Table 1 Study demographics grouped by type of surgery

 Afilalo, J et al. [17]^a

152

USA,

Canada

Mean age 75.9

34 % female

Prospective cohort study

Cardiac surgery

(Elective)

Fried criteria (or Cardiovascular Health Study frailty scale)

Modified CHS frailty scale

Fried + cognitive impairment + depressed mood

4-item MSSA frailty scale

gait speed, handgrip strength, inactivity, cognitive impairment

Gait speed

Composite end point of post-operative mortality or major morbidity

Fried criteria, non-sig

Modified CHS frailty scale, non-sig

4 item MSSA frailty scale, non-sig

Gait speed, OR 2.63 (p < 0.05)

 Green, P et al. [39]^a

244

USA

Median age, %female

- frail 87.1,53 %

- non-frail 85.4,45 %

Post-hoc analysis of PARTNER trial

Transcatheter Aortic Valve Replacement (TAVR)

(Elective)

Fried criteria condensed into 4 domains

gait speed, grip strength, serum albumin, Katz index of ADL

Frail ≥6/12

1) Adverse clinical events at 30 days

2) 1 year mortality

3) Poor outcome (composite mortality & QoL assessed by KCCQ-OS) a) 6 months

b) 1 year

Adjusted for covariates

1) non-sig

2) OR 2.5 (p = 0.0002)

3)

a) OR 2.21 (p = 0.03)

b) OR 2.4 (p = 0.02)

 Green, P. et al. [18]^b

159

USA

Mean age 86

50 % female

Prospective cohort study

Transcatheter aortic valve replacement, (TAVR)

(Elective)

Fried criteria condensed into 4 domains

gait speed, grip strength, serum albumin, Katz index of ADL

Frail >5/12

1) 1 year mortality

2) LOS

3) Procedural outcomes (any of major bleeding event, major vascular complications, stroke, acute kidney injury, 30 day mortality)

Adjusted for covariates

1) OR 3.5 (p = 0.006)

2) 9 vs 6 days (p = 0.004)

3) OR 2.2 (p = 0.04) for major bleeding but not other adverse outcomes

 Kamga, M et al. [19]^b

30

Belgium

Mean age 86

47 % female

Prospective cohort study

TAVI

(Elective)

Score Hospitalier d'Evaluation du Risque de Perte d'Autonomie (SHERPA-risk of functional decline) score

MMSE, age, perceived poor health, fall in the last year, number of iADL independently performed before admission

Identification of Seniors at Risk (ISAR) score

>3 medications, self reported memory problems, sensory problems, hospital admission within the last 6 months, increased need for help at home

1) 1 year mortality

2) Major cardiac and cerebral adverse events (MACCE)

Adjusted for covariates

1) SHERPA HR2.74 for every 1 point increase in score

(p = 0.004)

ISAR non-sig

2) SHERPA non-sig

ISAR non-sig

 Schoenenberger, A.W. et al. [20]^a

119

Switzerland

Mean age 83.4

55.5 % female

Prospective cohort study

TAVI

(Elective)

Mini Mental State Exam, Mini Nutritional Assessment, TUG, BADL, IADL, pre-clinical mobility disability

Frail ≥3

1) Functional decline (BADL ↓ ≥1 point)

2) Functional decline or death among all participants at 6 months

Univariate

1) OR 3.31 (p = 0.02)

2) OR 4.46 (p = 0.001)

 Stortecky, S. et al. [21]^a

100

Switzerland

Mean age 83.7

60 % female

Prospective cohort study

TAVI

(Elective)

Mini Mental State Exam, Mini Nutritional Assessment, TUG, BADL, IADL, pre-clinical mobility disability

Frail ≥3

1) 30 day MACCE

2) 30 day mortality

3) 1 year MACCE

4) 1-year mortality

Univariate analysis

1) OR 4.78 (p = 0.05)

2) OR 8.33 (p = 0.03)

3) OR 4.89 (p = 0.003)

4) OR 3.68 (p = 0.02)

 Sundermann S, et al. [22]^b

400

Germany

Mean age 80.3% female not reported

Prospective cohort study

Cardiac surgery

(Elective)

Comprehensive Assessment of Frailty

Fried minus unintentional weight loss, plus balance assessment, albumin, creatinine, brain natriuretic peptide, FEV1 and Clinical Frailty Scale

moderately frail = 11–25 points

severely frail = 26–35 points

30 day mortality

Severely frail vs non frail

21.7 % vs 3.6 %

AUC = 0.71 on logistic regression

 Sundermann S, et al. [23]^b

213

Germany

Mean age 80.1 % female not reported

Prospective cohort study

Cardiac surgery (Elective)

CAF

FORECAST (Frailty predicts death One year after Elective Cardiac Surgery Tests)

1) 1 year mortality

2) Requirement for resuscitation

3) ICU stay

4) MACCE

1) 1 year mortality

Adjusted for EuroSCORE

1) OR 1.097 (p = 0.001)

AUC 0.70

Frail vs non frail

2) 16 % vs 2 % (p < 0.05)

3) non-sig

4) non-sig

1) FORECAST AUC 0.76

 Sundermann S, et al. [24]^b

450

Germany

Mean age 79

50 % female

Prospective cohort study

Cardiac surgery (Elective)

CAF

FORECAST

chair rise test, subjective weakness on questionnaire, stair climbing, Clinical Frail Scale and serum creatinine.

1 year mortality

Adjusted for age

CAF OR 1.091 (p < 0.001)

FORECAST OR 1.265 (p < 0.001)

 Kristjansson S.R. et al. [25]^a

178

Norway

Mean age 79.63

57 % female

Prospective cohort study

Colorectal cancer surgery

(Elective)

Balducci Frailty Criteria from CGA

Cumulative Illness Rating Scale (CIRS), pADL, iADL, polypharmacy, MNA, MMSE, and GDS

30 day post-operative complications (Clavian-Dindo grading)

Adjusted for covariates

OR 3.13 (95 % CI 1.65–5.92)

 Kristjansson S.R. et al. [26]^a

176

Norway

Mean age 80

57 % female

Prospective longitudinal study

Cancer surgery

(Elective)

Balducci Frailty Criteria from CGA

Modified Fried criteria

30 day mortality

Adjusted for cancer stage and age

Balducci OR 3.39 (p < 0.001)

Modified Fried OR 2.67 (p = 0.029)

 Neuman, H.B. et al. [37]^a

12,979

USA

Mean age 84.4

61.4 % female

Retrospective analysis of Surveillance, Epidemiology and End Results(SEER)-Medicare database

Colectomy for stage I to III colon cancer

(Elective)

11 item frailty measure defined by the John Hopkins Adjusted Clinical Group case-mix system

Difficulty walking, weight loss, frequent falls, malnutrition, impaired vision, decubitus ulcer, incontinence (plus 4 additional unnamed conditions)

Frail ≥1/11

1) 90 day survival

2) 1-year survival

Adjusted for covariates

1) OR 10.4 (p < 0.001)

2) OR 8.4 (p < 0.001)

 Ommundsen, N. et al. [27]^a

178

Norway

Mean age 80

57 % female

Prospective cohort study

Colorectal cancer surgery

(Elective)

Balducci Frailty Criteria from CGA

5 year mortality

Multivariate adjusted for TNM stage and sex

OR 3.6 (p < 0.001)

 Ronning, B. et al. [28]^b

84

Norway

Median age 82

59 % female

Prospective cohort study

Colorectal cancer surgery

(Elective)

Balducci Frailty Criteria from CGA

Post-operative functional status

1) Barthel Index ↓

2) NEADL ↓

3) TUG ↑

4) Grip strength ↓

Logistic regression (95 % CI)

1) non-sig

2) non-sig

3) non-sig

4) non-sig

 Tan, K-Y et al. [29]^b

83

Singapore and Japan

Mean age 81.5 % female not reported

Prospective cohort study

Colorectal cancer

(Elective)

Fried criteria

Postop complications (Clavien-Dindo ≥ II)

Bivariate analysis

OR 4.08 (p = 0.006)

 Hewitt, J. et al. [30]^a

325

UK

Mean age 77.6

57 % female

Prospective cohort study

General surgical patients

(Acute)

- only 31 % underwent surgery

Clinical Frailty Scale

7 frailty levels based on visual observation combined with an abbreviated review of medical records

Frail is ≥5

1) 30 day mortality

2) 90 day mortality

3) LOS

4) 30 day hospital readmission

Adjusted for age and polypharmacy, frail vs non frail

1) non-sig

2) non-sig

3) 19 vs 7 days (p = 0.02)

4) non-sig

 Kenig, J et al. [31]^a

184

Poland

Mean age 76.9

53 % female

Prospective cohort study

Abdominal surgery

(Acute)

Vulnerable Elder Survey (VES)

age, self-rated health, limitation in physical function and functional disabilities

Triage Risk Screening Tool (TRST)

cognitive impairment, difficulty walking/transferring/recent falls, ≥5 medications, ED use in previous 30 days or hospitalization in previous 90 days, lives alone and/or no available caregiver, geriatric syndrome

G8

7 items from the Mini Nutritional Assessment (MNA) questionnaire and age

Groningen Frailty Indicator (GFI)

ADLs, sensory impairment, nutrition, polypharmacy, cognitive impairment, psychosocial wellbeing and subjective physical fitness

Rockwood’s brief clinical instrument to classify frailty (4 frailty levels)

Balducci Frailty Criteria

1) 30 day post-operative complications (Clavian-Dindo grading)

2) 30 day mortality

Adjusted for covariates

1) VES: OR 2.4 (p < 0.05)

TRST: non-sig

G8: OR 1.5 (p < 0.05)

GFI: OR 1.5 (p < 0.05)

Rockwood: non-sig

Balducci: OR 1.7 (p < 0.05)

2) VES: OR 2.4 (p < 0.05)

TRST: non-sig

G8: OR 1.8 (p < 0.05)

GFI: OR 1.4 (p < 0.05)

Rockwood: non-sig

Balducci: OR 1.4 (p < 0.05)

 Kim, S et al. [33]^a

275

Korea

Mean age,% female

- survivors 75.2, 46 %

- deceased 77.6, 32 %

Prospective cohort study

Intermediate or high risk general surgery

(Elective)

Multidimensional Frailty Score (MFS)

Malignant disease, Charleston comorbidity Index, Albumin, ADLs, IADLs, dementia, risk of delirium, malnutrition, mid-arm circumference

Low risk ≤5

High risk >5

1) 1 year mortality

2) Discharge to residential care

3) Postoperative complications

4) LOS (median)

Adjusted for covariates, for every 1 point increase in MFS

1) OR 2.05 (p < 0.001)

2) OR 1.42 (p = 0.01)

3) non-sig

4) 14 vs 9 days for high vs low risk group (p < 0.001)

 Ambler, G.K. et al. [32]^b

410

UK

Median age 77 % female not reported

Prospective cohort study

Vascular surgery (Elective and Acute)

Addenbrooke’s Vascular Frailty Score (AVFS; 6 items, score 0–6)

Not independently mobile on admission, depression, polypharmacy on admission (>8 medications), anaemia, Waterlow score >13 on admission, emergency admission

1) 1 year mortality

2) Readmission-free survival

3) Discharge to residential care

3) Prolonged LOS

Univariate; most vs least frail

1) 58 % vs 0 %, AUC 0.83

2) 0 % vs 68 % (p < 0⋅001), AUC 0.71

3) AUC 0.78

4) AUC 0.74

 Partridge, J.S.L. et al. [34]^a

125

UK

Mean age 76.3

31 % female

Prospective observational study

Vascular surgery

(Elective and Acute)

Edmonton Frail Scale (EFS)

cognitive impairment, dependence in iADL, recent burden of illnesses, self-perceived health, depression, weight loss, medication issues, incontinence, inadequate social support and mobility difficulties.

Frail is >7/18

1) Composite measure post-operative complications

2) Composite measure adverse functional outcomes

3) LOS ≥12 days

Multivariate, adjusted for significant baseline associations and age

1) non-sig

2) non-sig

3) non-sig

 Kistler, E et al. [35]^a

35

USA

Mean age 86

83 % female

Prospective cohort study

Hip fracture surgery

(Acute)

Modified Fried Criteria

1) Post-operative complications

2) Delirium

3) LOS

4) Time to surgery

Frail vs Non-frail

1) non-sig

2) non-sig

3) 7.3 vs 4.1 (p = 0.038)

4) non-sig

 Krishnan, M et al. [36]^a

178

UK

Mean age 81

73.5 % female

Prospective cohort study

Hip fracture surgery

(Acute)

FI (51 items)

1) 30-day mortality

2) Inpatient mortality

3) LOS-failure to return home by 30 days

Frail vs Non-frail

1) 17.2 % vs 0 % (p < 0.001)

2) 28.1 % vs 0 % (p < 0.001)

3) AUC 0.82

 Patel K.V. et al. [38]^a

218

USA

Mean age 81.2 % female not reported

Retrospective chart review

Hip fracture

(Acute)

Modified FI (19 items)

1 year mortality

2-year mortality

OR 4.97 (p < 0.001)

OR 4.01 (p < 0.001)