One of Lab Landâ€™s regular features is a post exploring a biomedical term that seems to be appearing frequently in connection with Emory research. This month Iâ€™d like to focus on frailty, which has been an important concept in treating elderly patients for some time. (This pieceÂ in The Atlantic nudged me into it.) Assessing frailty is emerging as a way for surgeons to predict post-operative complications.
Several teams of researchers have been trying to develop a standardized way of measuring frailty to aid in weighing the risks and benefits of surgery. Frailty may seem like a subjective quality (echoing Supreme Court Justice Potter Stewartâ€™s remarks on obscenity: â€œI know it when I see itâ€) but if frailty can be defined objectively, doctors and patients can use it to help in decision-making.
Frailty can be thought of as a decrease in physiological reserve or a decrease in the ability to recover from an infection or injury. Much of the credit for developing the concept of frailty should go to Linda Fried, now dean of Columbiaâ€™s school of public health. While at Johns Hopkins, her team developed the Hopkins Frailty Score: a composite based on recent weight loss, self-reported exhaustion, low daily activity levels, low grip strength and slow gait.
At Emory, Ken Ogan and colleagues from the Department of Urology examined whether the Hopkins Frailty Score was a good predictor of postoperative complications in a group of patients undergoing major intra-abdominal surgeries. This study was published in the Journal of the American College of Surgeons in 2013. Louis Revenig, a medical student at Emory who is now a urology resident at Northwestern, was the first author. The team compared the HFS with additional information from blood biomarkers or patient surveys, and found the HFS was better than the alternatives. This study was also unique in that it recruited patients from several surgical oncology disciplines and included those in their 40s and 50s.
In a separate paper, Revenig and colleagues also compared patient-assessed and surgeon-assessed frailty with the HFS. Doctors tend to place an over-reliance on the patientâ€™s age while the patients tended to overestimate their ability to withstand the stress of the operation, they found. Another study from the same teamÂ showed that frailty contributes toÂ risk of complicationsÂ in patients undergoing minimally invasive procedures, as well as traditional open procedures.
In a 2014 paper, Shipra Arya and her vascular surgery colleagues at Emory measured frailty in a different way: an index of problems with daily living and pre-existing conditions that could be examined retrospectively. This allowed them to mine a national database, and use that measure of frailty to assess risk for complications after abdominal aortic aneurysm surgery. Their results show frailtyÂ could predict 30-day mortality, complication rates and â€œfailure to rescueâ€ (mortality from a complication).
Lots of evidence is accumulating showing that frailty can be measured and can provide useful information in connection with surgery. Then the question becomes: what to do with that information? If someone needs surgery, can we reduce that person’sÂ frailty score by providing them a special diet or program of weight-bearing exercise beforehand, and does that intervention improve outcomes?
If interested, please also see these papers from Rebecca Gary and Javed Butler on frailty in the context of cardiovascular disease, and this MedPage Today piece examiningÂ whether aortic valve replacement is a good idea for patients in their 80s and 90s, some of whom (but not all)Â may be frail.