Advice for Combating Frailty's Fatal Impact in Liver Disease

Rowen K. Zetterman, MD


January 22, 2018

How Frailty Amplifies Postoperative Risk

Frailty is frequently observed in older adults.[1] Different from disability per se, frailty is associated with low physiologic reserve related to age and underlying chronic disease.[2] It is seen in patients with unintentional weight loss, documented muscle weakness, reduced speed of walking, low physical activity, and a sense of easy exhaustion.[1] Frailty occurs in approximately 7% of adults older than 65 years and increases the risk for early mortality compared with elderly patients who lack measurable frailty.

Frailty is associated with increased vulnerability in clinical response to acute healthcare events and increased surgical morbidity after common ambulatory or 23-hour-stay surgical operations (eg, hernia repair or breast, thyroid, or parathyroid surgery), and it is independent of patient age alone.[2] As frailty progresses, there is an even greater risk for postsurgical complications. One study of frail patients undergoing elective surgery identified it as an independent predictor of postoperative complications resulting in longer postsurgical hospital stays and more dismissals to skilled nursing facilities for postprocedure rehabilitation.[3] Even a procedure as seemingly simple as tracheostomy is associated with greater mortality in such patients.[4]

There is a need to recognize, measure, and reverse frailty before elective surgical procedures. Recognition of preoperative frailty can reduce postoperative mortality after careful preoperative assessment and optimization of perioperative care.[5]

Diagnosing Frailty in Patients With Cirrhosis

Frailty also increases the risk for morbidity and mortality in patients with chronic liver disease.[6,7] Sarcopenia (loss of muscle mass) and frailty may not directly correlate with the clinical severity of liver disease, and must be carefully sought to establish the diagnosis.[6]

Using observation alone to diagnose frailty in patients with end-stage liver disease is inadequate, because frailty may not be recognized by clinicians until late in the course of disease or simply be overlooked in well-groomed patients, some women, and those with obesity. Using body mass index as an indicator of malnutrition and frailty can be deceptive, because it fails to consider the functional issues of frailty. Multiple clinical measures of frailty have been published using a combination of findings, such as unintentional weight loss, reduced walking or gait speed, muscle weakness, and evidence of reduced physical activity.[1,2,7,8]

An easy bedside test is needed to assess frailty in patients with cirrhosis, including those awaiting liver transplantation.[9] Even something as simple as determining the reduction in walking speed in patients with cirrhosis can identify those with increased risk for hospitalization and greater cost of healthcare. Dunn and colleagues[10] reported that for each 0.10-m/sec reduction in speed of walking, there is a 22% increase in number of hospitalization days in frail patients with cirrhosis.

The Clinical Frailty Scale (CFS) is a bedside measure of frailty in elderly patients,[11] as defined by their clinical level of physical activity, severity of underlying medical problems, need for assistance in independent activities of daily living (ADL), dependency on others for personal care, or terminally ill status. In an assessment of the CFS in an elderly population,[12] those with a CFS score greater than 4 (ie, ranging from "with limited dependence on others for ADL" to "completely dependent on others for ADL") had a greater likelihood of unplanned hospitalization and death. A modification of the scale defines an increased risk for hospitalization or death in patients with end-stage liver disease.[13] The mildly frail patient with cirrhosis (CFS 5) with a slowing gait that reduces their ability to walk outside alone, coupled with the need for help in the usual independent ADL, identifies patients at greater risk for unplanned hospitalization or death.

Other indices can also be used to assess morbidity and mortality in frail cirrhotic patients. These include pairing of the frailty index with the Model for End-stage Liver Disease-Sodium score,[14] assessment of ADL or use of the Braden Scale,[7] and use of the Fried Frailty Index.[15]


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