Author: Angie Stewart
Becker’s ASC Review
Lee A. Fleisher, MD, is chair of Philadelphia-based University of Pennsylvania Perelman School of Medicine’s anesthesia and critical care departments. Dr. Fleisher is also chair of the American Society of Anesthesiologists Perioperative Brain Health Initiative.
Here, Dr. Fleisher shares his insights with Becker’s ASC Review on preoperative frailty assessments in the outpatient setting.
Question: Why is it important that ASC physicians conduct preoperative frailty assessment?
LF: There is increasing evidence that frailty may be the best predictor of how patients will do after surgery. It integrates a lot of other information and may be a better predictor of how someone is doing functionally. The METS trial (Lancet, 2019) demonstrated that anesthesiologists’ prediction of exercise tolerance is very poor, so a more objective measure may be more predictive.
Q: Which specialties or patient groups are most in need of preoperative frailty assessments?
LF: The appropriateness and evaluation of surgery depends upon the surgery and patient comorbidity. For more invasive surgery, the appropriateness of having surgery performed on an outpatient basis may be less ideal because of the risks of going home and being readmitted or making sure that there are caregivers available at home. Specific populations include the elderly, particularly with cardiovascular or pulmonary disease as well as cognitive impairment. Older patients should be screened, with an ideal age at 65 or 70, depending upon the population.
Q: What types of pre-existing cognitive impairments put patients at high risk of delirium after surgery?
LF: Any type of mild cognitive impairment puts patients at risk. Work by Debra Culley, MD, at [Boston-based Brigham and Women’s Hospital] represents the best evidence to show that a poor score on the mini-cog was a strong predictor.
Q: How should ASC physicians incorporate preoperative frailty assessments into their practice? What may be holding them back?
LF: There is no clear best way to assess frailty since it has mainly been assessed in research studies. Incorporating the mini-cog can be done today.
Q: What else do you want surgery center anesthesiologists know?
LF: [I want them to know] that it may be appropriate to perform surgery for older adults with mild cognitive impairment, but caregivers should be warned about the signs or symptoms of delirium and delayed cognitive recovery. This should include both hyper- and hypomanic delirium.