What is the appropriate definition for vulnerability to identify silent pre-frail patients?
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CORRESPONDENCE
What is the appropriate definition for vulnerability to identify silent pre-frail patients? Pascale Le Maguet, MD
. Gildas Gueret, MD, PhD
Received: 31 May 2020 / Revised: 24 June 2020 / Accepted: 26 June 2020 Ó Canadian Anesthesiologists’ Society 2020
Surgeons are increasingly treating older adults with multisystem diseases and concomitant physical and/or cognitive impairment. Frailty assessment is a meaningful tool in managing risk in these patients. Preoperative frailty screening is necessary to identify operative risk and is recommended in older surgical patients. Accordingly, we thank Wang et al.1 for their recent study of frailty and in particular, vulnerability, which they defined as a clinically silent process that predisposes individuals to frailty. In their report of 302 older patients undergoing elective surgery, the authors found that vulnerability, defined by a Clinical Frailty Score (CFS) of 4, was not associated with a longer hospital length of stay but with a higher risk of non-home discharge. Since 2001, two concepts have dominated the field of defining frailty: the frailty phenotype and the frailty index (deficit accumulation approach).2,3 The frailty phenotype defines frailty as a distinct clinical syndrome meeting three or more of five phenotypic criteria (fatigue, weight loss, weakness, reduced physical activity, poor motor performance, and cognitive loss) while the frailty index defines frailty as cumulative deficits identified in a comprehensive geriatric assessment. These two concepts are well validated but must be carried out prospectively with history and physical examination to detect frailty.
This letter is accompanied by a reply. Please see Can J Anesth 2021; 68: this issue. P. Le Maguet, MD (&) G. Gueret, MD, PhD Service d’anesthe´sie, Centre hospitalier de Cornouaille, Quimper, France e-mail: [email protected]
Despite the two above-mentioned concepts, there is yet to be a universally recognized definition of frailty, and different care providers assess frailty and vulnerability with different tools, from very complex to very simple scales.4 Unfortunately, frailty is sometimes mixed with multiple comorbidity to achieve an easier measure of frailty. This is the case in some surgical studies using the modified Frailty Index, an automated measure derived from coding data, which has been shown to be associated with increased morbidity and mortality in medical and general surgical patients.5 Wang et al. nicely present the two distinct concepts in a figure (although they may contribute to each other). We totally agree with their choice of screening instrument (CFS) to evaluate frailty. Despite an appropriate recruitment process, 270/743 (36%) eligible patients could not be included in the study analysis. The reasons why these patients could not be contacted in time before surgery need further explanation. For example, it might explain the skewed distribution with a few people in the highest frailty categories. The authors also mentioned that the observed pre
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