Preoperative Frailty and Cognitive Dysfunction Assessment

The first appearance of the phrase a “call to action” in the medical literature was from Sir Thomas Oliver in the British Medical Journal in 1913 in relation to the use of a toxic compound, diachylon, to induce abortion in working class women.1 Sir Oliver argued that physicians had a moral duty to recognize this practice and discourage the use of diachylon “by all means.” A call to action for the medical profession highlights a persistent public health problem and the need for specific actions to be taken to rectify the situation. The call to action to preoperatively screen for geriatric conditions that increase the risk of adverse perioperative outcomes, such as frailty and cognitive dysfunction, has been ongoing since at least 2011.2 Since then, research has only strengthened the association between frailty and cognitive dysfunction and the increased risk of perioperative mortality, postoperative delirium, and other adverse outcomes in geriatric patients.In this issue of Anesthesiology, Susano et al. report the results of a brief frailty and cognitive dysfunction screen in the preoperative clinic to predict the risk of postoperative delirium after elective spine procedures.3 The instruments used to screen for frailty and cognitive dysfunction, FRAIL scale, Mini-Cog, and animal fluency tests, are notable for their ease of use and efficiency to be implemented in a busy preoperative clinic.4,5 All the instruments are question-based, with only the Mini-Cog assessment requiring a pad of paper and a pencil to draw a clock. The cohort included 229 patients 70 yr of age or older, and 25% (55/219) of patients developed postoperative delirium, highlighting the frequency of this complication. The authors identified that a FRAIL scale score of 3 or greater (frail) and naming fewer animals on the fluency test was associated with greater odds of occurrence of postoperative delirium. Surprisingly, lower scores on the Mini-Cog, which would indicate preoperative cognitive dysfunction, were not associated with an increased risk of delirium, which highlights the different sensitivities of each instrument to identify the patient population at risk for each specific complication. The authors note some key limitations such as the single-center nature of the study and the high educational attainment of their population, which may limit the generalizability of their results.Despite the call to action to assess preoperative frailty and cognitive dysfunction, more progress needs to be made on implementation. Rates of formal screening for frailty and cognitive dysfunction are performed less than 10% of the time, according to more than 80% of physician anesthesiologists responding to a Web-based questionnaire on care for the geriatric surgical patient.6 The sheer number and heterogeneity of some of the instruments that measure frailty and cognitive dysfunction may have had a negative impact on adoption as more than 70 different tools exist to measure these constructs, making it challenging to pick “the right one” to integrate into clinical practice. In addition, different instruments are associated with different outcomes. In a recent meta-analysis of clinically applied frailty instruments, the Clinical Frailty Scale was most strongly associated with mortality and nonfavorable discharge, while the Frail Phenotype was most strongly associated with postoperative delirium.7 Further, the optimal preoperative assessment for geriatric patients by the American College of Surgeons (Chicago, Illinois) and the American Geriatrics Society (New York, New York) recommends the Mini-Cog but not the animal fluency test, and endorses the Frail Phenotype, which would require measuring grip strength and gait speed.8 A brief screening tool such as the ones implemented by Susano et al. may be appropriate for risk stratification, while a more formal assessment may be required to identify preoperative interventions that may improve perioperative outcomes, such as prehabilitation, changes in anesthetic plan, or preoperative consultation with a geriatrician.9,10 A recent study that implemented a comanagement strategy that included anesthesiologists, surgeons, and geriatricians in adults older than 75 yr undergoing major cancer surgery demonstrated a significant reduction in 90-day mortality.11The need for brief initial screening instruments is the result of an ever-increasing list of conditions that require evaluation during the preoperative visit. One of the consequences of the coronavirus disease 2019 pandemic is the rapid transition to telehealth visits, which only adds to the necessity of having question-based screening tools. Many institutions have pivoted to conducting most preoperative visits via telehealth to decrease exposure to coronavirus disease 2019 for patients at high risk. Instruments that are easy to administer and sensitive to identify at-risk patients are critical to effectively screen patients at risk of perioperative complications given the new challenges of examining patients without an objective physical exam. Patients who test positive on the screening test can then be further evaluated by an in-person appointment, which can prompt a better conversation about testing and preventative treatment.A preoperative frailty and cognitive dysfunction assessment should ideally be tailored to identify characteristics that are modifiable and directly linked to improve perioperative outcomes. Susano et al. have highlighted the implementation of a brief questionnaire-based frailty and cognitive dysfunction assessment to predict postoperative delirium, but this is only the first step. Institutions will need to develop interprofessional relationships with geriatricians and practical care pathways for patients who have a positive screen for a high risk of perioperative complications.9 Further, the aging research community will have to identify modifiable risk factors and demonstrate interventions that can improve perioperative outcomes of the geriatric patient that are generalizable. Institutions will need to invest in pathways to deploy preoperative optimization strategies to modify conditions identified through screening.12 Without these next steps, the call to action will continue to go unanswered. Much work remains to be done, but the first step begins when geriatric patients are screened for frailty and cognitive dysfunction. Only then is the degree of the local problem visible to all members of the perioperative team, and the call to action becomes relatable and meaningful.Dr. Rubin is the president of DRDR Mobile Health (Chicago, Illinois), a company that creates mobile applications for health care, including functional capacity assessment applications. He has engaged in consulting for mobile applications as well. He has not taken any salary or money from the company, but does own equity in the company. He has ongoing relationship with the United States Department of Justice serving as an expert witness. He is supported by grant No. R01 HL126892 from the National Institutes of Health/National Heart, Lung, and Blood Institute (Bethesda, Maryland).Dr. Peden is Chair of the American Society of Anesthesiologists Perioperative Brian Health Initiative (Schaumburg, Illinois) and has received consultancy fees from Merck (Kenilworth, New Jersey), the Institute for Healthcare Improvement (Boston, Massachusetts), and the American College of Surgeons (Chicago, Illinois) from their Agency for Healthcare Research and Quality Improving Surgical Care and Recovery grant.