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Association between frailty, as measured by the FRAIL scale, and 1-year mortality in older patients undergoing hip fracture surgery

BMC Geriatrics volume 25, Article number: 65 (2025) Cite this article

Abstract

Background

The FRAIL scale is a concise and user-friendly tool for frailty assessment. However, its effectiveness in predicting 1-year mortality among older patients undergoing hip fracture surgery remains unclear. This study explored the relationship between preoperative frailty, as measured by the FRAIL scale, and 1-year mortality after surgery in this population.

Methods

This retrospective analysis included 194 older patients (aged ≥ 75 years) with hip fractures who underwent surgical treatment in our departments from January 2019 to December 2022. Perioperative clinical data were collected, and all-cause mortality within 1 year after surgery was monitored. Patients were categorized into non-frail (n = 114) and frail (n = 80) groups based on their FRAIL scores. Postoperative complications and 1-year mortality rates were compared between these groups. The association of preoperative frailty with 1-year mortality and its predictive capability were assessed.

Results

Among the 194 older hip fracture patients, 78 (40.2%) were male, with a mean (standard deviation [SD]) age of 84.4 (6.3) years. The overall incidence of 1-year mortality after surgery was 11.3% (22/194). Frail patients had a higher incidence of Clavien-Dindo (CD) classification of surgical complications ≥ II (31.3% vs. 12.3%, p = 0.00) and greater 1-year mortality (21.3% vs. 4.4%, p = 0.00) compared with non-frail patients. Cox regression analysis indicated that preoperative frailty was independently associated with 1-year mortality (adjusted hazard ratio: 3.88; 95% confidence interval [CI]: 1.28–11.77; p = 0.02). The FRAIL scale demonstrated acceptable discriminatory capacity for predicting 1-year mortality in these patients (area under the curve: 0.70; 95% CI: 0.59–0.81).

Conclusions

Frailty, as measured by the FRAIL scale, was independently associated with 1-year mortality in older patients undergoing hip fracture surgery. The scale can be used to stratify risk and facilitate personalized perioperative treatment and management.

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Introduction

As the population ages, the incidence of fragility fractures in older individuals is increasing. Hip fractures, a common and serious type of fragility fracture, are projected to reach 6.3 million cases worldwide by 2050 [1]. Patients aged > 70 years experience 75% of all hip fractures [2]; these patients have high rates of morbidity and mortality. Prompt surgical intervention is typically recommended for hip fracture patients because delays may increase the risks of postoperative complications and mortality [3, 4]. Older patients with hip fractures often have multiple comorbidities and geriatric syndromes, significantly increasing the risk of adverse postoperative events [5]. Recent studies indicate that all-cause mortality rates after hip fracture surgery in older patients aged > 60 years are 2.9%, 7.3%, and 16.6% at 1 month, 6 months, and 1 year, respectively [6,7,8]. Therefore, early prognostic evaluation at the time of admission is crucial for better resource allocation and improved postoperative outcomes.

Frailty, characterized by an age-related decline in functional status and physiological reserves, results in increased vulnerability and reduced stress resistance [9]. Previous research has linked frailty to poor outcomes in older patients undergoing hip fracture surgery [6, 10, 11]. However, no universal diagnostic criteria for frailty exist, and numerous frailty assessment tools are available [12]. Among these, the FRAIL scale is a concise and easy-to-use tool that can be administered through a virtual interface or directly by a patient (i.e., self-administered) [13, 14]. A systematic review and meta-analysis [15] demonstrated that frailty, as measured by the FRAIL scale, is associated with postoperative complications, 30-day mortality, and 6-month mortality in older surgical patients. In geriatric fracture patients, FRAIL scale scores are also correlated with poor short-term (e.g., postoperative and 30-day) outcomes [6]. However, the effectiveness of the FRAIL scale in predicting 1-year mortality in older patients undergoing hip fracture surgery remains unclear. This study aimed to assess the ability of the FRAIL scale to predict 1-year mortality among Chinese older patients (aged ≥ 75 years) undergoing hip fracture surgery in a real-world clinical setting.

Methods

Study design and participants

This two-center, retrospective cohort study was conducted at the Second Medical Center of the Chinese PLA General Hospital and the Second Affiliated Hospital of Xingtai Medical College. Participants were individuals aged ≥ 75 years who underwent hip fracture surgery during hospitalization between January 2019 and December 2022. The study received approval from each institution according to their respective local hospital requirements and was conducted in accordance with the Declaration of Helsinki. Due to the retrospective nature of the study, the requirement for written informed consent from participants was waived by the Clinical Research Ethics Committee of Chinese PLA General Hospital and the Second Affiliated Hospital of Xingtai Medical College, respectively.

Eligibility criteria included age ≥ 75 years, a diagnosis of hip fracture, admission within 21 days of the fracture, and receipt of surgical treatment for the hip fracture during hospitalization. Patients were excluded if they exhibited a pathological or periprosthetic fracture, had incomplete medical or surgical records, or were lost to follow-up after discharge.

Data collection

Data were collected from clinical electronic medical records at the two hospitals. Collected variables included baseline demographics, concomitant diseases (e.g., chronic obstructive pulmonary disease [COPD], chronic kidney disease [CKD], hypertension, diabetes), laboratory values, modified preoperative risk score [16], type of hip fracture (femoral neck, intertrochanteric, or subtrochanteric femoral), time from admission to surgery, surgical approaches and related details, perioperative medications, length of stay, and postoperative complications (e.g., Clavien-Dindo [CD] classification of surgical complications). Mortality at 30 days, 6 months, and 1 year after surgery was assessed through phone interviews or clinical visits.

Assessment of frailty

The FRAIL scale [13, 14, 17] was used to assess frailty through a 5-item questionnaire: Fatigue (“Do you feel tired most of the time?“), Resistance (“Can you climb a flight of stairs?“), Aerobic (“Can you walk a block independently?“), Illness (“Do you have 5 or more of a total of 11 diseases?“), and Loss of weight (“Have you lost 5% or more of your weight within the past 6 months?“). Each “yes” response was scored as 1 point, resulting in a total possible score of 0–5. Patients were classified as robust (0 point), prefrail (1–2 points), or frail (≥ 3 points).

Outcomes

The primary outcome was 1-year mortality after surgery. Secondary outcomes included postoperative complications (e.g., CD classification of surgical complications), 30-day mortality, and 6-month mortality.

Statistical analysis

Continuous variables are reported as mean ± standard deviation (SD) and were compared using Student’s t-test or the Mann-Whitney U test, as appropriate. Categorical variables are presented as numbers (n) with percentages (%) and were compared using the Chi-squared test or Fisher’s exact test, as appropriate. Logistic regression analysis was performed to analyze the association between frailty and CD classification of surgical complications ≥ 2 during hospitalization after adjusting for age and the modified preoperative risk score. Kaplan-Meier (K-M) analysis was used for survival curves, with log-rank tests used to assess significance between frailty and non-frailty groups. Univariate and multivariate Cox regression analyses (with time-dependent covariates) were used to explore the association between frailty and postoperative 1-year all-cause mortality. Potential predictors of postoperative 1-year all-cause mortality were initially identified by univariate analysis (p < 0.05). These predictors, along with other clinically relevant variables, were included in the multivariate analysis.

The discriminatory ability of the FRAIL scale to predict postoperative 1-year all-cause mortality was evaluated using a receiver operating characteristic (ROC) curve. Calibration was assessed with the Hosmer-Lemeshow goodness-of-fit test, where p < 0.05 indicated a poor fit. The threshold for statistical significance was set to p < 0.05. All analyses were performed using SPSS Statistics software version 25.0 (IBM Corp., Armonk, NY, USA).

Results

Baseline characteristics, postoperative complications, and all-cause mortality

In total, 194 older patients were included in this analysis after the exclusion of 3 patients with pathological fractures, 2 patients with incomplete baseline variables, and 5 patients who were lost to follow-up after discharge. The mean (SD) age of participants was 84.4 (6.3) years, and 78 patients (40.2%) were men. Of the patients, 102 (52.6%) had femoral neck fractures, 88 (45.4%) had intertrochanteric fractures, and 4 (2.1%) had subtrochanteric femoral fractures. The baseline characteristics of the included patients are listed in Table 1. Overall, 39 patients (20.1%) experienced a CD classification of surgical complications ≥ 2 during hospitalization; 5 (2.6%) experienced complications with CD classification ≥ 3. The overall rates of all-cause mortality within 30 days, 6 months, and 1 year after surgery were 1.0% (2/194), 6.2% (12/194), and 11.3% (22/194), respectively.

Table 1 Demographic and clinical characteristics of the study group by frailty status
Full size table

Comparison of frailty and non-frailty groups

According to the FRAIL scale, 80 patients (41.2%) were included in the frailty group and 114 patients (58.8%) were included in the non-frailty group. Patients in the frailty group were typically older and more often men; they had higher prevalences of hypertension, arrhythmia, coronary heart disease, congestive heart failure, cerebrovascular disease, or central nervous system disease. Compared with non-frail patients, frail patients had higher modified preoperative risk scores (25.9 ± 9.2 vs. 19.6 ± 5.7, p = 0.00), longer times from admission to surgery (5.6 ± 3.9 vs. 3.5 ± 2.4 days, p = 0.00), and a higher proportion of CD classification of surgical complications ≥ 2 during hospitalization (31.3% vs. 12.3%, p = 0.00) (Table 1). Multivariable logistic regression analysis, adjusted for age and the modified preoperative risk score, demonstrated that frailty was independently associated with CD classification of surgical complications ≥ 2 during hospitalization (adjusted OR:2.24; 95% CI: 1.03–4.87; p = 0.04).

Association between preoperative frailty and 1-year all-cause mortality

Compared with the survival group (n = 172), the prevalence of preoperative frailty was significantly higher in the postoperative 1-year all-cause mortality group (n = 22) (36.6% vs. 77.3%, p = 0.00). The distribution of patients across risk categories of the FRAIL scale also significantly differed between the two groups (Fig. 1). Meanwhile, the incidence of 1-year all-cause mortality was significantly higher in preoperative frailty group than in the preoperative non-frailty group (21.3% vs. 4.4%, p = 0.00) (Table 1). The cumulative 1-year survival rates of the two groups were statistically significant according to the Kaplan-Meier curve (P = 0.00 by log-rank test) (Fig. 2). For frailty group, cumulative survival curve for 1-year mortality showed decreasing trajectories over time. Univariate Cox regression analysis indicated that preoperative frailty significantly increased the risk of 1-year mortality after surgery in older patients with hip fracture (hazard ratio [HR]: 5.27; 95% confidence interval [CI]: 1.94–14.29; p = 0.00). After adjustments for age, sex, the modified preoperative risk score, and concomitant diseases, multivariate Cox regression analysis demonstrated that frailty was independently associated with postoperative 1-year mortality (adjusted HR: 3.88; 95% CI: 1.28–11.77; p = 0.02).

Fig. 1
figure 1

Rating for patients across risk categories of the FRAIL Scale. P-value is for the comparison across the risk categories of the scoring system

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Fig. 2
figure 2

Cumulate 1-year survival rate according to risk stratification based on the FRAIL Scale. The Kaplan Meier curve for the cumulative 1-year survival rates between frailty and non-frailty groups. Log-rank test shows statistically significant difference between the two groups

Full size image

Calibration showed that preoperative frailty adequately predicted 1-year mortality in older patients undergoing hip fracture surgery (Hosmer-Lemeshow p > 0.05). Preoperative frailty also displayed acceptable discriminatory capacity for predicting postoperative 1-year mortality (area under the curve: 0.70; 95% CI: 0.59–0.81) (Fig. 3).

Fig. 3
figure 3

Receiver-operating characteristic curve for predicting 1-year mortality in elderly patients with hip fracture surgery using the FRAIL Scale for frailty (AUC 0.70, 95%CI: 0.59–0.81)

Full size image

Discussion

The principal findings of this study reveal that approximately 40% of older hip fracture patients (aged ≥ 75 years) exhibited frailty before surgery, as measured by the FRAIL scale. This type of frailty was independently associated with an increased risk of 1-year mortality after hip fracture surgery. To our knowledge, this is the first study to assess the ability of the FRAIL scale to predict 1-year mortality in older patients after hip fracture surgery.

As the population ages, the incidence of hip fractures also increases. Among all patients with hip fractures, those aged > 70 years constitute 75% [2]. Currently, there is no universal diagnostic criterion for frailty, and multiple assessment tools exist [12], including Fried’s frailty phenotype, Rockwood and Mitnitski’s Frailty Index (FI), the FRAIL scale, Clinical Frailty Scale (CFS), and the Study of Osteoporotic Fractures (SOF) Index. The rates of frailty detection vary among tools. Generally, the prevalence of frailty in older patients increases with age. Studies have shown that the prevalence of frailty in hip fracture patients ranges from 33.3 to 46.1% [6, 10, 18, 19]. Consistent with previous research, our study revealed that the prevalence of frailty, as measured by the FRAIL scale, was 41.2% (80/194). Patients with frailty had higher prevalences of hypertension, arrhythmia, coronary heart disease, congestive heart failure, cerebrovascular disease, or central nervous system disease. Although early surgery is often recommended for hip fracture patients [20], we found that patients with frailty had longer times from admission to surgery compared with their non-frail counterparts (5.6 ± 3.9 vs. 3.5 ± 2.4, p = 0.00). The most common cited reasons are that patients had multiple comorbidities (e.g. congestive heart failure, bleeding disorders, and low hematocrit), with awaiting medical review, medical management and optimization or organizational issues before surgery [3, 4]. For patients with surgeries performed 3 or more days after admission, the risk of in-hospital complications (e.g. pneumonia, urinary tract infection, and pressure sores) increased to more than 2-fold [3]. The main reasons might be that due to prolonged immobilization and severe hip pain, patients with hip fracture were unable to move not just the hip but also unable to cough and void properly [21]. In addition, frail patients had a higher incidence of CD classification of surgical complications ≥ 2 (31.3% vs. 12.3%, p = 0.00). After adjusted age and the modified preoperative risk score, frailty was independently associated with CD classification of surgical complications ≥ 2 (adjusted OR:2.24; 95% CI: 1.03–4.87; p = 0.04). The results are consistent with those of previous studies in terms of the FRAIL scale in predicting postoperative adverse outcomes [6, 10, 15]. Thus, the FRAIL scale may be a useful tool to screen for preoperative frailty among older hip fracture patients, which may facilitate personalized perioperative treatment and management.

The risk of all-cause mortality increases with age among hip fracture patients [22]. In our study, the incidence of 1-year mortality was 11.3% (22/194) in older patients aged ≥ 75 years undergoing hip fracture surgery. Patients with frailty exhibited significantly higher 1-year mortality rates relative to those without frailty (21.3% vs. 4.4%, p = 0.00). Frailty, as measured by the FRAIL scale, was independently associated with an increased risk of 1-year mortality (adjusted HR = 3.88). A meta-analysis encompassing 8 studies (none using the FRAIL scale) indicated that frailty was linked to a higher risk of 1-year mortality in patients after hip fracture surgery (risk ratio = 2.44; 95% CI: 1.47–4.04) [11]. This finding suggests that the FRAIL scale can be used to stratify risk in older patients prior to hip fracture surgery. Compared with other scales or screening tools, the FRAIL scale has the advantages of brevity and ease of use; its reliance on patient self-reporting makes it suitable for rapid clinical assessment. Among older hip fracture patients, early screening for frailty and proactive intervention could potentially reduce the risks of postoperative complications and 1-year mortality, thereby improving clinical outcomes [23]. Interventions for frailty may include exercise, nutritional support, management of comorbidities and polypharmacy, and surgical and medical co-management [24].

Limitations

This study is not without limitations. First, the sample size was relatively small (n = 194); however, the focus on patients aged ≥ 75 years undergoing hip fracture surgery makes it clinically relevant and representative. Additionally, the incidences of all-cause mortality at 30 days, 6 months, and 1 year after surgery were comparable to those reported in other studies [6,7,8], lending credibility to our findings. Second, because this was a two-center retrospective study, variations in care pathways may have existed. Third, although the potential associated factors were examined and adjusted in the multivariable analysis, the effects of unmeasured or non-observable confounding factors (e.g. nutritional status, family support, socioeconomic status and caregiver issue) have been omitted, which may have influenced the results. Previous research has linked malnutrition to poor outcomes in older patients with hip fracture [25,26,27]. Fourth, due to the retrospective nature of this study, there were no direct comparisons with other frailty assessment tools, such as the CFS, which was shown to be easy-to-use with good inter-rater reliability. Previous studies have shown the predictive validity of the CFS for poor outcomes after hip fracture surgery [28,29,30]. This should be addressed in future prospective studies. Fifth, the retrospective nature of the study implied a potential for inherent bias. Therefore, a larger, prospective study is necessary to generalize our findings.

Conclusions and implications

Frailty, as measured by the FRAIL scale, was common among older patients aged ≥ 75 years with hip fractures before surgery. It was independently associated with an increased risk of 1-year mortality after surgery. The FRAIL scale can be used to stratify risk and facilitate personalized perioperative treatment and management in older patients undergoing hip fracture surgery.

Data availability

The raw data supporting the conclusions of this study will be available upon request from the corresponding authors.

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Authors and Affiliations

  1. Second Department of Orthopaedics, The Second Affiliated Hospital of Xingtai Medical College, No. 618 North Iron and Steel Road, Xing Tai, 054000, China

    Shaohua Xi & Suran Yin

  2. Department of Cardiology, The Second Affiliated Hospital of Xingtai Medical College, No. 618 North Iron and Steel Road, Xing Tai, 054000, China

    Zhibin Wu

  3. Department of Anesthesiology, The Second Affiliated Hospital of Xingtai Medical College, No. 618 North Iron and Steel Road, Xing Tai, 054000, China

    Jian Cui

  4. Department of Comprehensive Surgery, The Second Medical Center and National Clinical Research Center for Geriatric Diseases, Chinese PLA General Hospital, No. 28 Fu Xing Road, Beijing, 100853, China

    Shaozhi Xi & Chaoyang Liu

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Contributions

Study concept and design: SX and CL; Acquisition of data: SX, SX and ZW; Analysis and interpretation of data: SX and JC; Drafting of the manuscript: SX, SX and SY; Critical revision of the manuscript for important intellectual content: CL.

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Correspondence to Shaozhi Xi or Chaoyang Liu.

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Ethics approval and consent to participate

This study was approved by the Clinical Research Ethics Committee of Chinese PLA General Hospital and the Second Affiliated Hospital of Xingtai Medical College, respectively. The study was conducted in accordance with the Declaration of Helsinki. We confirmed that all methods were carried out in accordance with relevant guidelines and regulations to protect human subjects. In addition, due to the retrospective nature of the study, the requirement for written informed consent from participants was waived by the Clinical Research Ethics Committee of Chinese PLA General Hospital and the Second Affiliated Hospital of Xingtai Medical College, respectively.

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Xi, S., Wu, Z., Cui, J. et al. Association between frailty, as measured by the FRAIL scale, and 1-year mortality in older patients undergoing hip fracture surgery. BMC Geriatr 25, 65 (2025). https://doiorg.publicaciones.saludcastillayleon.es/10.1186/s12877-025-05716-z

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BMC Geriatrics

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