One Last Question Before the Operation: Just How Frail Are You?
October 27, 2017
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THE NEW OLD AGE Oct. 27, 2017
Earlier this month, Dr. Thomas Robinson, a general surgeon at the Denver Veterans Affairs Medical Center, saw a patient in his mid 80s. The man had gallstones that caused infections, with 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. “In a 60-year-old, chances are it’s an outpatient operation,” Dr. Robinson said. In this case, though, he hesitated. Like a growing number of surgeons, he wanted to know, before presenting the options, whether his patient was frail.
In geriatrics, frail is not merely an adjective. A syndrome marked by slowness, weakness, fatigue and often weight loss, frailty tells doctors a lot about their patients’ likely futures. It can, for example, predict how well older patients rebound from physical stresses — like surgery.
“Some 86-year-olds live independently and are really healthy, and we take out their gallbladders all the time,” Dr. Robinson told me. But this patient, a nursing home resident who also had heart disease and pulmonary disease, scored moderately to highly frail on a commonly used index.
In particular, the man flunked what’s called the “timed up-and-go,” which measures how long it takes someone to rise from a chair, walk 10 feet, turn around, walk back and sit down again.
Along with other frailty measures, that meant that “surgery is not going to go very well,” Dr. Robinson said. In a frank half-hour conversation, he explained to his patient that he faced a 30 to 40 percent risk of dying from the surgery. If he survived, he probably would endure a long, difficult recovery and might not regain the functional abilities he had now.
Dilemmas like these will grow more common as the population ages. Already, 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. “There’s a much higher prevalence in the Deep South and among African Americans,” said Dr. Jeremy Walston, principal investigator at the Older Americans Independence Center at Johns Hopkins Medicine.
Geriatricians like Dr. Walston have been publishing research on frailty for nearly 20 years, as measured by tools developed at Johns Hopkins or by a Canadian group, and variants thereof. The Hopkins approach uses tests like grip strength and walking speed; the Canadian index relies on health deficits, including chronic illnesses and dementia.
Both assessments do a good job of identifying patients vulnerable to health problems, regardless of chronological age. A British group has used meta-analyses, for instance, to show that frail older adults are more prone to falls, fractures, hospitalizations, dementia and nursing home placement.
In the United States, though, “it’s the surgeons who have picked up the banner,” Dr. Walston said. They’re starting to use frailty to help make decisions about which procedures make sense for which older patients.
You can see why: Frailty involves decreased physiological reserve, which helps determine how patients respond to physical stress.
Surgery brings plenty of that, said Dr. Carolyn Seib, a general and endocrine surgeon at the University of California, San Francisco. 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.
“The more frail a patient is, the higher the risk of complications,” Dr. Seib said.
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.
But a study that Dr. Seib and her colleagues published in JAMA Surgery this month shows that frail seniors face higher complications even after ambulatory surgery, outpatient procedures often considered routine.
Hernia repairs, thyroid or parathyroid surgery, operations for breast cancer — “patients and providers often don’t think twice about these,” Dr. Seib said.
Yet when the researchers looked at 141,000 patients over age 40 in a national surgical database, they found that serious complications were two to four times higher in patients with moderate to high frailty, although complication rates overall were low (1.7 percent, with .7 percent experiencing serious complications).
“We have to take frailty into account for any operation, big or small,” Dr. Seib said. Although surgeons increasingly screen for frailty, “I wouldn’t say it’s routine yet,” she added.
So she and other researchers recommend that before an operation, patients and families ask: Is my mother showing signs of frailty? Should we do an assessment that indicates how frail she might be?
Unlike some conditions, frailty is something patients and doctors can actually do something about. “There are interventions that can improve or even resolve it,” said Dr. Linda Fried, dean of the Mailman School of Public Health at Columbia University and a pioneer in frailty research.
First, many surgical centers offer a “prehabilitation” program, shown to improve patients’ results through exercise, better nutrition and smoking cessation. Undertaken even for a few weeks before an operation, “it improves your bounce-back capability,” Dr. Fried said.
Physical activity, in particular, “seems to be the key to preventing frailty and its progression,” Dr. Fried added — 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.
With frailty, “I’m going to counsel the patient differently,” Dr. Robinson said.
“Maybe change the surgery I do. Maybe find an alternative. There’s a spectrum of possibilities.”
Take his patient with gallstone disease.
After their discussion, the man decided that instead of undergoing what would be, for him, a high-risk operation, he would go home and try to avoid foods that triggered his symptoms. If the pain flared again, Dr. Robinson would insert a tube through his skin to drain the gallbladder, a much safer procedure.
Because the tube, and the bag into which it drained, would be permanent, it might not represent a welcome alternative for a healthier patient. But “for a physiologically vulnerable older adult,” Dr. Robinson said, “it’s a whole different equation.”
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