Lown Right Care

Reducing Overuse and Underuse

Preoperative Evaluation and Frailty Assessment in Older Patients


Am Fam Physician. 2020 Dec 15;102(12):753-755.

  Related letter: All Patients Undergoing Any Surgical Procedure Should Be Assessed for Frailty

Related article: Frailty: Evaluation and Management

Author disclosure: No relevant financial affiliations.

Case Scenario

Mr. M is an 80-year-old widower who lives in an assisted living facility. He has mild congestive heart failure and right knee osteoarthritis. Despite treatment with acetaminophen and a steroid injection from his primary care physician, increasing pain in his arthritic knee limits his ability to participate in yoga classes and walk for physical activity. He is not overweight and uses a walker for stability. He eats, toilets, and tends to his hygiene independently. During his appointment, he asks about knee replacement surgery. He mentions that his appetite is reduced, and he has lost 10 pounds since his last visit six months ago. His son, who accompanies him to the visit, says he has noticed his father has become more forgetful in the past three months.

Clinical Commentary

Knee replacement surgery is considered a moderate-stress procedure according to the Operative Stress Score.1 However, research suggests that the patient's preoperative health and function are more important considerations in estimating operative risk.1  Table 1 lists key components of the preoperative evaluation. Frailty is a term that describes patients, regardless of age, who have reduced physiologic reserve and are at increased risk of dying within five years. Patients who are frail and very frail who underwent lowest stress surgical procedures exceeded the 30-day mortality rate often used to define high-risk surgery.1 [corrected]

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Key Components of the Preoperative Evaluation in Older Patients

Cognitive status

Patient's life goals

PHQ-2 and PHQ-9, if indicated

Risk Analysis Index

Social and living situation

PHQ = Patient Health Questionnaire.


Key Components of the Preoperative Evaluation in Older Patients

Cognitive status

Patient's life goals

PHQ-2 and PHQ-9, if indicated

Risk Analysis Index

Social and living situation

PHQ = Patient Health Questionnaire.

Frailty can be measured using the revised Risk Analysis Index, a validated tool with high predictive power for postoperative mortality.2 The tool takes less than two minutes to complete, using 14 variables including demographic factors (age, sex), comorbidities (presence of disseminated cancer, unintentional weight loss, renal failure, congestive heart failure, loss of appetite, dyspnea at rest, cognitive decline), facility residence, and level of independence in four activities of daily living. A Risk Analysis Index score of 30 or more out of a possible 81 points indicates frailty, and 40 points or more indicates the patient is very frail.3,4 All surgical procedures are considered high risk for patients who are frail and very frail.1

One of the Risk Analysis Index questions is, “Have your cognitive skills or status deteriorated over the past three months?” Minor and major surgeries can trigger a significant reduction in functional status for older people who are frail, especially people with cognitive impairment. The Risk Analysis Index is only modestly sensitive for mild cognitive impairment or dementia; therefore, clinicians who have a high index of suspicion should use a screening tool for dementia such as the Mini-Cog (https://mini-cog.com). Patients with dementia who are hospitalized are at high risk of iatrogenic harms, including delirium, long-term cognitive and functional decline, longer hospital stays, and greater risk of institutionalization.5,6 The combination of physical frailty and mild cognitive impairment is associated with a higher risk of adverse outcomes than either factor alone.7

Preoperative evaluation for depression using the Patient Health Questionnaire-2 (PHQ-2) and PHQ-9, if indicated, may identify additional risks of surgery, including increased risk of postoperative infection, chronic pain, and delirium.8

Adequate evaluation of the patient's living situation is important to assess the need for skilled nursing or rehabilitation placement or to plan a safe discharge home. Will someone be with the patient during surgical recovery? How will meals be provided? Are stairs an issue? How will bathing and toileting be accomplished? How will prescriptions be filled? Do the patient and caregiver know how to get questions answered? If durable medical equipment, such as a portable toilet or a hospital bed, will be needed, who will arrange for that ahead of time? Are there fall risks at home? Would a preoperative home visit by a nurse or physical therapist be helpful? Preplanning can facilitate safe return to the home and avoid prolonged hospital stays or temporary placement in a skilled nursing facility.

Few preoperative risk reduction interventions have been tested in surgical patients who are frail. However, pre- and postoperative exercise therapy appears to improve functional outcomes and quality of life after hip replacement or cardiac surgery.9 Preoperative evaluation of older patients can also enable a clinician to more accurately inform the patient

Address correspondence to Ann Lindsay, MD, at adlindsa@stanford.edu. Reprints are not available from the authors.

Author disclosure: No relevant financial affiliations.


show all references

1. Shinall MC Jr, Arya S, Youk A, et al. Association of preoperative patient frailty and operative stress with postoperative mortality. JAMA Surg. 2019;155(1):e194620....

2. Shinall MC Jr, Youk A, Massarweh NN, et al. Association of preoperative patient frailty and operative stress with mortality after elective vs. emergency surgery. JAMA Netw Open. 2020;3(7):e2010358.

3. Hall DE, Arya S, Schmid KK, et al. Development and initial validation of the Risk Analysis Index for measuring frailty in surgical populations. JAMA Surg. 2017;152(2):175–182.

4. Arya S, Varley P, Youk A, et al. Recalibration and external validation of the Risk Analysis Index: a surgical frailty assessment tool [published online March 19, 2019]. Ann Surg. Accessed October 10, 2020. https://journals.lww.com/annalsofsurgery/Abstract/2020/12000/Recalibration_and_External_Validation_of_the_Risk.22.aspx

5. Gross AL, Jones RN, Habtemariam DA, et al. Delirium and long-term cognitive trajectory among persons with dementia. Arch Intern Med. 2012;172(17):1324–1331.

6. Sheckter CC, Bott NT, Milstein A, et al. Individualized acute medical care for cognitively impaired individuals: a call always to pause before hospitalization. J Am Geriatr Soc. 2018;66(2):219–221.

7. Aliberti MJR, Cenzer IS, Smith AK, et al. Assessing risk for adverse outcomes in older adults: the need to include both physical frailty and cognition. J Am Geriatr Soc. 2019;67(3):477–483.

8. Ghoneim MM, O'Hara MW. Depression and postoperative complications: an overview. BMC Surg. 2016;16:5.

9. McIsaac DI, Jen T, Mookerji N, et al. Interventions to improve the outcomes of frail people having surgery: a systematic review. PLoS One. 2017;12(12):e0190071.

10. Spatz ES, Krumholz HM, Moulton BW. Prime time for shared decision making. JAMA. 2017;317(13):1309–1310.

11. Fried TR, Bradley EH, Towle VR, et al. Understanding the treatment preferences of seriously ill patients. N Engl J Med. 2002;346(14):1061–1066.

12. The Rheumatologist. Physical therapy, exercise advances for knee osteoarthritis. May 15, 2015. Accessed October 10, 2020. https://www.the-rheumatologist.org/article/physical-therapy-exercise-advances-for-knee-osteoarthritis/

13. Kuo FC, Hsu CH, Chen WS, et al. Total knee arthroplasty in carefully selected patients aged 80 years or older. J Orthop Surg Res. 2014;9:61.

Lown Institute Right Care Alliance is a grassroots coalition of clinicians, patients, and community members organizing to make health care institutions accountable to communities and to put patients, not profits, at the heart of health care.

This series is coordinated by Kenny Lin, MD, MPH, deputy editor.

A collection of Lown Right Care published in AFP is available at https://www.aafp.org/afp/rightcare.



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