A new study finds that patients who are referred for surgery are often frail or at risk of frailty, suggesting frailty is under-recognized, and more surgical patients could be screened for the condition.1
Published in October 2016, in The Annals of Thoracic Surgery, the study included a cohort of thoracic surgical patients, ages 60 and older. Frailty was screened using an adapted version of Fried’s phenotypic frailty criteria, including weakness – grip strength, slow gait on 15-foot walk, unintentional weight loss, self-reported exhaustion, and self-reported low physical activity.1
Of the 125 participants who completed screening, 57% were pre-frail and 12% were frail. Exhaustion was their most common symptom.1
“We know that frailty has poor surgical outcomes, but there is less research about whether we can change somebody’s frailty status in a way that impacts surgical outcomes,” says Angela Beckert, MD, assistant professor of medicine at the Medical College of Wisconsin in Milwaukee, and the first author on the study.
While the solution is elusive, the first step is to identify the magnitude of the problem, says Mark K. Ferguson, MD, professor, department of surgery and The Cancer Research Center; head of the thoracic surgery service, and director of the residency program in cardiothoracic surgery at the University of Chicago medicine and biological sciences in Chicago. Ferguson is a co-author of the study.
Investigators wanted to learn how many patients are pre-frail or frail, so they started a screening study. Everyone who came into Ferguson’s clinic, who was a potential candidate for surgery, was assessed for frailty.
“In our thoracic surgery population, the most common sign of frailty was fatigue,” Ferguson says. “If you take an orthopedic surgical population, the most common element contributing to frailty is decreased gait speed.”
Physicians who observe fatigue or a slow gait in a patient might want to screen the patient for frailty prior to surgery.
It doesn’t take long to identify possible signs of frailty, Beckert notes. “Patients who are weak or walk really slowly will have a difficult time getting on the examination table. They’re not very active, so any complaint would trigger someone to think, ‘Maybe I should do a more formal assessment of their frailty status.’”
For instance, a physician might notice that the patient took 10 seconds or longer to walk a few steps in the exam room. For a non-frail patient, this might have taken a couple of seconds. “If you observe the patient doing that, then you have a pretty good idea of whether they need to be screened additionally.”
The literature on frailty shows that frail patients are more likely to have adverse effects and surgical complications that could result in hospitalization or increased hospitalization, and they are more likely to die from surgery, Beckert says.
Knowing a patient’s frailty status can be very useful to surgeons.
“They can use the findings to possibly alter the surgery plan,” Ferguson says. “For example, I treat lung cancer, and we could remove a small amount of lung tissue or a large amount of lung tissue; the larger might be the standard of care, but the smaller might be better for a frail patient if we’re concerned about them having risk with the bigger operation.”
Many older patients are pre-frail or frail, and these patients also might be the ones who most need medical attention and surgery, Beckert says. “Age alone isn’t a reason to withhold surgery from someone because some will do well with it.”
But if the patient is identified as frail then there might need to be a conversation with the patient and family about what they might expect from the surgery and what their options are, Beckert says.
Another benefit to screening patients for frailty would be that it gives surgery sites information that can be used to provide more intensive resources in the post-operative period and to help prepare families for complications.
For instance, families could be warned that the patient might have post-operative delirium, which is common in older and frailer people, Ferguson says.
“They might have an increased vulnerability to stress, usually physiological stress, and surgery is a huge physiological stress,” he explains. “Frail patients are more likely to have readmissions and a decreased quality of life in the post-op period.”
Future research could produce answers to why some patients become frail and others do not. There might be genetic markers and morphologic measures that will help identify frailty more accurately than screening tests, he says.
“If we identify somebody who is at increased risk because of frailty, there might be ways to intervene to reverse frailty characteristics, including exercise and nutrition, strength training, training for stamina, endurance, and balance training to prevent falls,” Ferguson says.
It might be possible to help a patient improve his or her physical strength well enough to improve chances of surgical success, he adds.
“Maybe in a few weeks – where it might not be too much of a delay – someone could get into better shape before surgery,” Ferguson says.
- Beckert AK, Huisingh-Scheetz M, Thompson K, et al. Screening for frailty in thoracic surgical patients. Ann Thorac Surg. 2016;S0003-4975(16)31146-8. Epub ahead of print.