The landscape of surgical practice is changing rapidly because of the aging of the U.S. population. The number of Americans older than 65 years will increase from 40 million in 2010 to 72 million in 2030.1 Optimal care of this older patient population will require a well-coordinated integration of the many facets of the modern-day health care system. We need to recognize that surgeons will be more likely to operate on patients well into their 70s, 80s, and even 90s. Delivery of surgical services to the vulnerable elderly cancer patient will be greatly strained. With complex surgical procedures—such as pancreaticoduodenectomy—being more commonly performed in the geriatric population, understanding who can tolerate and fully recover from these interventions has become an important and intense area of investigation.
What is frailty?
Frailty is a clinical syndrome of physiologic decline later in life and is not defined simply by advanced age. Frailty is associated with increased vulnerability to adverse outcomes and intolerance to surgical interventions due to an inability to adapt and withstand stressors. In 2001, Fried et al defined the frailty phenotype by the presence of three or more of the following: more than 10-pound weight loss, poor grip strength, self-reported exhaustion, slow gait, and low physical activity level.2 Numerous questionnaires, composite measures, devices, and instruments have been developed to help identify the frail patient. Common clinical assessments include the grip strength dynamometer, four-meter gait speed, “timed up and go” test, and short physical performance battery. Composite frailty scores also have been created using questionnaires, such as the Canadian Study of Health and Aging Frailty Index, or electronic health record, such as the modified Frailty Index.3,4
In a broad sense, frailty increases a patient’s risk of multiple adverse outcomes and is associated with inhospital falls, procedural complications, prolonged hospitalization, discharge to facility, and postoperative mortality. Using a comprehensive geriatric assessment, providers are able to identify at-risk frail patients. For example, Klepin and colleagues showed that geriatric assessment (in particular, impaired cognitive and physical function) was associated with worse overall survival in patients with newly diagnosed acute myelogenous leukemia, even after adjusting for disease severity and other potential confounders.5
While an exhaustive geriatric assessment can take more than 60 minutes, researchers have been successful in identifying the frail surgical patient using a simple and inexpensive grip strength test.6 To simplify the process of identifying this subpopulation of high-risk geriatric patients, researchers have developed electronic biomarkers of frailty using the medical record. Using the modified Frailty Index, Mogal and colleagues demonstrated that frailty was associated with increased morbidity and mortality in patients undergoing pancreaticoduodenectomy (see Figure 1).7
Figure 1. Morbidity and mortality of patients undergoing pancreaticoduodenectomy based on modified Frailty Index
Efforts to improve care in the frail patient
The American College of Surgeons (ACS) has recognized the critical importance of addressing frailty and optimizing the care of the geriatric patient. With funding from the John A. Hartford Foundation, the ACS joined with the American Geriatrics Society to develop the Coalition for Quality in Geriatric Surgery (CQGS), bringing together more than 50 stakeholder organizations. In 2016, the CQGS produced perioperative guidelines for care of the geriatric surgical patient, focusing on the three phases of care: immediate preoperative management, intraoperative management, and postoperative management.8 The ACS is in the process of developing a Geriatric Surgery Quality Program, along with educational programs focused on the care of the complex geriatric patient.
The Alliance for Clinical Trials in Oncology has recently activated a study (A171603) evaluating the feasibility of an electronic geriatric assessment for older adults with cancer. The multi-institutional study, led by Emily Guerard, MD, co-author of this column, will evaluate the ability to measure frailty using a self-reporting electronic-based questionnaire sampling 100 patients from both academic- and community-based clinics. Feasibility will be determined by the percentage of patients able to complete the self-reported section of the electronic assessment and have a completed health care professional section.
We anticipate continued efforts by the ACS CQGS and studies like A171603 sponsored by the Alliance will provide surgeons with the tools necessary to identify high-risk frail patients and ensure optimal care for these patients.
- Grayson KV, Velkoff VA. The next four decades: The older population in the United States: 2010–2050. Current Population Reports, Series P-25. No. 1138, pg. 14. May 2010. Available at: www.census.gov/prod/2010pubs/p25-1138.pdf. Accessed April 30, 2018.
- Fried LP, Tangen CM, Walston J, et al. Frailty in older adults: Evidence for a phenotype. J Gerontol A Biol Sci Med Sci. 2001;56(3):M146-M156.
- Rockwood K, Song X, MacKnight C, et al. A global clinical measure of fitness and frailty in elderly people. CMAJ. 2005;173(5):489-495.
- Karam J, Tsiouris A, Shepard A, Velanovich V, Rubinfeld I. Simplified frailty index to predict adverse outcomes and mortality in vascular surgery patients. Ann Vasc Surg. 2013;27(7):904-908.
- Klepin HD, Geiger AM, Tooze JA, et al. Geriatric assessment predicts survival for older adults receiving induction chemotherapy for acute myelogenous leukemia. Blood. 2013;121(21):4287-4294.
- Reeve TE IV, Ur R, Craven TE, et al. Grip strength measurement for frailty assessment in patients with vascular disease and associations with comorbidity, cardiac risk, and sarcopenia. J Vasc Surg. 2018;67(5):1512-1520.
- Mogal H, Vermilion SA, Dodson R, et al. Modified Frailty Index predicts morbidity and mortality after pancreaticoduodenectomy. Ann Surg Oncol. 2017;24(6):1714-1721.
- Mohanty S, Rosenthal RA, Russell MM, Neuman MD, Ko CY, Esnaola NF. Optimal perioperative management of the geriatric patient: A best practices guideline from the American College of Surgeons NSQIP and the American Geriatrics Society. J Am Coll Surg. 2016;222(5):930-947.