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Frailty

Frailty describes reduced physiological reserve and greater vulnerability to a stressor such as surgery. It adds information beyond age, diagnoses and the proposed operation.[1][2] Assessment should identify support needs and inform the patient's choices.[1][2]

Frailty is common in the surgical population: an estimated 30–50% of older patients presenting for major surgery live with frailty, and frailty is associated with more than twice the risk of morbidity, mortality and new patient-reported disability.[11] Community prevalence rises with age, from about 11% at 50–59 years to 51% at 90 years and older.[1]

See also: Risk Calculators, Cardiovascular Risk, Nutrition, ERAS.

What Guidelines Recommend​

  • AHA/ACC 2024. Validated frailty assessment can be useful in adults aged ≥65 and younger patients with perceived frailty undergoing elevated-risk noncardiac surgery (Class 2a, nonrandomized evidence).[2]
  • ASA 2025. Consider expanded preoperative evaluation in older adults scheduled for inpatient surgery, including physical, cognitive and psychosocial vulnerabilities. This conditional recommendation, supported by low-certainty evidence, aims particularly to reduce postoperative delirium.[3]
  • ESAIC 2025. For patients at high risk of postoperative complications who require a low-risk procedure, the guideline recommends frailty testing, particularly to assess delirium risk . When the preanesthesia examination identifies a frailty phenotype, it recommends the CFS and geriatric evaluation of cognition, nutrition and comorbidity, with delay of elective or time-sensitive surgery when feasible (1C).[29]

Frailty is associated with mortality, complications, functional decline and nonhome discharge, but the absolute risk depends on the instrument, population, operation and outcome.[2] Pooled estimates are given under Outcomes Associated with Frailty.

Two Definitions of Frailty​

The constructs overlap, but identify different aspects of vulnerability.[1][2]

ConstructAssessmentInterpretation
Fried physical phenotypeWeight loss, exhaustion, weakness, slow gait and low activity, assessed using the instrument's definitions0 features: nonfrail; 1–2: prefrail; 3–5: frail.
Deficit accumulationNumber of health deficits present divided by the number assessed, usually across at least 30 itemsHigher values reflect more accumulated deficits; cutoffs depend on the particular index and purpose

In most studies fewer than 1% of people have a frailty index above 0.70, a deficit burden that threatens survival.[1] Neither an extreme deficit index nor all five phenotype features is an automatic futility threshold. Cognitive, social and functional assessment remains necessary.[1] Frailty can change over time.[1]

Assessment Tools​

Choose a tool appropriate to the setting and use its current instructions consistently.[2][3] A brief screen can trigger further assessment.[2][3]

ToolWhat it measuresPractical limitation
Clinical Frailty Scale (CFS)Nine-level clinical judgment informed by activity, function and healthRequires clinical context and training; rate usual baseline health rather than simply scoring the current acute illness[4]
Fried phenotypeFive physical frailty featuresUses specified gait, grip and symptom criteria
FRAIL questionnaireFatigue, resistance, ambulation, illnesses and weight lossA brief symptom-based instrument
Frailty index / electronic frailty indexAccumulated deficits from clinical assessment or health recordsAvailable data, missingness and the particular algorithm affect interpretation
Edmonton Frail ScaleNine domains and 11 items, including cognition, nutrition, medication use and functional performanceFollow the actual instrument; the clock and performance tasks are part of its assessment[5]
Risk Analysis Index (RAI)Frailty measures developed for surgical populationsHas a prospective clinical questionnaire and an administrative-data version[6]
Modified frailty index (mFI-11, mFI-5)Count of comorbidity and functional-status items from NSQIP data; mFI-5 is the five-item versionSuited to database research and risk stratification rather than bedside assessment; mFI-5 tracked mFI-11 closely (correlation above 0.9 in most specialties) in NSQIP[12]
Gait speed / SPPBObjective physical performance—
Geriatric-8 (G8)Cancer-specific screen developed to flag older cancer patients for a fuller geriatric assessmentMedian sensitivity (85%) and specificity (64%) across studies for frailty on geriatric assessment; a trigger for further assessment before oncologic surgery[19][20]

Gait speed is the fastest objective screen. A speed below 0.8 m/s has 99% sensitivity for the Fried phenotype, so a normal walk makes physical frailty unlikely; a slow walk prompts fuller assessment without establishing a diagnosis.[1] Time it over a short, marked clinic corridor (about 4 m). The Short Physical Performance Battery combines balance, gait speed and sit-to-stand on a 0–12 scale; the AUA video below demonstrates the technique. In a Cochrane review of mobility training for community-dwelling older people with frailty, the pooled end-of-intervention mobility effect across different scales back-translated to an estimated 1.0-point difference on the SPPB (95% CI 0.51 to 1.51), exceeding the 0.5-point minimum important difference.[7]

Predictive accuracy has not differed significantly between the Fried phenotype, Edmonton Frail Scale and frailty index, and the AHA/ACC guideline notes that most comparisons between tools have been neutral. The CFS is the most feasible for use before surgery.[2][11] For centers in the ACS Geriatric Surgery Verification program, which targets adults aged 75 or older undergoing inpatient surgery, Standard 5.6 requires preoperative screening for age 85 or older, impaired cognition, delirium risk, impaired function, impaired mobility, malnutrition, swallowing difficulty and need for palliative care assessment; a positive screen in any domain designates high risk. The standard names no single frailty instrument or numeric cutoff; its appendix lists acceptable tools such as the Edmonton Frail Scale for frailty and the Mini-Cog, MMSE and MoCA for cognition.[18]

Interpreting the CFS Correctly​

The current CFS distinguishes 4, very mild frailty; 5, mild; 6, moderate; 7, severe; and 8, very severe frailty. CFS 7 can describe a dependent but stable person. CFS 9 means terminal illness with expected survival under six months in someone who is not otherwise severely frail. It is therefore incorrect to combine scores 8–9 as “terminal frailty.”[4]

Use the official scale and training material. Do not map CFS 4 directly to Fried “prefrailty”.

Outcomes Associated with Frailty​

SourcePopulationFinding
Tjeertes 2020 meta-analysis[13]56 studies, 1,106,653 patients undergoing noncardiac surgery; 11 frailty tools30-day mortality RR 3.71 (95% CI 2.89–4.77; 31 studies); 30-day complications RR 2.39 (2.02–2.83; 37 studies); 1-year mortality RR 3.40 (2.42–4.77; 6 studies); institutionalization RR 2.30 (1.81–2.92; 10 studies); delirium RR 2.13 (1.23–3.67; only 4 studies, n=438)
George 2021 cohort[14]NSQIP (n=2,339,031) and VASQIP (n=426,578), 9 noncardiac specialties, RAIFrailty was independently associated with higher 30-day mortality in every specialty regardless of case mix, including low-stress specialties (very frail vs normal, plastic surgery aOR 27.99; vascular aOR 10.85)
Ghaffar 2025 NSQIP study[15]4,734 patients, 2011–2020, AUS, sling or penile prosthesis30-day morbidity associated with RAI-A (OR 2.05, 95% CI 1.59–2.65) and ASA class (OR 1.55, 1.19–2.01) but not mFI-5; RAI-A predicted better than mFI-5 (p=0.023). All three tools were associated with discharge to continued care
Erekson 2026 ASPIRe supplement[16]146 women aged 65 or older underwent randomized vault-prolapse surgery; 145 entered the modified intention-to-treat analysis (native tissue, sacrocolpopexy, transvaginal mesh)No difference in geriatric outcomes by frailty status; prefrail/frail women who lived alone more often needed help in the first 6 weeks (19% vs 6%, p=0.04). Over 36–60 months, time to composite failure (retreatment with pessary or surgery, prolapse beyond the hymen, or a reported bulge with any bother) was shorter with prefrailty/frailty (adjusted HR 2.1, 95% CI 1.2–3.6)

These are observational associations from administrative and nested-cohort data; the delirium estimate rests on few studies. In the ASPIRe nested cohort of women aged ≥65 undergoing vault-prolapse surgery, 20/48 (42%) prefrail/frail participants had a 30-day complication and 9/46 (20%) had a Clavien–Dindo grade II or higher event, compared with 42/97 (43%) and 19/91 (21%) among nonfrail participants; frailty assessment can inform counseling and postoperative support planning.[16] In prosthetic surgery the choice of frailty instrument changes what is detected: mFI-5 missed the morbidity signal that RAI-A and ASA class captured.

Perioperative Pathway for the Frail Patient​

  1. Establish baseline function. Document mobility, activities of daily living, cognition, recent decline and available help. Ask what recovery the patient would regard as worthwhile.
  2. Combine risks. Review the proposed operation and alternatives alongside frailty, cardiopulmonary disease and the urgency of treatment. Discuss the possibility of prolonged recovery or increased care needs.
  3. Address identified deficits. Coordinate geriatrics, anesthesia, nutrition, rehabilitation, pharmacy and social support according to the findings. Medication review should lead to deliberate changes while avoiding abrupt cessation of treatment still indicated. In a cohort comparison of Duke's POSH program for elective abdominal surgery in high-risk patients over 65 with a preceding comparison group, median length of stay was 4 versus 6 days, 30-day readmission among those with available data was 14/180 (7.8%) versus 26/142 (18.3%), and mean complications were 0.9 versus 1.4; documented delirium was higher with more active screening.[21] A single-center cohort of cancer surgery patients aged 75 or older found geriatric comanagement associated with lower adjusted 90-day mortality (4.3% versus 8.9%).[22] A secondary analysis of that cohort (1,687 patients aged 75 or older with a length of stay of at least one day; 931 received comanagement) found lower unadjusted 90-day mortality with comanagement overall (31/931 [3.3%] versus 72/756 [9.5%]), without evidence that the association differed by frailty stratum (interaction P = .4).[24] A separate radical-cystectomy pilot found that 59 of 66 eligible patients (89%) received preoperative geriatric evaluation, no surgery was rescheduled for program logistics, and nine of 12 urology advanced practice providers responded to a survey and reported satisfaction.[25] The program did not meet its prespecified feasibility thresholds for preoperative evaluation (>90% target) or postoperative coverage (69% seen on at least 80% of non-ICU postoperative days, versus a >90% target).[25] The POSH, cancer comanagement and GERICO reports above are observational program evaluations. In OPTI-Surg, 29 thoracic, gastrointestinal and urologic cancer-surgery practices were randomized to usual care, a frailty-screening and guided-referral toolkit, or the toolkit with coaching; 325 patients aged ≥70 undergoing curative-intent surgery enrolled. Among 199 evaluable patients, 8-week postoperative caloric expenditure did not differ significantly between usual care and the combined toolkit arms (P = .53); among 279 evaluable patients, 90-day complications were 25.6% versus 35.3% (P = .5).[30] The GOSAFE baseline report described a separate 26-center cohort of older adults undergoing major cancer surgery; its later outcome analysis in 942 patients found that age and cancer site were not associated with 90-day mortality, while a Charlson Age Comorbidity Index score of 7 or more, moderate or severe malnutrition, and open surgery were associated with higher mortality after adjustment.[23][26]
  4. Plan delirium prevention. Include orientation, sleep, hearing or vision aids, hydration, mobilization and a medication plan that limits avoidable sedative burden while treating pain adequately.
  5. Plan recovery and discharge early. Arrange equipment, caregiver teaching, rehabilitation and follow-up when needed.[1][3]

For drug and anesthetic choices, use Analgesia and Anesthesia.[3]

Evidence-Based Interventions​

Mobility and Daily Function​

A 2022 Cochrane review of 12 trials involving 1,317 community-dwelling older adults with frailty found high-certainty evidence of improved mobility with mobility training. Evidence for improved function was moderate certainty; falls, nursing-home admission and mortality showed little or no clear difference.[7] The review did not assess GU surgical complications.[7]

Across 69 randomized trials in adults aged 60 or older, physical activity was the most effective single intervention for reducing frailty (pooled SMD 0.43), ahead of multicomponent programs (0.34) and nutrition alone (0.21). Among exercise types, resistance training performed best (SMD 0.58), followed by mind-body exercise (0.57), mixed physical training (0.47) and aerobic training (0.36). A resistance component is therefore a sensible element of any preoperative program.[17] In the NEJM review, comprehensive geriatric assessment with multidisciplinary intervention lowered the risk of Fried frailty (high certainty), and medication optimization in nursing-home residents reduced falls, mortality and hospitalization (high certainty).[1]

Address inadequate intake and nutrition risk with assessment and a tailored plan. Frailty is not itself an indication for routine immunonutrition, hormone treatment or high-dose supplements; see the dedicated Nutrition workflow.

PREPARE: Important Limits of Prehabilitation Evidence​

PREPARE, published online in December 2025 and in JAMA Surgery in 2026, randomized 850 adults aged ≥60 with CFS ≥4 at 13 Canadian centers to home-based exercise and nutritional advice with coaching or usual care; 847 remained after three withdrew consent. Among 705 who underwent surgery, complications occurred in 177/353 (50.1%) versus 168/352 (47.7%); adjusted OR 1.05 (97.5% CI 0.73–1.49). The coprimary disability analysis of all 847 retained randomized participants at 30 days after surgery (or 114 days after randomization when surgery did not occur) also found no significant benefit: adjusted difference −1.4 points (97.5% CI −4.9 to 2.0) on a 100-point WHODAS scale.[8]

Most participants had CFS 4; approximately 23% were scheduled for urologic or gynecologic surgery.[8] Only 43% of operated intervention participants achieved the prespecified adherence target.[8] A favorable per-protocol disability result is vulnerable to selection bias and does not overturn the randomized primary findings. The trial neither proves that every prehabilitation program is ineffective nor supports promising that a short program will reduce complications.[8] PRAEP-GO tested a three-week supervised individualized program in 1,199 analyzed adults aged 70 or older with Fried prefrailty or frailty. Despite a median 29.5 of 30 supervised sessions completed, 12-month care dependency did not improve (P = .33); 51% underwent orthopedic procedures.[27]

Prehabilitation for GU Reconstruction​

Offer preparation that addresses the patient's deficits and can realistically fit the treatment timeline: suitable physical activity, nutrition support, smoking cessation, treatment of anemia when indicated, and psychological or practical support. Set measurable goals such as walking tolerance, adequate intake or ability to manage postoperative care.

There is no established universal four-to-eight-week requirement for reconstructive urology. Balance the potential benefit of preparation against harm from delaying treatment. Avoid delaying surgery solely to normalize a frailty score or meet a blanket HbA1c threshold; see Diabetes. PREPARE’s home-based program did not reduce complications in older adults with frailty scheduled for elective noncardiac surgery.[8] A review of five randomized bladder-cancer surgery trials (282 patients) found insufficient evidence to determine whether prehabilitation changes postoperative complications or length of stay; all trials had some or high risk of bias.[31]

Frailty, Sarcopenia, and Malnutrition​

These conditions overlap but are not interchangeable:

ConditionDistinction
FrailtyMultidimensional vulnerability; physical, cognitive and social deficits may contribute
Sarcopenia under EWGSOP2Low strength indicates probable sarcopenia; low muscle quantity or quality confirms it. Additional poor physical performance identifies severe sarcopenia[9]
Malnutrition under GLIMAfter nutrition-risk screening, diagnosis requires at least one phenotypic criterion and one etiologic criterion. Reduced muscle mass with normal strength alone does not diagnose malnutrition[10]

Weight loss or reduced muscle mass should prompt evaluation of intake, disease burden and other causes.

GU-Reconstruction–Specific Considerations​

  • Major abdominal or pelvic reconstruction: assess likely loss of independence, bowel and stoma care, and the support required after discharge.
  • Pelvic organ prolapse: discuss observation or pessary care alongside reconstructive repair and colpocleisis. Ask whether preserving vaginal intercourse matters; the 2021 French HAS guideline describes colpocleisis for patients who no longer want vaginal intercourse or have surgical or anesthetic risk, and lists autologous vaginal surgery including colpocleisis for very elderly patients as a Grade C option when perioperative risk is prioritized.[28] See Prolapse Repair.
  • Urethroplasty: weigh symptoms, retention or infection burden, treatment alternatives, anesthesia and recovery demands.
  • AUS or other patient-operated devices: assess cognition, dexterity and ability to use the device.
  • Urgent surgery: obtain baseline information from family or caregivers when needed. Screening should assist planning without delaying time-critical treatment.

Reassess when health or function changes and after recovery from an acute illness. Record the trajectory and what changed in the care plan, without treating a single score as permanent.

Videos​

Geriatric Assessment with the Short Physical Performance Battery
AUA Core Curriculum (2025)

References​

1. Kim DH, Rockwood K. Frailty in Older Adults. N Engl J Med. 2024;391:538–548. doi:10.1056/NEJMra2301292.

2. Thompson A, Fleischmann KE, Smilowitz NR, et al. 2024 AHA/ACC Guideline for Perioperative Cardiovascular Management for Noncardiac Surgery. J Am Coll Cardiol. 2024;84:1869–1969. doi:10.1016/j.jacc.2024.06.013.

3. Sieber F, McIsaac DI, Deiner S, et al. 2025 American Society of Anesthesiologists Practice Advisory for Perioperative Care of Older Adults Scheduled for Inpatient Surgery. Anesthesiology. 2025;142:22–51. doi:10.1097/ALN.0000000000005172.

4. Dalhousie University, Geriatric Medicine Research. Clinical Frailty Scale, version 2.0, and guidance.

5. Edmonton Frail Scale. Introduction and domains.

6. Hall DE, Arya S, Schmid KK, et al. Development and Initial Validation of the Risk Analysis Index for Measuring Frailty in Surgical Populations. JAMA Surg. 2017;152:175–182. doi:10.1001/jamasurg.2016.4202.

7. Treacy D, Hassett L, Schurr K, et al. Mobility Training for Increasing Mobility and Functioning in Older People With Frailty. Cochrane Database Syst Rev. 2022;6:CD010494. doi:10.1002/14651858.CD010494.pub2.

8. McIsaac DI, et al. Home-Based Prehabilitation for Older Surgical Patients With Frailty: A Randomized Clinical Trial. JAMA Surg. 2026;161:113–123. doi:10.1001/jamasurg.2025.5288.

9. Cruz-Jentoft AJ, Bahat G, Bauer J, et al. Sarcopenia: Revised European Consensus on Definition and Diagnosis. Age Ageing. 2019;48:16–31. doi:10.1093/ageing/afy169.

10. Jensen GL, Cederholm T, Correia MITD, et al. GLIM Consensus Approach to Diagnosis of Malnutrition: A 5-Year Update. JPEN J Parenter Enteral Nutr. 2025;49:414–427. doi:10.1002/jpen.2756.

11. McIsaac DI, MacDonald DB, Aucoin SD. Frailty for Perioperative Clinicians: A Narrative Review. Anesth Analg. 2020;130:1450–1460. doi:10.1213/ANE.0000000000004602.

12. Subramaniam S, Aalberg JJ, Soriano RP, Divino CM. New 5-Factor Modified Frailty Index Using American College of Surgeons NSQIP Data. J Am Coll Surg. 2018;226:173–181.e8. doi:10.1016/j.jamcollsurg.2017.11.005.

13. Tjeertes EKM, van Fessem JMK, Mattace-Raso FUS, et al. Influence of Frailty on Outcome in Older Patients Undergoing Non-Cardiac Surgery: A Systematic Review and Meta-Analysis. Aging Dis. 2020;11:1276–1290. doi:10.14336/AD.2019.1024.

14. George EL, Hall DE, Youk A, et al. Association Between Patient Frailty and Postoperative Mortality Across Multiple Noncardiac Surgical Specialties. JAMA Surg. 2021;156:e205152. doi:10.1001/jamasurg.2020.5152.

15. Ghaffar U, Abbasi B, Hakam N, et al. Frailty and surgical outcomes in genitourinary prosthetic procedures: an ACS-NSQIP comparative analysis of risk indices. Int Urol Nephrol. 2025;57:2885–2892. doi:10.1007/s11255-025-04484-4.

16. Erekson E, Menefee SA, Whitworth R, et al. Outcomes by frailty and mobility in older patients undergoing major urogynecologic surgery: a planned supplementary study of the ASPIRe trial. Am J Obstet Gynecol. 2026;234:689–729. doi:10.1016/j.ajog.2025.11.002.

17. Sun X, Liu W, Gao Y, et al. Comparative Effectiveness of Non-Pharmacological Interventions for Frailty: A Systematic Review and Network Meta-Analysis. Age Ageing. 2023;52:afad004. doi:10.1093/ageing/afad004.

18. Coleman J, Finlayson E, Katlic M, et al. Geriatric Surgery Verification Program Standards. American College of Surgeons; 2019. Standard 5.6 and appendices.

19. van Walree IC, Scheepers E, van Huis-Tanja L, et al. A systematic review on the association of the G8 with geriatric assessment, prognosis and course of treatment in older patients with cancer. J Geriatr Oncol. 2019;10(6):847-858. doi:10.1016/j.jgo.2019.04.016.

20. Bellera CA, Rainfray M, Mathoulin-Pélissier S, et al. Screening older cancer patients: first evaluation of the G-8 geriatric screening tool. Ann Oncol. 2012;23(8):2166-2172. doi:10.1093/annonc/mdr587.

21. McDonald SR, Heflin MT, Whitson HE, et al. Association of Integrated Care Coordination With Postsurgical Outcomes in High-Risk Older Adults: The Perioperative Optimization of Senior Health (POSH) Initiative. JAMA Surg. 2018;153(5):454-462. doi:10.1001/jamasurg.2017.5513.

22. Shahrokni A, Tin AL, Sarraf S, et al. Association of Geriatric Comanagement and 90-Day Postoperative Mortality Among Patients Aged 75 Years and Older With Cancer. JAMA Netw Open. 2020;3(8):e209265. doi:10.1001/jamanetworkopen.2020.9265.

23. Montroni I, Rostoft S, Spinelli A, et al. GOSAFE - Geriatric Oncology Surgical Assessment and Functional rEcovery after Surgery: early analysis on 977 patients. J Geriatr Oncol. 2020;11(2):244-255. doi:10.1016/j.jgo.2019.06.017.

24. McMillan S, Kim SJ, Tin AL, et al. Association of frailty with 90-day postoperative mortality and geriatric comanagement among older adults with cancer. Eur J Surg Oncol. 2022;48(4):903-908. doi:10.1016/j.ejso.2021.10.019.

25. Letica-Kriegel AS, Tin AL, Nash GM, et al. Feasibility of a geriatric comanagement (GERICO) pilot program for patients 75 and older undergoing radical cystectomy. Eur J Surg Oncol. 2022;48(6):1427-1432. doi:10.1016/j.ejso.2022.02.023.

26. Montroni I, Ugolini G, Saur NM, et al. "Quality of Life in Older Adults After Major Cancer Surgery: The GOSAFE International Study." J Natl Cancer Inst. 2022;114(7):969–978. doi:10.1093/jnci/djac071.

27. Spies C, Schmidt K, Kiselev J, et al. "Supervised multimodal prehabilitation of older patients with frailty or prefrailty before elective surgery: a multicentre randomised controlled outcome assessor-blinded trial." Lancet Healthy Longev. 2026;7(8):100899. doi:10.1016/j.lanhl.2026.100899.

28. Pizzoferrato AC, Thuillier C, Vénara A, et al. "Management of female pelvic organ prolapse—Summary of the 2021 HAS guidelines." J Gynecol Obstet Hum Reprod. 2023;52(3):102535. doi:10.1016/j.jogoh.2023.102535.

29. Lamperti M, Romero CS, Guarracino F, et al. "Preoperative assessment of adults undergoing elective noncardiac surgery: Updated guidelines from the European Society of Anaesthesiology and Intensive Care." Eur J Anaesthesiol. 2025;42(1):1–35. doi:10.1097/EJA.0000000000002069

30. Chang GJ, Gunn HJ, Barber AK, et al. "Improving Surgical Care and Outcomes in Older Cancer Patients Through Implementation of a Presurgical Toolkit (OPTI-Surg)-Final Results of a Phase III Cluster Randomized Trial (Alliance A231601CD)." Ann Surg. 2024;280(4):623–632. doi:10.1097/SLA.0000000000006458

31. Steffens D, Koh C, Hirst N, et al. "Prehabilitation in patients undergoing bladder cancer surgery - A systematic review and meta-analysis." Can J Urol. 2024;31(5):12004–12012. PMID:39462531