Shrinking is measured by simply asking the patient if he/she has had recent unintentional weight loss of greater than 10 pounds; weakness (Figure 1) and slowness are quick physical tests that can be performed in the office or during the preoperative anesthesia visit; and, poor endurance/exhaustion and low activity are questionnaires that the patient fills out and is scored by an independent observer.27 Each component of frailty is scored individually on a binary scale.



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In Fried’s original study, patients were considered frail if they tested positive for ≥4 criteria, with patients positive for 2-3 criteria considered intermediately frail. Not surprisingly, in their large cohort of patients, there was an increased incidence of frailty with increasing age. 

For example, only 3.2% of patients aged 65-70 years were frail whereas 16.3% and 25.7% of patients aged 80-84 years and 85-89 years, respectively, were considered frail.27 Patients who were deemed frail had a statistically significant higher incidence of death, first hospitalization, first fall, worsening ADL disability, and worsening mobility (all p-values < 0.0001).27

Expanding on Fried’s work, Makary and colleagues established the importance of the relationship between frailty and surgical outcomes. In the study by Makary et al study, the authors reported complication rates of 11.4% and 43.5%, respectively, in frail patients undergoing minor and major procedures.28

On multivariate analysis, frailty remained an independent predictor of surgical complications with intermediately frail and frail patients having a nearly 2.0 and 2.5 times higher risk of complications, respectively, compared with non-frail patients. Furthermore, frailty was an independent predictor of increasing length of stay and discharge to a skilled or assisted-care facility. Although not studied by Makary et al, discharge to a skilled nursing facility has been shown to be a risk factor for 90-day mortality after radical cystectomy.29

The initial results found by Makary have been validated in other surgical populations. For example, in pa-
tients undergoing elective laparoscopic 
cholecystectomy, frailty was associated with an increased incidence of postoperative complications (p = 0.022), longer length of hospital stay (p=0.023), and higher pain scales (p = 0.04).30 Similarly, in a study of patients undergoing colorectal surgery for cancer, frail patients were 4.0 and 3.5 times more likely to experience a major complication or a surgical/medical complication.31

Finally, in a study of women with a gynecologic malignancy undergoing resection, 27% and 16% of the patients were either intermediately frail or frail. The presence of any degree of frailty was a statistically significant predictor of a 30 day post-operative complication (p = 0.04).32

These studies highlight that the traditional preoperative evaluation of elderly patients is lacking. Although the number of studies is not large and the ones to date have included a small number of patients, our present methods of understanding patients’ (especially elderly patients’) ability to withstand the intended physiologic stress of surgery is most likely unsophisticated. 

From the studies to date, it is evident that not all elderly surgical patients are created equal, and further refinement is needed. Even in younger patients, detecting frailty may be useful in identifying patients who 
require preoperative intervention/optimization or, perhaps, intensive post-operative care to help forestall adverse post-operative outcomes.


Due to the relative sparseness of measuring frailty in the present surgical literature, we have just completed an initial study and have started a second validation study measuring frailty in a multidisciplinary surgical setting (urology, general surgery, and surgical oncology). We have initially begun with Fried’s criteria as a template and have supplemented those measurements with an assessment of other questionnaires and biochemical variables (e.g., albumin, serum creatinine, estimated glomerular filtration rate, etc.).

The goal of these studies is to potentially create a more precise and potentially concise method to assess patients for preoperative frailty. Although still early, our initial experience has shown us that measuring frailty is quick and inexpensive and can be performed by clinic support staff with minimal disruption to the normal clinic flow.

Furthermore, our initial experience has shown that identifying patients who are either intermediately frail or frail is better at discriminating/predicting adverse postoperative outcomes than existing tools (data in press). If further validated, the routine preoperative measurement of frailty may serve to improve patient risk stratification.


Summary


In general, there is an increasing number of elderly patients that will require surgical procedures for their given medical condition, especially bladder cancer patients. Accurate preoperative assessment of the elderly surgical patient is paramount to identify those who will tolerate the insults of surgery.

Current preoperative assessment tools are inadequate to discriminate between fit and unfit surgical candidates. Failure to do so may either wrongly deny patients the standard of care treatment or put them at a greater, unnecessary risk for adverse perioperative outcomes.

As such, the relatively new concept of surgical frailty may better assess functional reserve and thus the ability of an elderly patient to avoid an untoward outcome after surgery.

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