Frailty is a state of decreased physiologic reserve and resistance to stressors. Its prevalence increases with age and is estimated to be 26% in those aged above 85 years. As the population ages, frailty will be increasingly seen in surgical patients receiving anesthesia.

Here, they evaluate the instruments which have been developed and validated for measuring frailty in surgical patients and summarize frailty tools used in 110 studies linking frailty status with adverse outcomes post-surgery.

Postoperative Cognitive Dysfunction

Frail older people are vulnerable to geriatric syndromes, and complications such as postoperative cognitive dysfunction and delirium are explored. This review also considers how frailty, with its decline of organ function, affects the metabolism of anesthetic agents and may influence the choice of anesthetic technique in an older person.

Perioperative Care

Optimal perioperative care includes the identification of frailty, a multisystem and multidisciplinary evaluation preoperatively, and discussion of treatment goals and expectations.


It is a term used by laymen and some medical staff to describe an older person who appears weak, unsteady, and underweight. This expression often carries a negative connotation implying some concerns about a person’s future outlook.

More recently, frailty has been conceptually defined to describe a state of increased vulnerability, a syndrome of decreased physiologic reserve and resistance to stressors. Frailty can lead to increased adverse outcomes, such as loss of mobility and independence, triggered by relatively small physical insults, such as a new medication or minor infection.

Frailty and surgery

Apart from the surgery itself, fasting, opioid analgesics, anesthetic agents, intraoperative blood loss, postoperative pain, nausea and vomiting, the unfamiliar hospital environment, and immobility during the perioperative period can all be triggers that lead a previously balanced but frail body system to fail.

The degree of insult needed to cause decompensation and subsequent adverse events is inversely related to the degree of frailty. A hospitalized older surgical patient is faced with many challenges during their journey through surgery and the recovery period.

Anesthesia and Cognition

Of the geriatric syndromes in older surgical patients, disturbances to cognition in the perioperative period are the most well studied. These disturbances in cognition have been termed postoperative cognitive dysfunction (POCD) and postoperative delirium (POD) which are important in prognosticating an older patient’s recovery from surgery.

Frail patients are more likely to have a pre-existing cognitive impairment with reduced cognitive reserve; hence, they are the most vulnerable to POCD and POD. Frailty is important to recognize in older surgical patients and has been measured by myriads of instruments. The two main methods of measuring frailty are the phenotypic and the cumulative deficit model.

Regional Anesthesia

Frailty is associated with significant postoperative mortality and morbidity and may affect the choice of anesthetic technique and analgesics used perioperatively. The use of GA compared to regional anesthesia is fiercely debated in the literature and clinical practice without a clear consensus.

The author concludes with an overview of the emerging evidence that Comprehensive Geriatric Assessment can improve postoperative outcomes and a discussion of the models of care that have been developed to improve preoperative assessment and enhance the postoperative recovery of older surgical patients.