Frailty
Frailty refers to a state of increased vulnerability, decreased physiological reserve, and reduced ability to withstand stressors. It is commonly associated with aging but can also affect individuals of any age who have underlying health conditions or are experiencing significant physiological or functional decline.
Frailty is characterized by a decline in various physiological systems, including the musculoskeletal, cardiovascular, endocrine, and immune systems. This decline often leads to decreased physical strength, endurance, and mobility, as well as an increased risk of adverse health outcomes such as falls, disability, hospitalization, and mortality.
Frailty is a multidimensional concept that encompasses both physical and cognitive aspects. Physical frailty is typically assessed through measures such as weakness, slow walking speed, low physical activity, exhaustion, and unintentional weight loss. Cognitive frailty involves cognitive impairment or decline in cognitive function, often in combination with physical frailty.
It is important to note that frailty is distinct from normal aging. While aging is a natural and inevitable process, frailty represents an accelerated decline in physical and cognitive function, making individuals more susceptible to adverse health outcomes.
Early identification of frailty is crucial for implementing appropriate interventions and care strategies to prevent or mitigate further decline and improve the overall well-being of individuals affected by frailty.
Frailty-based prehabilitation is a medical and healthcare approach that aims to optimize the physical and psychological health of individuals who are identified as frail before they undergo surgery or other medical procedures. It involves a combination of interventions and strategies designed to enhance a patient's resilience and reduce the risk of postoperative complications. Here's a breakdown of the key components and concepts associated with frailty-based prehabilitation:
Frailty Assessment: The first step in frailty-based prehabilitation is to identify patients who are frail or at risk of frailty. Frailty is a clinical syndrome characterized by reduced physiological reserves, diminished muscle mass and strength, and decreased functional capacity. Various tools and assessments, such as the Fried Frailty Phenotype or the Rockwood Clinical Frailty Scale, may be used to determine a patient's frailty status.
Multidisciplinary Approach: Prehabilitation involves a multidisciplinary team of healthcare professionals, including physicians, surgeons, physical therapists, dietitians, and mental health specialists. This team works collaboratively to assess the patient's physical and psychological health, set goals, and develop an individualized prehabilitation plan.
Exercise and Physical Conditioning: A central component of frailty-based prehabilitation is physical exercise. Patients are prescribed structured exercise programs that focus on improving strength, endurance, balance, and mobility. These exercises can help build muscle mass, improve cardiovascular fitness, and enhance overall physical function.
Nutrition Optimization: Dietitians assess the patient's nutritional status and may recommend dietary changes or supplementation to improve their nutritional intake. Adequate nutrition is essential for healing and recovery after surgery.
Psychological Support: Prehabilitation also addresses the psychological well-being of patients. Anxiety and stress can have a negative impact on surgical outcomes, so interventions such as relaxation techniques, counseling, and stress management may be incorporated.
Education and Empowerment: Patients are educated about their upcoming surgery, the importance of prehabilitation, and what to expect during the recovery process. Empowering patients with knowledge can enhance their commitment to the prehabilitation program.
Outcome Measurement: Throughout the prehabilitation process, healthcare providers monitor the patient's progress and adjust the plan as needed. The goal is to improve physical fitness and reduce frailty, which can lead to better surgical outcomes and a faster recovery.
Surgical Timing: In some cases, frailty-based prehabilitation may allow for optimization of a patient's health to the point where surgery is safer or can be delayed until the patient is better prepared physically and mentally.
Postoperative Continuation: The benefits of prehabilitation can extend into the postoperative period. Patients who have undergone prehabilitation often experience quicker recoveries, reduced complications, and improved quality of life after surgery.
Frailty-based prehabilitation is especially beneficial for older adults and individuals with multiple medical conditions who may be at a higher risk of complications following surgery. By addressing frailty and optimizing a patient's health before a procedure, healthcare providers aim to improve overall outcomes and enhance the patient's ability to return to a higher level of functioning.
Frailty in neurosurgery
Frailty has gained prominence in neurosurgical oncology, with more studies exploring its relationship to postoperative outcomes in brain tumor surgery. As this body of literature continues to grow, concisely reviewing recent developments in the field is necessary. Qureshi et al. provided a systematic review of frailty in brain tumor patients subdivided by tumor type, incorporating both modern frailty indices and traditional Karnofsky Performance Status (KPS) metrics.
A systematic literature review was performed using PRISMA guidelines. PubMed and Google Scholar were queried for articles related to frailty, KPS, and brain tumor outcomes. Only articles describing novel associations between frailty or KPS and primary intracranial tumors were included.
After exclusion criteria, a systematic review yielded 52 publications. Amongst malignant lesions, 16 studies focused on glioblastoma. Amongst benign tumors, 13 focused on meningiomas, and 6 focused on vestibular schwannomas. Seventeen studies grouped all brain tumor patients. Seven studies incorporated both frailty indices and KPS into their analyses. Studies correlated frailty with various postoperative outcomes, including complications and mortality.
The review identified several patterns of overall postsurgical outcomes reporting for patients with brain tumors and frailty. To date, reviews of frailty in patients with brain tumors have been largely limited to certain frailty indices, analyzing all patients together regardless of lesion etiology. Although this technique is beneficial in providing a general overview of frailty's use for brain tumor patients, given each tumor pathology has its unique etiology, this combined approach potentially neglects key nuances governing frailty's use and prognostic value 1).
Many countries are facing an aging population. As people live longer, surgeons face the prospect of operating on increasingly older patients. Traditional teaching is that with older age, these patients face an increased risk of mortality and morbidity, even to a level deemed too prohibitive for surgery. However, this is not always true. An active 90-year-old patient can be much fitter than an overweight, sedentary 65-year-old patient with comorbidities. Recent literature shows that frailty-an age-related cumulative decline in multiple physiological systems is therefore a better predictor of mortality and morbidity than chronological age alone. Despite recognizing frailty as an essential tool in identifying vulnerable surgical patients, many surgeons still shun objective tools 2)
This study aimed to review and analyze the neurosurgery body of literature to document the current knowledge of frailty within neurosurgery, standardizing terminology and how frailty is defined, including the different levels of frailty, while determining what conclusions can be drawn about frailty's impact on neurosurgical outcomes. While multiple studies on frailty in neurosurgery exist, no literature reviews have been conducted. Therefore, we performed a literature review to organize, tabulate, and present findings from the data to broaden our understanding of what we know about frailty and neurosurgery. We performed a PubMed search to identify studies that evaluated frailty and neurosurgery. The terms “frail,” “frailty,” “neurosurgery,” “spine surgery,” “craniotomy,” and “neurological surgery” were all used in the query. We then organized, analyzed, and summarized the comprehensive frailty and neurosurgical literature. The literature contained 25 published studies analyzing frailty in neurosurgery between December 2015 and December 2018. Five of these studies were cranial neurosurgical studies, the remaining studies focused on spinal neurosurgery. Over 100,000 surgical cases were analyzed among the 25 studies. Of these, 18 studies demonstrated that increasing frailty was associated with increased rate of complications, 10 studies showed that frailty was associated with higher mortality rates, 11 studies demonstrated an association between frailty and increased hospital length of stay, and 5 studies noted that higher frailty was associated with discharge to a higher level of care. The current body of literature repeatedly demonstrates that frailty is associated with worse outcomes across the neurosurgical subspecialties 3).
From a chronological viewpoint, medical treatment of the elderly (geriatrics) starts from the age of 65 years old. This definition per se is certainly not an adequate definition of an elderly patient and the reason to be treated by a geriatrician. In addition to chronological age, other factors must be considered to define the elderly patient. Functional reserves decrease with age, which leads to increased vulnerability. Frailty is a term that describes this situation and can be defined pathophysiologically by a mainly subclinical inflammatory state. Therefore, in 2007 the German Society of Geriatrics (DGG), the German Society of Gerontology and Geriatrics (DG), and the German Group of Geriatric Institutions (BAG) jointly developed a definition of the geriatric patient 4).
Scores
Clinical Frailty Scale (CFS) – A 9-point scale assessing physical and cognitive function.
Fried Frailty Phenotype (FFP) – Defines frailty based on five criteria: unintentional weight loss, exhaustion, weakness (grip strength), slow walking speed, and low physical activity.
Modified Frailty Index (mFI-5 or mFI-11) – Derived from the National Surgical Quality Improvement Program (NSQIP), using comorbidities and functional status to predict outcomes.
5-factor modified frailty index.
Risk Analysis Index (RAI) – A rapid frailty screening tool correlated with mortality.
Frailty Index (FI) based on Accumulated Deficits – Uses a broad range of health deficits to quantify frailty.
Trauma-Specific Frailty Index.
Risk Analysis Index-Administrative (RAI-A)
the CFS is the most frequently used. However, for surgical patients, the mFI-5 is preferred, and for research, the Frailty Index (FI) is most detailed.