According to a new study published Wednesday in JAMA Surgery, frailty may lead to a much greater risk of fatality in the first year after a elective surgery.

The study authors, examining 202,811 Canadian elderly patients who underwent noncardiac optional procedures, found that 13.6 percent of those judged to be frail died within 12 months, compared to only 4.8 percent of their non-frail counterparts. This increased risk was especially profound in the first three days following surgery, with frail patients being 35 times more likely to die during that time period than everyone else. More specifically, the highest increased mortality risks were found in people who underwent joint replacements involving the knee and hip as well as those younger.

“In this study of 1-year postoperative mortality, frailty was consistently associated with an increased risk of death,” concluded the authors.

Surprisingly, the concept of what makes someone frail isn’t scientifically concrete, with various measures that only partly agree with one another, though it’s already known that people are much more likely to become frail as they become older and that frailty is associated with premature death. That’s made it difficult for researchers to figure out how frailty exactly influences survival outcomes after surgery. Likewise, studies looking at the question are often short-lived, only focusing on the first 30 days after surgery.

For that latter reason, the researchers decided to cast a broader net, collecting ten years worth of anonymous data from Ontario, Canada’s publicly funded health care system (2002-2012). Frailty was defined as having a combination of 12 “frailty-defining diagnoses,” with 3.1 percent of patients (6289 in total) ultimately meeting the criteria.

The largest absolute risk of mortality was seen in people who underwent abdominal or arterial bypass surgery; one of every five frail patients died by year’s end following these surgeries; joint replacements were by far the most popular elective surgery, however. Coupled with their relatively higher risk, the authors suggest that people having these procedures “are a high-priority population for clinicians, administrators, and researchers.”

Unfortunately, because the authors’ measure only determined whether or not someone was frail, and not their degree of frailty, the study can’t tell us if being more frail adds onto someone’s overall mortality risk.

“The association between frailty and postoperative mortality is not surprising; by definition, frail patients are ‘sicker,’ and frailty is associated with early mortality in the general population,” explained the authors. “However, the interaction between frailty and postoperative time suggests that the early postoperative period is a window of markedly increased risk of mortality for frail elderly patients.”

Taken as a whole, the findings indicate doctors should have a frank discussion of the risks and benefits that come with surgical procedures for patients already struggling with their health and that hospital staff should pay particular attention to frail patients in the first few days after surgery. “Finally, while some evidence does support the role of preoperative optimization of frail patients, further efforts are needed to clearly delineate the role of ‘prehabilitation’ in improving the outcomes of frail surgical patients,” the authors added. For what it’s worth, even light exercise has repeatedly been shown to improve the health of the elderly.

While only 3.1 percent of patients were considered frail in this study, an accompanying editorial by Dr. Jason M. Johanning of the Nebraska-Western Iowa VA Medical Center points out that as much as 25 percent of Canadians and 15 percent of Americans over the age of 65 may be frail, indicating the urgency to make doctors and patients aware of these increased risks long before they schedule a surgery.

“Regardless of how frailty is measured, it still paints a picture of the same elephant; dramatically increased risks for postoperative mortality and morbidity,” wrote Johanning. “The elephant is now in our examination room and we, as surgeons, must address the optimal goals of care and honor patients' preferences. Yet the systems we will use and the metrics to ensure success remain to be seen."


McIssac D, Bryson G, Walraven C. Association of Frailty and 1-Year Postoperative Mortality Following Major Elective Noncardiac Surgery. JAMA Surgery. 2016.

Johanning J. Frailty and Mortality After Noncardiac Surgery in Elderly Individuals. JAMA Surgery. 2016.