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Assessing Frailty in Pre-op Patients

Frailty is a well-documented risk factor for post-operative disability. Thus, anesthesiologists and surgeons are encouraed to evaluate elderly patients pre-operatively using standardized frailty tests. Yet the reliability and usability of these tests vary considerably, making it difficult for providers to know which, if any, to use.

Last year, researchers at the University of Ottawa decided to evaluate two of the most widely used frailty assessment tools, the Clinical Fraily Scale (CFS) and the modified Freid Index (mFI.) Both proved to be consistently reliable, with the mFI being marginally more sensitive, reports Anesthesiology News. However, the CFS proved to be easier and faster to administer and was better tolerated by patients asked to complete the test.

To compare the tools, researchers led by Daniel McIsaac, M.D.,MPH, FRCPC, an assistant professor of anesthesiology and pain medicine at the the University of Ottawa, recruited 680 patients over the age of 65 who were undergoing elective, non-cardiac surgery. Providers evaluated frailty status preoperatively using one of the two tools. Patients were then assessed 90 days post-operatively for the presence of new disability.

According to CFS scores, 42 percent of patients in the study group were frail, compared to 36 percent for the mFI. The overall incidence of post-op disability was 11.2 percent. Sixteen percent of patients deemed frail by the CFS developing a new disability within 90 days of surgery, compared to 18 percent of those identified as frail by the mFI. Additionally, each unit increase on the CFS scale was associated with a 1.71-fold increase in the likelihood of new disability, comparied to a 1.64-fold increase for each unit on the mFI scale.

CFS Easier for Patients and Providers

Where the two tools diverged was in their ease of application. The CMS is a vignette-based tool that providers can administer in about 30 seconds by asking the patient a series of questions about nine distinct points. The mFI takes about 5 minutes to complete and requires that the patient perform grip-strength and gait speed tests. According to Dr. McIsaac, about 20 percent of patients evaluated during the study refused to complete all of these tasks.

“The mFI is currently recommended by the American Geriatrics Society and the American College of Surgeons,” said McIsaac, speaking at the annual meeting of the Candian Anesthesiology Society. And the tool is slightly more sensistive than the CFS. But, he added, “you’re going to miss a few people who won’t complete it.”  

“So if I’m screening people for relatively low-tech perioperative interventions,” McIssac said, “I’m personally going to use the CFS, because I know I’m going to get it done on everybody and get it done quickly.”

Frailty Interventions Lacking

Prior research has shown that frailty is associated with a significant increase in adverse outcomes after elective cardiac and non-cardiac surgeries. Frail patients have a “higher rate of early mortality and also suffer from geriatric-specific outcome trajectories, like loss of independence and cognitive dysfunction,” McIssac explained. Nevertheless, researchers have failed to identify pre-operative interventions that might diminish long-and-short term risks.

To address this shortfall, McIsaac and colleagues are currently recruiting patients for a randomized, controlled, single-blinded study of home-based prehabilitation for frail patients over the age of 65 who are scheduled for elective surgery. Patients in the intervention arm of the study will perform aerobic, strength and flexibility exercises three times a day for four weeks.  Patients in the control arm will receive usual care. The primary end point of the study will be a six-minute walk test at the first return visit after surgery. Other end-points will include length of hospital stay, post-operative complications, disability-free survival and all-cause mortality.

The program is based on a successful prehabilitation program for nonfrail surgical patients, McIsaac explained. 

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