Frailty for Anesthesiologists

This resource includes an introduction to frailty, frailty assessment and instruments, four case studies, and references in
perioperative frailty.
Curated by the Committee on Geriatric Anesthesia and updated June 2021.

Module 1 – Introduction to frailty

What is frailty?
Frailty is a multidimensional syndrome characterized by decreased reserve and diminished resistance to stressors.1 2 As a
syndrome most commonly associated with older people, the concept of frailty has been translated from geriatric medicine
practice across many areas of acute care medicine, including into anesthesiology and perioperative medicine. Experts
agree that frailty is present due to deficits related to physical performance, nutritional status, mental health, and
cognition.3 4
Prevalence of frailty in perioperative populations
Frailty has a higher prevalence in perioperative patients than it does in the general population at the same age.5 The
specific prevalence depends to some degree on the instrument used to define frailty (see Module 2 for an introduction to
frailty instruments), as well as the specific surgical specialty. In general, clinically assessed frailty using a
multidimensional instrument will define a prevalence of 25-40%, with higher prevalence tending to be in patients having
oncologic or emergency surgery.6
Is frailty associated with outcomes?
Surgery induces substantial physiologic stress. Not surprisingly, vulnerable older people with frailty are at much higher
risk of most adverse outcomes after surgery.7 Among older surgical patients, mortality and morbidity rates are at least
two- to four-times higher in those with frailty compared to those without; rates of new disability are also approximately
doubled.7–9 Frailty predicts a four-fold increase in the risk of delirium.10 Loss of independence (i.e., decreased ability to
ambulate and care for oneself) is common in older people after surgery, and the presence of frailty predicts a 5-fold
increase in the risk of non-home discharge after elective surgery.6 11 Length of stay, costs and intensive care unit
utilization rates are also significantly higher in older people with frailty.

Module 2 – Frailty assessment for anesthesiologists

Overview of frailty instruments
Dozens of frailty instruments have been developed and described.12 For the purposes of this module we will focus on five
instruments that have been most commonly used and studied in the perioperative setting and that align with consensus on
the multidimensional nature of frailty. While frailty is often thought of and assessed as a syndrome that is strictly present
or absent based on a specific cut-off, in reality frailty is best thought of as a continuum where higher scores on a frailty
instrument mean more severe frailty, which indicates greater risk of adverse outcome. Score ranges and cut-offs will be
discussed below for each instrument.
Fried Phenotype
The Fried Phenotype2 is the most studied frailty instrument in surgical patients and uses five variables to define frailty.
These include two questions asked directly to the patient (presence of unintentional weight loss (>10 lbs in the last year)
and feeling easily exhausted). Three measurements are also required. Gait slowness is measured using a 15-foot timed
walking test (slowness is defined as the lowest 20%, normalized for sex and height), grip strength using a hand-held
dynamometer (weakness is defined as lowest 20% by sex and body mass index) and low activity levels using a
standardized questionnaire (defined as <383 kilocals/week for men or <270 kilocals/week for women). These variables
are used to construct a score ranging from 0-5; frailty is present with a score >3, while individuals with a score 1-2 are
considered pre-frail.
Frailty Index
The frailty index13 is widely used in perioperative patients and non-surgical patients as well. A frailty index is constructed
by assessing at least 30 variables that cover multiple frailty-related domains (physical performance, nutritional status,
mental health, cognition and others).14 Importantly, the specific variables used are not as important as having an adequate
number that represent multiple domains.13 Variables are considered as deficits and are typically measured as present (1
point assigned) or absent (0 points assigned). Deficits can be assessed via direct patient interview, questionnaires or
(where adequate data are available) electronic health data.15 16 The number of points assigned is divided by the number of
deficits measured to provide a score ranging from 0 (no frailty) to 1 (completely frail); however, frailty index scores
exceeding 0.66 are rarely seen. A typical cut off point to define someone as frail would be >0.21. Categorizations are
often applied (<0.10 not frail, 0.10-0.21 pre-frail, 0.22-0.44 frail and >0.45 severely frail).
Clinical Frailty Scale
The Clinical Frailty Scale (CFS)1 is a clinically-oriented frailty instrument based on clinical assessment and judgement
combined with visual cues and brief vignettes. Vignettes prompt assessment of activity levels, disease symptoms, medical
problems, activities of daily living and cognition. Although designed to be simple and feasible for clinical use, the CFS
explains 80% of the information contained in the more complex FI. Scores range from 1 (very fit) to 8 (very severely
frail). The ninth category denotes individuals nearing end of life who are not otherwise showing signs of frailty (e.g.,
otherwise well patient with end-stage cancer) and is rarely applicable in preoperative assessment of older people.
Typically, the CFS cut off for assigning frailty is a score >4 or >5. Various categorizations have been applied, including 1-
3 (no frailty), 4-5 (vulnerable or mildly frail), >6 (moderate to severely frail).
Edmonton Frail Scale
The Edmonton Frail Scale (EFS) is a 10-domain frailty assessment that assess cognition, general health, functional
independence, social support, medications, nutrition, mood, continence and lower limb function.17 Nine questions are
directly answered by patient or proxies. Cognition requires completion of a clock-draw test, while lower limb function is
assessed using a timed up and go test. Answers to questions are graded on a 0-1 or 0-2 point scale, with the overall score
ranging from 0 (no frailty) to 17 (very frail). A typical cut off point to assign frailty is a score of >8, while a three-level
categorization has been used (0-3, no frailty; 4-7 pre-frailty; >8 frailty present).
Risk Analysis Index
The Risk Analysis Index (RAI) is a multidomain frailty instrument that assigns points for the presence and/or combination
of specific demographic, comorbid, oncologic and disability states.18 The tool is an adaptation of the Minimum Data Set
Mortality Risk Index, which used frailty-related variables to develop a smaller set of indicators that can be obtained from
patients (or their surrogate). A clinical tool (RAI-C) and electronic database tool (RAI-A) have been developed, and in
each higher scores suggest greater frailty. The RAI questionnaire includes 14 questions assessing 11 variables and 2
statistical interactions with scores ranging from 0 to 81. Patients are typically categorized as robust (RAI≤20), normal (21-
29), frail (30-39), and very frail (≥40). Use of a recent recalibration of RAI domains may improve performance.19
Accuracy of frailty instruments
The accuracy of frailty instruments can be considered from two perspectives. Since there is no single gold-standard
definition of frailty, we can’t compare each instrument to a common reference to determine how accurately each
diagnoses frailty. This means that frailty instruments are assessed to ensure that they are 1) consistent with the agreed-
upon multidimensional aspects of frailty, and 2) predictive of adverse outcomes relevant to older adults. This part of the
module will primarily focus on point 2 (that is, prediction of outcomes), specific to the frailty instruments identified
above.
Mortality: Recent systematic reviews show that each of the frailty instruments discussed above are associated with a
higher risk of death after surgery, and that none is markedly more accurate that the others.12 The CFS was most strongly
associated with mortality (odds ratio (OR) 4.89, 95%CI 1.83-13.05) across 6 studies, followed by the FP (OR 3.95,
95%CI 2.00-7.81) with data pooled across 10 studies.
All studied instruments were moderately effective at discriminating between high and low risk of death patients (area
under the receiver operating curve values ~0.7) and added extra discriminative information when assessed in addition to
traditional risk factors like age, ASA score and others.12 The RAI has consistently demonstrated higher discrimination for
mortality (area under the receiver operating curve values often>0.8) than other instruments, although head-to-head
comparisons are lacking.
Complications: All described frailty instruments also predict a higher risk of complications. The EFS had the strongest
association (OR 2.92, 95%CI 1.52-3.46), followed by the FP (OR 2.47, 95%CI 2.00-3.04), the FI (OR 2.29, 95% CI 1.52-
5.65) and CFS (OR 1.68, 95%CI 0.95-2.95). The FI may be the most effective frailty tool for discriminating between
older people at high or low risk of experiencing a complication.12
Need for non-home discharge: The CFS was most strongly associated with not being discharged home after surgery (OR
6.31, 95%CI 4.01-9.36) followed by the FP (OR 5.18, 95% CI 3.34-8.03) and FI (OR 2.29, 95% CI 1.52-3.46). The CFS
may provide more useful information related to providing older people with accurate estimates of how likely non-home
discharge is compared to the FP and FI.12
Delirium: The FP (OR 3.79, 95% CI 1.75-8.22) and EFS (OR 2.11, 95% CI 1.06-4.21) both predict the risk of delirium
after surgery. More data is needed for the CFS, RAI and FI.12
Feasibility, practical tips and guidance
Because there is no single ‘best frailty’ instrument, your choice of tool for your practice will need to consider the
outcomes you are trying to improve, as well as the setting you work in and resources available. Below are comments on
feasibility and practical tips for each frailty tool assembled through a systematic search of the available literature.

Summary and Infographic

Fried Phenotype:
Time: 5-20 minutes to administer; significantly longer to complete compared to the CFS
Resources: Hand-held dynamometer (for grip strength); space and timer for 15-foot walk; activity questionnaire
Other: Rated as being moderately difficult to use in preoperative clinic and less easy to use than the CFS. Adaptations (eg,
FRAIL Scale20) exist to decrease measurement burden (replaces formal measurements with patient questions)
Frailty Index
Time: 10-13 minutes to complete
Resources: Does not require extra space or instruments
Other: Tends to tolerate some missing data points. Can be constructed using electronic health record data in settings with
adequate access to multidimensional healthcare data.15 16
Clinical Frailty Scale
Time: Add less than 1 minute to a clinical assessment, significantly faster than Fried Phenotype.
Resources: Does not require extra space or instruments
Other: Rated as very easy to use and logistically appropriate in a preoperative anesthesiology clinic. Feasibility data most
strongly support use of the CFS compared to other instruments. Can be assessed via chart review or proxy history.21
Edmonton Frail Scale
Time: 1-5 minutes to complete
Resources: Paper, pen and assessor needed for clock draw test, space and chair for timed up and go
Other: An adaptation, called the reported EFS, replaces clock draw and walk tests with patient or proxy queries.22
Risk Analysis Index
Time: 2 minutes or less, longer in people with greater frailty23
Resources: Does not require extra space or instruments
Other: Clinical and database versions exist.18 Has greater weighting when cancer diagnoses present than other
instruments.
Case Studies
Case studies – Using frailty assessment before surgery to improve risk assessment and optimization
Case 1 – Cognitive concerns
While assessing a 76-year-old female scheduled for an upcoming total knee replacement, the patient and her
daughter express concerns about the risk of post-operative cognitive changes. The patient’s husband, now
deceased, had experienced delirium after a bowel resection, and the family felt that he had never recovered
his pre-operative level of cognitive function.
Question 1: How could frailty assessment help to address this patient’s concerns?
Answer: Systematic reviews demonstrate that, with the exception of a prior history of delirium for the individual
patient, the presence of frailty is the strongest risk factor for developing postoperative delirium in older people
having surgery (an approximately fourfold increase in the odds of delirium [odds ratio (OR) 4.1, 95%CI 1.4 to
11.7]). Systematic reviews also demonstrate that delirium is associated with subsequent long-term cognitive
decline.
By performing a frailty assessment, you could provide the patient and her family with important and relevant
information about how likely she was to experience delirium after surgery. For example, if the average risk of
delirium in older surgical patients is 20 percent, the presence of frailty would suggest that this patient had at
least a 50 percent risk of developing delirium after surgery, whereas the absence of frailty would suggest a risk
of 5 percent or less. Further information about delirium prevention, especially related to orientation, availability
of glasses and hearing aids, maintenance of normal homeostasis, and avoidance of deliriogenic medications,
could be discussed and considered.
Key references
(1) Watt J, et. al. Identifying Older Adults at Risk of Delirium Following Elective Surgery: A Systematic
Review and Meta-Analysis. J Gen Intern Med. 2018 Apr;33(4):500-509. doi: 10.1007/s11606-017-4204-
x.
(2) Goldberg TE, et. al. Association of Delirium With Long-term Cognitive Decline: A Meta-analysis. JAMA
Neurol. 2020 Jul 13;77(11):1-9. doi: 10.1001/jamaneurol.2020.2273.
(3) Chen CC, et. al. Effect of a Modified Hospital Elder Life Program on Delirium and Length of Hospital
Stay in Patients Undergoing Abdominal Surgery: A Cluster Randomized Clinical Trial. JAMA Surg.
2017 Sep 1;152(9):827-834. doi: 10.1001/jamasurg.2017.1083
(4) Because odds ratios can’t be used directly to calculate increases in risk, a formula is required that
considers the baseline risk and the odds ratio to calculate the post-test probability:
a. Pposttest=(OR*Pbaseline)/(1+OR*Pbaseline- Pbaseline)
Case 2 – Troubled transitions
The next patient in your anesthesia pre-assessment unit is a 79-year-old female who is scheduled for a right
hemicolectomy for a primary colorectal cancer.
In addition to her colorectal cancer, her past medical history is significant for Type 2 diabetes and
hypertension. She has had previous general and neuraxial anesthetics, including for fixation of a femoral neck
fracture 2 years ago, without any adverse outcomes. However, when asked, she reports having unintentional
weight loss over the past six months and feels that she has slowed down noticeably. Although she still
prepares her own meals and goes out to shop, she feels much more tired by day’s end and is concerned that
after surgery she will no longer be able to keep up the same level of independence.
Question 1: What is your initial impression of this patient’s frailty status based on the Clinical Frailty Scale?
Answer: Based on this initial assessment, this patient is likely a Clinical Frailty Scale 4 (Vulnerable). She states
that she is independent but has slowed down and is more easily tired.
Question 2: Your patient asks how likely it is that she will not be able to go home independently after surgery.
How can frailty assessment inform this discussion?
Answer: Approximately 50 percent of older people report losing some independence one month after surgery
(e.g., less able to ambulate independently or take care of activities of daily living [such as meal preparation,
self care, housework]). However, the presence of frailty provides important information beyond age in
determining risk. After elective non-cardiac surgery, 15-20 percent of older people who lived at home before
surgery are discharged to an institution (like a skilled nursing facility). Identifying frailty (e.g., Clinical Frailty
Scale 4 or higher) increases the odds of not being discharged home approximately fivefold.
Key references
(1) Rockwood K, et. al. A global clinical measure of fitness and frailty in elderly people. CMAJ. 2005 Aug
30;173(5):489-95. doi: 10.1503/cmaj.050051.
(2) McIsaac DI, et. al. Frailty as a Predictor of Death or New Disability After Surgery: A Prospective Cohort
Study. Ann Surg. 2020 Feb;271(2):283-289. doi: 10.1097/SLA.0000000000002967.
(3) Bentov I, et. al. Frailty assessment: from clinical to radiological tools. Br J Anaesth. 2019 Jul;123(1):37-
50. doi: 10.1016/j.bja.2019.03.034.
(4) Aucoin SD, et. al. Accuracy and Feasibility of Clinically Applied Frailty Instruments before Surgery: A
Systematic Review and Meta-analysis. Anesthesiology. 2020 Jul;133(1):78-95. doi:
10.1097/ALN.0000000000003257.
Case 3 – Instrumental Incentives
To support its new, fast-track minimally invasive cardiac surgery initiative, your hospital has asked your
Department of Anesthesiology to help guide patient assessment and selection. Their goal is to identify patients
who will be able to benefit from their procedure (e.g., transcatheter aortic valve insertions) and successfully
transition home with a hospitalization of <48 hours. As the target population is mainly older adults, a consultant
has recommended frailty assessment using grip strength as part of the patient selection criteria.
Question 1: How do single item frailty proxy assessments compare to multicomponent assessment?
“Frailty” has been defined in many ways by many people and little consensus on the best or gold standard
definition. However, international consensus has been reached on frailty being a multidimensional state or
condition. This means that single item assessments (e.g., grip strength, presence of a frailty defining
diagnosis) does not represent a true assessment of frailty. Research also demonstrates that single item frailty
proxies, or frailty definitions that only focus on one main area (such as comorbidity), are inferior to
multidimensional assessments when trying to accurately predict patients’ risk of morbidity, mortality, and
resource use. Therefore, your institution would likely be best served by considering a well validated,
multidimensional assessment (e.g., frailty index, Clinical Frailty Scale, Frailty Phenotype, or Edmonton Frail
Scale, although the best choice among these may depend on your environment and resources).
Key references
(1) Kim DH, et.al. Preoperative Frailty Assessment and Outcomes at 6 Months or Later in Older Adults
Undergoing Cardiac Surgical Procedures: A Systematic Review. Ann Intern Med. 2016 Nov
1;165(9):650-660. doi: 10.7326/M16-0652.
(2) McIsaac DI, et. al. A Bayesian Comparison of Frailty Instruments in Noncardiac Surgery: A Cohort
Study. Anesth Analg. 2020 Nov 30. doi: 10.1213/ANE.0000000000005290.
(3) Rodríguez-Mañas, L. Searching for an operational definition of frailty: A delphi method based
consensus statement. the frailty operative definition-consensus conference project. J Gerontol A Biol
Sci Med Sci. 2013 Jan;68(1):62-7. doi: 10.1093/gerona/gls119.
Case 4 – Looking long-term
You are about to anesthetize a 71-year-old male for a lower limb bypass vascular surgery. He tells you that in
his preoperative assessment by an internal medicine physician, he was told that he had frailty. He mentioned
this to his daughter, who had done some online research. She told him that his likelihood of a bad outcome
was much higher because of the frailty he had. He asks you whether he is, “crazy to be having this big
surgery? Is there any chance that my outcome will be okay?”.
Question 1: What could you tell this patient in response to his query about his frailty status?
Answer: Frailty is consistently associated with a higher risk of poor outcomes after surgery. However, even
with frailty, the large majority of older people survive surgery and get back home safely. Unfortunately, longer
term outcomes (e.g., beyond one to three months after surgery) are not well described for older surgical
patients. Promisingly, there is evidence that many older patients do have positive long-term outcomes after
surgery, and in one multicenter cohort study, older people with frailty had a greater improvement in their self-
reported disability status than people without frailty 1 year after elective non-cardiac surgery. This may be
because the surgical diagnosis may also contribute to a person’s frailty status, and safe and successful
surgical treatment could lead to benefit if an individual is safely able to transition through the perioperative
period. However, there are no studies that have randomized older people with frailty to a surgical vs. non-
surgical course of treatment, so no data are available to directly inform the question of how surgery impacts
frailty and related outcomes long-term.
Ultimately, though, research does suggest that just identifying frailty and communicating its presence to the
perioperative team may support better outcomes. This may be due to changes that are then made to the
overall approach to care. However, at the end of the day the decision to have surgery is always an individual
and autonomous decision for each patient, where frailty assessment can add important information to informed
consent and care planning.

Key references
(1) McIsaac DI, et. al. Frailty and long-term postoperative disability trajectories: a prospective multicentre
cohort study. Br J Anaesth. 2020 Nov;125(5):704-711. doi: 10.1016/j.bja.2020.07.003.
(2) Robinson T, et. al. Frailty for Surgeons: Review of a National Institute on Aging Conference on Frailty
for Specialists. J Am Coll Surg. 2015 Dec;221(6):1083-92. doi: 10.1016/j.jamcollsurg.2015.08.428
(3) Hall DE, et. al. Association of a Frailty Screening Initiative With Postoperative Survival at 30, 180, and
365 Days. JAMA Surg. 2017 Mar 1;152(3):233-240. doi: 10.1001/jamasurg.2016.4219.

References
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based consensus statement. the frailty operative definition-consensus conference project. Journals Gerontol - Ser A
Biol Sci Med Sci 2013; 68: 62–7
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comorbidity: implications for improved targeting and care. J Gerontol A Biol Sci Med Sci 2004; 59: 255–63
5. Gale CR, Cooper C, Sayer AA ihie. Prevalence of frailty and disability: findings from the English Longitudinal
Study of Ageing. Age Ageing 2015; 44: 162–5
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http://archsurg.jamanetwork.com/article.aspx?doi=10.1001/jamasurg.2016.4219