Importance of Frailty Measurement in Oncological Surgery: A Review of Preoperative-Frailty Assessment Tools
Main Article Content
Abstract
With the rising number of an aging population, the importance of frailty’s impact on perioperative outcomes is increasingly being recognized in the surgical community. Frailty is particularly prevalent in patients undergoing treatment for cancer. In this review article, we seek to summarize the relationship between frailty and oncological surgery and review the preoperative frailty assessment tools available for the practitioner. Due to its predictive value, frailty assessment should be applied within daily clinical practice for those patients undergoing oncological surgery. The choice of a frailty measurement tool seems to be both adaptable and circumstantial. Factors to consider when choosing a frailty measurement tool should include time constraint, patient population, clinical circumstance, resource availability, patient mobility, presence of a self-assessment option, and the statistical requirements/support available for each test. With improved recognition of the diagnosis of frailty, physicians can turn to early interventions aimed at limiting frailty-associated adverse outcomes.
Keywords:
Frailty, Frailty Measurement, Postoperative Outcomes
Article Details
How to Cite
CARROLL, Hayley M.; SCHWARTZ, Justin; KWON, Sung.
Importance of Frailty Measurement in Oncological Surgery: A Review of Preoperative-Frailty Assessment Tools.
Medical Research Archives, [S.l.], v. 10, n. 2, feb. 2022.
ISSN 2375-1924.
Available at: <https://esmed.org/MRA/mra/article/view/2668>. Date accessed: 04 dec. 2024.
doi: https://doi.org/10.18103/mra.v10i2.2668.
Section
Review Articles
The Medical Research Archives grants authors the right to publish and reproduce the unrevised contribution in whole or in part at any time and in any form for any scholarly non-commercial purpose with the condition that all publications of the contribution include a full citation to the journal as published by the Medical Research Archives.
References
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4. Song X, Mitnitski A, Rockwood K. Prevalence and 10-Year Outcomes of Frailty in Older Adults in Relation to Deficit Accumulation: FRAILTY PREVALENCE AND OUTCOME. J Am Geriatr Soc. 2010;58(4):681-687. doi:10.1111/j.1532-5415.2010.02764.x
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7. Dai S, Yang M, Song J, Dai S, Wu J. Impacts of Frailty on Prognosis in Lung Cancer Patients: A Systematic Review and Meta-Analysis. Front Med. 2021;8:715513. doi:10.3389/fmed.2021.715513
8. Williams GR, Deal AM, Sanoff HK, et al. Frailty and health-related quality of life in older women with breast cancer. Support Care Cancer. 2019;27(7):2693-2698. doi:10.1007/s00520-018-4558-6
9. Ness KK, Wogksch MD. Frailty and aging in cancer survivors. Transl Res. 2020;221:65-82. doi:10.1016/j.trsl.2020.03.013
10. Panayi AC, Orkaby AR, Sakthivel D, et al. Impact of frailty on outcomes in surgical patients: A systematic review and meta-analysis. Am J Surg. 2019;218(2):393-400. doi:10.1016/j.amjsurg.2018.11.020
11. Courtney-Brooks M, Tellawi AR, Scalici J, et al. Frailty: An outcome predictor for elderly gynecologic oncology patients. Gynecol Oncol. 2012;126(1):20-24. doi:10.1016/j.ygyno.2012.04.019
12. Kristjansson SR, Rønning B, Hurria A, et al. A comparison of two pre-operative frailty measures in older surgical cancer patients. J Geriatr Oncol. 2012;3(1):1-7. doi:10.1016/j.jgo.2011.09.002
13. Shen Y, Hao Q, Zhou J, Dong B. The impact of frailty and sarcopenia on postoperative outcomes in older patients undergoing gastrectomy surgery: a systematic review and meta-analysis. BMC Geriatr. 2017;17(1):188. doi:10.1186/s12877-017-0569-2
14. Artiles-Armas M, Roque-Castellano C, Fariña-Castro R, Conde-Martel A, Acosta-Mérida MA, Marchena-Gómez J. Impact of frailty on 5-year survival in patients older than 70 years undergoing colorectal surgery for cancer. World J Surg Oncol. 2021;19(1):106. doi:10.1186/s12957-021-02221-6
15. Leng S, Chen X, Mao G. Frailty syndrome: an overview. Clin Interv Aging. Published online March 2014:433. doi:10.2147/CIA.S45300
16. Morley JE, Vellas B, Abellan van Kan G, et al. Frailty Consensus: A Call to Action. J Am Med Dir Assoc. 2013;14(6):392-397. doi:10.1016/j.jamda.2013.03.022
17. Pritchard JM, Kennedy CC, Karampatos S, et al. Measuring frailty in clinical practice: a comparison of physical frailty assessment methods in a geriatric out-patient clinic. BMC Geriatr. 2017;17(1):264. doi:10.1186/s12877-017-0623-0
18. Xue QL. The Frailty Syndrome: Definition and Natural History. Clin Geriatr Med. 2011;27(1):1-15. doi:10.1016/j.cger.2010.08.009
19. Shahrokni A, Tin A, Alexander K, et al. Development and Evaluation of a New Frailty Index for Older Surgical Patients With Cancer. JAMA Netw Open. 2019;2(5):e193545. doi:10.1001/jamanetworkopen.2019.3545
20. de Vries NM, Staal JB, van Ravensberg CD, Hobbelen JSM, Olde Rikkert MGM, Nijhuis-van der Sanden MWG. Outcome instruments to measure frailty: A systematic review. Ageing Res Rev. 2011;10(1):104-114. doi:10.1016/j.arr.2010.09.001
21. Pangilinan J, Quanstrom K, Bridge M, Walter LC, Finlayson E, Suskind AM. The Timed Up and Go Test as a Measure of Frailty in Urologic Practice. Urology. 2017;106:32-38. doi:10.1016/j.urology.2017.03.054
22. Podsiadlo D, Richardson S. The Timed “Up & Go”: A Test of Basic Functional Mobility for Frail Elderly Persons. J Am Geriatr Soc. 1991;39(2):142-148. doi:10.1111/j.1532-5415.1991.tb01616.x
23. Apóstolo J, Cooke R, Bobrowicz-Campos E, et al. Predicting risk and outcomes for frail older adults: an umbrella review of frailty screening tools. JBI Database Syst Rev Implement Rep. 2017;15(4):1154-1208. doi:10.11124/JBISRIR-2016-003018
24. Kawashima C, Matsuzawa Y, Suzuki H, et al. Optimal Gait Speed Cut-Off Values According to Age and Gender in Predicting Cardiovascular Events in Patients after Acute Myocardial Infarction. Circulation. 2018;130(suppl_2):130.
25. Ibrahim K, Howson FFA, Culliford DJ, Sayer AA, Roberts HC. The feasibility of assessing frailty and sarcopenia in hospitalised older people: a comparison of commonly used tools. BMC Geriatr. 2019;19(1):42. doi:10.1186/s12877-019-1053-y
26. Santilli V. Clinical definition of sarcopenia. Clin Cases Miner Bone Metab. Published online 2014. doi:10.11138/ccmbm/2014.11.3.177
27. Bohannon RW. Grip Strength: An Indispensable Biomarker For Older Adults. Clin Interv Aging. 2019;Volume 14:1681-1691. doi:10.2147/CIA.S194543
28. Castell MV, Sánchez M, Julián R, Queipo R, Martín S, Otero Á. Frailty prevalence and slow walking speed in persons age 65 and older: implications for primary care. BMC Fam Pract. 2013;14(1):86. doi:10.1186/1471-2296-14-86
29. Fried LP, Tangen CM, Walston J, et al. Frailty in Older Adults: Evidence for a Phenotype. J Gerontol A Biol Sci Med Sci. 2001;56(3):M146-M157. doi:10.1093/gerona/56.3.M146
30. Szewieczek J, Bieniek J, Wilczyński K. Fried frailty phenotype assessment components as applied to geriatric inpatients. Clin Interv Aging. Published online April 2016:453. doi:10.2147/CIA.S101369
31. Cesari M, Gambassi G, Abellan van Kan G, Vellas B. The frailty phenotype and the frailty index: different instruments for different purposes. Age Ageing. 2014;43(1):10-12. doi:10.1093/ageing/aft160
32. Han B, Li Q, Chen X. Effects of the frailty phenotype on post-operative complications in older surgical patients: a systematic review and meta-analysis. BMC Geriatr. 2019;19(1):141. doi:10.1186/s12877-019-1153-8
33. Tsiouris A, Hammoud ZT, Velanovich V, Hodari A, Borgi J, Rubinfeld I. A modified frailty index to assess morbidity and mortality after lobectomy. J Surg Res. 2013;183(1):40-46. doi:10.1016/j.jss.2012.11.059
34. Cheung A, Haas B, Ringer TJ, McFarlan A, Wong CL. Canadian Study of Health and Aging Clinical Frailty Scale: Does It Predict Adverse Outcomes among Geriatric Trauma Patients? J Am Coll Surg. 2017;225(5):658-665.e3. doi:10.1016/j.jamcollsurg.2017.08.008
35. Ali R, Schwalb JM, Nerenz DR, Antoine HJ, Rubinfeld I. Use of the modified frailty index to predict 30-day morbidity and mortality from spine surgery. J Neurosurg Spine. 2016;25(4):537-541. doi:10.3171/2015.10.SPINE14582
36. Vermillion SA, Hsu FC, Dorrell RD, Shen P, Clark CJ. Modified frailty index predicts postoperative outcomes in older gastrointestinal cancer patients: mFI in gastrointestinal cancer patients. J Surg Oncol. 2017;115(8):997-1003. doi:10.1002/jso.24617
37. Shahrokni A, Tin A, Alexander K, et al. Memorial Sloan Kettering-Frailty Index (MSK-FI): Validation and its relationship with postoperative outcomes of older survivors of cancer. J Clin Oncol. 2018;36(34_suppl):172-172. doi:10.1200/JCO.2018.36.34_suppl.172
38. Solomon D, Sue Brown A, Brummel-Smith K, et al. Best Paper of the 1980s: National Institutes of Health Consensus Development Conference Statement: Geriatric Assessment Methods for Clinical Decision-Making: NIH CONSENSUS STATEMENT. J Am Geriatr Soc. 2003;51(10):1490-1494. doi:10.1046/j.1532-5415.2003.51471.x
39. Wildiers H, Heeren P, Puts M, et al. International Society of Geriatric Oncology Consensus on Geriatric Assessment in Older Patients With Cancer. J Clin Oncol. 2014;32(24):2595-2603. doi:10.1200/JCO.2013.54.8347
40. Avelino-Silva TJ, Farfel JM, Curiati JA, Amaral JR, Campora F, Jacob-Filho W. Comprehensive geriatric assessment predicts mortality and adverse outcomes in hospitalized older adults. BMC Geriatr. 2014;14(1):129. doi:10.1186/1471-2318-14-129
41. Kellen E, Bulens P, Deckx L, et al. Identifying an accurate pre-screening tool in geriatric oncology. Crit Rev Oncol Hematol. 2010;75(3):243-248. doi:10.1016/j.critrevonc.2009.12.002
42. Hurria A, Gupta S, Zauderer M, et al. Developing a cancer-specific geriatric assessment: A feasibility study. Cancer. 2005;104(9):1998-2005. doi:10.1002/cncr.21422
43. Morley JE, Malmstrom TK, Miller DK. A simple frailty questionnaire (FRAIL) predicts outcomes in middle aged African Americans. J Nutr Health Aging. 2012;16(7):601-608. doi:10.1007/s12603-012-0084-2
44. Robinson TN, Walston JD, Brummel NE, et al. Frailty for Surgeons: Review of a National Institute on Aging Conference on Frailty for Specialists. J Am Coll Surg. 2015;221(6):1083-1092. doi:10.1016/j.jamcollsurg.2015.08.428
45. Shinall MC, Arya S, Youk A, et al. Association of Preoperative Patient Frailty and Operative Stress With Postoperative Mortality. JAMA Surg. 2020;155(1):e194620. doi:10.1001/jamasurg.2019.4620
46. de Vries NM, van Ravensberg CD, Hobbelen JSM, Olde Rikkert MGM, Staal JB, Nijhuis-van der Sanden MWG. Effects of physical exercise therapy on mobility, physical functioning, physical activity and quality of life in community-dwelling older adults with impaired mobility, physical disability and/or multi-morbidity: A meta-analysis. Ageing Res Rev. 2012;11(1):136-149. doi:10.1016/j.arr.2011.11.002
47. Theou O, Stathokostas L, Roland KP, et al. The Effectiveness of Exercise Interventions for the Management of Frailty: A Systematic Review. J Aging Res. 2011;2011:1-19. doi:10.4061/2011/569194
48. Hulzebos EH, Smit Y, Helders PP, van Meeteren NL. Preoperative physical therapy for elective cardiac surgery patients. In: The Cochrane Collaboration, ed. Cochrane Database of Systematic Reviews. John Wiley & Sons, Ltd; 2012:CD010118. doi:10.1002/14651858.CD010118
49. Amrock LG, Deiner S. Perioperative Frailty. Int Anesthesiol Clin. 2014;52(4):26-41. doi:10.1097/AIA.0000000000000026
2. Handforth C, Clegg A, Young C, et al. The prevalence and outcomes of frailty in older cancer patients: a systematic review. Ann Oncol. 2015;26(6):1091-1101. doi:10.1093/annonc/mdu540
3. Lin HS, Watts JN, Peel NM, Hubbard RE. Frailty and post-operative outcomes in older surgical patients: a systematic review. BMC Geriatr. 2016;16(1):157. doi:10.1186/s12877-016-0329-8
4. Song X, Mitnitski A, Rockwood K. Prevalence and 10-Year Outcomes of Frailty in Older Adults in Relation to Deficit Accumulation: FRAILTY PREVALENCE AND OUTCOME. J Am Geriatr Soc. 2010;58(4):681-687. doi:10.1111/j.1532-5415.2010.02764.x
5. Ethun CG, Bilen MA, Jani AB, Maithel SK, Ogan K, Master VA. Frailty and cancer: Implications for oncology surgery, medical oncology, and radiation oncology: Frailty and Cancer. CA Cancer J Clin. 2017;67(5):362-377. doi:10.3322/caac.21406
6. Limpawattana P, Wirasorn K, Sookprasert A, et al. Frailty Syndrome in Biliary Tract Cancer Patients: Prevalence and Associated Factors. Asian Pac J Cancer Prev. 2019;20(5):1497-1501. doi:10.31557/APJCP.2019.20.5.1497
7. Dai S, Yang M, Song J, Dai S, Wu J. Impacts of Frailty on Prognosis in Lung Cancer Patients: A Systematic Review and Meta-Analysis. Front Med. 2021;8:715513. doi:10.3389/fmed.2021.715513
8. Williams GR, Deal AM, Sanoff HK, et al. Frailty and health-related quality of life in older women with breast cancer. Support Care Cancer. 2019;27(7):2693-2698. doi:10.1007/s00520-018-4558-6
9. Ness KK, Wogksch MD. Frailty and aging in cancer survivors. Transl Res. 2020;221:65-82. doi:10.1016/j.trsl.2020.03.013
10. Panayi AC, Orkaby AR, Sakthivel D, et al. Impact of frailty on outcomes in surgical patients: A systematic review and meta-analysis. Am J Surg. 2019;218(2):393-400. doi:10.1016/j.amjsurg.2018.11.020
11. Courtney-Brooks M, Tellawi AR, Scalici J, et al. Frailty: An outcome predictor for elderly gynecologic oncology patients. Gynecol Oncol. 2012;126(1):20-24. doi:10.1016/j.ygyno.2012.04.019
12. Kristjansson SR, Rønning B, Hurria A, et al. A comparison of two pre-operative frailty measures in older surgical cancer patients. J Geriatr Oncol. 2012;3(1):1-7. doi:10.1016/j.jgo.2011.09.002
13. Shen Y, Hao Q, Zhou J, Dong B. The impact of frailty and sarcopenia on postoperative outcomes in older patients undergoing gastrectomy surgery: a systematic review and meta-analysis. BMC Geriatr. 2017;17(1):188. doi:10.1186/s12877-017-0569-2
14. Artiles-Armas M, Roque-Castellano C, Fariña-Castro R, Conde-Martel A, Acosta-Mérida MA, Marchena-Gómez J. Impact of frailty on 5-year survival in patients older than 70 years undergoing colorectal surgery for cancer. World J Surg Oncol. 2021;19(1):106. doi:10.1186/s12957-021-02221-6
15. Leng S, Chen X, Mao G. Frailty syndrome: an overview. Clin Interv Aging. Published online March 2014:433. doi:10.2147/CIA.S45300
16. Morley JE, Vellas B, Abellan van Kan G, et al. Frailty Consensus: A Call to Action. J Am Med Dir Assoc. 2013;14(6):392-397. doi:10.1016/j.jamda.2013.03.022
17. Pritchard JM, Kennedy CC, Karampatos S, et al. Measuring frailty in clinical practice: a comparison of physical frailty assessment methods in a geriatric out-patient clinic. BMC Geriatr. 2017;17(1):264. doi:10.1186/s12877-017-0623-0
18. Xue QL. The Frailty Syndrome: Definition and Natural History. Clin Geriatr Med. 2011;27(1):1-15. doi:10.1016/j.cger.2010.08.009
19. Shahrokni A, Tin A, Alexander K, et al. Development and Evaluation of a New Frailty Index for Older Surgical Patients With Cancer. JAMA Netw Open. 2019;2(5):e193545. doi:10.1001/jamanetworkopen.2019.3545
20. de Vries NM, Staal JB, van Ravensberg CD, Hobbelen JSM, Olde Rikkert MGM, Nijhuis-van der Sanden MWG. Outcome instruments to measure frailty: A systematic review. Ageing Res Rev. 2011;10(1):104-114. doi:10.1016/j.arr.2010.09.001
21. Pangilinan J, Quanstrom K, Bridge M, Walter LC, Finlayson E, Suskind AM. The Timed Up and Go Test as a Measure of Frailty in Urologic Practice. Urology. 2017;106:32-38. doi:10.1016/j.urology.2017.03.054
22. Podsiadlo D, Richardson S. The Timed “Up & Go”: A Test of Basic Functional Mobility for Frail Elderly Persons. J Am Geriatr Soc. 1991;39(2):142-148. doi:10.1111/j.1532-5415.1991.tb01616.x
23. Apóstolo J, Cooke R, Bobrowicz-Campos E, et al. Predicting risk and outcomes for frail older adults: an umbrella review of frailty screening tools. JBI Database Syst Rev Implement Rep. 2017;15(4):1154-1208. doi:10.11124/JBISRIR-2016-003018
24. Kawashima C, Matsuzawa Y, Suzuki H, et al. Optimal Gait Speed Cut-Off Values According to Age and Gender in Predicting Cardiovascular Events in Patients after Acute Myocardial Infarction. Circulation. 2018;130(suppl_2):130.
25. Ibrahim K, Howson FFA, Culliford DJ, Sayer AA, Roberts HC. The feasibility of assessing frailty and sarcopenia in hospitalised older people: a comparison of commonly used tools. BMC Geriatr. 2019;19(1):42. doi:10.1186/s12877-019-1053-y
26. Santilli V. Clinical definition of sarcopenia. Clin Cases Miner Bone Metab. Published online 2014. doi:10.11138/ccmbm/2014.11.3.177
27. Bohannon RW. Grip Strength: An Indispensable Biomarker For Older Adults. Clin Interv Aging. 2019;Volume 14:1681-1691. doi:10.2147/CIA.S194543
28. Castell MV, Sánchez M, Julián R, Queipo R, Martín S, Otero Á. Frailty prevalence and slow walking speed in persons age 65 and older: implications for primary care. BMC Fam Pract. 2013;14(1):86. doi:10.1186/1471-2296-14-86
29. Fried LP, Tangen CM, Walston J, et al. Frailty in Older Adults: Evidence for a Phenotype. J Gerontol A Biol Sci Med Sci. 2001;56(3):M146-M157. doi:10.1093/gerona/56.3.M146
30. Szewieczek J, Bieniek J, Wilczyński K. Fried frailty phenotype assessment components as applied to geriatric inpatients. Clin Interv Aging. Published online April 2016:453. doi:10.2147/CIA.S101369
31. Cesari M, Gambassi G, Abellan van Kan G, Vellas B. The frailty phenotype and the frailty index: different instruments for different purposes. Age Ageing. 2014;43(1):10-12. doi:10.1093/ageing/aft160
32. Han B, Li Q, Chen X. Effects of the frailty phenotype on post-operative complications in older surgical patients: a systematic review and meta-analysis. BMC Geriatr. 2019;19(1):141. doi:10.1186/s12877-019-1153-8
33. Tsiouris A, Hammoud ZT, Velanovich V, Hodari A, Borgi J, Rubinfeld I. A modified frailty index to assess morbidity and mortality after lobectomy. J Surg Res. 2013;183(1):40-46. doi:10.1016/j.jss.2012.11.059
34. Cheung A, Haas B, Ringer TJ, McFarlan A, Wong CL. Canadian Study of Health and Aging Clinical Frailty Scale: Does It Predict Adverse Outcomes among Geriatric Trauma Patients? J Am Coll Surg. 2017;225(5):658-665.e3. doi:10.1016/j.jamcollsurg.2017.08.008
35. Ali R, Schwalb JM, Nerenz DR, Antoine HJ, Rubinfeld I. Use of the modified frailty index to predict 30-day morbidity and mortality from spine surgery. J Neurosurg Spine. 2016;25(4):537-541. doi:10.3171/2015.10.SPINE14582
36. Vermillion SA, Hsu FC, Dorrell RD, Shen P, Clark CJ. Modified frailty index predicts postoperative outcomes in older gastrointestinal cancer patients: mFI in gastrointestinal cancer patients. J Surg Oncol. 2017;115(8):997-1003. doi:10.1002/jso.24617
37. Shahrokni A, Tin A, Alexander K, et al. Memorial Sloan Kettering-Frailty Index (MSK-FI): Validation and its relationship with postoperative outcomes of older survivors of cancer. J Clin Oncol. 2018;36(34_suppl):172-172. doi:10.1200/JCO.2018.36.34_suppl.172
38. Solomon D, Sue Brown A, Brummel-Smith K, et al. Best Paper of the 1980s: National Institutes of Health Consensus Development Conference Statement: Geriatric Assessment Methods for Clinical Decision-Making: NIH CONSENSUS STATEMENT. J Am Geriatr Soc. 2003;51(10):1490-1494. doi:10.1046/j.1532-5415.2003.51471.x
39. Wildiers H, Heeren P, Puts M, et al. International Society of Geriatric Oncology Consensus on Geriatric Assessment in Older Patients With Cancer. J Clin Oncol. 2014;32(24):2595-2603. doi:10.1200/JCO.2013.54.8347
40. Avelino-Silva TJ, Farfel JM, Curiati JA, Amaral JR, Campora F, Jacob-Filho W. Comprehensive geriatric assessment predicts mortality and adverse outcomes in hospitalized older adults. BMC Geriatr. 2014;14(1):129. doi:10.1186/1471-2318-14-129
41. Kellen E, Bulens P, Deckx L, et al. Identifying an accurate pre-screening tool in geriatric oncology. Crit Rev Oncol Hematol. 2010;75(3):243-248. doi:10.1016/j.critrevonc.2009.12.002
42. Hurria A, Gupta S, Zauderer M, et al. Developing a cancer-specific geriatric assessment: A feasibility study. Cancer. 2005;104(9):1998-2005. doi:10.1002/cncr.21422
43. Morley JE, Malmstrom TK, Miller DK. A simple frailty questionnaire (FRAIL) predicts outcomes in middle aged African Americans. J Nutr Health Aging. 2012;16(7):601-608. doi:10.1007/s12603-012-0084-2
44. Robinson TN, Walston JD, Brummel NE, et al. Frailty for Surgeons: Review of a National Institute on Aging Conference on Frailty for Specialists. J Am Coll Surg. 2015;221(6):1083-1092. doi:10.1016/j.jamcollsurg.2015.08.428
45. Shinall MC, Arya S, Youk A, et al. Association of Preoperative Patient Frailty and Operative Stress With Postoperative Mortality. JAMA Surg. 2020;155(1):e194620. doi:10.1001/jamasurg.2019.4620
46. de Vries NM, van Ravensberg CD, Hobbelen JSM, Olde Rikkert MGM, Staal JB, Nijhuis-van der Sanden MWG. Effects of physical exercise therapy on mobility, physical functioning, physical activity and quality of life in community-dwelling older adults with impaired mobility, physical disability and/or multi-morbidity: A meta-analysis. Ageing Res Rev. 2012;11(1):136-149. doi:10.1016/j.arr.2011.11.002
47. Theou O, Stathokostas L, Roland KP, et al. The Effectiveness of Exercise Interventions for the Management of Frailty: A Systematic Review. J Aging Res. 2011;2011:1-19. doi:10.4061/2011/569194
48. Hulzebos EH, Smit Y, Helders PP, van Meeteren NL. Preoperative physical therapy for elective cardiac surgery patients. In: The Cochrane Collaboration, ed. Cochrane Database of Systematic Reviews. John Wiley & Sons, Ltd; 2012:CD010118. doi:10.1002/14651858.CD010118
49. Amrock LG, Deiner S. Perioperative Frailty. Int Anesthesiol Clin. 2014;52(4):26-41. doi:10.1097/AIA.0000000000000026