Modified Essential Frailty Toolset in Older Adults Undergoing Major Elective Surgery

Modified Essential Frailty Toolset for Predicting Postoperative Complications and Readmission in Older Adults Undergoing Major Elective Surgery

Frailty is a common geriatric syndrome associated with reduced physiological reserve and increased vulnerability to surgical stress. As the population ages, more older adults undergo major elective surgery, yet frailty is often insufficiently assessed in routine practice and no universally accepted screening tool exists.

The Essential Frailty Toolset (EFT) is a simple validated frailty assessments and has demonstrated strong predictive value for mortality and major postoperative complications, particularly in cardiac surgery populations. EFT incorporates four key domains of cognition, anemia, serum albumin, and physical function capturing both physical and cognitive vulnerability. A modified version (mEFT) has been developed to improve feasibility and applicability in broader surgical settings, requiring minimal training and only a few minutes to administer. Despite its promise, mEFT has not been evaluated in elderly patients undergoing major elective non-cardiac surgery, representing an important gap in the current literature and motivating the present study.

We therefore propose a modified and simplified frailty screening tool tailored for elderly patients undergoing major elective non-cardiac surgery at our institution. The modified Essential Frailty Toolset (mEFT) is a multi-dimensional assessment designed to address this gap by evaluating physical function, cognition, nutrition, and anemia in just a few minutes. In this version, the tool assigns points based on specific clinical markers: the Timed Up and Go (TUG) test provides one point for a time ≥11.0 seconds and two points for ≥15.0 seconds; the Clock Drawing Test (CDT) provides one point for a score of ≤2 on a 3-point scale; nutritional risk is captured with one point for a BMI <22.0 or unintentional weight loss of 5% over the last six months; and anemia provides one point based on hemoglobin levels (below 130g/L for men and 120 g/L for women). These modifications were made to enhance feasibility and clinical relevance in our population. Low serum albumin was rare in our cohort and therefore demonstrated limited discriminatory value as a screening marker. In contrast, low BMI and recent weight loss are well-established risk factors for malnutrition and sarcopenia and are readily obtainable in routine preoperative assessment. Similarly, both the TUG and CDT are quick, inexpensive, and require minimal training, making them well suited for large-scale screening in preoperative clinics.Importantly, the proposed components have been evaluated in a pilot study conducted in our institution.

This study will evaluate whether a high mEFT score (≥3) is associated with increased postoperative complications and 90-day readmissions among patients aged ≥70 years undergoing major elective surgery. Patients presenting for admission will be included. If mEFT accurately identifies high-risk patients, it may improve preoperative risk stratification, inform shared decision-making, and help identify individuals who could benefit from targeted prehabilitation, supporting broader implementation of frailty screening in surgical care.

Study Overview

• Status: Recruiting
• Conditions: Frailty Syndrome; Postoperative Complication; Readmission Rates; Elective Surgeries; Frailty in Adult Surgery
• Intervention / Treatment: Procedure: Major elective surgery

• Study Type: Observational
• Enrollment (Estimated): 250

Contacts and Locations

• Study Contact: Name: Martin I Sigurdsson, MD, PhD; Phone Number: +354-824-8282; Email: mingi@hi.is
• Study Contact Backup: Name: Luis G Rabelo, MD; Phone Number: +3548203587; Email: lgr2@hi.is

Study Locations

• Iceland
  • Hofudborgarsvaedid
    • Reykjavik, Hofudborgarsvaedid, Iceland, 101
      • Recruiting
      • Landspitali University Hospital
      • Contact: Luis Rabelo; Phone Number: 8203587; Email: lgr2@hi.is

Participation Criteria

Eligibility Criteria

• Ages Eligible for Study: Older Adult
• Accepts Healthy Volunteers: Yes

• Sampling Method: Probability Sample

Study Population

he study population will consist of all patients ≥70 years who have present for preoperative assessment at the admissions department at Landspitali before undergoing major surgery, University Hospital of Iceland.

Description

Inclusion Criteria:

• Patients ≥ 70 years who present for preoperative work-up at the admissions department at Landspitali and undergo frailty screening.
• Patients assigned to undergo major surgery

Exclusion Criteria:

• Cardiac surgery
• Not undergoing planned surgery

Study Plan

How is the study designed?

Number of groups / cohorts

1

Cohorts and Interventions

Group / Cohort

Intervention / Treatment

Frailty screening cohort undergoing major elective surgery; Patients ≥ 70 years undergoing major elective surgery who are triaged to present for preoperative assessment at the admissions department at Landspitali University Hospital in Iceland. Patients who screen positive on the mEFT (≥3 points) will be considered frail. Those who do not screen positive (≤2 points) will be part of the control group (non-frail).

Procedure: Major elective surgery; Any major elective surgery at Landspítali University Hospital

What is the study measuring?

Primary Outcome Measures

Outcome Measure	Measure Description	Time Frame
90-day Readmission	Readmission to any hospital in Iceland where the patient is admitted to any inpatient department. Emergency department enrollment without admission will not be counted as readmission. Readmissions to the same hospital on the same day for the same principal diagnosis are not counted in the outcome.	From the day of surgery to postoperative day 90.
Surgical Complications	Description: This outcome measures the incidence of adverse events after surgery and will be categorized based on the Clavien-Dindo classification grading system using the cut-off of ≥2; complications requiring pharmacological intervention (grade II), requiring additional procedures (grade III), life-threatening complications(grade IV) and a complication resulting in death (grade V).	From the same day after surgery to postoperative day 30.

Secondary Outcome Measures

Outcome Measure	Measure Description	Time Frame
Non-home discharge	Non-home discharge will be identified as the postoperative hospital discharge to a nursing home or a rehabilitation center. Discharge to patient hotels will not be included. In addition, non-home discharge will not include patients who live in a nursing home prior to the surgery.	From the day of surgery (postoperative day 0) until discharge to a non-home destination or discharge from the primary hospitalization, whichever occurs first, assessed up to 180 days postoperatively.
Prolonged length of hospital stay	Prolonged length of hospital stay will be defined as an index hospitalization lasting 10 days or longer following the surgical procedure. Length of stay will be calculated as the number of days from the day of surgery to discharge.	Postoperative day 0 through discharge from the index hospitalization (up to 180 days).
180-day mortality	Defined as the death of the patient after surgery	Up to 180 days after the primary surgery

Collaborators and Investigators

• Sponsor: University of Iceland

Publications and helpful links

General Publications

• Rabelo LG, Bjornsdottir A, Jonsdottir AB, Einarsson SG, Karason S, Sigurdsson MI. Frailty assessment tools and associated postoperative outcomes in older patients undergoing elective surgery: A prospective pilot study. Acta Anaesthesiol Scand. 2023 Feb;67(2):150-158. doi: 10.1111/aas.14162. Epub 2022 Nov 9.

Study record dates

Study Major Dates

• Study Start (Actual): January 20, 2025
• Primary Completion (Estimated): May 31, 2026
• Study Completion (Estimated): December 31, 2026

Study Registration Dates

• First Submitted: February 27, 2026
• First Submitted That Met QC Criteria: February 27, 2026
• First Posted (Actual): March 5, 2026

Study Record Updates

• Last Update Posted (Actual): March 10, 2026
• Last Update Submitted That Met QC Criteria: March 6, 2026
• Last Verified: March 1, 2026

More Information

Terms related to this study

• Keywords: Complications; Frailty; Readmission; Postoperative Outcomes; Major elective surgery; Surgical Frailty
• Additional Relevant MeSH Terms: Pathologic Processes; Pathological Conditions, Signs and Symptoms; Frailty; Postoperative Complications
• Other Study ID Numbers: UI-Frailty-VRN25/2024

Plan for Individual participant data (IPD)

• Plan to Share Individual Participant Data (IPD)?: NO
• IPD Plan Description: The individual participant data collected during this study will not be shared due to confidentiality. Additionally, there is no formal plan for making these data publicly available at this time.

Drug and device information, study documents

• Studies a U.S. FDA-regulated drug product: No
• Studies a U.S. FDA-regulated device product: No