Use of Frailty Classification in Predicting Adverse Surgical Outcomes in Seniors

March 22, 2021

With aging comes a heightened risk of physical disability. Seniors are also more likely to need surgical intervention for a variety of conditions which disproportionately affect older populations, such as cancer or joint failure. However, the inherently heterogeneous nature of age-related disabilities, ample comorbidities, and lack of an official diagnostic term has long made it difficult to incorporate these considerations into pre-surgical planning. Hence, the frailty classification system was born as part of a multi-faceted effort to combat these challenges. 

Frailty has been defined by Fried et al. as “age-associated decline in physiologic reserve and function across multiple organ systems, resulting in diminished strength and endurance, increased vulnerability to stressors, risk of falls, disability, hospitalization and mortality.”[1] The most common frailty classification system consists of four diagnostic categories: robust, post-robust, pre-frail, and frail, which are correlated with self-reported health, chronic pain, and outlook. However, there are several different classification systems currently in use, including the American College of Surgeons National Surgical Quality Improvement Program modified frailty index, the Johns Hopkins Adjusted Clinical Groups frailty index, and one endorsed by the American Society of Anesthesiologists. 

In order to evaluate the effectiveness of the frailty classification system, a 2017 longitudinal study assessed over 750 seniors and found that it was highly effective at predicting future hospitalizations and cancer prognosis, indicating overall accuracy as a qualitative assessment. [2] A study done on patients with head and neck cancer who were characterized using these scales found that the classifications by the American Society of Anesthesiologists and the American College of Surgeons were significant predictors of perioperative outcomes.[3] Yet another study was able to use the frailty classification index to accurately predict 30-day postoperative mortality in elderly populations.[4] These findings indicate that using a frailty classification system may improve pre-operative risk assessment.

Research clearly indicates the importance of frailty assessment in the surgical evaluation of elderly patients. The ability to anticipate postoperative complications in seniors is particularly valuable, as these difficulties can be especially difficult to predict. Surgeons and physicians alike should therefore take frailty into consideration when developing treatment plans.


[1] Fried LP, Tangen CM, Walston J, et al (2001). Frailty in older adults: evidence for a phenotype. J Gerontol A Biol Sci Med Sci. 56(3):M146-M156.

[2] Ferrat, E., Paillaud, E., Caillet, P., Laurent, M., Tournigand, C., Lagrange, J. L., Droz, J. P., Balducci, L., Audureau, E., Canouï-Poitrine, F., & Bastuji-Garin, S. (2017). Performance of Four Frailty Classifications in Older Patients With Cancer: Prospective Elderly Cancer Patients Cohort Study. Journal of Clinical Oncology35(7), 766–777.

[3] Pitts, K. D., Arteaga, A. A., Stevens, B. P., White, W. C., Su, D., Spankovich, C., Jefferson, G. D., & Jackson, L. L. (2019). Frailty as a Predictor of Postoperative Outcomes among Patients with Head and Neck Cancer. Otolaryngology: Head and Neck Surgery160(4), 664–671.

[4] Stortecky, S., Schoenenberger, A. W., Moser, A., Kalesan, B., Jüni, P., Carrel, T., Bischoff, S., Schoenenberger, C. M., Stuck, A. E., Windecker, S., & Wenaweser, P. (2012). Evaluation of multidimensional geriatric assessment as a predictor of mortality and cardiovascular events after transcatheter aortic valve implantation. JACC Cardiovascular Interventions5(5), 489–496.