The different types of frail to consider before surgery

“If I’d known I was going to live this long, I would have taken better care of myself.”
-Eubie Blake

He leaned forward, energetically listening to my conversation with his daughter. There was more than one cancer treatment option. We reviewed everything and she asked what he could expect with either a major surgery or seven weeks of daily radiation treatments. Soon, both the father and daughter were peppering me with questions about timing, quality of life, side effects, and expectations.

The conversation continued for several minutes while I did my best to answer each concern.

Finally, the big question emerged. The daughter took a breath. “Do you really think he could survive a big surgery, Doctor? After all, Dad is 90.”

Their eyes swung toward me. Here was a man who looked a lot younger than the calendar would predict. He still gets outside and walks every day and is fully engaged with his world. But, true enough, he has lived a very long time.

When I was first in training in the early 1980’s, we rarely operated on anyone who was over 70, thinking that “the elderly” were too likely to get very sick or die. Over the decades, as technology expanded and the population aged, the “ceiling” age climbed. Given the proper precautions, we found that we could safely operate on older and older individuals. We recognized that some of our patients were the “young old,” and some were the “old old.” It wasn’t very scientific, but it helped us make recommendations.

A recent article takes a step forward in assessing the risks of performing surgery on older patients. In a paper entitled “Frailty as a Predictor of Surgical Outcomes in Older Patients,” Makary measured “frailty” in almost 600 people over 65-years-old who were preparing to have surgery. What constitutes “frail?” The researchers looked at five factors:

  • More than 10 pounds of unintentional weight loss
  • Decreased measured grip strength
  • Exhaustion as shown by the patient’s agreeing that “everything I did was an effort” or “I could not get going”
  • Reported very low leisure-time physical activity
  • Very slow walking speed (for example, 6 seconds to go 15 feet)

Patients who had four or five of these characteristics were “very frail,” while patients who had two or three were “intermediately frail,” and patients with none or one were “non-frail.” The higher the preoperative frailty score, the more likely the patient would suffer a surgical complication, require a longer hospital stay, or be discharged to a facility of some kind.

Fortunately, my patient was in excellent health and remained very active. Despite his age, he appeared to be a great candidate for surgery. Soon, he had signed the surgical consent and picked a date for his procedure. Everyone seemed satisfied.

As I opened the door to leave, he stopped me. “Doctor, I realize that I can have the surgery. Thanks for that. I trust you. But, Doctor,” he paused, “should I have the surgery? I am 90-years-old, after all!”

That, of course, is a completely different question. “I am quite certain you will do well,” I told him. “Would you like to think about this for a few days?”

He and his daughter went home and discussed things with the rest of the family. When he returned for the surgery a few weeks later, he was relaxed, ready, and as “non-frail” as they come. It was a good day.

Bruce Campbell is an otolaryngologist who blogs at Reflections in a Head Mirror.

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