Frailty Calculator
Frailty is a multidimensional construct consisting of 6 domains (physical performance, gait speed, mobility, nutritional status, mental health and cognition) that together indicate increased risk of death, disability and institutionalization. Frailty goes beyond organ-specific comorbidities to characterize a broader stat of global health that extends to both physical and cognitive attributes. It increases with age, but the elderly are not necessarily frail, and the young are not necessarily robust. As such, frailty can be conceptualized as measure of “physiologic reserve” defined as the critical threshold at which external stressors overwhelm the human body’s multiple mechanisms for adaptation, resulting in decompensation (i.e., acute illness or injury). Frailty is the consequence of a process whereby small deficits accumulate in multiple adaptive systems, any one of which might be clinically insignificant, but together they produce significant vulnerability to stress that can lead to catastrophic decompensation. Thus, a robust 80 year old might survive an operation that a frail 60 year old might not.
The diagnosis of frailty is associated with markedly increased risks for postoperative mortality and morbidity. For example, when compared to robust patients, frail surgical patients are less likely to be discharged to home, more likely to be readmitted within 30 days, and have substantially increased rates of perioperative mortality and complications. In fact, data demonstrate that frailty better predicts these risks better than models based on age and comorbidity alone. As such, rapid and accurate assessment of frailty can help “objectify the eyeball test” and inform perioperative decision-making.
Consensus on how best to define and measure frailty is still emerging. Several tools for measuring frailty exist, but not all are suitable for wide-spread screening. For example, there are several ways to measure walking speed, grip strength or cognitive function, but they are typically too labor intensive to screen entire surgical populations. Other tools calculate a risk index from frailty-associated variables in administrative datasets such as VASQIP or NSQIP, but as such, they are not useful for real-time frailty assessment in preoperative settings.
The Risk Analysis Index (RAI) of frailty is a recently validated, 14 item survey that takes less than 2 minutes to administer and predicts 180-day mortality with an area under the receiver operating characteristic (c-statistic) of 0.772. It has been prospectively measured in over 10,000 patients at the Omaha VAMC and is currently implemented as a perioperative screening test at the VAMCs in PIttsburgh, Atlanta, Phoenix, Indianapolis, Nashville, Cleveland and others. It is not a perfect tool, but it strikes a pragmatic balance between speed and predictive power that can help surgeons objectively identify the highest risk patients, providing accurate prognostication that can inform shared decision-making.
An electronic version of the tool is available for use within any VA pursuant to minimal requirements to set up a local quality improvement project. You can check out a demo-version of the tool at the links below (please DO NOT use this for patient care). If you would like to begin using the tool in your VA, please contact Daniel Hall (halide@upmc.edu<mailto:halide@upmc.edu>) to learn how to get your own, facility-specific, version of the Online RAI for use in your clinics.
Demo-Version RAI (accessible from VA computers only; NOT for clinical use):
https://vhacdwweb05.vha.med.va.gov/surveys/?s=ELMTJMLFT7
Also consider this link that generates 5 functional measures of frailty for patients identified as high-risk according to the RAI:
https://vhacdwweb05.vha.med.va.gov/surverys/?s=NLXYDKJALT
Daniel E. Hall, MD, MDiv, MHSc, FACS
Associate Professor of Surgery
University of Pittsburgh
Staff Surgeon
VA Pittsburgh Healthcare System
The diagnosis of frailty is associated with markedly increased risks for postoperative mortality and morbidity. For example, when compared to robust patients, frail surgical patients are less likely to be discharged to home, more likely to be readmitted within 30 days, and have substantially increased rates of perioperative mortality and complications. In fact, data demonstrate that frailty better predicts these risks better than models based on age and comorbidity alone. As such, rapid and accurate assessment of frailty can help “objectify the eyeball test” and inform perioperative decision-making.
Consensus on how best to define and measure frailty is still emerging. Several tools for measuring frailty exist, but not all are suitable for wide-spread screening. For example, there are several ways to measure walking speed, grip strength or cognitive function, but they are typically too labor intensive to screen entire surgical populations. Other tools calculate a risk index from frailty-associated variables in administrative datasets such as VASQIP or NSQIP, but as such, they are not useful for real-time frailty assessment in preoperative settings.
The Risk Analysis Index (RAI) of frailty is a recently validated, 14 item survey that takes less than 2 minutes to administer and predicts 180-day mortality with an area under the receiver operating characteristic (c-statistic) of 0.772. It has been prospectively measured in over 10,000 patients at the Omaha VAMC and is currently implemented as a perioperative screening test at the VAMCs in PIttsburgh, Atlanta, Phoenix, Indianapolis, Nashville, Cleveland and others. It is not a perfect tool, but it strikes a pragmatic balance between speed and predictive power that can help surgeons objectively identify the highest risk patients, providing accurate prognostication that can inform shared decision-making.
An electronic version of the tool is available for use within any VA pursuant to minimal requirements to set up a local quality improvement project. You can check out a demo-version of the tool at the links below (please DO NOT use this for patient care). If you would like to begin using the tool in your VA, please contact Daniel Hall (halide@upmc.edu<mailto:halide@upmc.edu>) to learn how to get your own, facility-specific, version of the Online RAI for use in your clinics.
Demo-Version RAI (accessible from VA computers only; NOT for clinical use):
https://vhacdwweb05.vha.med.va.gov/surveys/?s=ELMTJMLFT7
Also consider this link that generates 5 functional measures of frailty for patients identified as high-risk according to the RAI:
https://vhacdwweb05.vha.med.va.gov/surverys/?s=NLXYDKJALT
Daniel E. Hall, MD, MDiv, MHSc, FACS
Associate Professor of Surgery
University of Pittsburgh
Staff Surgeon
VA Pittsburgh Healthcare System