Managing frailty in the outpatient surgical setting
Increasing numbers of older people are undergoing elective surgery. Studies examining older patients undergoing elective procedures have reported frailty prevalence of 40-50%.
Frailty is an independent risk factor for post-operative major morbidity, mortality, protracted length of stay and institutional discharge.
It is important to identify frailty preoperatively in order to manage risk, inform shared decision making and highlight areas for potential modification.
Whilst there is a lack of consensus on which tool should be used to identify frailty in surgical settings, as noted above, evidence is emerging for the use of the Edmonton Frail Scale 13. The strengths of this tool include brevity, clinical feasibility and identification of aspects of frailty amenable to preoperative optimisation (e.g. cognition, nutrition). Furthermore, the association of preoperative gait velocity with postoperative morbidity and mortality makes this a potentially useful frailty measure in the elective pre-operative setting.
There are no proven strategies for pre-operative management of frailty in surgical patients, however there is increasing evidence for exercise, nutritional and multi-component interventions to improve outcomes in this group 19. The translation of such approaches into routine clinical care requires close collaboration between surgeons, anaesthetists and geriatricians working as part of a multidisciplinary team. Examples of such working include proactive care of older people undergoing surgery 20 and systematic care of older people undergoing elective surgery 21. This will need to be factored into the commissioning of surgical pathways and has significant policy implications but has been endorsed by the National Confidential Enquiry into Patient Outcome and Death (NCEPOD) and the British Geriatrics Society (BGS).