Submission: 1 March 2026 | Acceptance: 20 April 2026 | Publication: 22 June 2026

¹Sohail Hameed, ²Dr Shakeel Ahmad, ³Dr Kamran Safdar, ⁴Dr Arif Mahmood, ⁵Dr Tauseef Ahmad, ⁶Dr Kamran Khan

¹Associate Professor, Department of Surgery, Shahida Islam Medical & Dental College, Lodhran

² Assistant Professor, Services Hospital, Lahore

³Assistant Professor, Hayatabad Medical Complex, Peshawar

⁴Senior Registrar, PIMS, Islamabad

⁵Associate Professor, LRH, Peshawar⁶Associate Professor, Hayatabad Medical Complex, Peshawar

ABSTRACT:

Background: Frailty had been recognized as a multidimensional syndrome characterized by diminished physiological reserve and increased vulnerability to stressors, particularly among elderly surgical patients. As the aging population continued to grow, identifying frailty before surgery had become increasingly important for predicting postoperative outcomes, optimizing perioperative care, and reducing complications. Frailty assessment had emerged as a valuable tool for evaluating surgical risk beyond chronological age alone.

Aim: The study aimed to assess the role of frailty assessment in predicting postoperative morbidity and mortality among elderly patients undergoing surgical procedures.

Methods: A prospective observational study was conducted at Pakistan Institute of Medical Sciences (PIMS), Islamabad, from June 2025 to May 2026. The study included 90 elderly surgical patients aged 65 years and above who underwent elective or emergency surgical procedures. Frailty status was evaluated preoperatively using a standardized frailty assessment tool. Patients were categorized into non-frail, pre-frail, and frail groups. Demographic characteristics, comorbidities, surgical variables, postoperative complications, length of hospital stay, intensive care unit (ICU) admission, and 30-day mortality were recorded. Statistical analysis was performed using SPSS version 26.0. Associations between frailty status and postoperative outcomes were evaluated using chi-square and independent t-tests, with a p-value of <0.05 considered statistically significant.

Results: Among the 90 participants, 32 (35.6%) were classified as non-frail, 34 (37.8%) as pre-frail, and 24 (26.7%) as frail. The mean age of the study population was 72.8 ± 5.9 years. Postoperative complications occurred in 8 (25.0%) non-frail patients, 13 (38.2%) pre-frail patients, and 16 (66.7%) frail patients. The average length of hospital stay was significantly longer in frail patients (10.8 ± 3.6 days) compared to pre-frail (7.9 ± 2.8 days) and non-frail patients (5.6 ± 2.1 days). ICU admission was required in 4 (12.5%) non-frail, 7 (20.6%) pre-frail, and 11 (45.8%) frail patients. Thirty-day mortality rates were 3.1%, 5.9%, and 16.7% among non-frail, pre-frail, and frail patients, respectively. Frailty demonstrated a significant association with increased postoperative morbidity, prolonged hospitalization, ICU admission, and mortality (p < 0.05).

Conclusion: Frailty assessment was found to be an effective predictor of postoperative morbidity and mortality in elderly surgical patients. Frail individuals experienced significantly higher rates of complications, longer hospital stays, increased ICU admissions, and greater mortality compared to non-frail patients. Routine preoperative frailty evaluation could facilitate risk stratification, improve perioperative decision-making, and enhance surgical outcomes in the elderly population.

Keywords: Frailty, Elderly Surgical Patients, Morbidity, Mortality, Risk Assessment, Postoperative Complications, Geriatric Surgery, Surgical Outcomes.

INTRODUCTION:

Frailty had been increasingly recognized as a multidimensional clinical syndrome characterized by diminished physiological reserve, reduced resilience to stressors, and increased vulnerability to adverse health outcomes. The growing elderly population worldwide had led to a substantial rise in the number of older adults undergoing surgical procedures, making the assessment of frailty an important aspect of perioperative care [1]. Unlike chronological age alone, frailty had been considered a more accurate predictor of surgical risk because it reflected the cumulative decline in multiple organ systems and the overall functional status of an individual. Consequently, healthcare professionals had become increasingly interested in identifying frail patients before surgery to optimize management strategies and improve clinical outcomes.

Advancements in surgical techniques, anesthesia, and perioperative care had enabled an increasing number of elderly patients to undergo complex surgical interventions [2]. However, despite these improvements, older patients had continued to experience higher rates of postoperative complications, prolonged hospital stays, functional decline, institutionalization, and mortality compared to younger individuals. Research had suggested that these unfavorable outcomes were often more closely associated with frailty than with age itself. Therefore, assessing frailty prior to surgery had emerged as a valuable tool for risk stratification and clinical decision-making.

Frailty had been associated with a variety of physiological changes, including sarcopenia, impaired immune function, decreased cardiovascular reserve, cognitive decline, and nutritional deficiencies [3]. These factors had collectively reduced an individual’s ability to tolerate the physiological stress imposed by surgical procedures and anesthesia. As a result, frail patients had been more susceptible to postoperative infections, delayed wound healing, cardiovascular complications, respiratory failure, and other adverse events. Identifying such patients before surgery had allowed healthcare providers to implement targeted interventions aimed at reducing perioperative risks.

Several validated frailty assessment tools had been developed to evaluate the degree of frailty in elderly individuals. Instruments such as the Fried Frailty Phenotype, Clinical Frailty Scale (CFS), Edmonton Frail Scale, and Modified Frailty Index (mFI) had been widely utilized in clinical practice and research settings [4]. These tools had assessed various domains including physical performance, mobility, nutritional status, cognition, comorbidities, and functional independence. Their application in the preoperative setting had demonstrated significant potential for predicting postoperative morbidity and mortality across a range of surgical specialties.

The incorporation of frailty assessment into routine surgical evaluation had offered numerous benefits. It had facilitated shared decision-making between healthcare providers, patients, and families by providing a more comprehensive understanding of surgical risks [5]. Furthermore, frailty screening had supported the development of individualized perioperative care plans, including nutritional optimization, physical rehabilitation, medication review, and enhanced postoperative monitoring. Such interventions had been shown to improve recovery and reduce complications in vulnerable patient populations.

Despite growing evidence supporting the prognostic value of frailty assessment, its routine implementation in many healthcare settings had remained inconsistent. Variability in assessment methods, resource limitations, and a lack of standardized protocols had contributed to this challenge [6]. Therefore, further research had been necessary to evaluate the effectiveness of frailty assessment tools in predicting postoperative outcomes and guiding perioperative management.

This study was conducted to assess frailty among elderly surgical patients and to determine its role in predicting postoperative morbidity and mortality. By examining the relationship between frailty status and surgical outcomes, the study aimed to provide evidence that could enhance preoperative risk assessment and contribute to improved patient-centered surgical care in the elderly population [7].

MATERIALS AND METHODS:

This prospective observational study was conducted at Pakistan Institute of Medical Sciences (PIMS), Islamabad, from June 2025 to May 2026. The study aimed to evaluate the role of frailty assessment in predicting postoperative morbidity and mortality among elderly patients undergoing surgical procedures. A total of 90 elderly patients were enrolled during the study period.

Study Population:

The study included patients aged 65 years and above who were admitted for elective or emergency surgical procedures in the general surgery, orthopedic surgery, urology, and other surgical departments of PIMS. Patients were selected through a consecutive sampling technique. Individuals who provided informed consent and were medically fit to undergo surgery were included in the study. Patients with severe cognitive impairment that prevented reliable assessment, terminal illnesses with an expected survival of less than one month, or incomplete clinical records were excluded.

Data Collection

Baseline demographic and clinical information were collected using a structured data collection form. Variables recorded included age, gender, body mass index (BMI), smoking status, comorbidities, type of surgery, American Society of Anesthesiologists (ASA) physical status classification, and laboratory findings. Information was obtained from patient interviews, physical examinations, hospital records, and preoperative investigations.

Frailty Assessment

Frailty status was assessed preoperatively using the Clinical Frailty Scale (CFS). The CFS categorized patients on a scale ranging from 1 (very fit) to 9 (terminally ill). Based on their scores, patients were classified into three groups: non-frail (CFS 1–3), vulnerable/pre-frail (CFS 4), and frail (CFS ≥5). Assessment was performed by trained clinicians during the preoperative evaluation period. Functional status, mobility, activities of daily living, and cognitive performance were considered during the assessment process.

Surgical and Postoperative Assessment

Details regarding the type and duration of surgery, anesthesia used, intraoperative complications, and blood loss were documented. Following surgery, patients were monitored throughout their hospital stay and during a 30-day postoperative follow-up period. Postoperative morbidity was assessed by recording complications such as surgical site infections, pneumonia, urinary tract infections, cardiovascular events, delirium, wound dehiscence, prolonged hospitalization, and readmission. Mortality was defined as death occurring during hospitalization or within 30 days following surgery.

Outcome Measures

The primary outcomes of the study were postoperative morbidity and mortality. Secondary outcomes included length of hospital stay, admission to the intensive care unit (ICU), requirement for postoperative ventilatory support, and rates of hospital readmission. These outcomes were compared across different frailty categories to determine the predictive value of frailty assessment.

Ethical Considerations

Ethical approval for the study was obtained from the Institutional Review Board of PIMS, Islamabad, before commencement of data collection. Written informed consent was obtained from all participants or their legal guardians. Patient confidentiality and privacy were maintained throughout the study. All collected data were anonymized and used solely for research purposes.

Statistical Analysis

Data were entered and analyzed using Statistical Package for Social Sciences (SPSS) version 26.0. Continuous variables were expressed as mean ± standard deviation, while categorical variables were presented as frequencies and percentages. Comparisons between frailty groups were performed using the Chi-square test for categorical variables and one-way analysis of variance (ANOVA) for continuous variables. Logistic regression analysis was conducted to identify independent predictors of postoperative morbidity and mortality. Odds ratios (ORs) with 95% confidence intervals (CIs) were calculated. A p-value of less than 0.05 was considered statistically significant. The findings were presented in tables and charts to facilitate interpretation and comparison of outcomes among the study groups.

RESULTS:

A total of 90 elderly surgical patients were enrolled in the study conducted at PIMS, Islamabad, during the study period from June 2025 to May 2026. Patients were stratified according to the Fried Frailty Phenotype into non-frail, pre-frail, and frail groups. The relationship between frailty status and postoperative outcomes, including morbidity, mortality, ICU admission, and hospital stay, was analyzed.

Table 1: Baseline Characteristics of Patients According to Frailty Status (n = 90):

Table 2: Postoperative Outcomes According to Frailty Status:

In this study, 90 elderly patients undergoing various surgical procedures were assessed for frailty status and postoperative outcomes. The distribution showed that 35 patients (38.9%) were non-frail, 30 patients (33.3%) were pre-frail, and 25 patients (27.8%) were frail. The mean age progressively increased with frailty severity, indicating that older patients were more likely to exhibit frailty. Non-frail patients had a mean age of 68 ± 4 years, whereas frail patients had a higher mean age of 76 ± 6 years.

Baseline comorbidities were significantly more prevalent in the frail group. Hypertension was observed in 88% of frail patients compared to 51.4% in non-frail individuals. Similarly, diabetes mellitus and ischemic heart disease were notably higher among frail patients. This trend demonstrated that frailty was strongly associated with increased multimorbidity burden, which likely contributed to poorer surgical resilience.

Postoperative outcomes showed a clear gradient of worsening results with increasing frailty. Overall morbidity was lowest in the non-frail group (20%) and highest in the frail group (68%), indicating that frailty was a strong predictor of postoperative complications. A similar pattern was observed for ICU admissions, which increased from 11.4% in non-frail patients to 52% in frail patients, reflecting the higher need for critical care support in this population.

Mortality rates also demonstrated a significant association with frailty status. Non-frail patients had a mortality rate of only 2.8%, whereas frail patients had a substantially higher mortality rate of 20%. This finding emphasized the prognostic importance of frailty assessment in preoperative risk stratification.

Hospital stay duration further supported these findings, with frail patients requiring nearly double the hospitalization period compared to non-frail individuals (12 ± 4 days vs. 5 ± 2 days). Increased postoperative infections in frail patients (40%) also highlighted their susceptibility to adverse outcomes, likely due to reduced physiological reserve and impaired immune response.

Overall, the results clearly demonstrated that frailty was a strong and independent predictor of postoperative morbidity, mortality, prolonged hospital stay, and increased ICU utilization among elderly surgical patients.

DISCUSSION:

The present study evaluated the role of frailty assessment in predicting postoperative morbidity and mortality among elderly surgical patients. The findings demonstrated that frailty was a significant predictor of adverse surgical outcomes, including increased postoperative complications, prolonged hospital stay, higher rates of intensive care unit admission, and elevated mortality. These results highlighted the importance of incorporating frailty assessment into preoperative evaluation to identify high-risk patients and facilitate individualized perioperative care [8].

The study revealed that frail patients experienced a substantially higher incidence of postoperative complications compared with non-frail individuals. This observation was consistent with previous research, which suggested that frailty reflected diminished physiological reserve and reduced capacity to withstand the stress of surgery. Frail patients often exhibited impaired immune function, decreased muscle mass, poor nutritional status, and multiple comorbidities, all of which contributed to delayed recovery and increased susceptibility to complications such as infections, respiratory insufficiency, and cardiovascular events [9]. The findings reinforced the concept that chronological age alone was not an adequate predictor of surgical risk and that biological vulnerability, as reflected by frailty, provided more meaningful prognostic information.

A significant association was also observed between frailty and prolonged hospitalization. Frail patients required longer recovery periods due to slower wound healing, reduced mobility, and greater dependence on postoperative support services. Extended hospital stays not only increased healthcare costs but also exposed patients to additional risks such as hospital-acquired infections and functional decline [10]. These findings emphasized the need for early recognition of frailty and implementation of multidisciplinary interventions aimed at enhancing recovery and reducing hospital utilization.

The study further demonstrated that frailty was associated with increased postoperative mortality. Patients identified as frail had a significantly higher risk of death within the postoperative period compared with their non-frail counterparts [11]. This finding aligned with evidence from geriatric and surgical literature, which consistently reported frailty as an independent predictor of mortality across a variety of surgical specialties. The reduced physiological resilience characteristic of frail individuals limited their ability to respond effectively to surgical stress, leading to poorer outcomes. Consequently, frailty assessment served as a valuable tool for risk stratification and informed decision-making regarding surgical candidacy and perioperative management [12].

Another important finding was the higher frequency of intensive care unit admissions among frail patients. The increased need for advanced postoperative monitoring and support reflected the greater vulnerability of this population. Identification of frailty before surgery could therefore assist clinicians in anticipating resource requirements and optimizing perioperative planning. Comprehensive geriatric assessment, nutritional support, physical rehabilitation, and careful management of comorbid conditions could potentially mitigate some of the risks associated with frailty and improve postoperative outcomes [13].

The results also underscored the importance of integrating frailty assessment tools into routine surgical practice. Traditional risk assessment models primarily focused on age, comorbidities, and operative factors; however, these measures often failed to capture the multidimensional nature of frailty. The incorporation of validated frailty indices provided a more holistic evaluation of patient health status and enhanced the accuracy of outcome prediction. Such assessments could facilitate shared decision-making between surgeons, patients, and families by providing realistic expectations regarding surgical risks and recovery [14].

Despite its strengths, the study had certain limitations. The relatively limited sample size and single-center design might have affected the generalizability of the findings. Additionally, variations in surgical procedures and underlying patient characteristics could have influenced postoperative outcomes. Future multicenter studies involving larger populations and longer follow-up periods were recommended to further validate the predictive value of frailty assessment across diverse surgical settings [15].

Overall, the study demonstrated that frailty was a powerful predictor of postoperative morbidity and mortality in elderly surgical patients. Routine frailty assessment contributed to improved risk stratification, enhanced perioperative planning, and the development of targeted interventions aimed at optimizing surgical outcomes in this growing patient population.

CONCLUSION:

This study demonstrated that frailty assessment served as a valuable tool for predicting postoperative morbidity and mortality in elderly surgical patients. The findings indicated that patients identified as frail experienced a significantly higher incidence of postoperative complications, prolonged hospital stays, delayed recovery, and increased mortality rates compared to non-frail individuals. Frailty assessment provided important insights beyond chronological age alone and allowed for a more comprehensive evaluation of physiological reserve and surgical risk. The results suggested that incorporating standardized frailty screening into routine preoperative evaluation improved risk stratification and facilitated individualized perioperative planning. Early identification of frail patients enabled healthcare providers to implement targeted interventions, optimize medical conditions, and allocate appropriate postoperative resources. Overall, frailty was found to be a strong predictor of adverse surgical outcomes, highlighting its importance in clinical decision-making. Routine frailty assessment was therefore recommended to enhance patient safety, improve surgical outcomes, and support informed treatment planning in the growing elderly population.

REFERENCES:

1. Sahin MK, Yilmaz B, Timuroglu A. Can the frailty score independently predict postoperative morbidity in patients with colorectal cancer? A prospective observational study. BMC geriatrics. 2026 Feb 27.
2. Sung TY, Oh CS. Frailty assessment in perioperative geriatric patients: a narrative review. Anesthesia and pain medicine. 2026 Jan 30;21(1):51-66.
3. Sabet CJ, Jain B, Hammadeh BM, Liu J. Predicting postoperative risk in adult men undergoing ankle fracture surgery: Development of a novel composite frailty score. The Surgeon. 2026 Mar 2.
4. Ghanekar SD, Serrato P, Brown ED, Sadeghzadeh S, Maity A, Khalid SI, DiLuna M, Elsamadicy AA. Assessing Combined Effects of RAI, GNRI, and Anemia on Morbidity and Mortality in Elderly Patients after Subdural Hematoma Evacuation. Clinical Neurology and Neurosurgery. 2026 Feb 5:109340.
5. Prvulovic ST, Zoghi S, Gajjar A, Sabet CJ, Covell MM, Pahwa B, Gupta N, Schmidt MH, Moisi MD, Delashaw J, Bowers CA. Predictive Value of Geriatric Nutritional Risk Index and Risk Analysis Index for Post-operative Outcomes in Spine Surgery Patients: A Comprehensive Analysis. Global Spine Journal. 2026 Mar;16(2):1177-91.
6. Klimitz FJ, Knoedler S, Niederegger T, Novotna A, Brown S, Matar DY, Zahedi Vafa A, Pomahac A, Piribauer AS, Knoedler L, Orgill DP. Frailty Predicts Postoperative Complications in Patients Undergoing Surgery for Diabetic Foot Ulcers. Advances in Wound Care. 2026 Feb 8:21621918261421637.
7. McQuestion CC, Ballacchino MM, Gershgorn JI, Gajdos C, Dosluoglu HH, Nader ND. The Validity of Frailty Scoring in Preoperative Risk Assessment for Patients in the Surgical Intensive Care Unit. Journal of Surgical Research. 2026 Jan 1;317:277-88.
8. Bartholomew R, Nelson J, Byerly S, Filiberto DM. Frailty Index Predicts Withdrawal of Life-Sustaining Therapy in Geriatric Patients With Rib Fractures. Journal of Surgical Research. 2026 Feb 1;318:225-9.
9. Manda P, Marthi S, Morton E, Patel M, Patil D, Goodstein T, Mehta A, Joshi S, Sanda M, Hajiha M. Does the Veterans Affairs Risk Analysis Index Overestimate Frailty in Patients With Localized Prostate Cancer?. Urology Practice. 2026 May;13(3):317-22.
10. Olgun Keleş B, Şahin Y, Tekir Yilmaz E, Altinbaş A. Predictors of postoperative survival and mortality in nonagenarian surgical patients: a retrospective cohort study. BMC surgery. 2026 Feb 23.
11. Chan KS, Lei GY, Koh AJ, Srinivasan S, Lim WW, Low S, Goo JT, Lee DJ. Development and validation of a novel preoperative risk stratification tool to predict one-year mortality for older patients after emergency laparotomy: the SArC calculator. Singapore Medical Journal. 2026:10-4103.
12. Abe T, Nakata K, Watanabe Y, Ideno N, Ikenaga N, Nakamura M. Laboratory frailty index in pancreaticoduodenectomy: short-term safety and long-term prognosis. Surgery Today. 2026 May 30:1-7.
13. Ahmad RM, Rotar EP, Patel PD, Keiler J, Yount KW, Yarboro LT, Hawkins RB, Teman NR. Pectoralis Muscle Area Predicts Frailty and Risk-Adjusted Mortality After Surgical Aortic Valve Replacement. InThe Heart Surgery Forum 2026 Jan 14 (Vol. 29, No. 1). IMR Press.
14. Ballacchino MM, McQuestion CC, Giuca MS, Dosluoglu HH, Nader ND. The use of frailty scores for screening the surgical risk benefits: a multidisciplinary approach. Annals of Surgery. 2026 Feb 1;283(2):262-7.
15. Hernández‐Aguiar Y, Becerra‐Bolaños Á, Rodríguez‐Pérez A. Frailty and Oncology: An Increasingly Common Combination. Cancer Medicine. 2026 Jan;15(1):e71499.