Accuracy and Feasibility of Clinically Applied Frailty Instruments before Surgery

Abstract

Background A barrier to routine preoperative frailty assessment is the large number of frailty instruments described. Previous systematic reviews estimate the association of frailty with outcomes, but none have evaluated outcomes at the individual instrument level or specific to clinical assessment of frailty, which must combine accuracy with feasibility to support clinical practice. Methods The authors conducted a preregistered systematic review (CRD42019107551) of studies prospectively applying a frailty instrument in a clinical setting before surgery. Medline, Excerpta Medica Database, Cochrane Library and the Comprehensive Index to Nursing and Allied Health Literature, and Cochrane databases were searched using a peer-reviewed strategy. All stages of the review were completed in duplicate. The primary outcome was mortality and secondary outcomes reflected routinely collected and patient-centered measures; feasibility measures were also collected. Effect estimates were pooled using random-effects models or narratively synthesized. Risk of bias was assessed. Results Seventy studies were included; 45 contributed to meta-analyses. Frailty was defined using 35 different instruments; five were meta-analyzed, with the Fried Phenotype having the largest number of studies. Most strongly associated with: mortality and nonfavorable discharge was the Clinical Frailty Scale (odds ratio, 4.89; 95% CI, 1.83 to 13.05 and odds ratio, 6.31; 95% CI, 4.00 to 9.94, respectively); complications was associated with the Edmonton Frail Scale (odds ratio, 2.93; 95% CI, 1.52 to 5.65); and delirium was associated with the Frailty Phenotype (odds ratio, 3.79; 95% CI, 1.75 to 8.22). The Clinical Frailty Scale had the highest reported measures of feasibility. Conclusions Clinicians should consider accuracy and feasibility when choosing a frailty instrument. Strong evidence in both domains support the Clinical Frailty Scale, while the Fried Phenotype may require a trade-off of accuracy with lower feasibility. Editor’s Perspective What We Already Know about This Topic What This Article Tells Us That Is New

Oncogeriatric. Other frailty assessment instruments

“…The Clinical Frailty Score was strongly associated with mortality (a 4.9-fold increase in the odds) and discharge to nursing facility (a 6.3-fold increase in the odds). In turn, the Edmonton Frailty Score was a better predictor of complications (a 2.9-fold increase in the odds) and the frailty phenotype was most strongly associated with postoperative delirium (a 3.8-fold increase in the odds) [36]. At present, we do not have a conclusive answer as to which scale should be used preoperatively, apart from the full Geriatric Assessment.…”

Frailty status as a potential factor in increased postoperative opioid use in older adults

“…1). Opioid prescribing is at the discretion of the physicians, but templates for older adults are available in some portions of the hospital through the electronic medical record [18]. Other medications for pain, such as gabapentin, ketamine, marijuana, NSAIDs, and over the counter medications were also recorded at each timepoint.…”

“…Seven days after discharge from the hospital, patients reported pain (using the Numerical Rating Score) and opioid use (in MME) during a phone or email interview. Abbreviations: CFS, Clinical Frailty Scale; EFS, Edmonton Frailty Scale; VAS, Visual Analog Scale; PCS, Pain Catastrophizing Scale; MME, morphine milligram equivalents; NRS, Numerical Rating Score; VRS, Verbal Rating Scale [18] were used in the study. Preoperative prescription frequency describes the percent of total preoperative opioid prescriptions.…”

“…The CFS is accompanied by description and pictographs for each category and requires less than 1 minute to perform [29][30][31]. The CFS was used since it is simple, highly feasible, and strongly correlated to postoperative outcomes [18,32]. To validate the use of a simple frailty tool in our cohort, we also evaluated frailty preoperatively using a comprehensive tool, the Edmonton Frailty Scale (EFS), administered by a trained researcher (Fig.…”

Ambulance helicopters for every emergency?

“…Frailty indices are relatively new instruments for assessment of elderly people in general and those in nursing homes in particular and could be of help to avoid futile emergency calls 4 . A frailty index may also contain a visual scale which facilitates communication with patients and their relatives when discussing these sensitive, difficult but necessary decisions in end‐of‐life care 5 …”