The Role of the Clinical Frailty Scale in Stratifying Management of Older Adults with Acute Calculous Cholecystitis and Acute Gallstone Pancreatitis

Abstract

Acute calculous cholecystitis (ACC) and acute gallstone pancreatitis (AGP) are common gallstone-related emergencies in older adults. Current guidelines emphasize early control of the acute event and definitive management when feasible, but their applicability in the older population is constrained by marked heterogeneity in physiological reserve that chronological age alone fails to capture. This narrative review examines the role of frailty in clinical decision-making for older adults with ACC and AGP, organized around two intersecting questions that recur at admission: how severe is the current acute event, and how depleted is the patient’s baseline reserve. The review outlines frailty assessment tools commonly used in emergency settings and focuses on the bedside utility of the Clinical Frailty Scale (CFS) as a practical means of operationalizing the baseline-reserve question. Drawing on existing guidelines and observational evidence, we summarize how management considerations shift according to baseline reserve: patients with substantially preserved reserve generally remain candidates for standard pathways; those with borderline reserve may require bridging and iterative reassessment; and those with substantial dependency or limited recovery potential require explicit goals-of-care discussion before further invasive management is pursued. The organizing perspective and stratification presented here are intended to support clinical judgment and risk communication rather than to serve as a validated algorithm.

Introduction

As population aging accelerates, the clinical burden of gallstone-related emergencies in older adults continues to rise.^1,2 Acute calculous cholecystitis (ACC) and acute gallstone pancreatitis (AGP) are the two most common gallstone-related emergencies,³ both characterized by acute onset, rapid fluctuations in clinical course, and time-sensitive management requirements. Stone composition, size, and migration pattern may influence the clinical phenotype of gallstone-related emergencies, although these factors do not replace disease-severity assessment or frailty evaluation.⁴ For ACC, the Tokyo Guidelines 2018 provide diagnostic criteria, severity grading, and a management flowchart that links treatment selection to disease severity, surgical risk, and institutional capability; early laparoscopic cholecystectomy is generally favored when patients can tolerate surgery, whereas gallbladder drainage is considered for selected high-risk patients. For AGP, contemporary guidelines emphasize early supportive care, severity assessment, identification of cholangitis or persistent biliary obstruction, timely endoscopic intervention when indicated, and cholecystectomy after stabilization to prevent recurrence.^5–7 However, adherence to these standard pathways is inconsistent in older patients,⁸ largely because this population exhibits marked heterogeneity in organ reserve, comorbidity burden, functional status, and recovery potential—factors that alter the risk–benefit balance of a given intervention even when the disease state is comparable. Thus, although disease-specific guidelines define the standard direction of care, they do not fully resolve how these pathways should be individualized for older adults with depleted physiological reserve.

Age has traditionally served as a key variable in emergency decision-making for older adults, yet age per se is an imprecise proxy for physiological reserve.^9,10 Patients of the same chronological age may differ substantially in mobility, cognitive function, nutritional status, and organ function; reliance on age alone for risk stratification therefore risks misalignment between treatment intensity and the patient’s actual tolerance. Frailty, by contrast, captures the composite state of multisystem reserve depletion, heightened stress vulnerability, and diminished recovery capacity that more directly determines how an older patient will respond to acute physiological insults.^11,12 In the context of ACC and AGP, frailty assessment can inform not only perioperative risk estimation but also the identification of patients who remain candidates for active intervention versus those who may benefit from bridging strategies, timing adjustments, or goal-of-care redefinition.^13,14

Against this background, the present narrative review examines the role of frailty in decision-making for older adults with ACC and AGP, organized around a dual-axis view of admission assessment in which acute disease severity and baseline physiological reserve are appraised in parallel rather than sequentially. Three questions frame the discussion: how baseline reserve can be assessed in the emergency setting, with attention to why the Clinical Frailty Scale (CFS) is particularly suited to this role; where current guideline recommendations reach the limits of their applicability in highly frail older patients; and how pathway decisions shift across frailty tiers when both axes are considered together. The aim is to synthesize available evidence and organize clinical reasoning rather than to conduct a systematic review or issue formal recommendations.

Literature Search and Study Selection

This is a narrative review. To ensure an adequate evidentiary foundation, PubMed, Web of Science, and Embase were searched for English-language articles published between January 2015 and March 2026, supplemented by hand-searching of reference lists from key guidelines and systematic reviews, and by targeted retrieval of seminal earlier publications where these established foundational concepts (for example, the original description of the CFS). The PubMed search combined two concept blocks with Boolean operators: (“frailty”[MeSH] OR “Clinical Frailty Scale” OR “frailty index” OR “Hospital Frailty Risk Score”) AND (“cholecystitis, acute”[MeSH] OR “acute cholecystitis” OR “gallstone pancreatitis” OR “biliary pancreatitis” OR “acute pancreatitis”[MeSH]), with results further filtered to studies enrolling patients aged 60 years or older. Analogous search strings were adapted for Web of Science and Embase syntax.

Study selection was guided by the core clinical questions addressed in this review. Three categories of literature were prioritized: first, clinical studies evaluating the association between frailty and outcomes or treatment pathways in older patients with ACC or AGP; second, key studies addressing conservative management, bridging interventions, ERCP, or cholecystectomy in the older population; and third, current relevant guidelines from major surgical, gastroenterological, and geriatric societies. Consistent with the narrative review format, formal eligibility criteria, dual independent screening, and quantitative synthesis were not applied; selection was instead guided by clinical relevance, methodological transparency of the original study, and informativeness for the questions framed in the Introduction. Where included studies enrolled broader biliary emergency populations rather than ACC or AGP specifically, this is noted in the corresponding evidence summaries. For each key study cited, details regarding population source, frailty instrument, outcome measures, and principal limitations are provided in the relevant sections.

Frailty and Baseline Reserve

Frailty is characterized by reduced physiological reserve across multiple organ systems and increased vulnerability to stressors.¹⁵ Although closely related to advanced age, multimorbidity, and disability, these constructs are not interchangeable.^16,17 Chronological age captures the passage of time, multimorbidity describes disease burden, and disability reflects functional consequences, whereas frailty more directly reflects a patient’s capacity to tolerate and recover from acute physiological insults such as infection, inflammation, anesthesia, and surgery.

This distinction is particularly relevant in ACC and AGP because the two conditions require different decision timelines. In ACC, early cholecystectomy is generally preferred when the patient can tolerate surgery, and delay may increase local inflammatory adhesions and technical difficulty.¹⁸ In AGP, decision-making often spans several phases, including supportive care, assessment for cholangitis or persistent biliary obstruction, possible ERCP, and cholecystectomy after acute stabilization.^6,7 Under these different time pressures, treatment tolerance cannot be inferred from age alone. Patients of similar chronological age may differ substantially in mobility, cognition, nutritional status, organ function, and recovery potential; therefore, assessment of baseline physiological reserve is needed to align treatment intensity with individual tolerance.^9,10,19

Frailty may modify the expected balance between benefit and harm across management pathways. It is commonly accompanied by chronic low-grade inflammation, sarcopenia, malnutrition, and immune dysfunction,^20–22 which may impair infection clearance, reduce tissue-repair capacity, and increase susceptibility to perioperative complications such as delirium.²³ In practice, frailty assessment should be anchored to the patient’s premorbid baseline rather than to the transient functional decline observed during acute illness.^24–27 Used in this way, frailty assessment is not merely a prognostic label, but a clinically useful basis for judging whether an older patient is likely to tolerate standard treatment, require bridging and reassessment, or need a shift toward goal-concordant care.²⁸

Frailty Assessment in the Emergency Setting

Selection of Frailty Assessment Tools for Emergency Use

Numerous frailty assessment instruments exist, but not all are suitable for early decision-making in elderly biliary emergencies.²⁹ In ACC and AGP, clinical teams typically must complete infection control, disease severity grading, anesthetic risk evaluation, and pathway selection within a limited time frame after admission. The practical value of a frailty tool therefore depends not only on its theoretical completeness but also on its simplicity, stability, and capacity to reflect the patient’s premorbid baseline.³⁰ Instruments that rely heavily on physical performance testing, complex questionnaires, or multidimensional item aggregation may offer finer granularity in research contexts but often have limited feasibility in emergency practice.³¹

For these reasons, the emergency setting favors instruments that are simple, stable, conducive to multidisciplinary communication, and associated with clinically meaningful outcomes (Table 1). The objective is not to generate more elaborate quantitative outputs but to gauge a patient’s premorbid functional reserve within a constrained time frame and thereby inform whether the standard treatment pathway can be pursued.

Table 1.

Comparison of Frailty Assessment Tools Commonly Used in Geriatric Biliary Emergencies

Assessment Tool	Core Dimensions/Indicators	Data source	Advantages in Emergency Biliary Settings	Limitations
Clinical Frailty Scale (CFS)32–34	Pre-morbid mobility, functional independence, and care dependency	Bedside clinical inquiry, medical history, or proxy report	Simple, intuitive, and easy to administer; provides a common risk-communication language across surgical, anesthetic, and geriatric teams	Relies on assessor judgment; requires separation of acute functional decline from true baseline status
5-factor modified Frailty Index (5-mFI)35,36	Five core clinical indicators (eg, diabetes, hypertension, CHF, COPD, and functional status)	Electronic medical records or administrative databases	Based on objective clinical diagnoses; stable data acquisition; well suited for large-scale retrospective cohort studies	Focuses on cumulative comorbidity burden; limited reflection of dynamic physiological reserve and functional capacity
Hospital Frailty Risk Score (HFRS)37	Comorbidity and high-risk diagnostic clusters derived from ICD-10 codes	Automated extraction from hospital information systems	Highly automated; requires no additional bedside personnel; suitable for hospital-level management and large-scale research	Heavily dependent on coding accuracy; may miss undiagnosed functional decline; limited real-time bedside utility

Application of the Clinical Frailty Scale to Emergency Stratification

Among available instruments, the Clinical Frailty Scale (CFS) is particularly well suited to rapid stratification in older patients with ACC and AGP.^32,33 The CFS characterizes the patient’s status along a continuum from fit to severely frail on the basis of premorbid mobility, functional independence, and care dependency. It retains meaningful clinical interpretability while offering strong bedside practicality.³⁸ Compared with tools that require multiple variables or specialized testing, the CFS is more readily completed in the early emergency phase and provides a relatively unified risk language across surgical, gastroenterological, anesthetic, and geriatric medicine teams.³⁹

In practice, however, appropriate use of the CFS requires that scoring be anchored to the patient’s premorbid baseline rather than to the functional decline or increased dependency observed during the acute episode.⁴⁰ When necessary, scoring should incorporate collateral information from family members, caregivers, and the medical record. In elderly biliary emergencies, the CFS is not intended to replace disease-specific assessment but to add a stratification dimension that reflects baseline reserve. On the basis of these attributes, the subsequent discussion uses the CFS as the primary stratification tool to examine pathway differences across frailty tiers in ACC and AGP.

The CFS also has limitations. Assessor familiarity with the patient’s premorbid functional status varies, and a single score may be influenced by the information source and by subjective judgment.⁴¹ In the emergency setting, therefore, the CFS is best regarded as a bedside stratification tool rather than as a stand-alone pathway determinant. Nonetheless, compared with instruments that depend on administrative coding or multivariable retrospective aggregation,^35,37 the CFS can be obtained more rapidly and more directly addresses the functional reserve question that lies at the heart of clinical decision-making.

Current Guideline Recommendations and Their Limitations

Disease-Specific Guideline Pathways for ACC and AGP

Current guidelines for ACC and AGP share two broad objectives: control of the acute event and prevention of recurrent biliary complications, but the pathways differ between the two conditions. For ACC, the Tokyo Guidelines provide diagnostic criteria, severity grading, and a management flowchart that links treatment selection to disease severity, surgical risk, and institutional capability.^42,43 When surgery is appropriate, early laparoscopic cholecystectomy within the recommended early window, often operationalized as approximately 72 hours in surgical pathways, is generally favored; however, timing should be balanced against frailty, organ dysfunction, and anesthetic risk. Antibiotics and gallbladder drainage may be considered for patients with severe inflammation, organ dysfunction, or prohibitive short-term operative risk.^5,18,42,43

For AGP, management begins with supportive care, severity assessment, and evaluation for cholangitis, persistent biliary obstruction, or local complications.^6,7 Imaging and laboratory assessment are therefore essential before selecting the next step. ERCP is indicated when cholangitis or ongoing biliary obstruction is present, but routine early ERCP is not recommended in uncomplicated biliary pancreatitis without evidence of obstruction.⁴⁴ Cholecystectomy after acute stabilization remains important for preventing recurrent biliary events, although its timing should be individualized according to pancreatitis severity, organ-function recovery, and procedural tolerance.^45,46

These disease-specific pathways are broadly accepted, but frail older adults often require multidisciplinary interpretation. Surgeons, gastroenterologists, interventional radiologists, anesthesiologists, geriatricians, and, when relevant, cardiologists may need to jointly determine whether the immediate priority is definitive treatment, biliary decompression, bridge therapy, or goal-concordant supportive care. Thus, current guidelines define the standard direction of care, whereas frailty assessment helps determine how much of that pathway can be safely pursued, deferred, or modified in an individual older patient.

Boundaries of Guideline Applicability in Highly Frail Older Patients

The principal evidence informing current guidelines is drawn from randomized controlled trials, prospective cohort studies, or highly selected clinical samples.^47,48 These studies tend to enroll patients with a relatively stable baseline, preserved organ function, and the capacity to complete a standard treatment course, whereas the patients who pose the greatest decision-making challenge in clinical practice—those of advanced age, with multiple comorbidities, declining baseline function, or overt frailty—are typically underrepresented in the original evidence base.⁴⁹ The resulting issue is not that the guidelines themselves are flawed, but that an extrapolation gap exists between guideline recommendations and the real-world older emergency population (Table 2).

Table 2.

Guideline-Recommended Pathways for ACC and AGP and Their Applicability Boundaries in Highly Frail Older Patients

Disease	Standard Guideline-Recommended Pathway	Evidence Base and Target Population	Applicability Gap in Highly Frail Older Patients
Acute calculous cholecystitis (ACC)	Early control of acute infection; early laparoscopic cholecystectomy (LC) generally regarded as first-line treatment	Predominantly derived from RCTs or cohorts enrolling patients with stable baseline organ function	Highly frail patients are prone to postoperative decompensation; net benefit of early cholecystectomy remains uncertain; antibiotics alone or gallbladder drainage as bridging measures are more commonly used, but stratification criteria are poorly defined
Acute gallstone pancreatitis (AGP)	Timely ERCP when cholangitis or persistent biliary obstruction is present; cholecystectomy after acute stabilization to reduce recurrence	Populations able to tolerate the full bridge-to-definitive treatment pathway	Frail patients recover slowly with elevated perioperative risk; optimal timing of post-acute cholecystectomy cannot be determined by standard time windows alone; guidance for dynamic reassessment is lacking

This gap is apparent in both ACC and AGP. For ACC, although early cholecystectomy is widely recommended, the evidence remains insufficient to confirm whether highly frail patients derive a net benefit comparable to that observed in the general study population.⁴⁶ For AGP, the pathway from acute stabilization to cholecystectomy is relatively straightforward in mild cases,⁴⁵ but when frailty is pronounced, recovery is slow, or perioperative risk is elevated, optimal timing often cannot be determined from guideline recommendations alone.¹⁴ Moreover, although bridging strategies are widely employed in clinical practice, the supporting evidence is frequently limited by small sample sizes, selection bias, and treatment heterogeneity, and remains inadequate to support robust stratified recommendations.⁵⁰ In elderly biliary emergencies, therefore, guidelines can provide general direction but cannot cover every decision scenario encountered in highly frail patients—a reality that constitutes the practical rationale for incorporating frailty assessment into management pathways.

Impact of Frailty on Treatment Selection and Clinical Outcomes

Frail Patients are More Likely to Receive Conservative or Delayed Treatment

Observational evidence indicates that frailty not only affects prognosis in older patients with biliary emergencies but also alters the treatment pathways they actually receive. In a UK single-center observational cohort of 200 patients aged ≥75 years admitted with acute benign biliary disease, frailty was assessed at admission using the CFS; the rate of surgical intervention in the frail group (CFS 5–9) was only 2%, compared with 11% in the non-frail group (CFS 1–4), while percutaneous drainage was more common in the frail group (15% vs. 5%).⁵¹ Although this cohort encompassed cholecystitis, cholangitis, and pancreatitis, it clearly demonstrates that frail patients with biliary emergencies are more likely to be managed along conservative, bridging, or delayed surgical pathways.

This trend is also evident in disease-specific cohorts. For ACC, an analysis of the 2017 Nationwide Readmissions Database including 53,412 patients aged ≥65 years, with frailty assessed by the 5-factor modified Frailty Index (5-mFI), found that approximately 38.4% of patients classified as frail received non-operative management during the index hospitalization; this non-operative group was further subdivided into antibiotic-only and percutaneous drainage subgroups.⁵² For AGP, another national database study enrolling 29,130 frail older patients with AGP used propensity score matching to compare index-admission cholecystectomy with ERCP followed by non-operative management, and found that non-operative pathways were widely adopted among frail patients.⁵³ Overall, frailty in real-world practice tends to shift management away from early definitive intervention and toward more conservative or delayed pathways; however, this shift does not automatically translate into superior outcomes.

Frailty Severity is Consistently Associated with Adverse Outcomes

At the outcomes level, the evidence points consistently in one direction: the greater the degree of frailty, the higher the risk of adverse outcomes in older patients with biliary emergencies. The UK cohort described above showed that frail patients had longer hospital stays (12 vs. 7 days), more frequent functional deconditioning (34% vs. 11%), greater escalation of discharge care level (19% vs. 3%), and higher 90-day mortality (8% vs. 3%) and 1-year mortality (48% vs. 24%) compared with non-frail patients.⁵¹ Although this study was not restricted to ACC or AGP, its findings demonstrate that even within the spectrum of “benign biliary disease”, frailty per se is associated with worse short- and medium-term outcomes.

Disease-specific studies reinforce this observation. In the national database analysis of frail older patients with ACC, the 6-month failure rate among those managed non-operatively during the index admission was 18.9%; compared with the surgical group, antibiotics alone and percutaneous drainage were associated with higher mortality risk, with adjusted odds ratios of 1.59 (95% CI 1.35–1.88) and 1.91 (95% CI 1.55–2.36), respectively.⁵² In the frail older AGP cohort, patients who underwent index-admission cholecystectomy had lower 6-month readmission rates, fewer pancreas-related complications, lower overall mortality, and shorter cumulative hospital stays than the non-operative group; non-operative management had a 12% failure rate, and approximately 7% of patients were readmitted for cholecystectomy within 6 months, of whom 56% required unplanned surgery.⁵³ A separate national inpatient study encompassing 162,202 admissions for AGP, stratified by Hospital Frailty Risk Score, found that frail patients had a higher 30-day readmission rate than non-frail patients (12.58% vs. 7.09%), with an adjusted readmission odds ratio of 1.32 (95% CI 1.24–1.42) and a markedly elevated mortality hazard ratio of 5.43 (95% CI 4.06–7.29).⁵⁴ These findings suggest that frailty is not only associated with adverse outcomes but may also modulate the expected net benefit across different management pathways.

Value and Limitations of the Current Evidence

The available evidence supports incorporating frailty into clinical judgment for older patients with ACC and AGP, but it is not yet sufficient to derive a fixed algorithm. First, the key studies are predominantly retrospective observational analyses, administrative database studies, or single-center cohorts;^51–54 treatment pathways were not randomly assigned, and the selection of surgery, drainage, or conservative management was simultaneously influenced by disease severity, institutional experience, and perioperative conditions, making it difficult to fully disentangle baseline risk from treatment effect. Second, the frailty instruments used across studies are inconsistent—the CFS, 5-mFI, and HFRS capture different constructs^35–37—and outcome measures vary, including complications, short-term mortality, readmission, treatment failure, and long-term mortality. Third, some studies included the broader category of benign biliary emergencies rather than strictly defined ACC or AGP.⁵¹

Accordingly, the current evidence is best positioned to address three questions: whether frailty is associated with adverse outcomes; which pathways highly frail patients tend to follow in real-world practice; and where the boundaries of guideline applicability lie for this population. The CFS is adopted as the organizational framework for subsequent discussion primarily because of its superior bedside accessibility;³² however, the supporting evidence is not derived exclusively from CFS-based studies and also includes data from 5-mFI, HFRS, and studies that did not specify the frailty instrument. For this reason, the CFS-based stratification proposed here should be regarded as a clinical discussion framework rather than as empirically validated treatment thresholds. Key study characteristics are summarized in Table 3, and the corresponding CFS-informed evidence overview is summarized in Table 4.

Table 3.

Studies on Frailty and Treatment Outcomes in Geriatric ACC and AGP

Study Population and Disease	Study Design and Sample Size	Frailty Tool	Key Findings: Treatment Pathway Differences	Key Findings: Clinical Outcome Associations
Age >75, acute benign biliary disease admissions51	Single-center observational cohort (n = 200)	CFS	Surgery rate markedly lower in the frail group (2% vs 11%); percutaneous drainage more common (15% vs 5%)	Frail group had longer hospital stay (12 vs 7 days), greater functional deconditioning (34% vs 11%), higher 90-day mortality (8% vs 3%), and higher 1-year mortality (48% vs 24%)
Age ≥65, ACC52	Nationwide Readmissions Database, retrospective (n = 53,412)	5-mFI	Approximately 38.4% of patients classified as frail received non-operative management (antibiotics or drainage)	6-month failure rate in the non-operative group was 18.9%; mortality risk was higher with antibiotics alone and drainage compared with surgery (adjusted OR 1.59, 95% CI 1.35–1.88 and 1.91, 95% CI 1.55–2.36, respectively)
Frail older adults with AGP53	National database analysis with propensity score matching (n = 29,130)	Not explicitly specified	Non-operative management was widely adopted among frail patients	Non-operative group: 12% failure rate; ~7% readmitted for cholecystectomy within 6 months (56% unplanned); index cholecystectomy was associated with lower overall mortality and complications
AGP inpatient admissions54	National inpatient database, retrospective (n = 162,202)	HFRS	Treatment pathway differences not specifically compared	Frail patients had higher 30-day readmission rates (12.58% vs 7.09%); adjusted readmission risk increased (OR 1.32, 95% CI 1.24–1.42); mortality risk markedly elevated (HR 5.43, 95% CI 4.06–7.29)
Age ≥65, patients undergoing emergency cholecystectomy55	Prospective single-center study (n = 358)	CFS	Cohort limited to patients who had already undergone emergency cholecystectomy	Admission CFS score independently predicted major postoperative complications

Table 4.

Evidence Overview for CFS-Informed Clinical Stratification in Older Adults with ACC and AGP

Clinical Question	CFS Tier	Evidence-Informed Considerations	Primary Supporting Evidence	Evidence Type	Key Limitations
Potential suitability for standard surgical pathway	Low frailty (CFS 1–3)	Standard surgical management is often feasible if acute disease control and perioperative assessment are acceptable	Prospective single-center cohort (n = 358, age ≥65, emergency LC)	Prospective observational	Includes only operated patients; cannot define who should defer surgery
Possible need for bridge or staged pathway	Moderate frailty (CFS 4–6)	Bridge treatment may be used when immediate surgery is poorly tolerated; next-step decisions should follow repeat assessment	UK single-center cohort (n = 200, age ≥75, benign biliary disease, CFS-stratified)	Retrospective observational	Not ACC/AGP-specific; surgery rate in frail group was low; pathway allocation was not randomized
Risk associated with non-operative management	Moderate-to-severe frailty	Non-operative pathways may carry higher failure and mortality risk and should be discussed explicitly	National database analysis (n = 53,412, age ≥65, ACC, 5-mFI stratified)	Retrospective database study	Administrative data; 5-mFI emphasizes comorbidity more than function
Timing of post-acute cholecystectomy	Moderate-to-severe frailty	Timing should follow recovery trajectory rather than a fixed schedule	National database analysis (n = 29,130, frail older AGP, PSM comparison)	Retrospective database study with PSM	Frailty tool not clearly specified; residual confounding remains
Readmission and mortality risk across frailty tiers	All frailty tiers	Greater frailty burden is associated with higher 30-day readmission and mortality	National inpatient records (n = 162,202, AGP, HFRS-stratified)	Large retrospective database study	HFRS depends on ICD coding and has limited bedside utility
Need for treatment-goal reappraisal in severe frailty	Severe frailty (CFS 7–9)	Care may shift toward symptom control, lower treatment burden, and multidisciplinary goal setting	UK single-center cohort (1-year mortality 48%) + indirect clinical inference	Observational + indirect inference	No dedicated study defines treatment goals in severely frail older patients with biliary emergencies

CFS-Stratified Management Pathway Discussion

The CFS-informed groupings adopted in this review are intended to organize the discussion around three broad clinical scenarios—substantially preserved baseline reserve, borderline reserve, and substantial dependency or limited recovery potential—rather than to propose prospectively validated treatment thresholds.³⁸ The discussion within each tier focuses on the issues that warrant attention during pathway decision-making, not on prescriptive treatment protocols.

Patients with Low-Level Frailty (CFS 1–3)

Patients with low-level frailty generally retain adequate functional status and organ reserve. In this tier, the principal role of frailty assessment is not to de-escalate treatment intensity but to confirm that most patients can proceed along standard pathways while alerting the clinical team to perioperative issues common in older adults.⁵⁶ For ACC, early cholecystectomy generally remains the preferred approach provided that infection is controlled and anesthetic assessment is satisfactory;⁴² for AGP, cholecystectomy following acute stabilization remains the standard strategy for recurrence prevention.⁴⁵

However, “suitable for the standard pathway” does not mean replicating the tempo of management in younger patients. Delirium, cognitive fluctuations, nutritional decline, and reduced mobility can all affect final outcomes.^55,56 Database studies suggest that frail older patients with ACC who receive non-operative management experience more adverse outcomes,⁵² but such findings are substantially confounded by indication and cannot be directly interpreted as evidence that surgery is invariably superior to conservative management. A more prudent interpretation is that patients with reasonably preserved baseline reserve should not be defaulted away from the standard pathway on the basis of age alone, and that bridging interventions are more appropriately reserved for those whose current risk profile is elevated but who may still tolerate definitive treatment at a later stage.⁵¹

Patients with Moderate Frailty (CFS 4–6)

Patients with moderate frailty are often the most challenging to manage, as they are neither suitable for straightforward application of the standard pathway nor ready to be committed to long-term conservative management at the time of admission.⁵⁷ For ACC, when infection remains uncontrolled, the local inflammatory burden is high, or short-term surgical risk is elevated, percutaneous gallbladder drainage or antibiotic therapy may address the immediate problem;⁵ however, bridging treatment should not be allowed to become the de facto definitive plan, and subsequent reassessment of infection control, functional recovery, and overall tolerance is needed to determine whether delayed surgery remains appropriate.⁸ For AGP, the decision to proceed with cholecystectomy after supportive care should not rest on a single time point but should integrate organ function recovery, nutritional status, and functional trajectory.⁵³

The two most common pitfalls at this tier are, first, moving too quickly by treating moderately frail patients as though they were in the low-frailty tier, and second, moving too slowly by indefinitely deferring further intervention after bridging.⁵⁸ The former risks perioperative stress that exceeds the patient’s reserve; the latter effectively converts a bridging strategy into permanent conservative management. For this group, the more appropriate approach is not to impose a fixed timetable but to reassess iteratively once the acute event has resolved: has the patient now reached a condition that permits advancement to the next step?

Patients with Severe Frailty (CFS 7–9)

In patients with severe frailty, the focus typically shifts from completing the full standard definitive pathway to first articulating the current goals of care.⁵⁹ For these patients, infection control, symptom relief, minimization of additional physiological insults, and preservation of existing function are often more realistic objectives than long-term recurrence prevention. For ACC, once the acute infection is controlled, whether to proceed with subsequent definitive intervention should be determined on the basis of the recovery trajectory, long-term functional prognosis, and patient preferences;⁵⁷ for AGP, management of obstruction or infection may still be necessary, but post-acute cholecystectomy should not be assumed as the default pathway.⁵³

Severe frailty does not equate to treatment withdrawal. What it signals is a shift in treatment goals.⁶⁰ At this tier, the patient’s values, family caregiving capacity, and long-term care arrangements directly influence pathway decisions; consequently, linear decision-making by a single specialty is often insufficient.⁶¹

An Integrated Decision Framework

Dual-Axis Assessment and Pathway Allocation at Admission

The organizing perspective of this review places two questions side by side at the time of admission: first, how severe is the current acute event; and second, how depleted is the patient’s baseline reserve.^13,19 The former is addressed primarily through infection severity, organ function status, and biliary obstruction findings—dimensions for which current guidelines already offer relatively clear grading criteria.^5,6 The latter is less well integrated into standard decision-making and is where frailty assessment, with the CFS as the bedside tool adopted in this review, provides the most direct operational handle.^32,38 Pathway decisions based predominantly on disease severity risk overlooking the genuine heterogeneity in stress tolerance that exists among older patients with nominally similar disease presentations;⁹ conversely, decisions based predominantly on frailty risk under-weighting time-sensitive disease features that demand prompt intervention regardless of baseline status. Neither axis is sufficient alone. In practice the two operate together, and the pathway appropriate for a given patient is best understood as lying at their intersection rather than along either axis considered in isolation.

Within this organizing perspective, patients with low-level frailty can generally be managed along standard pathways; those with moderate frailty require repeated reassessment after bridging interventions; and those with severe frailty should first establish the current goals of care before discussing whether further invasive management is warranted. This stratification serves to clarify the sequence of clinical reasoning, not to prescribe a fixed algorithm.

Reassessment Nodes and Pathway Switching Triggers

After initial management, the key question is not merely “wait and observe” but rather when to formally reassess the pathway.⁶² For moderately frail patients who have undergone bridging, reassessment should not be indefinitely deferred; it should take place as soon as initial improvement in infection control, organ function, and global status is observed.⁵⁸ For ACC, reassessment focuses on three domains: whether infection has been controlled, whether mobility has recovered, and whether nutrition and overall tolerance have improved relative to the admission state. For AGP, the emphasis is on whether local complications have stabilized and whether the patient has recovered to a level that permits further intervention.^6,45

Pathways should also accommodate adjustment. If infection control is inadequate, functional status continues to decline, or the patient and family reassess their treatment goals, the existing plan should be revisited.^59,61 For patients with moderate-to-severe frailty, pathway changes during hospitalization are not uncommon and do not necessarily indicate that earlier decisions were wrong; rather, they reflect the inherent trajectory variability in this population (Figure 1).

Figure 1.

CFS-informed clinical framework for older adults with ACC and AGP. Early assessment should consider both acute disease severity and premorbid baseline functional status. CFS 1–3, CFS 4–6, and CFS 7–9 are used as pragmatic clinical groupings to organize pathway discussion rather than as prospectively validated treatment thresholds. CFS 1–3: standard surgical pathways may still be suitable when tolerated; CFS 4–6: bridge treatment may be used, followed by repeat assessment of recovery trajectory; CFS 7–9: management may shift toward supportive, goal-concordant care with multidisciplinary input. This framework is intended to support, not replace, guideline-based decision-making.

Additional Clinical Modifiers

In addition to frailty and acute disease severity, pathway selection may be influenced by disease-specific and patient-level modifiers. Imaging evaluation should precede definitive treatment decisions when common bile duct stones, cholangitis, local pancreatic complications, or atypical anatomy are suspected. Liver function, coagulation status, major cardiopulmonary comorbidities, and institutional expertise may further shape the feasibility and timing of ERCP, gallbladder drainage, or surgery. In selected complex biliary cases, advanced endoscopic or percutaneous approaches, including peroral or percutaneous cholangioscopy-assisted stone management, may be considered as adjuncts to guideline-based care when conventional biliary clearance is difficult or ductal pathology remains uncertain.⁶³ These considerations reinforce the need for multidisciplinary interpretation rather than reliance on disease severity or frailty status alone.

Strengths and Limitations

This review has several strengths. It addresses a common but insufficiently standardized decision problem in older adults with ACC and AGP, integrates disease-specific guideline pathways with frailty assessment, and explicitly distinguishes a CFS-informed clinical reasoning framework from a validated treatment algorithm. The proposed framework may also facilitate communication among surgical, gastroenterological, anesthetic, geriatric, and interventional teams.

Several limitations should be acknowledged. This is a narrative review rather than a systematic review or meta-analysis, and formal risk-of-bias assessment was not performed. The available evidence is dominated by retrospective cohorts, administrative database studies, and studies using different frailty instruments, including the CFS, 5-mFI, and HFRS. Evidence specific to CFS-guided treatment selection in older adults with ACC or AGP remains limited; therefore, the proposed stratification should not be interpreted as prospectively validated treatment thresholds. Finally, disease-specific factors such as biliary anatomy, stone burden, local complications, liver function, coagulation status, and institutional expertise may modify management decisions beyond frailty status alone.

Conclusion

Frailty should be incorporated into early decision-making for older adults with ACC and AGP, not passively identified at the perioperative endpoint. Considered alongside acute disease severity as a parallel axis of admission assessment, baseline physiological reserve reframes pathway selection from a disease-driven decision into a patient–disease decision. The CFS offers a rapid, bedside-accessible means of gauging premorbid functional reserve and, in our view, is the most practical tool currently available for operationalizing this second axis in the emergency setting; however, as the supporting evidence remains predominantly observational and the frailty instruments used across studies are not uniform, the CFS-based stratification discussed here is best regarded as a clinical organizing perspective rather than a validated algorithm. Within this perspective, low-frailty patients can generally follow standard pathways; moderate-frailty patients require iterative reassessment after bridging; and severe-frailty patients should first establish explicit goals of care before further invasive management is pursued.

Several specific questions warrant prospective investigation. First, whether moderately frail older ACC patients managed with percutaneous cholecystostomy followed by delayed laparoscopic cholecystectomy differ from those managed with long-term antibiotic strategies in 1-year composite outcomes of mortality, functional deconditioning, and readmission. Second, whether index-admission cholecystectomy in frail AGP patients offers a net benefit over a watchful waiting strategy when results are stratified by CFS tier rather than pooled. Third, whether structured CFS-informed admission assessment, compared with usual care, alters pathway selection, perioperative decision timing, and patient-centered outcomes. CFS-stratified multicenter prospective cohorts or target trial emulation using high-quality registry data would be needed to address these questions; until such evidence accrues, the stratification discussed here should be used to support, not to replace, individualized clinical judgment.

Funding Statement

There is no funding to report.

Data Sharing Statement

Data sharing is not applicable to this article as no new datasets were generated or analyzed during the current study.

Ethical Approval and Consent to Participate

Not applicable. This study is a narrative review based on previously published studies. Therefore, ethical approval and consent to participate were not required.

Consent for Publication

Not applicable. This study does not contain any individual person’s data in any form.

Author Contributions

Ting Hua and Guoxing Jin contributed equally to this work and performed the literature search, evidence synthesis, and initial manuscript drafting. Jinfeng Zhao, as the corresponding author, conceptualized and designed the study, supervised the work, and critically revised the manuscript for important intellectual content. All authors made a significant contribution to the work reported, whether that is in the conception, study design, execution, acquisition of data, analysis and interpretation, or in all these areas; took part in drafting, revising or critically reviewing the article; gave final approval of the version to be published; have agreed on the journal to which the article has been submitted; and agree to be accountable for all aspects of the work.

Disclosure

All authors declared no potential conflicts of interest with respect to the research, authorship, and publication of this article.