Frailty

and
anesthesia
SERGEJ RADOVIĆ

DEPARTEMENT OF CARDIAC
ANESTHESIA AND CRITICAL CARE

CLINICAL CENTER OF
MONTENEGRO

PODGORICA
 Clinical context

▪ Worldwide acceleration of population ageing ( 461 million

older than 65y in 2004, to estimated more than 2 billions
in 2050 )
▪ Profound implications for the planning and delivery of
health and social care
▪ USA, 2010 : 65 year and older 15% of population, 33% of
hospital discharges, 44% of days of inpatient care
▪ The amount of surgery performed in older patients is
increasing at a rate greater than the aging of the
population
▪ New therapies designed for elderly ( TAVI )
 Preoperative risk assessment for
older surgical patients

▪ Before the late 70s : overall health of the patient and

physicians’ judgements regarding survival prognosis
▪ Goldman’s Cardiac Risk Index (1977) : more
quantitative and organ-specific focus
▪ Risk scoring systems for cardiac, pulmonary, renal and
neurological events
▪ Progressive, systemic geriatric syndromes, ( frailty and
baseline disability ) were not captured by organ-based
risk scoring systems !
▪ Frailty - central concept in research on surgical
outcomes for older patients, drawn from geriatrics and
gerontology into surgical and anesthetic practice
 Frailty – first definition in literature ?

„ ...the sixth age shifts into the lean and slipper’d

pantaloon, with spectacles on nose and pouch on
side, his youthful hose well sav’d, a world too wide, for
his shrunk shank…„
W. Shakespeare „ As you like it „

…pa u doba šesto on je k’o lutak, sav presamićen, sa

papučama, s’ naočarima na svom nosu, s’ kesom o
svom boku, a mladićke mu, dobro očuvane, čakšire oko
suvih listova landaraju, široke bestraga...
V. Šekspir „ Kako vam drago “
( prevod Borivoje Nedić i Velimir Živojinović )
 Frailty – concept from gerontology

Williams TF. Comprehensive assessment of

frail elderly in relation to needs for long –
term care.
In: Calkins E, Davis PJ, Ford AB, eds. The
practice of geriatrics. Philadelphia: W B
Saunders 1986
 Frailty – definition ?
Frailty an age-related, multi-dimensional state of decreased physiologic
reserves that results in diminished resiliency, loss of adaptive capacity, and
increased vulnerability to stressors ( accelerated accumulation of health
deficits )

Frailty is a state with high vulnerability to adverse health care

outcomes - hospitalization, functional dependence, disability, falls,
need for institutionalization and mortality
Prevalence of frailty
PATHOPHYSIOLOGY ANS CLINICAL
PRESENTATION OF FRAILTY

Frequent clinical presentations of

frailty
- Non-specific
Extreme fatigue, unexplained weight loss,
and frequent infections.
- Falls
- Delirium
- Fluctuating disability
Day-to-day instability, resulting in patients
with ”good”, independent days, and ”bad”
days on which (professional) care is often
needed

Lancet 2013; 381: 752–62

Frailty – clinical implication

Fit older person

Frail older person

 Frailty – clinical tests

Simple tests single-item frailty markers (high sensitivity,

low specificity) and clinical frailty scores

• Slow walking speed: >5 seconds to walk 4 meters

• Timed up-and-go test: >10 seconds to stand from a chair, walk 3
meters, turn round and sit down again
• Six minute walk test (6MWT): walk as far as possible in 6 min ( 631
± 93 meters )
• Number of medication taken ( appropriate for emergencies )
• Falls
• FRAIL screening tool
• Edmonton Frail Scale
• Multidimesional Frail Score
• ACG (Adjusted Clinical Groups, Johns Hopkins )
• ??????
 Frailty models
Frailty models
- able in predicting both natural history and response to therapeutic
interventions
- underpinned by biological principles of causality
Phenotype model Cumulative deficit model
▪ 5 variables: unintentional weight
loss, self-reported exhaustion,
low energy expenditure, slow gait
speed, and weak grip strength
(The lowest quintile values were
used to define absence or
presence of these variables)
People with Parkinson’s disease,
previous stroke, cognitive
impairment, or depression were
excluded.
▪ ≥ 3 factors frail (7%); 1-2 factors
pre-frail (47%); 0 factors robust =
not frail (46%)
Journal of Gerontology 2001, Vol. 56A, No. 3, M146–M156
- part of the CSHA study 5-year
prospective cohort (n=10 263)
mean age 82 years
- 92 baseline variables of symptoms
(eg, low mood), signs (eg, tremor),
and abnormal laboratory values,
disease states, and disabilities
(collectively referred to as deficits),
were used to define frailty
- frailty index was a simple
calculation of the presence or
absence of each variable as a
proportion of the total (20/92=0·22)
.
CMAJ 2005; 173:489–95
Frailty – screening instruments
Journal of Gerontology 2001, Vol. 56A, No. 3, M146–M156
4,735 in the original and 582 in the African
American cohort = 5,317

Journal of Gerontology 2001, Vol. 56A, No. 3, M146–M156

Journal of Gerontology 2001, Vol. 56A, No. 3, M146–M156
-92 baseline variables of symptoms (eg, low mood),
signs (eg, tremor), and abnormal laboratory values,
disease states, and disabilities (collectively referred to
as deficits), were used to define frailty

CMAJ2005;173(5):489-95
Normal aging, frailty and performance
4 risk models:
- the frailty index (Fried),
- ASA score,
- Lee’s revised cardiac risk index
- Eagle score

Ability of the specific risk index to predict

surgical complications and discharge to an
assisted or skilled nursing facility. Frailty was
added to the risk index scoring to
demonstrate the combined ability of these
indices to predict discharge disposition

J Am Coll Surg 2010;210:901–908

DESIGN, SETTING AND PARTICIPANTS From October 19, 2011, to July 31, 2012,
a single tertiary care center, 275 consecutive elderly patients (aged ≥ 65 years)
undergoing intermediate- or high-risk elective operations

JAMA Surg. 2014;149(7):633-640

JAMA Surg. 2014;149(7):633-640
OBJECTIVE: To measure the population-level effect of patient frailty on, and its
association with, 1-year postoperative mortality
EXPOSURE: Frailty, as defined by the Johns Hopkins Adjusted Clinical Groups
(ACG) frailty-defining diagnoses indicator ( a binary variable that uses 12
clusters of frailty-defining diagnoses)
MAIN OUTCOMES AND MEASURES: One-year all-cause postoperative
mortality
 While the choice to proceed with an elective surgery must be weighed
on a case-by-case basis, our findings support the need for thorough
considerations of risk vs benefit and the overall goals of care in frail
patients considering major surgery
…A surgical frail score probably should be tailored to define frail
characteristics that are modifiable, with the goal of improving surgical
outcomes…
JACC Vol. 221, No. 6, December 2015
 Frailty and cardiac surgery

▪ Significant overestimation of EuroSCORE II in

patients with isolated CABG ; a slight
underestimation of predictions in high-risk patients
( meta-analysis of 22 studies; 145,592 cardiac
surgery procedures ) J Thorac Cardiovasc Surg.2014;148:3049–57
▪ 2014 AHA/ACC guideline for the management of
patients with valvular heart disease: frailty must be
taken into consideration as an evaluation of
surgical and interventional risk
 Frailty and cardiac surgery

Frailty is an independent predictor of adverse outcome following cardiac

surgery or transcatheter aortic valve implantation, increasing the risk of
mortality 2- to 4-fold compared with non-frail patients
Interactive CardioVascular and Thoracic Surgery 17 (2013) 398–402

Preoperative surgical risk assessment using frailty scores or indices may

be useful tools and have the potential to consider surgical intervention
for elderly patients
Gen Thorac Cardiovasc Surg (2015) 63:425–433
 Frailty and TAVI

Relation Between Six-Minute Walk Test

Performance and Outcomes After Transcatheter
Aortic Valve Implantation (from the PARTNER
Trial)
Among high-risk older adults undergoing TAVI, baseline 6MWTD does not predict
procedural outcomes but does predict long-term mortality.
Am J Cardiol. 2013;112:700–6

Impact of frailty on short- and long-term morbidity and mortality after

transcatheter aortic valve implantation: risk assessment by Katz Index of
activities of daily living
Katz Index < 6 was identified as a significant independent predictor of long-term
all-cause mortality by multivariate analysis (HR 2.67 [95% CI: 1.7-4.3],
p<0.0001). During follow-up (median observation period 537 days) 56% of frail
vs. 24% of non-frail patients died.
Eurointervention. 2014;10:609–19
 Frailty and cardiac surgery

Surgeons need objective, standardized frailty criteria to confirm their

bedside ‘‘eyeball’’ test. In today’s environment, the notion that we can
operate does not always equate to we should operate.

The Journal of Thoracic and Cardiovascular Surgery ( 2014 ) Volume 148, Number 6
Frailty & cognitive dysfunction
shared outcomes
Frailty and risk of cognitive decline

The Journal of Nutrition, Health & Aging Volume 17, Number 9, 2013
Frailty and cognition
longitudinal studies

Samper-Ternent et al., J Am Geriatr Soc 2008

 Cognitive frailty
more questions than answers

▪ No universally adopted definition

▪ Need to be differentiated from prodromal
dementia
▪ Unknown prevalence
▪ Not validated in surgical settings
▪ Value of prehabilitation ?
 FRAILTY IS RELATED TO AGEING
AGEING DOESN’T EQUATES FRAILTY