Search strategy

We searched seven electronic databases (Medline, CINAHL, The Cochrane Library, AMED, PSYCINFO, EMBASE and Web of Science) for manuscripts published from 1 January 1980 to 31 December 2022. All identified and relevant studies’ references were manually reviewed to identify any potential studies that met the inclusion criteria. The search terms were based on MeSH terms (Medical Subject Headings) and other controlled vocabulary. Search terms relating to surgery, frailty and risk factors were used.

Eligibility criteria and study identification

Randomized controlled trials, cohort studies and case–control study designs were eligible for inclusion. Only studies using a validated method of frailty identification were included [14]. Studies based solely in intensive care were excluded since these populations are atypical and could introduce additional confounders. No language restrictions were applied.

Data extraction and quality assessment

Demographics, frailty tools, frailty prevalence and outcomes data were extracted from the included studies. Prospective, randomized controlled trials and meta-analyses were given preference in developing these guidelines. The final grade of recommendation was performed using the Grades of Recommendation, Assessment, Development, and Evaluation system.

Recommendations 1a.

All patients being considered for, or undergoing emergency laparotomy aged 65 years or more, should undergo a routine frailty screening, e.g., Clinical Frailty Scale. Grade of recommendation: strong recommendation based on high-quality evidence, 1A.

1b.

Vulnerable patients identified via the screening should receive a Comprehensive Geriatric Assessment (CGA) ideally upon admission, if not within 72 h of admission to a ward or step down from critical care to a ward. Grade of recommendation: strong recommendation based on high-quality evidence, 1A.

There are many frailty screening tools available. We recommend using a simple screening tool such as the Clinical Frailty Scale [9] which has been validated for use in patients. While CGA is the gold standard, this can be very time-consuming and inappropriate, especially if resources are limited or if the patient is very sick, hence a screening tool is a preferred choice upfront. [15].

A consensus group, consisting of 6-major international, European, and US societies, recommended administering routine frailty screening in all older people aged 70 years or older [16].

In the area of surgery, frailty is an independent risk factor for mortality, morbidity, length of stay, and postoperative complication [17, 18]. This has been well validated in the study of hip fractures, where frailty has been shown to be significantly associated with adverse outcome including mortality and length of hospital stay [19].

In the realm of trauma, a 15-item trauma-specific frailty index (TSFI) was validated from various centers. This TSFI, which consists of comorbidities, daily activities, health attitudes, sexual function, and nutrition domains, can also be assessed by the caregiver. It is an independent predictor of unfavorable discharge if greater than 0.27 [20].

The Guidelines from American College of Surgeons for Surgery and National Institute for Health and Care Excellence has emphasized frailty assessment in acute care settings or preoperative period as a new screening criterion for fitness [10, 19]. The 15-variable Emergency general surgery specific frailty index (EGSFI) was validated in a prospective cohort [21]. The EGSFI-based frailty status significantly predicted postoperative complications (odd ratio, 7.3; 95% confidence interval, 1.7–19.8), but age was not a relevant factor.

Similarly, the Emergency Laparotomy and Frailty [ELF] study showed an association between frailty and 90-day mortality (clinical frailty scale 5, OR 3.18, 95% CI 1.24–8.14), increased risk of complications and length of hospital stay in older emergency laparotomy patients [22].

One of the most important and scarce studies in the field of emergency laparotomy and frailty is the NELA audit [23]. The NELA audit [23] acknowledged that there are multiple frailty tools [24]. The audit adopted the Clinical Frailty Score and found it be prevalent in 11% of people over 65 years, rising to 50% in those over 85 years of age [23]. This score can also be applied to the younger surgical populations [25]. Therefore, the NELA proposed that the Clinical Frailty Score was the most appropriate screening tool for patients undergoing emergency laparotomy.

After screening the patients, the NELA audit utilized a cut off for Clinical Frailty Score of ≥ 5 (or aged ≥ 80 years with any frailty score), to identify patients who should receive geriatrician-led multidisciplinary comprehensive geriatric assessment (CGA) ideally upon admission, if not within 72 h of admission to a ward or step down from critical care to a ward [23].

The CGA has emerging evidence when applied to both elective and emergency older surgical populations [24,25,26,27,28,29,30,31,32,33,34,35,36,37]. Older emergency general surgical patients have been shown to benefit from perioperative CGA in terms of reduced mortality [28], LOS [27] and additional diagnoses and/or interventions made [29].

The CGA [30] is considered the benchmark for frailty assessment and generally includes follow-up care such as geriatric-specific optimization interventions [31]. The CGA addresses multidisciplinary components related to patients’ physical, mental, and psychosocial well-being and functional capabilities. However, it may be time-consuming to administer, and a geriatric assessment composed of questionnaires assessing different domains of well-being can often be used instead [32, 33]. Although most CGA studies for abdominal surgery have been performed for the elective setting and in oncology.

Feng et al. [36] performed a systematic review and showed that the CGA predicted surgical outcomes in 1019 patients who underwent a variety of elective oncologic operations. This study showed that dependency in instrumental activities of daily living (IADLs: preparing hot meals, grocery shopping, making telephone calls, taking medicines, and managing money), fatigue, and frailty were significantly associated with overall complications, and that dependency in IADL was predictive of discharge to an institutional setting (i.e., not the patient’s home). Although major complications were more frequent in patients with cognitive impairment and dependency in IADL and activities of daily living (ADL: walking, dressing, bathing, eating, getting into and out of bed, and toileting), age, per se, was not associated with a higher complication rate.

However, there are no studies on CGA when applied to emergency laparotomies in silo. Nevertheless, the depth of literature on CGA and outcomes in general shows that this can be considered. More research into this topic is needed. We also acknowledge that these studies used large databases and retrospective methodology that put more emphasis on the metrics of frailty obtained from a chart review (i.e., comorbidities and reported dependence) than on objective office-based frailty measures (i.e., grip strength and walking time).

Hence, the combination of frailty screening tools and the selective application of CGA is a good strategy. Using such screening tools to assess frailty preoperatively may help patients and their caregivers decide on a personalized treatment plan that aligns with their goals of care.

It is important to note that although studies on frailty and its impact on emergency laparotomy are limited, there are multiple studies on frailty and elective abdominal surgery. A multivariate analysis of a prospective study of 980 patients aged ≥ 75 years undergoing oncologic surgery demonstrated that frailty was associated with 6-month mortality after surgery (OR 1.14 for each unit increase in CGA score; p = 0.01). Interestingly, the ASA Physical Status Classification System Score, a commonly used marker of preoperative functional status, and age, was not associated with 6-month mortality in this study [37].

Similarly, a multivariate logistic regression analysis of 7337 patients from the American College of Surgeons National Surgical Quality Improvement Program (ACSNSQIP) who underwent elective colorectal cancer resection (mean age 65.8 ± 13.6 years) showed that frailty, assessed using an 11-point modified frailty index (m-FI), not age, was independently associated with readmission within a month of surgery (OR 1.4; 95% CI, 1.1–1.8) [38].

Meanwhile, another ACS-NSQIP study of 295,490 patients who underwent colorectal surgery for any indication between 2011 and 2016 showed that frailty, as assessed using a 5-item m-FI, was associated with significantly higher risks of prolonged length of stay (OR 1.24; 95% CI, 1.20–1.27), discharge to an institutional setting (OR 2.80; 95% CI, 2.70–2.90), 30-day serious morbidity (OR 1.39; 95% CI, 1.35–1.43), and mortality (OR 2.00; 95% CI, 1.87–2.14) [39].

2.

Decisions regarding surgery should also consider patients’ degree of frailty rather than chronological age, as surgery may at times, result in poor outcomes. Grade of recommendation: strong recommendation based on high-quality evidence, 1A.

Neither surgeons nor patients have a true understanding about what their likely outcome is after emergency laparotomy surgery, particularly when frail. The recent Emergency Laparotomy in the Frail (or ELF) study had highlighted the deleterious effect of frailty on those who require an emergency laparotomy [22]. In nearly 1,000 consecutive patients aged over 65 years in 49 sites across England, Scotland and Wales, the ELF study showed that the presence of frailty was associated with greater risks of postoperative mortality. Their findings also demonstrated that as the degree of frailty increased, there was a linear increase in mortality.

The NELA audit [23] demonstrated that patients aged 65 years or over have worse clinical outcomes compared to their younger counterparts. These include longer length of hospital stay (median 15.2 days vs 11.3 days) and higher 30-day and 90-day mortality (15.3% vs. 4.9% and 20.4% vs. 7.2%). In addition, there is an association between frailty, which is known to increase with age, and increased 90-day mortality following emergency laparotomy (aOR for patients who were mildly frail and moderately/severely frail was 3.18 and 6.10), 1-year hospital visits (7.2 vs. 2.0) and care level (aOR for an increase in care level was 4·48 for vulnerable patients, 5·94 for those mildly frail and 7·88 for those moderately or severely frail, compared with patients who were fit). In NELA year 4, 6.7% of older patients compared with 1.9% (P < 0.001) of younger patients were discharged to care-home accommodation.

In general for patients who survived surgery, frailty is associated with worse surgical outcomes: increased mortality, prolonged hospital stay, complications and an increased level of social care provision on discharge from hospital [40]. Over 30% of older patients do not return to their own homes after emergency laparotomy surgery [41]. However, data highlighting long-term quality of life following emergency surgery are lacking, and epidemiological studies addressing this neglected area are desperately needed.

The research community are working hard to gather the evidence for the best interventions in this frail group of patients. The recent EPOCH study, a large-scale and well-designed step-wedged randomized controlled study of the implementation of a care pathway, in emergency abdominal surgery, showed no benefit of the intervention [42]. In the future, we may be able to personalize the intervention and better predict outcomes in this patient group.

3.

Treatment plans for frail older adults should align with patients’ goals of care and should be based on a discussion regarding realistic outcomes. Grade of recommendation: strong recommendation based on low-quality evidence, 1C.

When contemplating the care plan for a frail patient, the goals of care should be discussed with the patient, engaged family, caregivers or advocates, and other members of the multidisciplinary team that may include representatives from surgery, geriatrics, palliative care, primary care, oncology, radiation oncology, and so on [43].

Typically, these discussions address domains such as anticipated longevity, functional status, independence, and comfort [44, 45]. In circumstances involving potential surgical intervention, deliberating whether to proceed with surgery should consider the likely treatment outcomes (including curative versus palliative objectives) and patient and family preferences.

A realistic picture should be presented based on the anticipated risks of morbidity, mortality, and cognitive decline for each of the proposed treatment options taking into consideration the patient’s unique presentation, degree of frailty, and functional status [46]. Specifically, patients may value their functional performance and cognitive status more than other treatment-related considerations and, as a result, patients may base their decisions on the likelihood of maintaining a certain level of performance.

Of note, the degree of cognitive decline associated with an individual surgery or anesthetic exposure is unknown. However, the Mayo Clinic performed a 5-year longitudinal study of 1819 patients aged ≥ 70 years and showed that exposure to general anesthesia and surgery was associated with subtle accelerated cognitive decline [47].

On an individual patient basis, it is important to clarify what matters most to patients‚ and online resources are available to facilitate these discussions (e.g., the American.

Geriatrics Society’s Health in Aging Foundation website, https://www.healthinaging.org/age-friendly-healthcareyou/ care-what-matters-most). In practice, it may be helpful to include a geriatrician and/or the patient’s primary care physician in treatment planning discussions. When planning operative treatment, it is helpful to clarify patients’ current living situation and existing support, to communicate goals for postoperative disposition as well as code status, and to have patients designate a surrogate decision-maker. Importantly, clinicians should recognize that patients’ goals of care may change during the perioperative period [42].

In the emergency setting, it may be difficult to have comprehensive goals of care discussions with patients, particularly if they are septic or unstable, have cognitive impairment, or are otherwise unable to have a meaningful discussion. An interdisciplinary, 23-member expert panel recommended a structured communication framework addressing 9 key elements to facilitate decision-making among seriously ill older patients with emergency surgical conditions [48].

The difficulties with having discussions in the setting of emergency circumstances highlight the importance of taking the opportunity to engage patients and their families in early goals of care discussions, especially when patients have multiple comorbidities or a condition that may result in a subsequent emergency (e.g., obstructing colorectal cancer) [49, 50].

4.

Cognitive function should be assessed preoperatively routinely in frail older adults. Grade of recommendation: strong recommendation based on low-quality evidence, 1C.

The prevalence of dementia is estimated to be 5% among 70- to 79-year-olds, 24% among 80- to 89-year-olds, and nearly 40% among people older than 90 years [51]. Meanwhile, mild cognitive impairment (MCI) is distinguished from dementia in that the impairment is not severe enough to interfere with independent function. MCI is common among older adults, even those living independently, and affects up to 50% of patients older than 65 years [52].

Although the American College of Surgeons and the American Geriatrics Society recommend routinely assessing preoperative cognitive function and advocate using cognitive assessment tools such as the Mini-Cog preoperatively to detect MCI [53], the results of studies evaluating an association between MCI and postoperative outcomes such as complications, length of stay, and mortality are mixed and studies have been underpowered [54, 55].

Nonetheless, the most compelling reason to evaluate for cognitive impairment preoperatively is to predict and prepare patients and caregivers for the likelihood of postoperative delirium; preoperative MCI is one of the strongest predictors of postoperative delirium [56]. In patients found to have cognitive impairment, it is advisable, when feasible, to involve a geriatrician and/or psychiatrist and to implement delirium risk reduction interventions such as orientation to staff and surroundings, sleep hygiene, early mobilization, and optimization of vision and hearing [57,58,59].

In addition, decision-making capacity may be diminished in patients with cognitive impairment or dementia, and family members, health-care surrogates, and primary care physicians should be included in the decision-making process in appropriately selected patients [60]. Upon returning home postoperatively, patients with cognitive or memory impairment may benefit from close surveillance from caregivers or home care services.

Culley et al. studied 211 patients who underwent orthopedic surgery using the Mini-Cog‚ which includes a 3-item recall test and a clock-drawing task that tests visuospatial representation, memory, recall, and executive function. In this prospective study, 24% of the patients were identified with preoperative cognitive impairment (Mini-Cog score ≤ 2), which was associated with an increased postoperative incidence of delirium (21% versus 7%; OR 4.52; 95% CI, 1.30–15.68) [61]. Cognitive impairment, again measured using the Mini-Cog, was also observed in 21% of 1003 patients older than 70 years before undergoing major elective oncologic surgery in the prospective, multicenter Geriatric Oncology Surgical Assessment and Functional Recovery after Surgery study [62].

Another method for evaluating preoperative, baseline cognitive function is the 12-item Self-Administered Gerocognitive Examination‚ which detects MCI and early dementia among geriatric patients [63]. Benefits of the Self-Administered Gerocognitive Examination include its digital format‚ which can be administered while patients are in waiting rooms or even at home‚ and its ability to trend serial results over time [64].

5.

Frail older adults should be actively screened for postoperative signs and symptoms of delirium and treated appropriately. Grade of recommendation: strong recommendation based on moderate-quality evidence, 1B.

Delirium, an acute confused state with hallmarks of fluctuating inattention and global cognitive dysfunction, occurs in up to 50% of older adults postoperatively [65] and may remain unrecognized in up to two-thirds of cases [66].

Delirium is associated with functional and cognitive decline, increased morbidity and mortality, longer lengths of stay, higher rates of nursing home placement, and increased health-care costs [67,68,69,70,71,72,73]. Moreover, as complications may present atypically in older adults, clinicians should recognize that postoperative delirium may be an indicator or manifestation of an underlying complication.

Maintaining an appropriate index of suspicion in frail older adults experiencing postoperative delirium and initiating a broad clinical workup under these circumstances may be advised (e.g., evaluating for infections, electrolyte abnormalities, and drug side effects) [74].

The Confusion Assessment Method screens for delirium by evaluating for (1) mental status changes with acute onset and fluctuating severity, (2) inattention, (3) disorganized thinking, and (4) an altered level of consciousness. Using the Confusion Assessment Method, the presence of 1, 2, and either 3 or 4 confirms the diagnosis of delirium [75].

Patients experiencing delirium may benefit from early geriatric or neuropsychiatric specialist consultation to assist with perioperative management as well as multimodal, nonpharmacologic interventions such as cognitive stimulation, early mobilization, preservation of the sleep–wake cycle, and ensuring adequate hydration [58, 59, 71].

Importantly, delirium can be prevented in up to 50% of patients by using a delirium prevention bundle [76]. Watt et al. performed a meta-analysis of 8557 patients older than 60 years who underwent elective orthopedic, cardiac, or abdominal surgery and found a pooled postoperative delirium incidence rate of 18.4% (95% CI, 14.3–23.3). In this study, the strongest predictors of postoperative delirium were a personal history of delirium (OR 6.4; 95% CI, 2.2–17.9), frailty (OR 4.1; 95% CI, 1.4–11.7), and cognitive impairment (OR 2.7; 95% CI, 1.9–3.8). In this study, prognostic factors that could potentially be modified to reduce the incidence of delirium included decreasing the use of psychotropic medications, smoking cessation, and increasing caregiver support [56].

Another intervention shown to decrease the incidence of delirium is avoiding or reducing the use of specific medications such as opioids, benzodiazepines, antihistamines, atropine, sedative hypnotics, and corticosteroids [77].

In 2019, in an effort to reduce adverse drug events in older patients and to decrease the incidence of delirium, the American Geriatric Society updated the Beers Criteria describing potentially inappropriate medication use in patients aged ≥ 65 years and specifically highlighted the detrimental effects related to antipsychotics, benzodiazepines, H2 receptor antagonists, anticholinergics, and meperidine [78].

7.

Frail patients may benefit from a multidisciplinary approach to perioperative care that includes a health care provider with geriatric expertise. The provision of geriatric medicine support should be consultant-led throughout the patient pathway and integrated in the perioperative clinical care pathway. Grade of recommendation: strong recommendation based on low-quality evidence, 1C.

Geriatricians and practitioners with geriatrics expertise have specialized training and experience in assessing and managing geriatric syndromes (e.g., dementia, delirium, propensity for falling, comorbidity, and polypharmacy) and frailty and can improve the perioperative care of patients with these conditions. However, multidisciplinary approaches engaging these providers are commonly underused due to practice patterns and the limited number of available specialists [79].

Additionally, as previously mentioned, access to resources and support may limit the individual practitioner’s ability to engage a multidisciplinary team for the care of these patients. To supplement the work of geriatricians, practices can use other specialists, such as adult/geriatric nurse practitioners, social workers, nurse navigators, pharmacists, dieticians, rehabilitative medicine physicians, physical and occupational therapists, psychologists, and psychiatrists, to complete portions of the geriatric assessment and provide geriatric-related optimization [80].

Shahrokni et al. retrospectively studied the effects of geriatricians comanaging a cohort of 1020 patients who underwent cancer surgery for a variety of cancer types and required at least a 1-day hospital stay and com