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Page 4 of 9 Sioutas et al. Hepatoma Res 2020;6:4 I http://dx.doi.org/10.20517/2394-5079.2019.43

Figure 2. “Deficit Accumulation Index” by Rockwood et al. [15]

standpoints, including physical medical comorbidities, nutritional status, mental and cognitive status,
physical functioning and fitness, social networking, and environmental status [50,51] . A downside that CGA
[51]
shares with FI is that it is time-consuming, mostly due to its complexity . Two screening tools that can
help identify elderly patients who will benefit from a more comprehensive assessment with the CGA are
the Geriatric-8 (G8) and the Vulnerable Elders Survey-13 (VES-13) . Those take into consideration age,
[52]
[53]
self-rated health, and physical function along with other factors , and both of them take only 5 min to
complete . The first one is specifically designed to identify vulnerable older patients with cancer, while
[52]
the latter is designed to detect vulnerable older patients in the community. Hence, G8 was found to be
predictive of postoperative complications in elderly patients with HCC, while VES-13 was not shown to
[53]
have a predictive role . The abbreviated CGA is another screening tool for elderly cancer patients that
incorporates only the 15 most important items of the full assessment tool and requires only 5 min to
complete [54,55] .

The FRAIL (Fatigue, Resistance, Ambulation, Illness, and weight Loss) index is another easy to complete
[56]
screening tool that deems patients frail if three or more of its components are present . A great advantage
of this scale is that it has been validated not only in the elderly but also in middle-aged individuals [56,57] .
On the other hand, the Edmonton Frail Scale (EFS) assesses the patients’ health over ten frailty domains
(including cognition, general health status, mood, continence, functional performance and independence,
[58]
social support, polypharmacy, and nutrition) . A score below 5 indicates the “no frailty” patients, a
score between 6 and 11 identifies the “apparently vulnerable” individuals, and a score between 12 and 17
[59]
distinguishes the “severe frailty” patients . Studies have shown that EFS is a valid and accurate tool that
can be efficiently administered by non-geriatricians to assess and preoperatively optimize geriatric patients
with or without cancer [58,60,61] . The Clinical Frailty Scale (CFS) is another quick frailty assessment tool based
[62]
on clinical judgment . Data suggest that it can accurately identify patients who may need institutional
[62]
care, as well as those less likely to survive . Data have shown that CFS can reliably distinguish patients
[63]
who are going to have a complicated course and prolonged LOS while in the acute medical ward . A
screening tool for frailty broadly used in Japan is the Kihon Checklist (KCL) . KCL is a self-reporting
[64]
“yes/no” survey that can help clinicians assess the status of older individuals in several frailty domains
(functional, physical, psychological, and social) .
[65]
Moreover, there are some single item tools that are less comprehensive but can serve as quick and easy to
apply screening tools. The most common tool falling into this category is the handgrip test, which utilizes
[52]
a hydraulic hand dynamometer to evaluate the maximum strength of the dominant hand . Its role in
distinguishing “fit” from “frail” older individuals has been validated not only in the general population but
also in cancer patients, as handgrip strength is highly associated with survival outcomes [52,66] . Although the