciplinary approach (Wick et al., 2015). In a similar fashion, other programs such as the Geriatric Oncology Surgical Assessment and Functional Recovery after Surgery (GOSAFE) have been implemented to provide personalized oncology care for geriatric patients (Montroni et al., 2020).
Research is needed to identify effective pre-operative interventions, modifications to operative techniques, or post-operative care algorithms that will improve outcomes for higher risk older patients. The current interventions which have shown promise include pre and post-surgery exercise programs, nutritional support, and multimodal perioperative pain management. Although there is no consensus on the best form of exercise, some authors have demonstrated the any functional exercise capacity improvement preoperatively was associated with an improved postoperative recovery (McIsaac et al., 2017). In addition, several studies have demonstrated that a minimally invasive surgical approach limits postoperative pain and mobility concerns and improves outcomes in older patients (Cowan et al., 2017; Saxer et al., 2018; Konstantinidis et al., 2017). Currently, there are several ongoing trials using more targeted interventions which aim to evaluate the effects of exercise (strength, aerobic, and stretching) and high-protein nutritional supplements on postoperative recovery and health-related quality following surgery in our older frail patients.