SEPTEMBER 24, 2025
Originally published by our sister publication Anesthesiology News
PHOENIX—The value of measuring frailty scores, including risks versus benefits, was a topic of debate at the 2025 annual meeting of the Society for Ambulatory Anesthesia.
The speakers debated whether calculating frailty scores actually gives valuable information about how to care for patients, and whether the scores only provide a random number that is not useful.
For instance, physicians might use the 9-point Clinical
Originally published by our sister publication Anesthesiology News
PHOENIX—The value of measuring frailty scores, including risks versus benefits, was a topic of debate at the 2025 annual meeting of the Society for Ambulatory Anesthesia.
The speakers debated whether calculating frailty scores actually gives valuable information about how to care for patients, and whether the scores only provide a random number that is not useful.
For instance, physicians might use the 9-point Clinical Frailty Scale for people aged 65 years and older, or the longer Frailty Index for all adults, to calculate frailty. Other calculators are available too. A score of 5 or higher on the Clinical Frailty Scale indicates increasing frailty, with a 9 denoting terminal illness. The Frailty Index is calculated from 0 to 1, with higher numbers in that range (e.g., =0.7) indicating more frailty.
There’s No Routine Procedure When You’re Frail
“There’s been a slew of studies outlining how even minor surgeries in patients who are frail carry high risk,” said BobbieJean Sweitzer, MD, the systems director of preoperative medicine at Inova Health, in Falls Church, Va., and a professor of medical education at the University of Virginia, in Charlottesville.
Sweitzer, a member of the Anesthesiology News editorial board, cited a 2017 study that found an association between elevated frailty and increased risk for 30-day mortality after seemingly low-risk procedures like hand/wrist cyst removal, hernia repair or an appendectomy. Among frail patients, the 30-day mortality rate was 1.5% after a low-risk procedure, with greater than 10% mortality at 30 days for the frailest patients. For moderate-risk procedures—cholecystectomy and joint replacement—the 30-day mortality rates exceeded 5% in frail people, and reached 19% among the very frail (JAMA Surg 2017;152[3]:233-240).
Anesthesiologists can sometimes mitigate the negative effects of frailty after ambulatory surgery, she noted. A 2018 study of 140,000 adults found an association between receiving local or monitored anesthesia care, and fewer serious 30-day complications after ambulatory surgery (JAMA Surg 2018;153[2]:160-168). That said, the frailest patients may not be able to receive any anesthesia.
“When a patient is too sick for general anesthesia, they are probably too sick for any other kind of anesthesia,” Sweitzer said.
Of note, some of the 140,000 patients in the 2018 study—who underwent hernia, thyroid, parathyroid or breast surgeries—were as young as 40 years of age, with high degrees of frailty.
Hospital readmissions due to postsurgical complications may be higher in frail than non-frail patients, Sweitzer said. A 2019 study of 417,840 elective surgeries found frail people were almost twice as likely to return to the hospital within 30 days after surgery as non-frail patients (adjusted relative risk, 1.8; 95% CI, 1.6-2.1) (JAMA Netw Open 2019;2[5]:e194330).
Perhaps these risks of ambulatory surgery are acceptable, as long as clinicians inform frail patients about them in advance, she said, although this conversation does not always happen. So a frail person may agree to ambulatory surgery unaware of what can happen.
Sweitzer recommended the patient preferences framework for clinicians to guide conversations about surgical risks and benefits. Developed at the University of Wisconsin–Madison School of Medicine and Public Health, the framework guides patients through their choices, expectations and potential complications of surgery.
“Chronologic age is less important than physiologic age. We don’t appreciate, really, how high a risk frailty is independent of age,” she said, stressing that no procedure carries a low risk when a patient is frail.
Measuring Frailty May Lead to Ageism
Although frailty scores can be measured for any adult, they are most often used in people 65 years of age and older. An overreliance on frailty scores could mean some older patients are declared ineligible for surgical procedures, even when those patients fully understand the risks, said Michael Presta, DO, an associate professor of anesthesiology and perioperative medicine at Loyola University Health System, in Chicago.
“Frailty could become the new ageism. When does the patient’s right to have a procedure trump the physician’s right not to do the procedure?” he asked.
Presta noted another challenge with measuring frailty: There’s no gold standard for doing so. The Frailty Index and Clinical Frailty Score are just two of many measurement options; others include the Modified Frailty Index and Johns Hopkins Frailty Assessment Calculator.
The lack of clarity about how to measure frailty is bad enough; what’s perhaps even worse is that higher frailty scores do not necessarily predict worse postoperative outcomes.
There are certainly retrospective associations between higher frailty and worse outcomes. But a prospective observational study at Cleveland Clinic, which included more than 1,000 patients, found that higher frailty scores poorly predicted postoperative complications or hospital readmissions after noncardiac surgery (Anesthesiology 2020;132[1]:82-94).
Presta called for further validation studies of the predictive power of frailty scores. He also issued a call to action to health systems to develop systematic protocols and procedures for counseling frail patients. Even if there were a clear metric of frailty, there are no standard ways of responding to it.
“It’s not so much that frailty scores are bad. It may be worth our time to measure, so long as this does not bar patients from surgical procedures they choose for themselves.”
By Marcus A. Banks
Presta reported no relevant financial disclosures. Sweitzer reported funding from the International Anesthesia Research Society and UpToDate.
