Frailty

Definition

• Frailty is defined as increased physical vulnerability of a patient due to a number of pre-disposing factors
• Frailty is an aging-related syndrome of physiological decline, characterized by marked vulnerability to adverse health outcomes.”

Assessment

Frailty can be assessed with a number of factors and scoring systems.

Eastern Cooperative Oncology Group score

• Identifies how active and functional a person is (From 0 fully active -4 bed or chairbound requiring complete care, based on their limitations)
• PS 0 – you are fully active, more or less as you were before your illness
• PS 1 – you can’t carry out heavy physical work, but can do anything else
• PS 2 – you are up and about more than half the day. You can look after yourself but can’t work
• PS 3 – you are in bed or a chair for more than half the day. You need help to look after yourself
• PS 4 – you are in bed or a chair all the time and need complete care

Clinical Frailty Scale

A scale of 1-9, which takes into account comorbidities, physical activity, degree of independence with ADL’s and life expectancy. ability to mobilise, independence, risk of falls and activities of daily living

FRAIL scale

• Fatigue (“Have you felt fatigued? Most or all of the time over the past month?“) Yes = 1, No = 0
• Resistance (“Do you have difficulty climbing a flight of stairs?“) Yes = 1, No = 0
• Ambulation (“Do you have difficulty walking one block?“) Yes = 1, No = 0
• Illnesses (“Do you have any of these illnesses: hypertension, diabetes, cancer (other than a minor skin cancer), chronic lung disease, heart attack, congestive heart failure, angina, asthma, arthritis, stroke, and kidney disease?”) Five or greater = 1, fewer than 5 = 0
• Loss of weight (“Have you lost more than 5 percent of your weight in the past year?”) Yes= 1, No = 0

Frail scale scores range from 0 to 5 (0 = best, 5 = worst) and represent frail (3 to 5), pre-frail (1 to 2), and robust (0) health status.

Reducing perioperative risk

• Pre-op
  • Discussion with patient and family about risk vs benefits. Goals of care. Risk of loss of independence, need for higher level care, delirium, progressive decline
  • Formal assessment of risk of surgery using P-possum or NZ risk score
  • Pre-habilitation: Optimising strength, nutrition, social support, cognitive function and comorbidities prior to surgery
  • Involvement of MDT (physio, social worker, OT) geriatrician or physician to optimize patient
• Intra-op
  • Choosing less invasive, less extensive or less risky options where available
• Post-op
  • Monitoring and aggressively treating post-op complications (delirium, UTI, pneumonia, infection)
  • Involvement of family and social supports
  • Involvement of MDT to assist recovery and return to function
  • Consideration of rehabilitation admission to assist