Is Frailty More Important Than Age? A Population-Based Study on 47,190 Admissions with Colorectal Cancer Surgery in Older Adults

Background

Surgery is the curative-intent management of colorectal cancer (CRC). Chronological age inadequately captures perioperative vulnerability. Frailty is associated with worse perioperative morbidity, mortality, and longer hospitalization. Hospital Frailty Risk Score (HFRS) is validated for risk-stratifying hospitalized patients.

Methods

A total of 47,190 admissions with age ≥65 years and CRC who underwent colorectal surgery in 2022 in the USA were extracted from the national inpatient sample database. Admissions were categorized into 6 admission groups based on age-groups (65-75, 75-85, ≥85 years) and frailty-status (present, absent) if HFRS>5. Multivariable logistic regression (MLR) adjusted for sex, race, income, and insurance were performed for inpatient mortality and peri-operative complications for each admission group stratified by frailty-status.

Results

Admissions with age-groups of 65-75, 75-85, and ≥85 years represented 46.0%, 38.8%, and 15.2%, respectively. Frailty was present in 27.3% of admissions and was highest in the ≥85 years group (42%). Females and white race represented 50.8% and 76% of admissions, respectively. The median length of stay (LOS), inpatient mortality rate, and perioperative complication rate were 5 days, 1.9%, and 44.9%, respectively. LOS was similar across all non-frail age groups (4-5 days). MLR showed that both age and frailty were statistically associated with inpatient mortality, delirium, ileus/obstruction, sepsis, pneumonia, acute kidney injury, venous thromboembolism, cardiac complications but with higher magnitude for frailty when compared to age group. MLR showed that only frailty was associated with surgical-site-infection, respiratory failure, urinary tract infections, Clostridium-Difficile infection, wound dehiscence, and shock, with minimal effect of age group.

Conclusion

Both age and frailty were associated with higher odds of inpatient mortality and several major perioperative complications. Notably, several complications were driven primarily by frailty status with minimal age-group effects. These findings support incorporating routine frailty screening and frailty-informed perioperative optimization to improve short-term outcomes in older adults undergoing CRC surgery.