International landscape of guidelines for perioperative frailty assessment and barriers to clinical translation

Frailty significantly influences perioperative outcomes and healthcare resource utilization among older adults. Although the importance of intervention has been recognized, guidelines vary significantly across regions. This review synthesizes geriatric, perioperative, and specialty guidelines from the UK, the US, Europe, and the Asia-Pacific region. We found that, although they widely share core principles such as the use of validated tools and comprehensive geriatric assessment (CGA), guidance specific to the perioperative setting remains limited. Existing recommendations are often restricted to the preoperative phase and lack standardization of risk thresholds. However, high-quality evidence on the clinical and economic impact of frailty-based pathway redesigns is limited. Future research should focus on multicenter pragmatic trials that evaluate integrated care pathways extending from preoperative optimization through postoperative care. In parallel, further development of automated screening using electronic health records and electronic frailty indices is warranted. Such initiatives will require careful evaluation of feasibility and equity to support successful implementation in routine clinical practice. We recommend that clinicians routinely incorporate validated frailty screening into preoperative evaluation for all patients age 65 and older and that healthcare systems prioritize the development of an interoperable data infrastructure to enable the seamless transfer of community-derived frailty information into surgical decision-making workflows.