Comment to “Association between preoperative frailty and postoperative delirium and cognitive dysfunction in elderly patients undergoing surgery under general anaesthesia”

Dear Editor, I read with interest the article titled ‘Association between preoperative frailty and postoperative delirium and cognitive dysfunction in elderly patients undergoing surgery under general anaesthesia’ by Anjaleekrishna et al.1 The study is well-conducted. It provides valuable insights into the predictive role of frailty, as assessed by the 5-factor modified frailty index (5mFI), on postoperative neurocognitive outcomes. However, there are certain concerns. The statement ‘Our study proves the hypothesis that frailty, apart from age, contributes to POD and POCD’ is not consistent with the nature of the study design. This was a prospective observational cohort study, which, although robust for identifying associations and adjusting for confounders, cannot establish causality.2 The term ‘proves’ implies a causal relationship, which is more appropriately demonstrated through randomised controlled trials or advanced statistical methods, such as causal inference modelling, instrumental variable analysis, or propensity score matching. The study’s strength lies in demonstrating a statistically significant association between higher 5mFI scores and increased risk of postoperative delirium and postoperative cognitive dysfunction, with ORs of 2.933 and 5.380, respectively. These findings underscore the clinical importance of frailty screening during preoperative assessments. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest. Presentation at conferences/CMEs and abstract publication None Study data availability Not applicable. Disclosure of use of artificial intelligence (AI)-assistive or generative tools Choose any ONE The AI tools or language models (LLM) have not been utilised in the manuscript, except that software has been used for grammar corrections and references. Declaration of Use of Permitted Tools Choose any ONE Not applicable. Authors contributions AK: Concepts and manuscript preparation, TB: Manuscript Preparation Supplementary material None.