Perioperative frailty: lessons learned and future directions

Abstract

Purpose of reviewAs the surgical population ages, preoperative diagnosis and optimization of frailty becomes increasingly important. Various concepts are used to define frailty, and several tools have been validated for use in the perioperative period. This article reviews current conceptual frameworks of frailty, references current literature and provides a practical approach to the preoperative frailty assessment with a focus on potential interventions. Recent findingsA multipronged approach toward preoperative optimization should be used in patients with frailty syndrome. Oral protein supplementation and immunonutrition therapy can reduce complications in patients with malnutrition. Initiating a preoperative physical exercise regimen may mitigate frailty. Nonpharmacologic interventions to reduce preoperative anxiety and improve mood are effective, low-cost adjuncts associated with improvement in postoperative outcomes. Engaging in shared decision making is a critical component of the preoperative evaluation of frail patients.

Mortality after chronic subdural hematoma is associated with frailty

“…There are also recommendations for perioperative management of frailty that could be beneficial for our CSDH patients. The most often suggested improvement in perioperative frailty is to increase attention for frailty by implementing frailty screening tools [ 1 , 2 ]. While this seems to be obvious, the implementation of orthogeriatrics, an intensive collaboration between Geriatrics and Orthopedic Surgery, focusing on the optimal perioperative care for elderly patients with (fall-related) fractures, has shown to lead to better survival after hip fractures [ 18 , 24 ].…”

Preoperative optimization of geriatric and frail patients

“…97,101 Folate and vitamin B 12 levels may also be checked as part of the preoperative nutritional deficiency anemia workup. 97 Although IDA is the most common form of anemia, nutritional deficiency anemia can be caused by insufficient consumption of vitamins A, B 6 , B 12 , C, D, and E, folate, riboflavin, and copper. 101 When nutritional deficiency anemia is diagnosed early in the preoperative evaluation process, a registered dietician nutritionist may initiate therapy by way of oral iron therapy and vitamin supplementation more than 4 weeks before surgery.…”

“…101 When nutritional deficiency anemia is diagnosed early in the preoperative evaluation process, a registered dietician nutritionist may initiate therapy by way of oral iron therapy and vitamin supplementation more than 4 weeks before surgery. 97 Although some institutions have established preoperative anemia clinics streamlined to provide anemia managements, 99,104 it is crucial to provide a preoperative optimization process to test, diagnose, and treat anemia even if such entity is not available. Hematology and medical oncology or internal medicine consultation may be utilized to provide intravenous iron administration and erythropoiesis-stimulating agents in addition to nutritional managements.…”

“…In the frail geriatric population, preoperative anemia is a common finding, with iron deficiency anemia (IDA) being one of the most common causes. 97 Anemia is an independent risk factor for perioperative morbidity and mortality, it is also a predictor for perioperative blood transfusion with the associated risks of transfusion-related complications. 99 It was found that, for geriatric patients undergoing major noncardiac surgery, even mild degrees of preoperative anemia were associated with an increased risk of postoperative mortality and cardiac complications.…”

“…The fear of losing decision autonomy, physical independence, and financial stability can all exacerbate preoperative anxiety and depression. 97 If untreated, preoperative mental health issues can also unhinge prehabilitation program, further worsening the patient's postoperative outcomes. 119 Unfortunately, the effects of psychosocial factors on postoperative complications are too often underappreciated.…”