LAUSR

Over the past decade, prehabilitation has become increasingly important with regard to improving outcomes, particularly in surgery. Preparing older or frail individuals for upcoming surgeries and other invasive procedures is crucial, as these individuals tend to be at risk for higher rates of morbidity and mortality. For example, Shinall et al. studied more than 430,000 mostly male patients who underwent a noncardiac surgical procedure, with a mean age of 61 years and found that the 30-day mortality rate among patients who were frail far exceeded the 1%mortality rate that is often used to define high-risk surgery. This study reported that the 30-day mortality rate for “frail” patients who underwent the lowest-stress surgical procedures (eg, cystoscopy) was 1.6% (95% CI, 1.2% to 2.0%), and for moderate-stress surgical procedures (eg, laparoscopic cholecystectomy) it was 5.1% (95% CI, 4.8% to 5.5%). Among patients who were deemed “very frail,” the 30-day mortality rates were higher after the loweststress surgical procedures (10.3%; 95% CI, 7.7% to 13.5%) and after the moderate-stress surgical procedures (18.7%; 95% CI, 17.7% to 19.8%). For patients who were scored as frail and very frail, mortality continued to increase at 90 and 180 days, reaching 43% (95%CI, 41.7% to 44.3%) for very frail patients at 180 days after moderate-stress surgical procedures. Frailty may be a better predictor of poor surgical outcomes than age alone, and while there are many descriptions of frailty, there is no uniform consensus on its definition or how best to measure it. In general, frailty is a multidimensional clinical syndrome that involves lower thresholds of reserve and function from dysregulation across physiological and molecular pathways that are involved with and may further cause vulnerabilities to multiple organ systems. Nearly a quarter century ago, Fried et al. described the “phenotype of frailty” that bears the hallmark of people with diminished endurance and strength, a higher risk of falls, disability, hospitalization, and mortality. In addition to frailty, other factors may be associated with complications in patients undergoing surgery. For instance, a recent study from the Netherlands examined outcomes in octogenarians following major surgical procedures and found that, depending on the diagnosis, they had increased median length of stay, 30-day major morbidity, and 30-day mortality. Additional risk factors for overall complications in elderly patients scheduled for surgery include smoking and alcohol consumption, malnutrition, excessive polypharmacy, mental health disorders (eg, preoperative depression or anxiety), hemoglobin < 11 g/dl, diabetes and glycemic control (eg, increased HBA1c). These studies and many others highlight the significant risks associated with surgical and other interventions performed on older and frail individuals, and it has been suggested that prehabilitation may be an important antidote that supports improved outcomes. Prehabilitation involves either a single intervention (unimodal) or multiple interventions (multimodal), and it aims to increase patients’ health status before elective or scheduled surgeries and procedures. Prehabilitation typically begins weeks ahead of the surgery or procedure in preparation for the upcoming stressor. Increasingly, there is interest as to whether conventional care (ie, the usual preoperative instructions and education and postoperative recovery recommendations) should be replaced with prehabilitation protocols (beginning weeks prior), early recovery programs (generally the 48 to 72-hour perioperative period), or both. Prehabilitation has been understudied in older and frail individuals, and the aim of this review is to summarize the current aDepartment of Psychiatry, Massachusetts General Hospital, Boston, Massachusetts, bDepartment of Psychiatry, Harvard Medical School, Boston, Massachusetts, fDepartment of Physical Medicine and Rehabilitation, Spaulding Rehabilitation Hospital, Charlestown, Massachusetts, gDepartment of Physical Medicine and Rehabilitation, Harvard Medical School, Boston, Massachusetts, kDepartment of Physical Medicine and Rehabilitation, Massachusetts General Hospital, Boston, Massachusetts, hUniversity of Rochester School of Medicine and Dentistry, Rochester, New York, iUniversity of Nebraska Medical Center, Omaha, Nebraska, cDepartment of Psychosomatic Medicine and Psychotherapy, University of Göttingen Medical Center, Göttingen, Germany, dDepartment of Cardiovascular and Thoracic Surgery, University of Göttingen Medical Center, Göttingen, Germany, eDZHK (German Center for Cardiovascular Research), partner site Göttingen, Germany and jDepartment of Geriatrics, University of Göttingen Medical Center, Göttingen, Germany