Frailty index score from standard Anaesthesia textbooks .
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Frailty Index / Frailty Scoring in Anaesthesia - From Standard Textbooks
Background
Frailty is a state of increased vulnerability to physiologic stressors arising from impaired functional and physiological reserve. It is distinct from - though overlapping with - disability and comorbidity. In community-dwelling adults aged ≥65, approximately 22.7% are frail; in surgical patients >65 presenting for major non-cardiac surgery, roughly 1 in 3 (29%) are frail. Frail patients have significantly higher rates of postoperative mortality, morbidity, prolonged length of stay, and non-home discharge.
There are two foundational conceptual models underlying all frailty scores:
Model 1: The Frailty Phenotype (Fried Phenotype)
Described by Linda Fried and colleagues (Cardiovascular Health Study, 2001). Defines frailty as a clinical syndrome when ≥3 of 5 criteria are present:
| Domain | Criterion |
|---|---|
| Weight loss | Unintentional loss of ≥10 lb (≥4.5 kg) in the past year |
| Exhaustion | Self-reported fatigue / difficulty initiating movement |
| Weakness | Reduced grip strength (stratified by sex and BMI quartile; <20th percentile on Jamar dynamometer) |
| Slowness | Slow walking speed (stratified by sex and height; timed 4-metre walk at usual pace) |
| Low activity | Low physical activity level |
Scoring:
- 0 criteria = Robust / Non-frail
- 1-2 criteria = Pre-frail
- ≥3 criteria = Frail
Anaesthetic relevance: Most widely studied frailty tool. Requires special equipment (grip dynamometer, stopwatch, measured walking track). Takes 5-20 minutes. Strongly associated with postoperative delirium. Also predicts surgical complications, length of stay, and discharge to institutional care. Augments ASA score, RCRI, and Eagle's cardiac risk index.
- Miller's Anesthesia 10e, p. 9153; Barash Clinical Anesthesia 9e, p. 2715; Current Surgical Therapy 14e, Table 1
Model 2: The Frailty Index (Deficit Accumulation Model)
Developed by Rockwood and colleagues (Canada Study of Health and Aging, CSHA). The CSHA Frailty Index originally surveyed 70 items covering cognitive function, nutritional status, gait, grip strength, and comorbidities.
Calculation:
Frailty Index = Number of positive deficits / Total number of deficits surveyed
For example: 10 positive deficits out of 40 surveyed = FI of 0.25
Scoring thresholds (ASA Frailty Toolkit):
| Score | Category |
|---|---|
| < 0.10 | Not frail |
| 0.10 - 0.21 | Pre-frail |
| 0.22 - 0.44 | Frail |
| > 0.45 | Severely frail |
| > 0.66 | Rarely seen |
- Scored in a binomial (yes/no) fashion for each deficit
- Takes 10-13 minutes; patient-reported
- Does not require extra space or equipment
- Associated with postoperative complications
- Barash Clinical Anesthesia 9e, p. 2716; ASA Frailty Toolkit
Modified Frailty Index (mFI) - ACS NSQIP Derived
The ACS NSQIP database was used to derive an 11-item modified Frailty Index (mFI-11), later simplified to a 5-item version (mFI-5) by Subramaniam et al., shown to be an equally effective predictor of mortality and postoperative complications across all surgical subspecialties.
mFI-5 Components (1 point each):
| Item | Criterion |
|---|---|
| 1 | Functional status dependence (non-independent) |
| 2 | Diabetes mellitus |
| 3 | Chronic obstructive pulmonary disease (COPD) |
| 4 | Congestive heart failure (CHF) |
| 5 | Hypertension requiring medication |
Score range: 0-5. Higher scores = greater frailty and increased operative risk.
Perioperative outcomes (spine surgery data, Flexman et al., n = 52,671):
-
Every 0.1 increase in mFI score:
- Major postoperative complications: OR 1.58
- Prolonged length of stay: OR 1.89
- Discharge to higher level of care: OR 2.29
- 30-day mortality: OR 2.05
-
Sabiston Textbook of Surgery, p. 138; Miller's Anesthesia 10e, p. 9153; Current Surgical Therapy 14e
Model 3: The Clinical Frailty Scale (CFS)
Developed by Rockwood (2005). A 9-level observational scale - not a questionnaire but a clinical summary judgment tool. Takes <2 minutes. No special equipment required.
| CFS Score | Category |
|---|---|
| 1 | Very Fit |
| 2 | Well |
| 3 | Managing Well (well-treated comorbid disease) |
| 4 | Vulnerable |
| 5 | Mildly Frail |
| 6 | Moderately Frail |
| 7 | Severely Frail |
| 8 | Very Severely Frail |
| 9 | Terminally Ill (rarely applicable preoperatively) |
Frailty threshold: CFS ≥ 4 (or > 5 by some guidelines)
Anaesthetic relevance: Most feasibility-supported tool in preoperative anaesthesia settings. A systematic review and meta-analysis found the CFS had the strongest accuracy and feasibility among all available frailty scales. Predicts postoperative mortality and non-home discharge. Can be assessed via chart review or proxy history in < 1 minute (versus 5 minutes for the modified Fried Index).
- Miller's Anesthesia 10e, p. 9153-9154; Barash Clinical Anesthesia 9e, p. 2717; Miller's Anesthesia block 10, p. 3858-3859
Model 4: Edmonton Frail Scale (EFS)
An 11-item combined observational and patient-reported scale. Takes <5 minutes.
Components (8 domains):
- Cognition (clock-drawing test)
- General health status
- Functional independence
- Social support
- Medication use (polypharmacy)
- Nutrition
- Mood
- Continence
- Timed Up-and-Go test
Score: 0-17. Higher = more frail. Can be administered by non-medical staff; validated against geriatric specialist comprehensive assessment. Best predictor of postoperative complications among the common bedside tools. A software application is available.
- Barash Clinical Anesthesia 9e, Table 34-1; Miller's Anesthesia block 10, p. 3859
Model 5: FRAIL Scale
A 5-item rapid screening questionnaire (acronym-based). Takes 1-2 minutes. No equipment needed.
| Letter | Domain | Question |
|---|---|---|
| F | Fatigue | Do you feel tired most of the time? |
| R | Resistance | Can you climb a flight of stairs without difficulty? |
| A | Ambulation | Can you walk one block without difficulty? |
| I | Illnesses | Do you have ≥5 illnesses? |
| L | Loss of weight | Have you lost >5% body weight in the past year? |
Score: 0-5
- 0 = Robust
- 1-2 = Pre-frail
- ≥3 = Frail
Barash Clinical Anesthesia 9e, Table 34-1; Miller's Anesthesia 10e
Summary Comparison Table (from Barash Clinical Anesthesia 9e, Table 34-1)
| Tool | Time | Type | Key Perioperative Use |
|---|---|---|---|
| Clinical Frailty Scale | <2 min | Observational | Mortality + non-home discharge; most feasible |
| Edmonton Frail Scale | <5 min | Observational + patient-reported | Best for predicting postop complications |
| FRAIL Scale | 1-2 min | Patient-reported | Quick screening; less studied |
| Risk Analysis Index (RAI) | 5-10 min | Patient-reported | Includes standard nursing interview items |
| ACS NSQIP / mFI | 5-10 min | Chart review | 30-day outcome prediction |
| Fried Phenotype | 5-20 min | Observational | Most widely studied; links to delirium |
| Frailty Index | 10-13 min | Patient-reported | Comprehensive; predicts complications |
| VESPA (short form) | ~10 min | Patient-reported | Modest sensitivity |
Robinson Criteria (Surgical Patients - Miller's Anesthesia 10e)
Two validated alternative frailty definitions for surgical patients:
Option A:
- Mini-Cog score ≤3, plus
- Serum albumin ≤30 g/L, plus
- ≥1 fall in prior 6 months, plus
- Haematocrit <35%
Option B:
- Timed Up-And-Go ≥15 seconds, plus
- ADL dependence, plus
- Charlson Comorbidity Index ≥3
Key Anaesthetic Implications
- Frailty augments - but does not replace - ASA score, RCRI, or Eagle's cardiac risk index
- The CFS is the most practical for the preoperative anaesthesia clinic - takes <1 minute, no equipment
- Frailty scores should be accompanied by Comprehensive Geriatric Assessment (CGA) including comorbidity burden, polypharmacy, physical function, psychological status, nutrition, delirium risk, and social support
- Well-crafted CGA can be a more powerful predictor of perioperative risk than ASA score alone
- Frailty is a potentially modifiable risk factor - prehabilitation programmes (exercise, nutrition, lifestyle, stress management) can reduce it preoperatively
- Potentially inappropriate medications (benzodiazepines, first-generation antihistamines, antipsychotics, meperidine) should be especially avoided in frail patients perioperatively
Sources: Miller's Anesthesia 10e (Ch. 61) | Barash, Cullen & Stoelting's Clinical Anesthesia 9e (Ch. 34) | Current Surgical Therapy 14e | Sabiston Textbook of Surgery | Fischer's Mastery of Surgery 8e | Campbell's Operative Orthopaedics 15e
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