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How frail are you?

November 4, 2017



In a ‘New York Times’ article by Paula Span titled ‘One Last Question Before the Operation: Just How Frail Are You?’, the author discusses the need to consider frailty before opting for surgical solutions, more so in elderly patients.


In geriatrics, frail is a syndrome marked by slowness, weakness, fatigue and often weight loss, frailty tells doctors a lot about their patients’ likely futures. It can predict how well older patients rebound from physical stresses like surgery. Some other frailty index relies on health deficits, including chronic illnesses and dementia. Most assessments help identify patients vulnerable to health problems, regardless of chronological age.


For instance, a patient in his mid 80s, suffering from gallstones caused infections, would have abdominal pain severe enough to send him to an emergency room every couple of months. The surgical solution to this problem is usually clear: Remove the gallbladder with a procedure called a cholecystectomy.


Cholecystectomy, an outpatient operation in a 60-year-old, is not as simple in an 80-year-old. A growing number of surgeons would want to know, before presenting the options, whether his patient was frail.


Some 80-year-olds are really healthy, but some others could have a heart disease or pulmonary disease, scored moderately to highly frail. Such patients flunk the “timed up-and-go” test, which measures how long it takes someone to rise from a chair, walk 10 feet, turn around, walk back and sit down again. They face a 30 to 40 percent risk of dying from the surgery. If they survive, these patients would probably endure a long, difficult recovery and might not regain functional abilities.


Dilemmas like these will grow more common as the population ages. More than a third of inpatient surgical procedures are performed on patients over age 65. But about 15 percent of the older population, excluding nursing home residents, meets the criteria for frailty, rising to more than a third of those over age 85. Frail older adults are more prone to falls, fractures, hospitalizations, dementia and nursing home placement. Frailty involves decreased physiological reserve, which helps determine how patients respond to physical stress.


The effects of anesthesia and inflammation, the risk of blood clots or infection, muscle weakness caused by days in bed, all can take a toll.


Researchers have shown that after major operations — including cardiac and colon cancer surgery and kidney transplants — frail older patients are more prone than others to longer hospital stays, being readmitted within a month of a procedure and winding up in nursing homes after they’re discharged. They’re also more likely to die.


Frail seniors face higher complications even after ambulatory surgery, outpatient procedures often considered routine, even hernia repairs, thyroid or parathyroid surgery, operations for breast cancer.


Unlike some conditions, frailty is something patients and doctors can actually do something about. Some surgical centers offer prehabilitation to improve patients’ results through exercise and better nutrition a few weeks before an operation.


Physical activity is the key to preventing frailty and its progression even for those not contemplating surgery.


Second, surgical decision-making is not a binary choice between patients agreeing to the standard operation or doing nothing. Alerted to frailty, a surgeon might opt for a less aggressive approach or a different kind of anesthesia. A patient, understanding that she may be looking at an altered future even if the surgery fixes the physical problem, will have her own priorities to weigh.



Read full report here:

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