Preoperative frailty assessments should be standard, anesthesiologist says

Pre-surgery frailty assessments on older patients can have a significant impact on post-surgery outcomes, but are not happening often enough, says Ontario anesthesiologist and researcher Dr. Daniel McIsaac. An associate professor, anesthesiology and pain medicine, at the University of Ottawa, Dr. McIsaac presented his latest findings at the 68th Annual Ontario Anesthesia Meeting and Conference Weekend in Toronto at the end of October. “Even though we’ve got this decade-long experience telling us that we should be doing frailty assessments unfortunately, the evidence is very, very clear, that even now in 2023, this is rarely happening for patients in Ontario, in Canada, or across the world,” Dr. McIsaac said. “And unfortunately, there's some pretty major implications of this for both the patients we care for, as well as the health system and societal perspective as well,” he said at the conference, which was attended by 300+ anesthesiologists.Although older age is a strong risk factor for adverse outcomes after surgery, it has limited value predicting outcomes or informing and optimizing perioperative care. A frailty assessment, carried out by anesthesiologists or allied health professionals, should become a standard part of assessment of older adults before surgery, said Dr. McIsaac, who recently published, “Preoperative frailty assessment: Just do it!,” in the Canadian Journal of Anesthesia.Huge opportunity“Over the past 10 years, we’ve probably attributed about 10,000 extra deaths in Ontario to the presence of frailty before surgery, and probably more than 150,000 complications. Now, I’m not suggesting that just by doing a frailty assessment, we would have been able to write down these adverse outcomes. What the evidence does show us is that there’s a huge opportunity to improve outcomes through frailty-guided care.”Dr. McIsaac pointed to the February 2023 JAMA Surgery article “Association of Routine Preoperative Frailty Assessment With 1-Year Postoperative Mortality,” which reported on a U.S. study that showed one-year mortality decreased significantly from 20.2% to 16% when a frailty screening was used.“By doing a frailty assessment, we will have better information. That’s step one. Patients are going to better understand what they face, colleagues are going to be able to better plan for the care that patient needs, and hopefully, the health system will be better-structured to improve things for patients.”Read: Popular weight loss drugs like Wegovy may raise risk of complications under anesthesiaAlthough there are various measures of frailty, Dr. McIsaac recommends the Clinical Frailty Scale (CFS). The nine-point scale assesses patients on various physical, mental and functional areas and determines if they are: Very fit, Fit, Managing well, Living with very mild frailty, Living with mild frailty, Living with moderate frailty, Living with severe frailty, Living with very severe frailty, Terminally ill.Dr. McIsaac, also a scientist at the Ottawa Hospital Research Institute, pointed out that the aging of the population has had a direct impact on anesthesia and surgical care, with more than 50% of adults having inpatient surgery aged 65 years or older. “Everybody in this room who's not a pediatric- or obstetrical-focused anesthesiologist has probably cared for a huge number of older people with frailty,” he said.By using the CFS, he said, health systems can be improved to serve patients. At the individual level, it helps health teams build specific plans around exercise, nutrition, and cognition—essentially optimizing patients before and after surgery so that they can have better outcomes.Exercise, nutrition, therapies“Exercise, nutrition, medical therapies, and social interventions all have evidence supporting their role in decreasing manifestations of frailty at the individual level,” he wrote in the Preoperative frailty assessment: Just do it!, co-authored with Dr. Alexa L. Grudzinski, Dr. Sylvie D. Aucoin. “If we can accurately and routinely identify preoperative frailty, we can optimize patients before surgery based on their personal profile and needs, and even plan for transitions in care leaving hospital. This could have positive implications for patient and caregiver experience, health outcomes, care coordination, and healthcare costs.” After an assessment, anesthesiologists are also well-positioned to enhance intraoperative and postoperative care, he said, by, for example, avoiding unnecessarily deep general anesthesia and avoiding potentially inappropriate medications or polypharmacy both during anesthesia and acute pain service.Read: Anesthesia can cause disturbing sexual hallucinations, leading to lasting psychological trauma“Frailty isn’t the same as having a bunch of comorbidities or having dementia. Frailty is this lack of reserve across multiple domains . . . issues of physical function, cognitive function, issues of malnutrition, and issues of mental health, all contribute to frailty.”It may seem paradoxical but, he said, on average, a patient with frailty who comes to the operating room is more likely to have a meaningful improvement in their overall function after surgery than someone without frailty. That’s largely because they start with a sizable disability baseline. If the surgery to address a disability is carried out, preceded and succeeded by assessment-informed plans that help navigate the risky early post-op days, the patient can have a positive functional recovery.Dr. McIsaac says conducting a CFS takes less than a minute and is easy to learn. Ottawa’s Aging Innovation In Perioperative Medicine & Surgery Research Group, led by Dr. McIsaac and collaborators, has created a training module to provide learners with a comprehensive understanding of frailty and how to accurately determine a person's CFS score based on their specific circumstances.

Preoperative frailty assessments should be standard, anesthesiologist says

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