Are you too old for surgery? Even a little bitty tiny surgery? What is your risk?
This is something which makes intuitive sense. As you get older, your body becomes less adept and responding to stressors, and this includes the stress of surgery. No matter how little the surgery may seem, it is still a stress on the body. We also know not all 70 year olds are the same. Some are hiking Mt. Kilimanjaro, others can barely walk to their car. Some are living alone and take a few vitamins, others are in skilled help facilities and have a medication list a page long.
So how do we assess the risk?
The RAI -C Questionnaire comes to the rescue. It looks at age, sex, cancer status, medical issues, your activities of daily living and cognitive function.
A SCORE OF GREATER OR EQUAL TO 21 PUTS YOU IN THE INCREASED FRAILTY CATEGORY. This affects your risk for surgery (please see my other blog on “Can You Be Too Old for Surgery?“).
AGE
- <69 SCORE: 2 (with cancer 20), excludes non melanoma skin cancers
- 70-74 3 ———–> 19 (with cancer)
- 75-59 4 18
- 80-84 5 17
- 85-59 6 16
- 90-94 7 15
GENDER
- Female = 0
- Male = 5
MEDICAL CO MORBIDITIES
- Unintentional weight loss in the past 3 months? (>10 pounds) No = 0, Yes = 5
- Renal failure? No = 0, Yes = 6
- Chronic/congestive heart failure? No = 0, Yes =4
- Poor appetite? No = 0, Yes = 4
- Shortness of breath at rest? No =0, Yes = 8
ACTIVITIES OF DAILY LIVING
Range is Independent = 0, Supervised = 1, Limited assistance = 2, Extensive assistance = 3, and Total Dependence = 4
- Mobility/Locomotion
- Eating
- Toilet Use
- Personal Hygiene
COGNITIVE SKILLS
ADL Score (sum of the ADL score) without cognitive decline is 0 – 16. If you have cognitive decline, you need to adjust the score:
- ADL score = 0, ADL score WITH cognitive decline = -2
- ADL score 1,2 ——————————————–> -1
- ADL score 3,4 ——————————————–> 0
- ADL score 5-7———————————————> +1
- ADL score 8,9———————————————> +2
- ADL score 10,11——————————————-> +3
- ADL score 12,13 ——————————————> +4
- ADL score 14-16 ——————————————> +5
TOTAL RAI SCORE:
This score will range from 0 to 81. Anything over 21 puts you in the “frailty” category. To find your score, add your age /cancer status score, your sex score, your comorbidity score, and then your ADL score (use the cognitive impairment scale if you cognitive impairment).
In their study, they found mortality increased as the frailty score increased, going out to the one year mark.
Looking at the one year mark,
- RAI 0-15 ——————-> 1.8% mortality at one year
- RAI 16-25——————> 7.3%
- RAI 26-35——————> 16.7%
- RAI >35 ——————–> 28.3%
What does this mean?
None of these are absolutes. But when deciding to do an elective cosmetic surgery, my question is always what is the risk? is it safe to do the surgery? As people get older, the question becomes trickier. This questionnaire has been shown to help give us another data point when making the decision to do/ not do a surgery. We all know to look at age, your medications, and your smoking history. But this includes other parameters like cognitive decline, your eating habits and weight loss, and your activities of daily life. Do you live alone, are walking and driving, and cooking for yourself? or are you in a home where others help you?
If you are a 70 year old male, no history of cancer, but have had a cardiac bypass and otherwise are doing your normal living and have no cognitive decline, your score would be 5 (male), 3 (age 70), 4 (heart failure) = 12. You could have surgery.
Now let’s add prostate cancer. Your score is now 5 + 19 (70 year old with cancer) +4 = 28. You are now in the increased frailty risk. The study would indicate your one year mortality risk is almost 17%. So should you be doing elective surgery? Probably not.
Again, none of these are absolutes, but it does help us in the discussion of risk.