Pre-Op Assessment of the Elderly and Frail

Introduction
Frailty is not addressed adequately in traditional models of pre-op assessment
- these assume that chronological age is less important than comorbidities accumulated
- but chronological age is an independent risk factor for major surgery
Geriatric patients develop 'frailty'
- a physiological vulnerability not adequately captured by individual end-organ assessments
- a lack of physical reserve across multiple organ systems
Assessment of elderly and frailty should supplement and not replace traditional pre-op assessment

Frailty
A multisystem reduced physiologic reserve associated with increased disability and culminating in an increased susceptibility to stress.
Consider all organ systems and functions in the elderly
- cognitive, mobility, ADLs, continence, skin and pressure areas, delirium, nutrition, falls, depression, etc
- independent risk factors within frailty include cognitive dysfunction, recent wgt loss, low albumin, functional dependence and depression.
Associated with polypharmacy and psychosocial isolation
Can be quantitatively measured by sum of frailty traits
- three or more = frailty
- less but still some = pre-frailty, also associated with poorer surgical outcomes in major procedures.
--> E.g. indicators include Charlson index, MMSE, Katz ADL score
Disability is difficulty or dependence on ADLs
- another risk factor for mortality after surgery
- bathing is the first ADL that usually requires assistance so is a good screening guide to disability
Comorbidity
- Charlson Index has proven utility
- by comparison ASA has not adequately reflected poor outcomes
Malnutrition
- occurs in old frail pts; physiological anorexia of ageing
Consider social vulnerability as a marker of frailty

Frailty and Surgery
Strong correlation between degree of frailty and poor outcomes from surgery
- ie morbidity, organ dysfunction, mortality, stay, institutionalization after surgery
- associated with delerium, which itself is associated with markedly worse surgical outcomes
Can be applied within the global risk assessment of elderly surgical patients
- preop nurse can be used to quantify frailty according to established quantifying tools
--> can usefully inform in patient / family consultation, risk assessment and decision to operate or not.
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