Table 1.

A multidomain approach to modifying the frailty syndrome in the perioperative setting. Adapted from Dhesi JK, Partridge JSL, Moppett IK. Anaesthesia for the older person. In: Thompson JP, Wiles MD, Moppett IK (eds), Smith and Aitkenhead's textbook of anaesthesia, 7th edn. Elsevier, 2019.

DomainIssueHistory/examinationScreening or diagnostic toolsInvestigationOptimisation
MedicalPostural hypotension with visual hallucinationsHistory of falls.
Reports of slowing, falls, tremor, rigidity etc.
Proactive assessment for non-motor symptoms if Parkinson's disease likely.
Physical examination.
Unified Parkinson's disease rating scale.DaTSCAN.
Cerebral imaging with computed tomography or magnetic resonance imaging (does not necessarily need to be preoperative).
In established cases, proactive plan around medications including timings and alternative drugs or routes of administration when nil by mouth.
Pre-emptive advice to ward teams about non-motor complications likely at time of surgery (constipation, delirium or falls).
In newly identified cases, consider starting medications preoperatively versus outpatient follow-up based on symptoms and urgency of surgery.
Exertional dyspnoea and daily coughSmoking history but no prior known chronic lung disease.
History of symptoms of chronic obstructive pulmonary disease.
Medical research council breathlessness scale.
6-minute walk test.
Smoking cessation advice.
Flu vaccination.
Inhaled therapy according to NICE / British Thoracic Society guidelines.
Pulmonary rehabilitation according to local guidelines.
Geriatric syndromesFallsPrevious history.
History of ‘near misses’, suggestive underlying causes and injuries sustained.
Bone health screening.
Gait speed.
Timed up and go.
Fracture risk assessment tool.
Bone profile and vitamin D.
Suggestion to GP about DEXA and follow-up.
Medical management of bone health (eg bisphosphate and calcium-vitamin D supplementation).
Medical falls review.
Strength and balance training.
Cognitive impairmentSelf-reported history of cognitive issues.
Collateral history from relative/carer.
Cerebral imaging or recommendation to GP for this.Delirium risk assessment and optimisation eg cessation of anticholinergic medications, ensuring normal electrolytes and treating constipation.
Signposting to standardised postoperative management of delirium.
Communication with patient and relatives.
Long-term vascular risk factor management.
Referral to memory services for long-term follow-up.
PsychologicalAnxiety and depressionSelf-reported history.
Collateral from family/carer.
Hospital anxiety and depression score.Thyroid function tests.
Exclusion of cognitive impairment.
Referral for psychological support (talking services).
Consider pharmacological treatment.
Explanation or counselling regarding surgery if this is prominent trigger for symptoms.
Functional and socialFunctional dependencySelf-reported concerns.
Collateral from family/carer.
Assessment of underlying cause.
Nottingham extended activities of daily living.
Physical examination and investigation of pathology causing disability eg proximal myopathy secondary to vitamin D deficiency.
Prescribe analgesia for osteoarthritis.
Preoperative physiotherapy.
Occupational therapy intervention (eg home adaptations).
Social worker intervention to proactively identify barriers to discharge.
Proactive communication regarding anticipated length of stay and access to rehabilitation or care at discharge.
Non-adherence to prescribed medicationsSelf or family reported concerns.
Clinical evidence of non-adherence.
Assessment of understanding of medications.
STOPP/START.Assessment of cognition and understanding of medications.Liaising with community pharmacist to assist with dosette box and with care services or telecare to prompt medication.
  • 4AT = four 'A's test; CXR = chest X-ray; DaTscan = dopamine transporter single photon emission computed tomography; DEXA = dual-energy X-ray absorptiometry; GP = general practitioner; MoCA = Montreal cognitive assessment; NICE = National Institute for Health and Care Excellence; START = screening tool to alert doctors to right treatments; STOPP = screening tool of older people's potentially inappropriate prescriptions.