Using a Frailty Index to Determine Whether to Operate on an Elderly Patient
Posted Jan 04 2011 12:00am
As our population ages, a question that arises more frequently is whether to perform surgery on octogenarians and nonagenarians.Which among them are robust enough to withstand the stress of the procedure? I found that a recent article offered practical advice about this issue. (see: Who Thrives After Surgery? ). Below is an excerpt from it
Martin A. Makary, a surgeon and public health researcher at Johns Hopkins Hospital in Baltimore, had a long talk with a patient last week. The man had a tumor in his pancreas that was probably benign but might not be. Should Dr. Makary remove it? Or should the man have regular scans to see whether it grew?....[T]his patient was 89....Surgeons eyeball their patients all the time to try to evaluate whether they can recover well from the stress of an operation, but it’s an inexact science....The usual tests surgeons use to try to predict how older patients will fare are crude, Dr. Makary added, mostly based on cardiovascular strength....[S]tandard estimates of mortality and length of hospitalization for specific operations are all but useless for patients who might be 30 or 40 years older than the norm....For years, the geriatrician and gerontologist Linda P. Fried...has been talking and writing about frailty....[Frailty of a patient can be assessed on the basis of] a series of [observations] that include weight loss (specifically, an unintentional loss of 10 pounds or more in the past year), a weaker grip, exhaustion and lack of physical activity, and a slower gait. The assessment takes perhaps 15 minutes to conduct in an office. Then the doctors assign a score: 0 to 1 for those who aren’t frail, 2 to 3 for the intermediately frail. Patients who score 4 to 5 are frail....Those who were intermediately frail faced twice the odds of complications after surgery, compared to patients who were not frail, according to the study; frail patients had more than two and a half times the complication rate. Hospital stays were 44 percent to 53 percent longer for those intermediately frail, and 65 percent to 89 percent longer for the frail....The frail were 20 times...as likely to go to a nursing home or assisted living — from which they may or may not have emerged....[O]lder patients and their families ought to routinely ask their surgeons in fairly blunt terms: You want to operate on my father? You think he’s too old for surgery? What’s his frailty score?
The decision to operate on an older patient can be agonizing. Both the patient and family are forced to face issues of mortality and prolonged recuperation. Extended bed-rest can cause a downward spiral. Action may be given more weight than non-action. Surgeons are often predisposed to operate but may exercise extreme caution when confronting older patients. The frailty index described above makes perfect sense to me -- a rather objective means on which to base a medical decision. But I suspect that few older patients relish the idea of being described as frail.The good news is that this index could be used with some precision even by non-physician relatives of patients in parallel with the attending physician or geriatrician.