Frailty in over-90s after elective surgery: the risk shows after ICU

Design

Retrospective binational registry cohort, propensity matched

Population

5,398 patients aged ≥90 admitted to ICU after elective surgery

Primary outcome

One-year all-cause mortality

Effect

HR 1.66 (95% CI 1.47 to 1.87) for frail vs non-frail

Using the Australian and New Zealand Intensive Care Society database, researchers matched 2,699 frail and 2,699 non-frail patients aged 90 or over who were admitted to intensive care after elective surgery. Frailty was scored on the Clinical Frailty Scale at ICU admission, with 5 to 8 counted as frail.

ICU mortality was low and similar in both groups. But frailty was associated with higher in-hospital mortality (HR 1.66, 95% CI 1.22 to 2.27) and higher one-year mortality (HR 1.66, 95% CI 1.47 to 1.87). Non-frail patients were more likely to return to their previous home. Frail patients stayed longer and had more delirium and acute kidney injury.

The lesson is that a smooth ICU stay can mislead. In the very old, frailty shapes what happens on the ward and in the year afterwards. The study is observational and frailty was scored after surgery, so it describes risk rather than showing what changing management would achieve.

A Clinical Frailty Scale score belongs in the preoperative assessment of every nonagenarian, and in the conversation with patient and family about what recovery is likely to look like.

• Record a Clinical Frailty Scale score before elective surgery in patients aged 90 or over
• Discuss one-year survival and the chance of returning home, not just operative risk
• Plan delirium prevention and kidney protection for frail patients
• Involve geriatric medicine early where frailty is present
• A low ICU mortality does not mean a low overall risk in this group

Why it matters

It shows frailty predicts the longer course even when the ICU stay goes well.

Don't overread it

This is observational; it does not show that frailty-guided changes in care improve survival.

The statistics, in plain English

A hazard ratio of 1.66 means frail patients died at about two-thirds higher rate over the year than matched non-frail patients. Matching balanced measured factors, but unmeasured differences could still contribute.

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