Evidence-Based Frailty Assessment for the Older Surgical Patient: a Narrative Review of Instruments, Barriers and Solutions

Surgical frailty is a previously unrecognized clinical entity that objectifies a multiorgan decrease in physiologic reserve in those undergoing surgery. Although penile implantation has been demonstrated to be an effective means of restoring erectile function in patients whose previous conservative measures have failed, there are limited data regarding the assessment of frailty in patients undergoing penile implantation. To review the various objective methods used to describe surgical frailty in medical and surgical disciplines, report on methodologies of frailty assessment, and discuss the relevance of surgical frailty in the preoperative evaluation of patients undergoing implantation of an inflatable penile prosthesis. A literature review was performed through PubMed regarding surgical frailty in the disciplines of medicine, surgery, and urology. Key words and phrases included frailty, elderly, aging, erectile dysfunction, penile implantation, and penile prosthesis. Critical assessment of frailty in medicine and its application to male prosthetic health. Frailty has been assessed by different metrics in multiple fields. Validated modalities to determine physiologic reserve include an accumulation of deficits and phenotypic objective assessments that are reviewed in detail. Frail patients experience longer length of stay, postoperative complications, unplanned returns to the operating room, and readmissions and are less likely to be discharged to home. Novel frailty assessments objectified through grip strength measurements from our institution demonstrate that a considerable number of patients, young and old, undergoing penile implantation exhibit surgical frailty. There is a growing need to incorporate frailty assessment in the preoperative risk stratification of patients undergoing penile implantation. Grip strength evaluation seems to be an obvious standard because it is likely the easiest to measure and is clinically relevant given the user's dependence on manual dexterity to use the device. Screening for frailty does not create a substantial time, financial, or resource burden for the urologist. Brennan MS, Barlotta RM, Simhan J. Frailty Assessments in Surgical Practice: What is Frailty and How Can It Be Used in Prosthetic Health? Sex Med Rev 2018;6:302-309.

Optimizing emergency care for the aging population is an important future challenge, as the proportion of older patients at the emergency department (ED) rapidly increases. Older patients, particularly those who are frail, have a high risk of adverse outcomes after an ED visit, such as functional decline, institutionalization, and death. The ED can have a key position in identifying frail older patients who benefit most from comprehensive geriatric care [including delirium preventive measures, early evaluation of after-discharge care, and a comprehensive geriatric assessment (CGA)]. However, performing extensive frailty assessment is not suitable at the ED. Therefore, quick and easy-to-use instruments are needed to identify older patients at risk for adverse outcomes. This narrative review outlines the importance and complexity of frailty assessment at the ED. It aligns the available screening instruments, including clinical judgment as frailty assessment, and summarizes arguments for and against frailty assessment at the ED.

Frailty and aging-associated syndromes in lung transplant candidates and recipients.

Longevity has increased the proportion of the elderly in the population, and as a result ageing has become the leading factor for diseases such as cerebrovascular and cardiovascular disorders. It also makes surgical procedures more complex with potential life-threatening complications. In order to further investigate the role of ageing in modern healthcare, the term 'frailty' has been proposed to describe a condition of reduced functional reserve that leads to an increased risk of adverse health outcomes. The aim of this study was to review the pathophysiology of frailty and to highlight the most important tools to diagnose it, and their ability to predict the postoperative outcome. There are two major conceptual models that provide guidance for the detection of frailty: the Fried Phenotype Model and the Cumulative Deficit Model. These two main models have provided a base from which the assessment of frailty has developed. Two frailty assessment tools, the modified frailty index and the simplified frailty index play a key role in the preoperative setting because of their predictive power for postoperative risk quantification. Assessments of independence and/or cognitive function represent the main components that an ideal frailty tool should have to identify elderly people who are at risk of postoperative functional and cognitive deterioration. Cognitive impairment undoubtedly has a high association with frailty, but cognitive status is not included in many frailty assessments. In this regard, comprehensive geriatric assessment is a more complete evaluation tool, and it should be used whenever a frailty tool screening gives a positive result. Finally, frailty assessment is useful to explore the cumulative effect of comorbidities on the ageing patients' functional reserves and to identify the appropriate level of in-hospital and postdischarge care.

Degenerative spine disease increases in prevalence and may become debilitating as people age. Complex spine surgery may offer relief but becomes riskier with age. Efforts to lessen the physiological impact of surgery through minimally invasive techniques and enhanced recovery programs mitigate risk only after the decision for surgery. Frailty assessments outperform traditional tools of perioperative risk stratification. The extent of frailty predicts complications after spine surgery such as reoperation for infection and 30-day mortality, as well as elements of social cost such as hospital length of stay and discharge to an advanced care facility. Symptoms of spine disease overlap with phenotypic markers of frailty; therefore, different frailty assessment tools may perform differently in patients with degenerative spine disease. Beyond frailty, however, cognitive decline and psychosocial isolation may interact with frailty and affect achievable surgical outcomes. Prehabilitation, which has reduced perioperative risk in colorectal and cardiac surgery, may benefit potential complex spine surgery patients. Typical prehabilitation includes physical exercise, nutrition supplementation, and behavioral measures that may offer symptomatic relief even in the absence of surgery. Nonetheless, the data on the efficacy of prehabilitation for spine surgery remains sparse and barriers to prehabilitation are poorly defined. This narrative review concludes that a frailty assessment-potentially supplemented by an assessment of cognition and psychosocial resources-should be part of shared decision-making for patients considering complex spine surgery. Such an assessment may suffice to prompt interventions that form a prehabilitation program. Formal prehabilitation programs will require further study to better define their place in complex spine care.

Narrative Review: Clinical Implications and Assessment of Frailty in Patients With Advanced CKD

There is a lack of reliable tools to assess the knowledge of frailty and malnutrition in community-dwelling older adults. To develop and validate reliable frailty and malnutrition knowledge assessment scales for this population, two scales were developed and validated through five phases. Phase 1: the item pools were constructed through a literature review and research panel based on the symptom interpretation model. Phase 2: the expert consultation was performed to select the items. Phase 3: a pilot survey was conducted to assess the clarity of the items and further revise the scales. Phase 4: 242 older adults were surveyed to finalize the items. Phase 5: 241 older adults were surveyed to test the psychometric properties. The two scales each comprise 3 dimensions (symptoms, risk factors, and management strategies) and 11 items. They had good construct validity, with all indicators of correlation analysis and confirmatory factor analysis meeting their specific criteria. The reliability of the frailty and malnutrition knowledge assessment scales was good, with composite reliability coefficients all>0.60, Cronbach's alpha being 0.81 and 0.83, and the Spearman-Brown coefficient being 0.74 and 0.80, respectively. Their acceptability was good, with both having a completion rate of 92.18% and an average completion time of 3 min. The two scales are reliable tools to assess the knowledge of frailty and malnutrition among community-dwelling older adults, especially for large-scale surveys. They can help identify knowledge gaps in older adults and provide a basis for developing targeted educational interventions.

Frailty has been recognized as a major risk factor for adverse perioperative and oncological outcomes in patients with genitourinary malignancies. Yet, the evidence supporting such an association in patients with renal cell carcinoma (RCC) is still sparse. Herein we provide an updated comprehensive overview of the impact of frailty on perioperative and oncologic outcomes in patients undergoing surgery or ablation for RCC. A systematic review of the English-language literature was conducted using the MEDLINE (via PubMed), Web of Science and the Cochrane Library databases according to the principles highlighted by the EAU Guidelines Office and the PRISMA statement recommendations. The review protocol was registered on PROSPERO (CRD42021242516). The overall quality of evidence was assessed according to GRADE recommendations. Overall, 18 studies were included in the qualitative analysis. Most of these were retrospective single-center series including patients undergoing surgery for non-metastatic RCC. The overall quality of evidence was low. A variety of measures were used for frailty assessment, including the Canadian Study of Health and Aging Frailty Index, the five-item frailty index, the Modified Rockwood's Clinical Frailty Scale Score, the Hopkins Frailty score, the Groningen Frailty Index, and the Geriatric nutritional risk index. Sarcopenia was defined based on the Lumbar skeletal muscle mass at cross-sectional imaging, the skeletal muscle index, the total psoas area, or the Psoas Muscle Index. Overall, available studies point to frailty and sarcopenia as potential independent risk factors for worse perioperative and oncological outcomes after surgery or ablation for different RCC stages. Increased patient's frailty was indeed associated with higher risk of perioperative complications, healthcare resources utilization, readmission rates and longer hospitalization periods, as well as potentially lower cancer specific or overall survival. Frailty has been consistently associated with worse outcomes after surgery for RCC, reinforcing the value of preoperative frailty assessment in carefully selected patients. Given the low quality of the available evidence (especially in the setting of tumor ablation), prospective studies are needed to standardize frailty assessments and to identify patients who are expected to benefit most from preoperative geriatric evaluation, aiming to optimize decision-making and postoperative outcomes in patients with RCC.

Introduction: As new treatments have become established, more frail pre-ICU patients are being admitted to intensive care units (ICUs); this is creating new challenges to provide adequate care and to ensure that resources are allocated in an ethical and economical manner. This systematic review evaluates the current standard for assessing frailty on the ICU, including methods of assessment, time point of measurements, and cut-offs. Methods: A systematic search was conducted on MEDLINE, Clinical Trials, Cochrane Library, and Embase. Randomized and non-randomized controlled studies were included that evaluated diagnostic tools and ICU outcomes for frailty. Exclusion criteria were the following: studies without baseline assessment of frailty on ICU admission, studies in paediatric patients or pregnant women, and studies that targeted very narrow populations of ICU patients. Eligible articles were included until January 31, 2021. Methodological quality was assessed using the Newcastle-Ottawa Scale. No meta-analysis was performed, due to heterogeneity. Results: N = 57 articles (253,376 patients) were included using 19 different methods to assess frailty or a surrogate. Frailty on ICU admission was most frequently detected using the Clinical Frailty Scale (CFS) (n = 35, 60.3%), the Frailty Index (n = 5, 8.6%), and Fried’s frailty phenotype (n = 6, 10.3%). N = 22 (37.9%) studies assessed functional status. Cut-offs, time points, and manner of baseline assessment of frailty on ICU admission varied widely. Frailty on ICU admission was associated with short- and long-term mortality, functional and cognitive impairment, increased health care dependency, and impaired quality of life post-ICU discharge. Conclusions: Frailty assessment on the ICU is heterogeneous with respect to methods, cut-offs, and time points. The CFS may best reflect frailty in the ICU. Frailty assessments should be harmonized and performed routinely in the critically ill.

Background: Ministerial Decree (D.M.) 77/2022 aims to reform Italy's primary care system by establishing community health centres and integrating digital tools to address healthcare access disparities and workforce shortages. This review focuses on frailty assessment tools, digital health innovations, and workforce challenges in the Autonomous Province of Bolzano, South Tyrol, emphasising interprofessional trust and collaboration issues. Methods: Using a narrative custom review approach guided by the SANRA checklist, this study synthesised findings from PubMed, official health websites, and regional surveys on frailty, workforce dynamics, interprofessional collaboration, and digital infrastructure in South Tyrol. Results: General practitioners (GPs) exhibited high professional motivation but expressed concerns about autonomy and administrative burdens in collaborative care models. Trust issues between GPs and specialists hinder workforce cohesion and care coordination, highlighting the need for structured inter-professional communication. Frailty assessments, such as the PRISMA-7 tool, identify over 33% of community-dwelling individuals aged 75 years and older as frail, necessitating targeted interventions. Digital health adoption, particularly electronic health records and telemedicine, is slow because of workforce shortages and infrastructure limitations. Conclusions: The successful implementation of D.M. 77/2022 in South Tyrol requires addressing workforce challenges, improving interprofessional trust, expanding digital infrastructure, and integrating frailty assessment findings into care strategies. These measures are critical for achieving a more resilient, equitable, and effective primary healthcare system.

Frailty assessment using routine clinical data: An integrative review

Frailty refers to the state of decreased physiological function reserve caused by the increase of age-related multisystemic accumulated defects. The number of elderly patients with frailty undergoing elective operations is gradually increasing. The stages of frailty have strong correlation with the prognosis and mortality after surgery. By summarizing the frailty assessment scales used in foreign countries, we provide reference to the selection of clinical frailty assessment tools in Chinese population. This article reviewed two frailty models (phenotype model and the cumulative deficit model) and three assessment tools [Simple Frailty Questionnaire (FRAIL), Edmonton Frail Scale (EFS) and Program on Research for Integrating Services for the Maintenance of Autonomy (PRISMA)- 7 Scale]. In addition, three assistant indexes [handgrip strength, gait speed and Timed Up-And-Go Test (TUGT)] are introduced. The present review provides reference for the studies on perioperative complications in patients with frailty. Key words: Aged; Frailty; Risk assessment

As the UK's older population continues to rise, the more likely it is for practice nurses to encounter patients living with Alzheimer's and frailty. Kirsty Smith and Sophie Wallington explore the definitions and models of frailty available in medical literature As a consequence of an ageing global population, it is likely that encounters between health professionals and frail patients will rise. Patients with both suspected frailty and Alzheimer's disease are frequently encountered in primary care. There are links and overlaps between these disease states; however, the key theories and models of frailty propose some contradictions. This review of the definition, theories and models of frailty, and relevance to patients with Alzheimer's disease will add a quality, evidence-based approach to the assessment of frailty in patients in primary care living with Alzheimer's disease.

Background: This thesis explores the concept of frailty, as a latent vulnerability in older people, with the aim of refining its measurement by generating a new measure of frailty - the British Frailty Index (FI). This index was developed and validated in a cohort of community-dwelling older women, the British Women's Heart and Health Study (BWHHS), in 23 towns in Britain. Findings were replicated in another large Medical Research Council (MRC) Assessment of Older People study Methods: A systematic literature review examined the evolution of the concept and definitions of frailty. A meta-analysis on the prognostic value of current frailty measures confirmed extensive heterogeneity in the prediction of all-cause mortality despite consideration of age, sex, type of measure and duration of follow up. A 'General Specific' model of frailty was derived from factor analysis in the BWHHS population and replicated in the MRC cohort. Construct, external criterion and predictive validity of the British FI were assessed and its performance compared to another widely used index - the Canadian Frailty Index - with single indicators of frailty. Results: Frailty was explained by seven factors; physical ability, cardiovascular and respiratory disease and symptoms, visual impairments, other comorbidities, psychological problems and physiological measures. Associations with frailty included increased age, female sex, smoking, living alone, not living in own home, poor social contact and low socioeconomic position. Frailty was an independent predictor of all-cause mortality in both cohorts and predicted hospitalization and institutionalization in the MRC study, performing better than the Canadian Index. Conclusion: This thesis provides better understanding of the multi-dimensional domains of frailty in older people. The British FI demonstrates validity in relation to adverse outcomes, provides a more reliable measurement tool and its application offers further opportunities for the prevention, detection and treatment of frailty at a clinical level.

With increasing life expectancy and technological advancement, provision of anaesthesia for elderly patients has become a significant part of the overall case-load. These patients are unique, not only because they are older with more propensity for comorbidity but a decline in physiological reserve and cognitive function invariably accompanies ageing; this can substantially impact peri-operative outcome and quality of recovery. Furthermore, it is not only morbidity and mortality that matters; quality of life is also especially relevant in this vulnerable population. Comprehensive geriatric assessment is a patient-centred and multidisciplinary approach to peri-operative care. The assessment of frailty has a central role in the pre-operative evaluation of the elderly. Other essential domains include optimisation of nutritional status, assessment of baseline cognitive function and proper approach to patient counselling and the decision-making process. Anaesthetists should be proactive in multidisciplinary care to achieve better outcomes; they are integral to the process.