SAN DIEGO — Frail elderly patients face a significantly increased risk of mortality in the year after undergoing major elective noncardiac surgery, a large study from Canada showed. “The current literature on perioperative frailty clearly shows that being frail before surgery substantially increases your risk of adverse postoperative outcomes,” Daniel I. McIsaac, MD, said in an interview prior to the annual meeting of the American Society of Anesthesiologists, where the study was presented. “In fact, frailty may underlie a lot of the associations between advanced age and adverse postoperative outcomes. Frailty increases in prevalence with increasing age, and as we all know, the population is aging. Therefore, we expect to see an increasing number of frail patients coming for surgery.” To determine the risk of 1-year mortality in frail elderly patients having major elective surgery, the researchers used population-based health administrative data in Ontario, to identify 202,811 patients over the age of 65 who had intermediate- to high-risk elective noncardiac surgery between 2002 and 2012. They used the Johns Hopkins Adjusted Clinical Groups frailty indicator and captured all deaths that occurred within 1 year of surgery. Proportional hazards regression models adjusted for age, gender, and socioeconomic status were used to evaluate the impact of frailty on 1-year postoperative mortality. Of the 202,811 patients, 6,289 (3.1%) were frail, reported Dr. McIsaac, an assistant professor of anesthesiology at the University of Ottawa. The 1-year postoperative mortality was 13.6% among frail patients, compared with 4.8% of nonfrail patients, for an adjusted hazard ratio of 2.23. Mortality was higher among frail patients for all types of surgery, compared with their nonfrail counterparts, with the exception of pancreaticoduodenectomy. Frailty had the strongest impact on the risk of mortality after total joint arthroplasty. The risk of postoperative mortality for frail patients was much higher than for nonfrail patients in the early time period after surgery, especially during the first postoperative week. “Depending on how you control for other variables, a frail patient was 13 to 35 times more likely to die in the week after surgery than a nonfrail patient of the same age having the same surgery,” said Dr. McIsaac, who is also a staff anesthesiologist at the Ottawa Hospital. “This makes a lot of sense; frail patients are vulnerable to stressors, and surgery puts an enormous physiological stress on even healthy patients. Future work clearly needs to focus [on] addressing this high-risk time in the immediate postoperative period.” Clinicians should focus on identifying frail patients prior to surgery, and “support them to ensure they are more likely to derive benefit from surgery than harm, and focus on optimizing their care after surgery to address this early mortality risk,” Dr. McIsaac said. Doug Brunk is with the San Diego bureau of Frontline Medical News. There is increasing evidence that physical frailty, which can be rapidly determined by the FRAIL scale (fatigue, resistance, ambulation, illness, loss of weight), is highly predictive of outcomes. In many cases it is more predictive of outcomes than well recognized risk factors. For example, in diabetes, frailty predicts hospitalization and mortality to a greater extent than cardiovascular disease, HgBA1C, and cholesterol. It would appear that the time has come for all older persons to be screened for frailty as part of the annual Medicare wellness exam. In the December issue of JAMDA an article from Hong Kong suggests that the FRAIL-NH scale may be a better marker for poor outcomes in nursing home residents (see page 22). —John Morley, MD St. Louis University School of Medicine