Frailty assessment in perioperative geriatric patients: a narrative review

Frailty assessment

Article information

Anesth Pain Med. 2026;21(1):51-66

Publication date (electronic) : 2026 January 30

doi : https://doi.org/10.17085/apm.25480

Tae-Yun Sung ¹

, Chung-Sik Oh^,²^,³

¹Department of Anesthesiology and Pain Medicine, Myunggok Medical Research Center, Konyang University Hospital, Konyang University College of Medicine, Daejeon, Korea

²Department of Anesthesiology and Pain Medicine, Konkuk University Medical Center, Konkuk University School of Medicine, Seoul, Korea

³Research Institute of Medical Sciences, Konkuk University School of Medicine, Seoul, Korea

Corresponding author Chung-Sik Oh, M.D., Ph.D. Department of Anesthesiology and Pain Medicine, Konkuk University Medical Center, Konkuk University School of Medicine, 120-1 Neungdong-ro, Gwangjin-gu, Seoul 05030, Korea Tel: 82-2-2030-5457 Fax: 82-2-2030-5449 E-mail: ohcsik@naver.com

Received 2025 December 10; Revised 2026 January 6; Accepted 2026 January 19.

Abstract

Frailty is increasingly recognized as a major determinant of perioperative risk in the geriatric population. It is characterized by reduced physiological reserve and impaired stress tolerance and arises from multisystem dysregulation involving chronic inflammation, neuroendocrine changes, sarcopenia, and organ dysfunction. Unlike chronological aging, frailty reflects biological vulnerability independent of comorbidity or disability and is strongly associated with postoperative complications, prolonged hospitalization, cognitive decline, and mortality. Therefore, early and systematic frailty assessment is essential to optimize perioperative management, support clinical decision-making, and implement tailored interventions. Multiple validated frailty assessment strategies exist, ranging from phenotypic models such as the Fried Frailty Phenotype to deficit accumulation tools such as the Frailty Index (FI). Practical bedside instruments, including the Clinical Frailty Scale, Edmonton Frail Scale, Fatigue, Resistance, Ambulation, Illnesses, Loss of Weight (FRAIL) scale, modified FI, and disease-specific screening tools, enable rapid detection in clinical settings. Frailty assessment should be performed early and efficiently to facilitate targeted prehabilitation, nutritional optimization, and cognitive support, all of which have been associated with improved functional outcomes. It also informs individualized anesthetic strategies, including drug titration, hemodynamic stabilization, lung-protective ventilation, and delirium prevention. However, barriers to implementation—such as limited clinician awareness, time constraints, and lack of standardized protocols—continue to hinder routine use. Future integration may be accelerated by artificial intelligence, telemedicine, and digital monitoring technologies to enhance geriatric anesthesia. This review provides a comprehensive overview of frailty in geriatric patients, highlighting its definition, pathophysiology, assessment methods, and clinical impact.

Keywords: Anesthesia; Frailty; Geriatric assessment; Perioperative care; Sarcopenia

INTRODUCTION

The global population of older adults is rapidly increasing and is projected to reach 2 billion by 2050, resulting in a growing proportion of geriatric patients [1]. These patients often present with multimorbidity and face an elevated risk of perioperative complications. Frailty, characterized by increased vulnerability and disability due to diminished physiological reserves, is particularly prevalent in this age group, affecting approximately 20% to 30% of geriatric patients [2,3]. Frailty reflects vulnerability arising from reduced physiological reserves across multiorgan systems and a diminished capacity to maintain homeostasis, regardless of chronological age. Moreover, frailty in geriatric patients is heterogeneous and is closely associated with postoperative complications and mortality [4]. Accordingly, assessing frailty is crucial for tailoring treatment strategies, improving functional capacity, and predicting perioperative outcomes.

This review explores available frailty assessment tools, emphasizes the importance of incorporating frailty assessment into routine clinical practice, and outlines future research directions. By clarifying the concept of frailty and describing its mechanisms, epidemiology, assessment methods, and clinical impact, we aim to enhance understanding of frailty in geriatric patients and promote its clinical and research applications.

CONCEPT AND PATHOPHYSIOLOGY OF FRAILTY

Definitions

There are various definitions of frailty. The key concept of frailty is physiological dysregulation across multiple clinical functions and multisystem decline, which contribute to comorbid conditions and disability [5]. In general, frailty can be defined as vulnerability to stress, with reduced ability to maintain homeostasis after a destabilizing event and decline of physiological reserve [6,7]. Importantly, the concept of frailty is shifting from chronological age to physiological aging and biological reserve. While frailty is more common in geriatric patients, it is not solely age-related, and not all frail patients are elderly [8]. Symptoms of frailty include weakness, fatigue, cognitive dysfunction, weight loss, reduced balance and physical activity, slowness, and social withdrawal [7,9].

Pathophysiologic mechanisms of frailty in geriatric patients

Frailty is a multifactorial condition influenced by interactions among inflammation, the central nervous system (CNS), sarcopenia, the neuroendocrine system, and comorbidities. These factors can contribute to the development of frailty in geriatric patients (Fig. 1) [6].

Fig. 1.

Complex interplay of multiple factors leading to the development of frailty. Frailty is driven by multisystem dysregulation characterized by chronic inflammation, neuroendocrine imbalance, central nervous system (CNS) dysfunction, sarcopenia, and comorbidity. These mechanisms reduce physiological reserve and impair homeostasis, leading to heightened vulnerability and adverse perioperative outcomes in geriatric patients. Interactions among these systems create a cycle that accelerates frailty progression.

(1) Inflammation: Inflammatory cytokines contribute to the development of frailty [10]. The release of proinflammatory cytokines and cell apoptosis impair multiple physiological systems [11,12]. Inflammation-related oxidative stress and free radicals contribute to mitochondrial changes, resulting in cellular impairment and age-associated lipid and protein damage [13]. Chronic inflammation is a critical factor in frailty associated with diabetes and cardiovascular diseases, further deteriorating physical function and increasing mortality risk [14]. Inflammation has strong relationships with the CNS, sarcopenia, hematopoietic and coagulation systems, and the neuroendocrine system in frail geriatric patients.

(2) CNS dysfunction: CNS dysfunction can act as a driver of frailty progression. Age-associated loss and inflammation contribute to the deterioration of the CNS and neurons [10]. Cognitive impairment and neurodegenerative diseases can, in turn, promote frailty through reduced mobility, apathy, malnutrition, and decreased physical activity. Baseline neurocognitive impairment in older adults can lead to the later development of physical frailty and disability in daily activities [15]. This decline in physical function can further exacerbate frailty, creating a vicious cycle that promotes frailty in geriatric patients, particularly during the perioperative period.

(3) Sarcopenia: Sarcopenia is characterized by the loss of skeletal muscle mass, strength, and function, occurring when the rate of muscle protein breakdown exceeds synthesis [16]. Malnutrition is a primary cause of skeletal muscle mass decline in geriatric patients. However, sarcopenia is influenced by multiple factors, including hormonal, inflammatory, neurological, and activity-related components [17]. Furthermore, patients with sarcopenia often exhibit increased inflammation [18].

(4) Hormonal imbalance: Dysregulation of hormones, such as steroids and growth hormone, contributes to age-associated changes in geriatric patients and can lead to frailty [10]. Inflammation also plays a role in the downregulation of growth hormone, and hormonal imbalances are linked to appetite changes, ultimately contributing to sarcopenia [19].

(5) Comorbidities: As organ dysfunction progresses, frailty can be exacerbated [20].

All of these mechanisms interact with each other, creating a cycle of decline in which impairment in one system accelerates dysfunction in others.

Difference between frailty, comorbidity, and disability

Frailty, comorbidity, and disability are distinct but potentially related concepts within the spectrum of overall health conditions. While they often coexist, they are conceptually and operationally different. Disability refers to a physical or cognitive limitation in performing daily activities, often associated with a specific disease [21]. However, frailty differs from disability because many frail patients can still perform daily activities, and not all frail patients have disabilities. Frailty denotes vulnerability due to reduced physiological reserve and impaired ability to maintain homeostasis. This vulnerability can exist irrespective of the presence of disease or disability [22]. Comorbidity refers to the coexistence of multiple diseases or medical conditions. Frailty can be related to single- or multiorgan dysfunction, and some geriatric patients may exhibit frailty even in the absence of comorbidities. Multifactorial influences, such as disability and comorbidity, as well as genetic, psychosocial, behavioral, cellular, and molecular factors, can contribute to the development of frailty in geriatric patients [23].

FRAILTY ASSESSMENT

Frailty assessment in the perioperative setting is clinically important for clarifying therapeutic approaches. Disease-specific treatments address comorbidity, rehabilitation addresses disability, and multidomain interventions such as exercise, nutrition, and medication optimization address frailty. Various frailty assessment methods include evaluations of cognition, nutrition, social status, and physical activities (Table 1) [24]. Most assessment tools include common parameters representing vulnerability, weakness, instability, and limitations in daily activity. Individuals classified as frail on one instrument may not be classified as frail on another due to heterogeneity in assessment instruments. Nevertheless, frailty assessment facilitates the identification of geriatric patients at high risk of perioperative complications, anticipates perioperative morbidity and mortality, and contributes to reducing perioperative complications by enabling tailored treatment plans. While there is no consensus on the best way to measure frailty, the two most validated and widely accepted methods are the Fried Frailty Phenotype and the Frailty Index (FI) [25,26].

Table 1.

Reliable Frailty Assessment Tools

Phenotypic models

• Fried Frailty Phenotype: Fried et al. [22] introduced the widely used physical frailty phenotype, characterizing frailty by specific measurable features such as weakness (measured by grip strength with a dynamometer), slow gait (measured by seconds across 15 feet), self-reported exhaustion, low physical activity (measured by the Minnesota Leisure Time Activity Questionnaire), and unintentional weight loss (measured as > 10 pounds loss in the past year). Individuals meeting more than 3 criteria are classified as frail, 1–2 criteria as pre-frail, and none as nonfrail. This model emphasizes the physical manifestations of frailty and highlights sarcopenia and physical performance as key parameters. The phenotypic approach is objective and represents biological status well, detecting patients with specific vulnerabilities regardless of age and comorbidities [27]. Phenotypic frailty is particularly useful when physical frailty is the primary concern and when planning exercise-based interventions [28]. Performing the assessments requires less geriatric expertise (compared with the FI) and may provide multicomponent general interventions for high-risk patients [25]. However, it requires space for gait speed tests and equipment to measure grip strength, which may not be feasible in all clinical settings. In addition, it does not include cognitive, psychological, or social aspects [24].

Deficit accumulation models

• Frailty Index: Frailty is quantified as the proportion of accumulated deficits, including symptoms, signs, diseases, disabilities, and laboratory abnormalities [29]. The deficit accumulation model is a highly age-related tool [30]. The proposed FI included 70 variables covering physical, cognitive, functional, and psychosocial domains, and a higher FI indicates greater frailty [31]. It provides a comprehensive assessment of physiological reserve and has strong predictive validity for perioperative complications [32]. While the Fried Frailty Phenotype does not provide the geriatric assessment needed to identify where interventions should be directed, the FI, upon completion of the assessment, allows the clinician to quickly identify the domains where interventions can be directed perioperatively [25]. However, the FI requires extensive data collection and a time-consuming process, which is not feasible in routine clinical practice.

Practical tools for clinical use

Both of the above-mentioned measurement models (especially deficit accumulation models) are time- and resource-consuming processes for screening frailty in the perioperative setting. Thus, multiple screening tools were derived from the two models. These tools generally take up to 15 min to screen for frailty and do not require space or equipment for assessment. In addition, these tools have acceptable validity and reliability (Fig. 2) [33,34]. Therefore, it is useful to screen for frailty using these simplified and shorter tools before diagnosing frailty. Among the numerous frailty assessment tools available, there is no “one-size-fits-all” approach. Clinicians should select an assessment tool by considering the patient population, clinical context, feasibility, and intended use [26]. One thing to keep in mind is that the prevalence of frailty will depend on the screening tool used and the target population selected [35].

Fig. 2.

Practical simplified frailty assessment instruments, including the Program of Research to Integrate the Services for the Maintenance of Autonomy (PRISMA)-7, Fatigue, Resistance, Ambulation, Lllnesses, Loss of Weight (FRAIL) scale, modified Frailty Index (mFI), G-8, Clinical Frailty Scale (CFS), Gérontopôle Frailty Screening Tool (GFST), Tilburg Frailty Indicator (TFI), Groningen Frailty Indicator (GFI), Edmonton Frail Scale (EFS), and Short Physical Performance Battery (SPPB), represent a broad spectrum of assessment complexity, ranging from brief clinical scales to more comprehensive performance-based batteries.

(1) Clinical Frailty Scale (CFS): The original CFS was developed as a 7-point CFS [31] and has shown high predictive validity for frailty compared with other scale indices. The CFS uses 7 graded category scores (1 to 7) rather than multiple separate checklist items. The categories include very fit, well, well-treated comorbid disease, apparently vulnerable, mildly frail, moderately frail, and severely frail. Each category is defined by brief descriptors and pictographs summarizing overall fitness, comorbidity, and functional dependence. Later, the scale was expanded to 9 categories, adding very severely frail and terminally ill as distinct grades. The CFS can be performed rapidly, within 10 min at the bedside, and does not require special equipment. Instead, it requires clinical judgment and a patient or caregiver interview. It has strong predictive validity and consistently predicts mortality, readmission, and length of stay [36].

(2) Edmonton Frail Scale (EFS): The EFS is a frailty screening scale initially developed to predict complications of cardiac surgery in older people [37]. The EFS evaluates 9 domains, including cognition, general health status, functional independence, social support, medication use, nutrition, mood, continence, and functional performance, and provides a score out of 17 points, stratifying patients into four categories: not frail, mild frailty, moderate frailty, and severe frailty. With questions covering cognitive, functional, social, nutritional, mood, and continence status, as well as medication use and a general health assessment, the EFS provides more multifaceted information and is quick to administer, taking around 10 min. It is valid, reliable, and feasible for routine use in frail geriatric patients [35].

(3) Fatigue, Resistance, Ambulation, Illnesses, Loss of Weight (FRAIL) scale: The FRAIL scale, often called the FRAIL scale, is a very short, 5-item screening tool designed to identify frailty, prefrailty, and no frailty [38]. The name FRAIL is an acronym for its five domains, including fatigue, resistance, ambulation, illnesses, and loss of weight. Each domain scores 1 point if present and 0 if absent, yielding a total score of 0 to 5. It uses simple yes/no questions and can usually be administered in 1–2 min. It is brief and easy to use at the bedside with minimal training and low respondent burden. It is a useful screening tool to flag patients who may need a more comprehensive geriatric or perioperative assessment, rather than replacing full frailty indices.

(4) Modified Frailty Index (mFI): The mFI is a short, comorbidity-based frailty score derived from the original FI and designed to be easily calculated from routine clinical or registry data to predict postoperative risk [39]. The classic mFI includes 11 variables (mFI-11), assigning 1 point for each underlying condition and dividing by the number of possible items to yield a score between 0 and 1. Higher mFI values are consistently associated with increased postoperative complications, mortality, readmission, and prolonged length of stay across many surgical populations [40]. Newer very short forms that include only 5 variables (mFI-5) were developed by selecting a subset of comorbidities, including hypertension, diabetes mellitus, chronic obstructive pulmonary disease or active pneumonia, functional status at the time of surgery, and congestive heart failure [41]. The mFI-5 is increasingly used as a pragmatic perioperative frailty screener in large registries and in routine clinical workflows because it shows similar prognostic accuracy to mFI-11 for outcomes such as postoperative complications or functional dependence at discharge [42,43]. Recently, mFI-4 was also developed to further simplify the FI and requires additional validation [44].

(5) The Gérontopôle Frailty Screening Tool (GFST): The GFST is a brief, clinician-administered instrument to help primary care and geriatric clinicians quickly identify geriatric patients and is particularly targeted to community-dwelling or ambulatory geriatrics [45,46]. The GFST is based on the idea that frailty can be detected early through simple clinical questions plus the physician’s overall judgment, rather than only through performance tests. The GFST has two main parts. Part one is a short questionnaire exploring common warning signs such as recent weight loss, fatigue, mobility difficulties, cognitive complaints, social or functional decline, and polypharmacy, and part two is a global clinician rating in which the physician states whether they consider the patient frail based on the questionnaire and clinical impression. There is no numerical score in the GFST, and the key output is whether the clinician concludes that the patient is frail or not frail. Patients judged frail are candidates for comprehensive geriatric assessment, targeted interventions, and closer follow-up.

(6) Tilburg Frailty Indicator (TFI): The TFI is a brief self-report questionnaire that assesses physical, psychological, and social domains of vulnerability [47]. The original TFI consists of 15 items grouped into three domains: physical (8 items), psychological (4 items), and social (3 items). Each item is self-reported, primarily with “yes” or “no” responses scored as 0 or 1. Total scores range from 0 to 15, with a cutoff score of ≥ 5 used to classify an individual as frail. The TFI demonstrates good reliability and validity compared with other multidimensional frailty tools and shows strong predictive value for disability.

(7) Groningen Frailty Indicator (GFI): The GFI is a 15-item screening tool covering physical, cognitive, social, and psychological domains [48]. It offers advantages due to its multidimensional approach and good validation for predicting perioperative complications [34]. However, it takes longer than the briefest screens and requires patient comprehension.

(8) Program of Research to Integrate the Services for the Maintenance of Autonomy (PRISMA)-7: The PRISMA-7 measures 7 items across four domains: age, gender, social support, and daily activities [49]. It demonstrates high feasibility and acceptability, as it requires minimal space, equipment, skills, and time for implementation, resulting in the fastest completion time [50].

(9) G-8: The G-8 is an oncology patient-specific tool comprising an 8-item screening questionnaire used to identify older cancer patients who require a comprehensive geriatric assessment [51]. It covers nutritional status, weight loss, mobility, neuropsychological problems, body mass index, medications, self-rated health, and age. The G-8 demonstrates good validation in relation to cancer progression and metastasis, offering advantages related to its oncology-validated focus and quick screening capability [52]. It is intended for initial screening only, and a positive screen necessitates follow-up comprehensive assessment.

(10) Short Physical Performance Battery (SPPB): The SPPB is an objective tool for assessing physical frailty and lower-extremity function [53]. The SPPB consists of three domains: balance tests, gait speed, and chair-stand tests. Each domain is scored from 0 to 4, yielding a composite score ranging from 0 to 12, with a cutoff score of ≤ 5 used to classify an individual as frail. This tool has been adopted in multiple studies due to its high reproducibility and proven predictive validity for postoperative complications and functional decline in geriatric populations [54,55].

(11) Imaging-based assessment: Image-based tools using computed tomography (CT) or ultrasonography can be used as a surrogate for muscle mass. These tools can augment clinical assessment in cases where imaging is already performed, offering objective data for perioperative planning. These include the psoas muscle area derived from abdominal CT, the skeletal muscle index calculated from the total muscle area at the third lumbar vertebral level, and muscle attenuation as an indicator of muscle quality [56]. These radiological measures correlate well with frailty and provide objective data for predicting surgical outcomes [57].

(12) Laboratory-based assessment: The frailty assessment process typically requires substantial effort and time, involving direct contact and communication with patients. To address this challenge, a recent study demonstrated the feasibility of laboratory-based frailty assessment [58]. This tool utilized 22 routine conventional laboratory parameters, such as complete blood count, liver function tests, electrolytes, and urine spot parameters. It showed relatively good reliability for predicting delirium and 1-year mortality in patients admitted to the intensive care unit (ICU) [59]. However, further studies are necessary to clarify the validation of this type of laboratory-based frailty assessment, given the current lack of sufficient validation.

CLINICAL IMPLICATION OF FRAILTY ASSESSMENT IN ANESTHESIA FOR GERIATRIC PATIENTS

A positive frailty screen should ideally be followed by a more accurate diagnostic frailty assessment and, when feasible, a comprehensive geriatric assessment [25]. Comprehensive geriatric assessment is crucial for distinguishing among frailty-related domains and helps identify reversible contributors within the frailty construct, such as polypharmacy, depression, malnutrition, and social isolation [60]. Furthermore, appropriate application of comprehensive geriatric assessment not only reduces functional decline but also contributes to decreasing the burden on caregivers and the use of health services, while providing useful information for advance care planning [61]. Early and proper assessment of frailty in geriatric patients enables early identification of high-risk patients before a crisis occurs, proactive interventions to prevent or slow frailty progression, and coordination of community services and preventive care [24,62].

Predicts clinical outcomes

Frailty is related to physical function in geriatric patients and arises from subclinical conditions, acute or chronic diseases, and behavioral and social risk factors [6]. Thus, regardless of the surgical population and the frailty assessment tool used, frail patients are associated with poorer postoperative outcomes [63]. Frail geriatric patients have a high risk of falls, functional decline, postoperative delirium, hospitalization, postoperative complications, ICU admission, and mortality [64,65]. Geriatric patients with frailty admitted to the ICU had 6.21 times the odds of postoperative delirium during their ICU stay [59]. Furthermore, geriatric patients with frailty have a higher chance of thrombosis than nonfrail patients [66]. Reduced ambulation and slow gait-related blood flow stasis may contribute to thrombosis formation. Age-associated inflammation is also a causal factor in thrombosis through deterioration of the clotting cascade, complement system, and endothelial cells [67]. Frail patients with diabetes were associated with a two-fold higher risk of cerebrovascular disease-related mortality [68]. Frail patients with kidney disease have a significant association with cardiovascular disease and neuropathy [69,70]. Early and proper assessment of frailty consistently predicts all-cause mortality, readmission, length of stay, adverse discharge destination, and functional decline in acute clinical settings, with studies across multiple countries and cohorts reporting independent associations after adjustment for age and comorbidity [32,36,71].

Guides clinical decision making

Frailty assessment can support shared decision-making with patients and families. Careful discussion with frail patients about their wishes through a shared decision-making process can help patients make better-informed decisions before surgery, set realistic expectations, and ultimately contribute to reduced morbidity and mortality [72]. For many frail patients, avoiding deterioration in independence, quality of life, disability, and morbidity may be more important than longevity. In addition, frailty assessment supports shared decision-making with patients and families. A nonsurgical option can be helpful in avoiding deterioration of the physical status of frail geriatric patients with cancer [73]. Careful patient selection, reduction in chemotherapy dose, and alternative schedules can improve tolerance without affecting treatment efficacy in frail geriatric patients [74]. A previous study revealed that treatment choice for frail patients with end-stage kidney disease tends toward continued dialysis rather than kidney transplantation [75]. Likewise, frailty assessment in geriatric patients with kidney disease may influence hemodialysis decision-making [76]. Another study also showed lower surgery rates in frail colorectal cancer patients compared with their nonfrail counterparts [77]. Furthermore, geriatric assessment frequently leads to modifications in treatment plans, often resulting in de-escalation rather than escalation of care intensity. Consequently, this process optimizes clinical decision-making by sparing high-risk patients from futile procedures while ensuring appropriate interventions for suitable candidates. Previous studies have revealed that minimally invasive surgical techniques can significantly reduce morbidity and mortality in frail geriatric patients [78,79]. Moreover, early and proper management of frailty in geriatric patients may enable caregivers to more effectively perform critical kidney disease management, such as medication adherence or diet [80].

Facilitates targeted interventions in terms of prehabilitation and rehabilitation

Early detection through frailty screening and diagnosis using comprehensive geriatric assessment facilitates patient-tailored prehabilitation interventions. Prehabilitation programs include nutritional optimization, pre- and postoperative exercise, psychological interventions, and optimization of medication and medical conditions. Identifying high-risk frail geriatric patients helps prioritize interventions such as rehabilitation, nutrition, and social support. Interventions encompassing prehabilitation and rehabilitation can restore reversible vulnerability and enhance social support to reduce frailty. A previous study comparing prehabilitation and postoperative rehabilitation in frail colorectal patients showed that even if prehabilitation did not alter complication rates, postoperative rehabilitation still played a role in functional recovery [81]. Furthermore, structured rehabilitation can be beneficial in ameliorating functional decline and postoperative complications in frail geriatric patients [82,83]. A preventive approach to frailty reduces healthcare costs and improves long-term outcomes. Previous studies have shown that frailty in geriatric patients may be treated with combinations of exercise, psychological support, cognitive training, anemia correction, and vitamin supplementation [84-86]. Theoretically, exercise and muscle strength training are the most effective interventions for improving frailty components, with beneficial exercise programs typically lasting four to twelve weeks [23]. Meanwhile, psychological interventions, including procedural information, behavioral instruction, cognitive intervention, and relaxation techniques, may be beneficial for reducing length of hospital stay, postoperative pain, negative affect, and promoting behavioral recovery [87].

Integration into precision geriatric medicine and perioperative care pathways can be challenging. A previous study showed that increasing protein intake in conjunction with strength training can have a synergistic effect on improving functional outcomes in frail geriatric patients [88]. Even though a previous study showed that hormonal replacement had beneficial effects on improving strength, muscle mass, and physical function [89], the effect of hormone replacement on improving functional outcomes in frail geriatric patients remains controversial [90]. Erythropoietin appears to have potential neuroprotective and regenerative effects, as well as a positive effect on anemia in frail geriatric patients [91,92]. Antihypertensive medication can also improve strength and muscle mass in frail geriatric patients [93]. Recent ongoing trials are investigating the effects of statins on stroke prevention in frail geriatric patients [94]. However, some clinicians suggest that prescribing statins in frail geriatric patients should be avoided due to their limited usefulness in sarcopenic patients [95]. The use of statins remains controversial regarding improved outcomes in frail geriatric patients [96,97]. Therefore, further studies are needed to clarify the beneficial effect of statins on improving functional outcomes in frail geriatric patients, given their strong anti-inflammatory effects and potential for reducing cardiovascular complications.

IMPLICATIONS FOR ANESTHETIC MANAGEMENT

Frailty can influence anesthetic technique, pharmacological choices, hemodynamic and respiratory strategies, and monitoring intensity (Fig. 3) because frail geriatric patients are more prone to hemodynamic instability, prolonged ventilation, and perioperative adverse events. The recent guideline states that both neuraxial and general anesthesia are acceptable, and the anesthetic choice should be individualized [98]. There is no definitive evidence that specific types of anesthesia prevent delirium or improve survival in frail geriatric patients. Local anesthesia or limited-dose regional techniques can be considered the first choice when they can provide adequate surgical conditions, to avoid the physiological stress and polypharmacy associated with general anesthesia [99]. The crucial issue for minimizing perioperative complications in frail geriatric patients is not the type of anesthesia, but rather the severity of frailty.

Fig. 3.

Integration of tailored anesthesia domains, including patient-specific techniques, medication adjustments, hemodynamic management, and delirium prevention, collectively mitigates adverse outcomes in frail geriatric patients. EEG: electroencephalogram.

Medication selection and dosing strategy should start with a low dose and should be titrated for sedatives and opioids, given the altered pharmacodynamics and increased sensitivity in frail geriatric patients [100]. Age-adjusted anesthetic titration combined with processed electroencephalogram monitoring can reduce the requirement for hypnotics and neuromuscular blocking agents. Furthermore, the use of short-acting anesthetics is advantageous for promoting early recovery. Individualized, careful titration is essential because specific dose–response data in frail geriatric patients are limited.

Previous studies showed a high risk associated with frailty for post-induction hypotension and perioperative cardiac arrest [101]. Therefore, prompt treatment of hypotension with careful use of vasopressors, optimization of intravascular volume, and strict blood pressure control with invasive hemodynamic monitoring are essential in frail geriatric patients [100,101].

To minimize ventilation-associated pulmonary complications, a lung-protective strategy and early extubation should be considered. The extubation plan should be coordinated with surgical and respiratory specialists to minimize the possibility of delayed recovery and the potential need for prolonged postoperative ventilatory support [102].

Standardized delirium prevention is also essential in frail geriatric patients. In collaboration with the surgical team, application of a sleep protocol, vision and hearing aids, active ambulation, and minimal use of sedatives and anticholinergics during the perioperative period are crucial to mitigate postoperative cognitive decline in frail geriatric patients [103,104].

OVERCOMING BARRIERS TO ROUTINE FRAILTY ASSESSMENT

In general, frailty assessment is not easy to perform due to the difficulty of objective measurement. Most clinicians do not recognize frailty assessment tools because of their heterogeneity [105], and a lack of knowledge about frailty has been identified as a key barrier to its use in clinical practice [106]. Furthermore, time constraints often prevent frailty assessment from becoming part of routine clinical practice. In addition, the social and psychological aspects of frailty are difficult to measure. To overcome these limitations, several strategies are essential.

Strategies to overcome difficulties in frailty assessment include training programs on routine frailty assessment, using simplified tools, and integrating frailty assessment into routine preoperative evaluation. To successfully incorporate frailty assessment into routine preoperative evaluation, it is important for medical staff to become familiar with frailty and its assessment criteria, and institution-specific resource availability should be considered [63]. Routine frailty assessment becomes much easier if clinicians consistently use one simple tool, embed it in their workflow, and link it to clear actions instead of treating it as extra work. The key is to choose a pragmatic and simple scale, standardize when and where it is administered, and support staff with training and feedback. Most clinicians still lack clarity regarding their specific role in utilizing a frailty assessment [107]. Physicians also report uncertainty about whether frailty screening is part of their role, alongside concerns about resources and workflow disruption. Therefore, application of frailty assessment in the routine workflow is essential [108]. Clinicians are highly interested in more education on frailty but often lack training and local protocols [109]. Short online modules, pocket cards, and case-based teaching can improve confidence and compliance with screening. Successful programs make frailty scoring mandatory at defined process points, including the pre-assessment clinic, surgical admission, and discharge process. Implementation of a single, quick tool would be beneficial to avoid confusion in assessment. Tools such as the PRISMA-7, FRAIL scale, mFI, G-8, CFS, GFST, TFI, GFI, EFS, and SPPB would be helpful for brief evaluation of frailty in geriatric patients when clinicians lack sufficient time for a comprehensive assessment. These tools can usually be completed in a few minutes based on history and observation and are accurate. Selection of the appropriate frailty assessment tool must be tailored to the specific clinical purpose, ranging from rapid screening instruments to comprehensive measures, such as the FI or Fried Frailty Phenotype for detailed risk stratification (Fig. 4).

Fig. 4.

Proposed algorithm for preoperative frailty assessment and management in geriatric surgical patients. PRISMA: Program of Research to Integrate the Services for the Maintenance of Autonomy, FRAIL: Fatigue, Resistance, Ambulation, Illnesses, Loss of Weight, mFI: modified Frailty Index, CFS: Clinical Frailty Scale, GFST: Gérontopôle Frailty Screening Tool, TFI: Tilburg Frailty Indicator, GFI: Groningen Frailty Indicator, EFS: Edmonton Frail Scale, SPPB: Short Physical Performance Battery.

Structured frailty pathways can reduce readmissions, length of stay, and non-home discharge in high-risk surgical patients [110]. Communicating these outcome gains and demonstrating how frailty scores support patient-centered decisions and prehabilitation helps clinicians see frailty assessment as integral to care rather than an administrative burden.

FUTURE DIRECTIONS IN THE ASSESSMENT AND MANAGEMENT OF FRAILTY

Recent advancements in frailty assessment use artificial intelligence (AI) to predict frailty from electronic health record data [111]. AI-based risk prediction models can be used to reduce perioperative complications in frail geriatric patients. Machine learning programs can identify factors contributing to falls in frail geriatric patients with advanced cancer and can predict in-hospital falls [112].

Digital frailty assessments, such as smartphone gait analysis or grip sensors, are also available through the use of wearable sensors for continuous monitoring of activity and gait [113]. The use of devices such as activity and heart rate monitors is evolving to customize home-based exercise programs aimed at alleviating frailty in geriatric patients [114]. Other emerging methods include voice analysis, which uses speech patterns as markers [115]. Currently, multicomponent exercise programs are ongoing to improve morbidity and mortality in frail geriatric patients with cancer [116].

Telemedicine for remote screening of home-care patients is feasible for managing frail geriatric patients [117]. In addition, the concept of telerehabilitation was introduced for stroke patients during the pandemic era due to difficulty with hospital visits [118]. Home-based prehabilitation also has a positive effect on reducing postoperative complications in frail geriatric patients [119]. These approaches can be implemented for frail geriatric patients to restore daily activity and consequently reduce perioperative mortality. These technologies offer significant promise for scalable and objective assessment; however, they require comprehensive validation before they can be widely adopted in clinical practice. A previous study showed that predicting postoperative morbidity and mortality using electronic health records is feasible in clinical practice and is effective at predicting postoperative complications in frail geriatric patients [120]. Therefore, meticulous investigation in frail geriatric patients prior to anesthesia and surgery is essential.

CONCLUSION

Early and systematic frailty assessment enables clinicians to identify vulnerable geriatric patients before acute deterioration, predict postoperative complications, guide shared decision-making, and initiate targeted interventions such as prehabilitation and comprehensive geriatric optimization. These strategies not only reduce morbidity and deterioration of functional status but also support meaningful treatment. The presence and severity of frailty should inform anesthetic technique, pharmacologic management, hemodynamic optimization, and perioperative strategies including delirium prevention and early mobilization. Effective integration of frailty into clinical pathways, accompanied by simplified screening tools and workforce education, is essential to overcome barriers such as time limitations and lack of standardized workflow. Future advances will rely on AI, electronic health record–based risk stratification, imaging and laboratory biomarkers, and telemedicine-supported assessment to enhance feasibility and precision. Ultimately, embedding frailty assessment into routine perioperative care is critical for achieving personalized anesthesia and improving long-term outcomes for frail geriatric patients.

Notes

FUNDING

None.

ACKNOWLEDGMENTS

This study was supported by the Korean Society of Geriatric Anesthesia and Pain.

CONFLICTS OF INTEREST

Chung-Sik Oh has been an editor of the Anesthesia and Pain Medicine since 2024; however, he was not involved in the peer reviewer selection, evaluation, or decision process of this article. No other potential conflicts of interest relevant to this article were reported.

DATA AVAILABILITY STATEMENT

The datasets generated during and/or analyzed during the current study are available from the corresponding author on reasonable request.

AUTHOR CONTRIBUTIONS

Conceptualization: Tae-Yun Sung, Chung-Sik Oh. Writing - original draft: Tae-Yun Sung, Chung-Sik Oh. Writing - review & editing: Tae-Yun Sung, Chung-Sik Oh.

References

1. Bloom DE, Chatterji S, Kowal P, Lloyd-Sherlock P, McKee M, Rechel B, et al. Macroeconomic implications of population ageing and selected policy responses. Lancet 2015;385:649–57. 10.1016/s0140-6736(14)61464-1. 25468167.

2. Collard RM, Boter H, Schoevers RA, Oude Voshaar RC. Prevalence of frailty in community-dwelling older persons: a systematic review. J Am Geriatr Soc 2012;60:1487–92. 10.1111/j.1532-5415.2012.04054.x. 22881367.

3. O'Caoimh R, Sezgin D, O'Donovan MR, Molloy DW, Clegg A, Rockwood K, et al. Prevalence of frailty in 62 countries across the world: a systematic review and meta-analysis of population-level studies. Age Ageing 2021;50:96–104. 10.1093/ageing/afaa219. 33068107.

4. Clegg A, Young J, Iliffe S, Rikkert MO, Rockwood K. Frailty in elderly people. Lancet 2013;381:752–62. 10.1016/s0140-6736(12)62167-9. 23395245.

5. Lipsitz LA. Dynamics of stability: the physiologic basis of functional health and frailty. J Gerontol A Biol Sci Med Sci 2002;57:B115–25. 10.1093/gerona/57.3.b115. 11867648.

6. Walston J, Hadley EC, Ferrucci L, Guralnik JM, Newman AB, Studenski SA, et al. Research agenda for frailty in older adults: toward a better understanding of physiology and etiology: summary from the American Geriatrics Society/National Institute on Aging research conference on frailty in older adults. J Am Geriatr Soc 2006;54:991–1001. 10.1111/j.1532-5415.2006.00745.x. 16776798.

7. Rockwood K. Frailty and its definition: a worthy challenge. J Am Geriatr Soc 2005;53:1069–70. 10.1111/j.1532-5415.2005.53312.x. 15935037.

8. Vitale C, Spoletini I, Rosano GM. Frailty in heart failure: implications for management. Card Fail Rev 2018;4:104–6. 10.15420/cfr.2018.22.2. 30206485.

9. Ferrucci L, Guralnik JM, Studenski S, Fried LP, Cutler GB, Walston JD. Designing randomized, controlled trials aimed at preventing or delaying functional decline and disability in frail, older persons: a consensus report. J Am Geriatr Soc 2004;52:625–34. 10.1111/j.1532-5415.2004.52174.x. 15066083.

10. Ershler WB, Keller ET. Age-associated increased interleukin-6 gene expression, late-life diseases, and frailty. Annu Rev Med 2000;51:245–70. 10.1146/annurev.med.51.1.245. 10774463.

11. Roubenoff R, Parise H, Payette HA, Abad LW, D'Agostino R, Jacques PF, et al. Cytokines, insulin-like growth factor 1, sarcopenia, and mortality in very old community-dwelling men and women: the Framingham Heart Study. Am J Med 2003;115:429–35. 10.1016/j.amjmed.2003.05.001. 14563498.

12. Papanicolaou DA, Wilder RL, Manolagas SC, Chrousos GP. The pathophysiologic roles of interleukin-6 in human disease. Ann Intern Med 1998;128:127–37. 10.7326/0003-4819-128-2-199801150-00009. 9441573.

13. Rahman I. Oxidative stress, chromatin remodeling and gene transcription in inflammation and chronic lung diseases. J Biochem Mol Biol 2003;36:95–109. 10.5483/bmbrep.2003.36.1.095. 12542980.

14. Vlachakis D, Zacharaki EI, Tsiamaki E, Koulouri M, Raftopoulou S, Papageorgiou L, et al. Insights into the molecular mechanisms of stress and inflammation in ageing and frailty of the elderly. J Mol Biochem 2017;6:41–4. 29387657.

15. Gauchard GC, Gangloff P, Jeandel C, Perrin PP. Influence of regular proprioceptive and bioenergetic physical activities on balance control in elderly women. J Gerontol A Biol Sci Med Sci 2003;58:M846–50. 10.1093/gerona/58.9.m846. 14528042.

16. Cesari M, Landi F, Vellas B, Bernabei R, Marzetti E. Sarcopenia and physical frailty: two sides of the same coin. Front Aging Neurosci 2014;6:192. 10.3389/fnagi.2014.00192. 25120482.

17. Volpi E, Nazemi R, Fujita S. Muscle tissue changes with aging. Curr Opin Clin Nutr Metab Care 2004;7:405–10. 10.1097/01.mco.0000134362.76653.b2. 15192443.

18. Chao CT, Huang JW, Chiang CK, Hung KY. Applicability of laboratory deficit-based frailty index in predominantly older patients with end-stage renal disease under chronic dialysis: a pilot test of its correlation with survival and self-reported instruments. Nephrology (Carlton) 2020;25:73–81. 10.1111/nep.13583. 30834584.

19. Cappola AR, Xue QL, Ferrucci L, Guralnik JM, Volpato S, Fried LP. Insulin-like growth factor I and interleukin-6 contribute synergistically to disability and mortality in older women. J Clin Endocrinol Metab 2003;88:2019–25. 10.1210/jc.2002-021694. 12727948.

20. Roshanravan B, Khatri M, Robinson-Cohen C, Levin G, Patel KV, de Boer IH, et al. A prospective study of frailty in nephrology-referred patients with CKD. Am J Kidney Dis 2012;60:912–21. 10.1053/j.ajkd.2012.05.017. 22770927.

21. Espinoza SE, Quiben M, Hazuda HP. Distinguishing comorbidity, disability, and frailty. Curr Geriatr Rep 2018;7:201–9. 10.1007/s13670-018-0254-0. 30984516.

22. Fried LP, Tangen CM, Walston J, Newman AB, Hirsch C, Gottdiener J, et al. Frailty in older adults: evidence for a phenotype. J Gerontol A Biol Sci Med Sci 2001;56:M146–56. 10.1093/gerona/56.3.m146. 11253156.

23. Nair D, Liu CK, Raslan R, McAdams-DeMarco M, Hall RK. Frailty in kidney disease: a comprehensive review to advance its clinical and research applications. Am J Kidney Dis 2025;85:89–103. 10.1053/j.ajkd.2024.04.018. 38906506.

24. Dent E, Kowal P, Hoogendijk EO. Frailty measurement in research and clinical practice: a review. Eur J Intern Med 2016;31:3–10. 10.1016/j.ejim.2016.03.007. 27039014.

25. Alvarez-Nebreda ML, Bentov N, Urman RD, Setia S, Huang JC, Pfeifer K, et al. Recommendations for preoperative management of frailty from the Society for Perioperative Assessment and Quality Improvement (SPAQI). J Clin Anesth 2018;47:33–42. 10.1016/j.jclinane.2018.02.011. 29550619.

26. Sandrucci S. Frailty: how to assess, prognostic role. Eur J Surg Oncol 2024;50:106862. 10.1016/j.ejso.2023.03.002. 36922252.

27. Wagner D, DeMarco MM, Amini N, Buttner S, Segev D, Gani F, et al. Role of frailty and sarcopenia in predicting outcomes among patients undergoing gastrointestinal surgery. World J Gastrointest Surg 2016;8:27–40. 10.4240/wjgs.v8.i1.27. 26843911.

28. Cesari M, Kritchevsky SB, Newman AB, Simonsick EM, Harris TB, Penninx BW, et al. Added value of physical performance measures in predicting adverse health-related events: results from the Health, Aging and Body Composition Study. J Am Geriatr Soc 2009;57:251–9. 10.1111/j.1532-5415.2008.02126.x. 19207142.

29. Mitnitski AB, Mogilner AJ, Rockwood K. Accumulation of deficits as a proxy measure of aging. ScientificWorldJournal 2001;1:323–36. 10.1100/tsw.2001.58. 12806071.

30. Rockwood K, Mitnitski AB, MacKnight C. Some mathematical models of frailty and their clinical implications. Rev Clin Gerontol 2002;12:109–17. 10.1017/s0959259802012236.

31. Rockwood K, Song X, MacKnight C, Bergman H, Hogan DB, McDowell I, et al. A global clinical measure of fitness and frailty in elderly people. CMAJ 2005;173:489–95. 10.1503/cmaj.050051. 16129869.

32. Evans SJ, Sayers M, Mitnitski A, Rockwood K. The risk of adverse outcomes in hospitalized older patients in relation to a frailty index based on a comprehensive geriatric assessment. Age Ageing 2014;43:127–32. 10.1093/ageing/aft156. 24171946.

33. Dent E, Lien C, Lim WS, Wong WC, Wong CH, Ng TP, et al. The Asia-Pacific clinical practice guidelines for the management of frailty. J Am Med Dir Assoc 2017;18:564–75. 10.1016/j.jamda.2017.04.018. 28648901.

34. Vo NT, Tu YK, Lin KC, Chiu HY, Huang HC. Diagnostic accuracy of the FRAIL scale, Groningen Frailty Indicator, Tilburg Frailty Indicator, and PRISMA-7 for frailty screening among older adults in community settings: a systematic review and network meta-analysis. Gerontologist 2024;64gnae008. 10.1093/geront/gnae008.

35. Theou O, Brothers TD, Mitnitski A, Rockwood K. Operationalization of frailty using eight commonly used scales and comparison of their ability to predict all-cause mortality. J Am Geriatr Soc 2013;61:1537–51. 10.1111/jgs.12420. 24028357.

36. Falk Erhag H, Guðnadóttir G, Alfredsson J, Cederholm T, Ekerstad N, Religa D, et al. The association between the Clinical Frailty Scale and adverse health outcomes in older adults in acute clinical settings - a systematic review of the literature. Clin Interv Aging 2023;18:249–61. 10.2147/CIA.S388160. 36843633.

37. Rolfson DB, Majumdar SR, Tsuyuki RT, Tahir A, Rockwood K. Validity and reliability of the Edmonton Frail Scale. Age Ageing 2006;35:526–9. 10.1093/ageing/afl041. 16757522.

38. Abellan van Kan G, Rolland YM, Morley JE, Vellas B. Frailty: toward a clinical definition. J Am Med Dir Assoc 2008;9:71–2. 10.1016/j.jamda.2007.11.005. 18261696.

39. Obeid NM, Azuh O, Reddy S, Webb S, Reickert C, Velanovich V, et al. Predictors of critical care-related complications in colectomy patients using the National Surgical Quality Improvement Program: exploring frailty and aggressive laparoscopic approaches. J Trauma Acute Care Surg 2012;72:878–83. 10.1097/TA.0b013e31824d0f70. 22491599.

40. Wahl TS, Graham LA, Hawn MT, Richman J, Hollis RH, Jones CE, et al. Association of the modified frailty index with 30-day surgical readmission. JAMA Surg 2017;152:749–57. 10.1001/jamasurg.2017.1025. 28467535.

41. 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;226:173–81.e8. 10.1016/j.jamcollsurg.2017.11.005. 29155268.

42. Mouchtouris N, Luck T, Locke K, Hines K, Franco D, Yudkoff C, et al. Comparison of 5-item and 11-item modified frailty index as predictors of functional independence in patients with spinal cord injury. Global Spine J 2025;15:782–9. 10.1177/21925682231211279. 37918861.

43. Wu H, Shi F, Hu C, Zhang L, Qu P, She J. Association between 5-item modified frailty index and clinical outcomes in elderly rectal cancer patients after radical surgery. Sci Rep 2025;15:4262. 10.1038/s41598-025-88726-6. 39905111.

44. Agathis AZ, Wu J, Divino CM. New surgical frailty scoring tool: modified 4-factor functional frailty index. J Am Coll Surg 2025;241:370–8. 10.1097/xcs.0000000000001362. 39981954.

45. Subra J, Gillette-Guyonnet S, Cesari M, Oustric S, Vellas B. The integration of frailty into clinical practice: preliminary results from the Gérontopôle. J Nutr Health Aging 2012;16:714–20. 10.1007/s12603-012-0391-7. 23076514.

46. Morley JE, Vellas B, van Kan GA, Anker SD, Bauer JM, Bernabei R, et al. Frailty consensus: a call to action. J Am Med Dir Assoc 2013;14:392–7. 10.1016/j.jamda.2013.03.022. 23764209.

47. Gobbens RJ, van Assen MA, Luijkx KG, Wijnen-Sponselee MT, Schols JM. The Tilburg Frailty Indicator: psychometric properties. J Am Med Dir Assoc 2010;11:344–55. 10.1016/j.jamda.2009.11.003. 20511102.

48. Steverink N, Slaets JPJ, Schuurmans H, van Lis M. Measuring frailty: developing and testing the GFI (Groningen frailty indicator). Gerontologist 2001;41:236–7.

49. Raîche M, Hébert R, Dubois MF. Prisma-7: a case-finding tool to identify older adults with moderate to severe disabilities. Arch Gerontol Geriatr 2008;47:9–18. 10.1016/j.archger.2007.06.004. 17723247.

50. Ambagtsheer RC, Archibald MM, Lawless M, Kitson A, Beilby J. Feasibility and acceptability of commonly used screening instruments to identify frailty among community-dwelling older people: a mixed methods study. BMC Geriatr 2020;20:152. 10.1186/s12877-020-01551-6. 32321431.

51. Bellera CA, Rainfray M, Mathoulin-Pélissier S, Mertens C, Delva F, Fonck M, et al. Screening older cancer patients: first evaluation of the G-8 geriatric screening tool. Ann Oncol 2012;23:2166–72. 10.1093/annonc/mdr587. 22250183.

52. Liuu E, Canouï-Poitrine F, Tournigand C, Laurent M, Caillet P, Le Thuaut A, et al. Accuracy of the G-8 geriatric-oncology screening tool for identifying vulnerable elderly patients with cancer according to tumour site: the ELCAPA-02 study. J Geriatr Oncol 2014;5:11–9. 10.1016/j.jgo.2013.08.003. 24484713.

53. Guralnik JM, Simonsick EM, Ferrucci L, Glynn RJ, Berkman LF, Blazer DG, et al. A short physical performance battery assessing lower extremity function: association with self-reported disability and prediction of mortality and nursing home admission. J Gerontol 1994;49:M85–94. 10.1093/geronj/49.2.m85. 8126356.

54. de Fátima Ribeiro Silva C, Ohara DG, Matos AP, Pinto ACPN, Pegorari MS. Short physical performance battery as a measure of physical performance and mortality predictor in older adults: a comprehensive literature review. Int J Environ Res Public Health 2021;18:10612.

55. Welch SA, Ward RE, Beauchamp MK, Leveille SG, Travison T, Bean JF. The Short Physical Performance Battery (SPPB): A quick and useful tool for fall risk stratification among older primary care patients. J Am Med Dir Assoc 2021;22:1646–51. 10.1016/j.jamda.2020.09.038. 33191134.

56. Bentov I, Kaplan SJ, Pham TN, Reed MJ. Frailty assessment: from clinical to radiological tools. Br J Anaesth 2019;123:37–50. 10.1016/j.bja.2019.03.034. 31056240.

57. Kleczynski P, Tokarek T, Dziewierz A, Sorysz D, Bagienski M, Rzeszutko L, et al. Usefulness of psoas muscle area and volume and frailty scoring to predict outcomes after transcatheter aortic valve implantation. Am J Cardiol 2018;122:135–40. 10.1016/j.amjcard.2018.03.020. 29703441.

58. Ritt M, Jäger J, Ritt JI, Sieber CC, Gaßmann KG. Operationalizing a frailty index using routine blood and urine tests. Clin Interv Aging 2017;12:1029–40. 10.2147/cia.s131987. 28721031.

59. Ji H, Lee JJ, Lee KH. Association between laboratory data-based frailty index and clinical health outcomes in critically ill older patients: a retrospective correlational study. Nurs Crit Care 2025;30e13222. 10.1111/nicc.13222. 39763246.

60. Lee H, Lee E, Jang IY. Frailty and comprehensive geriatric assessment. J Korean Med Sci 2020;35e16. 10.3346/jkms.2020.35.e16. 31950775.

61. Heckman GA, Barnard K, McKelvie RS. Yes, frailty matters: time for action. Can J Cardiol 2024;40:685–7. 10.1016/j.cjca.2024.01.001. 38181973.

62. Cesari M, Prince M, Thiyagarajan JA, De Carvalho IA, Bernabei R, Chan P, et al. Frailty: an emerging public health priority. J Am Med Dir Assoc 2016;17:188–92. 10.1016/j.jamda.2015.12.016. 26805753.

63. Beggs T, Sepehri A, Szwajcer A, Tangri N, Arora RC. Frailty and perioperative outcomes: a narrative review. Can J Anaesth 2015;62:143–57. 10.1007/s12630-014-0273-z. 25420470.

64. Millan-Domingo F, Viña J. Lifestyle interventions in frailty. Adv Exp Med Biol 2025;1478:407–19. 10.1007/978-3-031-88361-3_16. 40879948.

65. Cechinel C, Lenardt MH, Rodrigues JAM, Binotto MA, Aristides MM, Kraus R. Frailty and delirium in hospitalized older adults: a systematic review with meta-analysis. Rev Lat Am Enfermagem 2022;30e3687. 10.1590/1518-8345.6120.3687. 36287400.

66. Chiu TS, Pankow JS, Cushman M, Windham BG, Matsushita K, Mok Y, et al. Frailty and risk of venous thromboembolism in older adults: the Atherosclerosis Risk in Communities Study. J Thromb Haemost 2025;23:1531–8. 10.1016/j.jtha.2025.01.006. 39894445.

67. Tracy RP. Emerging relationships of inflammation, cardiovascular disease and chronic diseases of aging. Int J Obes Relat Metab Disord 2003;27 Suppl 3:S29–34. 10.1038/sj.ijo.0802497. 14704741.

68. Wen L, Lu Y, Li X, An Y, Tan X, Chen L. Association of frailty and pre-frailty with all-cause and cardiovascular mortality in diabetes: three prospective cohorts and a meta-analysis. Ageing Res Rev 2025;106:102696. 10.1016/j.arr.2025.102696. 39971101.

69. Johansen KL, Dalrymple LS, Delgado C, Chertow GM, Segal MR, Chiang J, et al. Factors associated with frailty and its trajectory among patients on hemodialysis. Clin J Am Soc Nephrol 2017;12:1100–8. 10.2215/cjn.12131116. 28576906.

70. Kakio Y, Uchida HA, Takeuchi H, Okuyama Y, Okuyama M, Umebayashi R, et al. Diabetic nephropathy is associated with frailty in patients with chronic hemodialysis. Geriatr Gerontol Int 2018;18:1597–602. 10.1111/ggi.13534. 30311338.

71. Mafla-España MA, Torregrosa MD, Cauli O. Analysis of frailty syndrome in men with metastatic prostate cancer: a scoping review. J Pers Med 2023;13:319.

72. Ernst KF, Hall DE, Schmid KK, Seever G, Lavedan P, Lynch TG, et al. Surgical palliative care consultations over time in relationship to systemwide frailty screening. JAMA Surg 2014;149:1121–6. 10.1001/jamasurg.2014.1393. 25207603.

73. Caillet P, Laurent M, Bastuji-Garin S, Liuu E, Culine S, Lagrange JL, et al. Optimal management of elderly cancer patients: usefulness of the Comprehensive Geriatric Assessment. Clin Interv Aging 2014;9:1645–60. 10.2147/CIA.S57849. 25302022.

74. Horgan AM, Seruga B, Pond GR, Alibhai SM, Amir E, De Wit R, et al. Tolerability and efficacy of docetaxel in older men with metastatic castrate-resistant prostate cancer (mCRPC) in the TAX 327 trial. J Geriatr Oncol 2014;5:119–26. 10.1016/j.jgo.2013.12.001. 24495703.

75. Haugen CE, Chu NM, Ying H, Warsame F, Holscher CM, Desai NM, et al. Frailty and access to kidney transplantation. Clin J Am Soc Nephrol 2019;14:576–82. 10.2215/cjn.12921118. 30890577.

76. Kurella Tamura M, Covinsky KE, Chertow GM, Yaffe K, Landefeld CS, McCulloch CE. Functional status of elderly adults before and after initiation of dialysis. N Engl J Med 2009;361:1539–47. 10.1056/nejmoa0904655. 19828531.

77. Ketelaers SHJ, Jacobs A, van der Linden CMJ, Nieuwenhuijzen GAP, Tolenaar JL, Rutten HJT, et al. An evaluation of postoperative outcomes and treatment changes after frailty screening and geriatric assessment and management in a cohort of older patients with colorectal cancer. J Geriatr Oncol 2023;14:101647. 10.1016/j.jgo.2023.101647. 37862736.

78. Turrentine FE, Wang H, Simpson VB, Jones RS. Surgical risk factors, morbidity, and mortality in elderly patients. J Am Coll Surg 2006;203:865–77. 10.1016/j.jamcollsurg.2006.08.026. 17116555.

79. Antoniou SA, Antoniou GA, Koch OO, Pointner R, Granderath FA. Laparoscopic colorectal surgery confers lower mortality in the elderly: a systematic review and meta-analysis of 66,483 patients. Surg Endosc 2015;29:322–33. 10.1007/s00464-014-3672-x. 24986017.

80. Hall RK, Haines C, Gorbatkin SM, Schlanger L, Shaban H, Schell JO, et al. Incorporating geriatric assessment into a nephrology clinic: preliminary data from two models of care. J Am Geriatr Soc 2016;64:2154–8. 10.1111/jgs.14262. 27377350.

81. Carli F, Bousquet-Dion G, Awasthi R, Elsherbini N, Liberman S, Boutros M, et al. Effect of multimodal prehabilitation vs postoperative rehabilitation on 30-day postoperative complications for frail patients undergoing resection of colorectal cancer: a randomized clinical trial. JAMA Surg 2020;155:233–42. 10.1001/jamasurg.2019.5474. 31968063.

82. Gill TM, Baker DI, Gottschalk M, Peduzzi PN, Allore H, Byers A. A program to prevent functional decline in physically frail, elderly persons who live at home. N Engl J Med 2002;347:1068–74. 10.1056/nejmoa020423. 12362007.

83. Chang CY, Lu CH, Hung CY, Liu KH, Hsu JT, Tsai CY, et al. Effect of geriatric interventions on postoperative outcomes in frail older patients undergoing elective gastrectomy for gastric cancer. J Geriatr Oncol 2025;16:102324. 10.1016/j.jgo.2025.102324. 40694948.

84. Ng TP, Feng L, Nyunt MS, Feng L, Niti M, Tan BY, et al. Nutritional, physical, cognitive, and combination interventions and frailty reversal among older adults: a randomized controlled trial. Am J Med 2015;128:1225–36.e1. 10.1016/j.amjmed.2015.06.017. 26159634.

85. Kim H, Suzuki T, Kim M, Kojima N, Ota N, Shimotoyodome A, et al. Effects of exercise and milk fat globule membrane (MFGM) supplementation on body composition, physical function, and hematological parameters in community-dwelling frail Japanese women: a randomized double blind, placebo-controlled, follow-up trial. PLoS One 2015;10e0116256. 10.1371/journal.pone.0116256. 25659147.

86. Theou O, Stathokostas L, Roland KP, Jakobi JM, Patterson C, Vandervoort AA, et al. The effectiveness of exercise interventions for the management of frailty: a systematic review. J Aging Res 2011;2011:569194. 10.4061/2011/569194. 21584244.

87. Powell R, Scott NW, Manyande A, Bruce J, Vögele C, Byrne-Davis LM, et al. Psychological preparation and postoperative outcomes for adults undergoing surgery under general anaesthesia. Cochrane Database Syst Rev 2016;2016:CD008646. 10.1002/14651858.cd008646.pub2. 27228096.

88. Fiatarone MA, O'Neill EF, Ryan ND, Clements KM, Solares GR, Nelson ME, et al. Exercise training and nutritional supplementation for physical frailty in very elderly people. N Engl J Med 1994;330:1769–75. 10.1056/nejm199406233302501. 8190152.

89. Page ST, Amory JK, Bowman FD, Anawalt BD, Matsumoto AM, Bremner WJ, et al. Exogenous testosterone (T) alone or with finasteride increases physical performance, grip strength, and lean body mass in older men with low serum T. J Clin Endocrinol Metab 2005;90:1502–10. 10.1210/jc.2004-1933. 15572415.

90. Percheron G, Hogrel JY, Denot-Ledunois S, Fayet G, Forette F, Baulieu EE, et al. Effect of 1-year oral administration of dehydroepiandrosterone to 60- to 80-year-old individuals on muscle function and cross-sectional area: a double-blind placebo-controlled trial. Arch Intern Med 2003;163:720–7. 10.1001/archinte.163.6.720. 12639206.

91. Leng S, Chaves P, Koenig K, Walston J. Serum interleukin-6 and hemoglobin as physiological correlates in the geriatric syndrome of frailty: a pilot study. J Am Geriatr Soc 2002;50:1268–71. 10.1046/j.1532-5415.2002.50315.x. 12133023.

92. Ehrenreich H, Aust C, Krampe H, Jahn H, Jacob S, Herrmann M, et al. Erythropoietin: novel approaches to neuroprotection in human brain disease. Metab Brain Dis 2004;19:195–206. 10.1023/b:mebr.0000043969.96895.3c. 15554415.

93. Onder G, Penninx BW, Balkrishnan R, Fried LP, Chaves PH, Williamson J, et al. Relation between use of angiotensin-converting enzyme inhibitors and muscle strength and physical function in older women: an observational study. Lancet 2002;359:926–30. 10.1016/s0140-6736(02)08024-8. 11918911.

94. Prins SR, Damoiseaux-Volman BA, Vermeer SE, Bossuyt PMM, Van Eekelen R, Bosmans JE, et al. Rationale and design of 'StAtins in frail older patients with ischemic stroke or transient ischemic attack-the randomized controlled trial' (SAFEST-RCT). BMJ Neurol Open 2025;7e001297. 10.1136/bmjno-2025-001297. 41070271.

95. Mallery LH, Moorhouse P, McLean Veysey P, Allen M, Fleming I. Severely frail elderly patients do not need lipid-lowering drugs. Cleve Clin J Med 2017;84:131–42. 10.3949/ccjm.84a.15114. 28198686.

96. Clark D, Cho LS. Statin therapy in the frail elderly: a nuanced decision. Cleve Clin J Med 2017;84:143–5. 10.3949/ccjm.84a.16036. 28198684.

97. Lynch JE, Henderson NR, Ramage L, McMurdo ME, Witham MD. Association between statin medication use and improved outcomes during inpatient rehabilitation in older people. Age Ageing 2012;41:260–2. 10.1093/ageing/afr159. 22156557.

98. Sieber F, McIsaac DI, Deiner S, Azefor T, Berger M, Hughes C, et al. 2025 American Society of Anesthesiologists practice advisory for perioperative care of older adults scheduled for inpatient surgery. Anesthesiology 2025;142:22–51. 10.1097/aln.0000000000005172. 39655991.

99. Cuvillon P, Lefrant JY, Gricourt Y. Considerations for the use of local anesthesia in the frail elderly: current perspectives. Local Reg Anesth 2022;15:71–5. 10.2147/lra.s325877. 35982729.

100. Penfold RS, Hunt A. Redefining risk in peri-operative frailty: towards routine frailty assessment and a whole pathway approach. Anaesthesia 2024;79:797–800. 10.1111/anae.16264. 38775328.

101. McIsaac DI, MacDonald DB, Aucoin SD. Frailty for perioperative clinicians: a narrative review. Anesth Analg 2020;130:1450–60. 10.1213/ane.0000000000004602. 32384334.

102. Derwall M, Coburn M. Safety and quality of perioperative anesthesia care-Ensuring safe care for older people living with frailty. Best Pract Res Clin Anaesthesiol 2021;35:3–9. 10.1016/j.bpa.2020.04.007. 33742576.

103. Busse JW, Ranker A, Gogol M, Macke C, Liodakis E, Strack D, et al. Reduced perioperative sensory impairment could lower postoperative delirium incidence: a before-and-after study in older patients with hip fracture. BMC Geriatr 2025;25:673. 10.1186/s12877-025-06318-5. 40885890.

104. Holler E, Mohanty S, Rosenberg M, Kalbaugh C, Miled ZB, Boustani M, et al. Perioperative anticholinergic medication use and incident dementia among older surgical patients: a retrospective cohort study using real-world data. Drugs Aging 2025;42:235–43. 10.1007/s40266-025-01185-6. 39903336.

105. Hladkowicz E, Dorrance K, Bryson GL, Forster A, Gagne S, Huang A, et al. Identifying barriers and facilitators to routine preoperative frailty assessment: a qualitative interview study. Can J Anaesth 2022;69:1375–89. 10.1007/s12630-022-02298-x. 35978162.

106. Eamer G, Gibson JA, Gillis C, Hsu AT, Krawczyk M, MacDonald E, et al. Surgical frailty assessment: a missed opportunity. BMC Anesthesiol 2017;17:99. 10.1186/s12871-017-0390-7. 28738809.

107. Hothi H, Paolone AR, Pezeshki M, Griffith LE, Kennedy CC, Leong DP, et al. The implementation of frailty assessment tools in the acute care setting: a scoping review. J Am Geriatr Soc 2025;73:2571–8. 10.1111/jgs.19438. 40088041.

108. George EL, Arya S. The importance of incorporating frailty screening into surgical clinical workflow. JAMA Netw Open 2019;2e193538. 10.1001/jamanetworkopen.2019.3538. 31074807.

109. Shafiee Hanjani L, Fox S, Hubbard RE, Gordon E, Reid N, Hilmer SN, et al. Frailty knowledge, training and barriers to frailty management: a national cross-sectional survey of health professionals in Australia. Australas J Ageing 2024;43:271–80. 10.1111/ajag.13232. 37563782.

110. Dossabhoy SS, Manuel SR, Yawary F, Lahiji-Neary T, Cheng N, Cianfichi L, et al. Implementation of a preoperative frailty screening and optimization pathway for vascular surgery patients is associated with decreased 30-day readmission. J Vasc Surg 2025;81:965–72.e2. 10.1016/j.jvs.2024.11.018. 39581332.

111. Hoogendijk EO, Afilalo J, Ensrud KE, Kowal P, Onder G, Fried LP. Frailty: implications for clinical practice and public health. Lancet 2019;394:1365–75. 10.1016/s0140-6736(19)31786-6. 31609228.

112. Ramsdale E, Kunduru M, Smith L, Culakova E, Shen J, Meng S, et al. Supervised learning applied to classifying fallers versus non-fallers among older adults with cancer. J Geriatr Oncol 2023;14:101498. 10.1016/j.jgo.2023.101498. 37084629.

113. Schwenk M, Howe C, Saleh A, Mohler J, Grewal G, Armstrong D, et al. Frailty and technology: a systematic review of gait analysis in those with frailty. Gerontology 2014;60:79–89. 10.1159/000354211. 23949441.

114. Geraedts HAE, Dijkstra H, Zhang W, Ibarra F, Far IK, Zijlstra W, et al. Effectiveness of an individually tailored home-based exercise rogramme for pre-frail older adults, driven by a tablet application and mobility monitoring: a pilot study. Eur Rev Aging Phys Act 2021;18:10. 10.1186/s11556-021-00264-y. 34154524.

115. Vasquez-Correa JC, Arias-Vergara T, Orozco-Arroyave JR, Eskofier B, Klucken J, Noth E. Multimodal assessment of Parkinson's disease: a deep learning approach. IEEE J Biomed Health Inform 2019;23:1618–30. 10.1109/jbhi.2018.2866873. 30137018.

116. Wilson RL, Vulczak A, Morgans AK, Norris M, Greer J, Votta J, et al. Design of debunking the frailty-sarcopenia-ADT axis in metastatic prostate cancer with multicomponent exercise: the FIERCE trial protocol. Front Sports Act Living 2025;7:1602123. 10.3389/fspor.2025.1602123. 41210271.

117. Merchant RA, Hui RJY, Kwek SC, Sundram M, Tay A, Jayasundram J, et al. Rapid geriatric assessment using mobile app in primary care: prevalence of geriatric syndromes and review of its feasibility. Front Med (Lausanne) 2020;7:261. 10.3389/fmed.2020.00261. 32733901.

118. Olowoyo P, Dhamija RK, Owolabi MO. Telerehabilitation - historical perspectives and conceptual framework in reference to neurological disorders: a narrative review. NeuroRehabilitation 2025;56:5–18. 10.3233/nre-240079. 38995808.

119. D'Amico F, Dormio S, Veronesi G, Guarracino F, Donadello K, Cinnella G, et al. Home-based prehabilitation: a systematic review and meta-analysis of randomised trials. Br J Anaesth 2025;134:1018–28. 10.1016/j.bja.2025.01.010. 39919985.

120. Yap EN, Huang J, Chiu J, Chang RW, Cohn B, Hwang JCF, et al. Development and validation of an EHR-based risk prediction model for geriatric patients undergoing urgent and emergency surgery. BMC Anesthesiol 2025;25:33. 10.1186/s12871-024-02880-4. 39865251.

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	No. of items or categories	Measurement domains or items	Scoring
Fried Frailty Phenotype [22]	5 items	Body weight, grip strength, exhaustion, walking time, expended calories	0–5 (each item = 1 point); 0 (nonfrail), 1–2 (prefrail), ≥ 3 (frail)
FI [29,31]	70 items (multiple domains)	Laboratory findings, physical function and disability, diseases, symptoms, cognitive difficulty, etc.	0–1 (sum of item scores ÷ total number of measured items); < 0.15 (nonfrail), 0.15–0.24 (prefrail), ≥ 0.25 (frail)
CFS [31]	9 categories	Very fit, well, well with treated comorbid disease, apparently vulnerable, mildly frail, moderately frail, severely frail, very severely frail, terminally ill	Single score from 1 (very fit) to 9 (terminally ill); ≥ 5 (frail)
EFS [37]	9 items	Cognition, general health status, functional independence, social support, medication use, nutrition, mood, continence, functional performance	0–17 (items scored on an ordinal scale, typically 0–2 points each; summed to 17); 0–4 (nonfrail), 5–6 (prefrail), 7–8 (mild frailty), 9–10 (moderate frailty), ≥ 11 (severe frailty)
FRAIL scale [38]	5 items	Fatigue, Resistance, Ambulation, Illnesses, Loss of Weight	0–5 (each item = 1 point); 0 (nonfrail), 1–2 (intermediate frailty), ≥ 3 (frail)
mFI-11 [39]	11 items	Nonindependent functional status; history of DM; history of COPD or pneumonia; history of MI; history of PCI, cardiac surgery, or angina; HTN with medication; peripheral vascular disease or rest pain; impaired sensorium; TIA or CVA without residual deficit; CVA with deficit	0–1 (each item = 1 point); score = sum of item scores ÷ 11; ≥ 0.27 or ≥ 3 items (frail)
mFI-5 [41]	5 items	CHF; DM; COPD or recent pneumonia; partially or fully dependent functional status at the time of surgery; HTN with medication	0–5 (each item = 1 point); 0 (nonfrail), 1 (prefrail), ≥ 2 (frail)
GFST [45]	8 items	Social isolation, unintentional weight loss, fatigue, mobility problems, memory problems, slow gait, clinician’s judgment regarding frailty, and recent hospital visit	No cutoff score; frailty is determined by clinician judgment
TFI [47]	15 items (3 domains)	Physical domain: 8 items (physical health, weight loss, difficulty walking, balance, hearing, vision, hand strength, physical tiredness); psychological domain: 4 items (memory problems, feeling down, feeling nervous or anxious, difficulty coping with problems); social domain: 3 items (living alone, lack of social relations, lack of social support)	0–15 (each item = 1 point); ≥ 5 (frail)
GFI [48]	15 items (4 domains)	Physical domain: 9 items (shopping, walking outside, dressing and undressing, toileting, perceived physical fitness, hearing problems, vision problems, weight loss, medication); cognitive domain: 1 item (memory problems); social domain: 3 items (social network, attention from others, help from others); psychological domain: 2 items (calm and relaxed, nervous or downhearted)	0–15 (each item = 1 point); ≥ 4 (frail)
PRISMA-7 [49]	7 items	Age, sex, disability, dependence, homebound status, support, mobility	0–7 (each item = 1 point); ≥ 3 (frail)
G-8 [51]	8 items	Food intake, weight loss, BMI, mobility, neuropsychological problems, medications, self-perceived health status compared with peers of the same age, age category	0–17 (items scored on an ordinal scale, typically 0–2 or 0–3 points each); higher scores indicate better health status (less frailty); ≤ 14 (possible frailty; further evaluation needed)
SPPB [53]	5 items (3 domains)	Static balance (side-by-side stand, semi-tandem stand, tandem stand); gait speed (time to walk 4 m at usual pace); chair-stand test (time to complete five sit-to-stand cycles without arm support)	0–12 (each domain scored 0–4); ≤ 6 (frail)