Refinement and validation of the IDIOM score for predicting the risk of gastrointestinal cancer in iron deficiency anaemia

OBJECTIVE

To refine and validate a model for predicting the risk of gastrointestinal (GI) cancer in iron deficiency anaemia (IDA) and to develop an app to facilitate use in clinical practice.

DESIGN

Three elements: (1) analysis of a dataset of 2390 cases of IDA to validate the predictive value of age, sex, blood haemoglobin concentration (Hb), mean cell volume (MCV) and iron studies on the probability of underlying GI cancer; (2) a pilot study of the benefit of adding faecal immunochemical testing (FIT) into the model; and (3) development of an app based on the model.

RESULTS

Age, sex and Hb were all strong, independent predictors of the risk of GI cancer, with ORs (95% CI) of 1.05 per year (1.03 to 1.07, p<0.00001), 2.86 for men (2.03 to 4.06, p<0.00001) and 1.03 for each g/L reduction in Hb (1.01 to 1.04, p<0.0001) respectively. An association with MCV was also revealed, with an OR of 1.03 for each fl reduction (1.01 to 1.05, p<0.02). The model was confirmed to be robust by an internal validation exercise. In the pilot study of high-risk cases, FIT was also predictive of GI cancer (OR 6.6, 95% CI 1.6 to 51.8), but the sensitivity was low at 23.5% (95% CI 6.8% to 49.9%). An app based on the model was developed.

CONCLUSION

This predictive model may help rationalise the use of investigational resources in IDA, by fast-tracking high-risk cases and, with appropriate safeguards, avoiding invasive investigation altogether in those at ultra-low predicted risk.

Study protocol for a cluster randomised controlled feasibility trial evaluating personalised care planning for older people with frailty: PROSPER V2 27/11/18

Background

Frailty is characterised by increased vulnerability to falls, disability, hospitalisation and care home admission. However, it is relatively reversible in the early stages. Older people living with frailty often have multiple health and social issues which are difficult to address but could benefit from proactive, person-centred care. Personalised care planning aims to improve outcomes through better self-management, care coordination and access to community resources.

Methods

This feasibility cluster randomised controlled trial aims to recruit 400 participants from 11 general practice clusters across Bradford and Leeds in the north of England. Eligible patients will be aged over 65 with an electronic frailty index score of 0.21 (identified via their electronic health record), living in their own homes, without severe cognitive impairment and not in receipt of end of life care. After screening for eligible patients, a restricted 1:1 cluster-level randomisation will be used to allocate practices to the PROSPER intervention, which will be delivered over 12 weeks by a personal independence co-ordinator worker, or usual care. Following initial consent, participants will complete a baseline questionnaire in their own home including measures of health-related quality of life, activities of daily living, depression and health and social care resource use. Follow-up will be at six and 12 months. Feasibility outcomes relate to progression criteria based around recruitment, intervention delivery, retention and follow-up. An embedded process evaluation will contribute to iterative intervention optimisation and logic model development by examining staff training, intervention implementation and contextual factors influencing delivery and uptake of the intervention.

Discussion

Whilst personalised care planning can improve outcomes in long-term conditions, implementation in routine settings is poor. We will evaluate the feasibility of conducting a cluster randomised controlled trial of personalised care planning in a community population based on frailty status. Key objectives will be to test fidelity of trial design, gather data to refine sample size calculation for the planned definitive trial, optimise data collection processes and optimise the intervention including training and delivery.

Trial registration

ISRCTN12363970 – 08/11/18.

Moving Towards Common Data Elements and Core Outcome Measures in Frailty Research

With aging populations around the world, frailty is becoming more prevalent increasing the need for health systems and social systems to deliver optimal evidence based care. However, in spite of the growing number of frailty publications, high-quality evidence for decision making is often lacking. Inadequate descriptions of the populations enrolled including frailty severity and frailty conceptualization, lack of use of validated frailty assessment tools, utilization of different frailty instruments between studies, and variation in reported outcomes impairs the ability to interpret, generalize and implement the research findings. The utilization of common data elements (CDEs) and core outcome measures (COMs) in clinical trials is increasingly being adopted to address such concerns. To catalyze the development and use of CDEs and COMs for future frailty studies, the Canadian Frailty Network (www.cfn-nce.ca; CFN), a not-for-profit pan-Canadian nationally-funded research network, convened an international group of experts to examine the issue and plan the path forward. The meeting was structured to allow for an examination of current frailty evidence, ability to learn from other COMs and CDEs initiatives, discussions about specific considerations for frailty COMs and CDEs and finally the identification of the necessary steps for a COMs and CDEs consensus initiative going forward. It was agreed at the onset of the meeting that a statement based on the meeting would be published and herein we report the statement.

Recruiting older people from the Pakistani community in Community Ageing Research 75

Older people from a South Asian background, particularly Pakistanis, are under-represented in health research, possibly because their recruitment to studies is hampered by language barriers and cultural differences. This article describes the observations of two bi-lingual researchers (FM and IJ) who successfully recruited older people (≥75 years) from Bradford's South Asian population to the Community Ageing Research 75+ Study (CARE 75+), a longitudinal cohort study collecting an extensive range of health, social and economic outcome data. The researchers recruited non-English-speaking Pakistani participants, ensuring they were flexible with appointments to accommodate the wishes of family members, who were often present during consent and assessment visits. Using community language was an important facilitator, and questions (and constructs) were translated to the community dialect (Potwari). To date, 233 South Asian people have been invited to participate in CARE75+, and 78 have been recruited (recruitment rate=33%), of which 62 are of Pakistani origin. The observed recruitment rate for South Asian participants is comparable to that of the whole study population (36%). Language barriers should not be used as a basis for excluding participants from research studies. Appropriate facilitation, through skilled researchers who have knowledge of, and are attuned to, the cultural sensitivities of the community, can allow recruitment of BME participants to research studies.

Content of exercise programmes targeting older people with sarcopenia or frailty - findings from a UK survey

OBJECTIVES

To establish whether existing exercise programmes offered to people with sarcopenia or frailty adhere to the current evidence base.

METHODS

We conducted a national survey of practitioners delivering exercise programmes to older people with sarcopenia or frailty in the UK. The link to the online survey was distributed through email lists of professional societies, practice networks and social media. Questions covered target population and programme aims, type, duration and frequency of exercise, progress assessment and outcome measures.

RESULTS

One hundred and thirty-six responses were received. 94% of respondents reported prescribing or delivering exercise programmes to people with sarcopenia or frailty. Most programmes (81/135 [60%]) were primarily designed to prevent or reduce falls. Resistance training was the main focus in only 11/123 (9%), balance training in 61/123 (50%) and functional exercise in 28/123 (23%). Exercise was offered once a week or less by 81/124 (65%) of respondents. Outcome measures suitable for assessing the effect of resistance training programmes were reported by fewer than half of respondents (hand grip: 13/119 [11%]; chair stands: 55/119 [46%]).

CONCLUSIONS

Current UK exercise programmes offered to older people with sarcopenia or frailty lack the specificity, frequency or duration of exercise likely to improve outcomes for this patient group.

Dynamic contrast-enhanced computed tomography for the diagnosis of solitary pulmonary nodules: a systematic review and meta-analysis

INTRODUCTION

A systematic review and meta-analysis were performed to determine the diagnostic performance of dynamic contrast-enhanced computed tomography (DCE-CT) for the differentiation between malignant and benign pulmonary nodules.

METHODS

Ovid MEDLINE and EMBASE were searched for studies published up to October 2018 on the diagnostic accuracy of DCE-CT for the characterisation of pulmonary nodules. For the index test, studies with a minimum of a pre- and post-contrast computed tomography scan were evaluated. Studies with a reference standard of biopsy for malignancy, and biopsy or 2-year follow-up for benign disease were included. Study bias was assessed using QUADAS-2 (Quality Assessment of Diagnostic Accuracy Studies). The sensitivities, specificities, and diagnostic odds ratios were determined along with 95% confidence intervals (CIs) using a bivariate random effects model.

RESULTS

Twenty-three studies were included, including 2397 study participants with 2514 nodules of which 55.3% were malignant (1389/2514). The pooled accuracy results were sensitivity 94.8% (95% CI 91.5; 96.9), specificity 75.5% (69.4; 80.6), and diagnostic odds ratio 56.6 (24.2-88.9). QUADAS 2 assessment showed intermediate/high risk of bias in a large proportion of the studies (52-78% across the domains). No difference was present in sensitivity or specificity between subgroups when studies were split based on CT technique, sample size, nodule size, or publication date.

CONCLUSION

DCE-CT has a high diagnostic accuracy for the diagnosis of pulmonary nodules although study quality was indeterminate in a large number of cases.

KEY POINTS

• The pooled accuracy results were sensitivity 95.1% and specificity 73.8% although individual studies showed wide ranges of values. • This is comparable to the results of previous meta-analyses of PET/CT (positron emission tomography/computed tomography) diagnostic accuracy for the diagnosis of solitary pulmonary nodules. • Robust direct comparative accuracy and cost-effectiveness studies are warranted to determine the optimal use of DCE-CT and PET/CT in the diagnosis of SPNs.

85 A Cross-Sectional Study Assessing Agreement Between Self-Reported and General Practice Recorded Health Conditions Among Community Dwelling Older Adults

Introduction

Self-reported data regarding health conditions are utilised in both clinical practice and research, however, their agreement with general practice records is variable. The extent of this variability is poorly studied among older adults, particularly among those with multiple health conditions, cognitive impairment or frailty. This study investigates the agreement between self-reported and general practice recorded data among such patients and the impact of participant factors on this agreement.

Methods

Data on health conditions was collected from participants in the Community Ageing Research 75+ (CARE75+) study (n=964) by self-reporting during face to face assessment and interrogation of the participants’ practice health records. Agreement between self-report and practice records was assessed using Kappa statistics and the effect of participant demographics using logistic regression.

Results

Agreement ranged from K=0.25-1.00. The presence of ≥2 health conditions modified agreement for cancer (odds ratio, OR:0.62, 95% confidence interval, CI:0.42-0.94), diabetes (OR:0.55, 95%CI:0.38-0.80), dementia (OR:2.82, 95%CI:1.31-6.13) and visual impairment (OR:3.85, 95%CI:1.71-8.62). Frailty reduced agreement for cerebrovascular disease (OR:0.45, 95%CI:0.23-0.89), heart failure (OR:0.40, 95%CI:0.19-0.84) and rheumatoid arthritis (OR:0.41, 95%CI:0.23-0.75). Cognitive impairment reduced agreement for dementia (OR:0.36, 95%CI:0.21-0.62), diabetes (OR:0.47, 95%CI:0.33-0.67), heart failure (OR:0.53, 95%CI:0.35-0.80), visual impairment (OR:0.42, 95%CI:0.25-0.69) and rheumatoid arthritis (OR:0.53, 95%CI:0.37-0.76).

Conclusions

Significant variability exists for agreement between self-reported and general practice recorded comorbidities. This is further affected by individuals’ baseline demographics. This study is the first to assess frailty as a factor modifying agreement and highlights the importance of utilising the general practice records as the gold standard for data collection from older adults.

A cross-sectional study assessing agreement between self-reported and general practice-recorded health conditions among community dwelling older adults

BACKGROUND

self-reported data regarding health conditions are utilised in both clinical practice and research, but their agreement with general practice records is variable. The extent of this variability is poorly studied amongst older adults, particularly amongst those with multiple health conditions, cognitive impairment or frailty. This study investigates the agreement between self-reported and general practice-recorded data amongst such patients and the impact of participant factors on this agreement.

METHODS

data on health conditions was collected from participants in the Community Ageing Research 75+ (CARE75+) study (n = 964) by self-report during face-to-face assessment and interrogation of the participants' general practice electronic health records. Agreement between self-report and practice records was assessed using Kappa statistics and the effect of participant demographics using logistic regression.

RESULTS

agreement ranged from K = 0.25 to 1.00. The presence of ≥2 health conditions modified agreement for cancer (odds ratio, OR:0.62, 95%confidence interval, CI:0.42-0.94), diabetes (OR:0.55, 95%CI:0.38-0.80), dementia (OR:2.82, 95%CI:1.31-6.13) and visual impairment (OR:3.85, 95%CI:1.71-8.62). Frailty reduced agreement for cerebrovascular disease (OR:0.45, 95%CI:0.23-0.89), heart failure (OR:0.40, 95%CI:0.19-0.84) and rheumatoid arthritis (OR:0.41, 95%CI:0.23-0.75). Cognitive impairment reduced agreement for dementia (OR:0.36, 95%CI:0.21-0.62), diabetes (OR:0.47, 95%CI:0.33-0.67), heart failure (OR:0.53, 95%CI:0.35-0.80), visual impairment (OR:0.42, 95%CI:0.25-0.69) and rheumatoid arthritis (OR:0.53, 95%CI:0.37-0.76).

CONCLUSIONS

significant variability exists for agreement between self-reported and general practice-recorded comorbidities. This is further affected by an individual's health conditions. This study is the first to assess frailty as a factor modifying agreement and highlights the importance of utilising the general practice records as the gold standard for data collection from older adults.

AM I FRAIL, LOVE? YES, I SUPPOSE I AM: WHAT 10 OLDER PEOPLE CAN TELL US ABOUT LIVING WITH FRAILTY

We sought to explore what matters in later life with frailty from an older persons perspective. Between March and May 2018, we recruited ten people, purposively sampled from the CARE75+ ageing cohort study. Interviews took place at the participant’s own home in two sittings, each 45 minutes long. Interviews were semi-structured, used narrative techniques based on a topic guide developed with a patient representative. We used systematic analysis of the narrative experience to identify meaning in the context of an individual’s time, space and history. Participants had a mean age of 84 years (range 77 to 93), half were women, and three were interviewed with their care-givers. All had moderate or severe frailty: mean frailty index 0.36 (range 0.25 to 0.47); mean Fried score 4 (range 3 -5). Half knew hunger as children; most grew up in large families and left school early; two survived TB in early life; all lived through or were affected by war. The term frailty was: never voluntarily used; described negatively and in value laden terms; seen better in others than themselves. Decision making was best delegated to doctors who knew you and your family over time. Narratives focused on health events of a spouse; symptoms featured more than diagnoses. Survivorship, reciprocity and community were sustaining values. To engage elders in shared decision making we learnt to consider influences of cohort, of people closest to them; and to describe rather than declare someone to be frail, in terms that are real to them.

P2524Extent and outcomes of frailty in older people with atrial fibrillation: a nationwide study using primary care data

Background

The prevalence of atrial fibrillation (AF) in older people is increasing, as is frailty. Frailty describes an increased vulnerability to adverse outcomes, whereby the balance of risk and benefit associated with an intervention may be more nuanced. However, there are limited data from a community setting on the prevalence of AF and frailty in older people.

It is important to understand the burden of AF and frailty, and the associated impact on mortality and stroke disease in order to inform shared decision making with patients, and also inform guidelines for this increasing group of older people.

Purpose

To estimate the prevalence of AF and the burden of frailty in patients with AF, in a large primary care dataset. To report stroke and mortality by frailty group.

Methods

We used electronic health records of 537,051 patients in England aged 65 years or older on 31/12/2015, with follow-up for all-cause mortality and ischaemic or unclassified stroke to 11/04/2017. Patients with a history of AF were identified using Clinical Terms Version 3 (CTV-3) codes. Frailty was identified up to the point of study entry using the electronic frailty index (eFI, the proportion of deficits out of 36 possible deficits), and categorised into robust (0–0.12), mild (>0.12–0.24), moderate (>0.24–0.36) or severe (>0.36) frailty.

Median CHA2DS2-VASc and ATRIA scores for patients with frailty were compared with the robust group using Mann-Whitney.

The association between frailty status, all-cause mortality and stroke was calculated using Cox proportional hazards models, adjusted for age and sex.

Results

Of the cohort, 61,177 patients (11.4%) had AF. Of those with AF, 27,987 (45.8%) were female, and 54,734 (89.5%) had frailty. 6,443 (10.5%) were classified as robust; 20,352 (33.3%) mildly frail; 20,315 (33.2%) moderately frail; and 14,067 (23.0%) severely frail.

The median number of eFI-defined deficits among patients with AF was 9 (interquartile range [IQR] 6–12). Median stroke and bleeding scores were higher in those with frailty compared with the robust group (CHA2DS2-VASc 4 [IQR 3–5] v 2 [2–3], p≤0.001; ATRIA 4 [2–6] v 1 [0–2], p≤0.001).

During 73,338 patient-years of follow-up, there were 6,805 (11.1%) deaths and 945 (1.54%) strokes. Compared with the robust group, all-cause mortality and stroke were higher with increasing frailty. Mortality: mild frailty hazard ratio 1.53 (95% confidence interval 1.29–1.80); moderate frailty 2.50 (2.13–2.94); severe frailty 4.26 (3.63–5.01). Stroke: mild frailty 1.36 (0.99–1.85); moderate frailty 1.67 (1.23–2.28); severe 1.99 (1.45–2.73).

Kaplan-Meier survival curves by frailty

Conclusion

The prevalence of AF among those aged over 65 years in primary care in England is high, the majority of whom are frail. Increasing severity of frailty was associated with higher mortality and stroke rates.

The extent to which the judicious use of oral anticoagulation may improve clinical outcomes for patients with AF and frailty is currently unknown.

Acknowledgement/Funding

CPG: Bayer, BMS, AstraZeneca, Novartis Vifor Pharma, Menerini

269 Early Identification of Frailty: Developing an International Delphi Consensus for a Definition of Pre-frailty

Background

Frailty is associated with a prodromal stage called pre-frailty, a potentially reversible and highly prevalent condition before frailty becomes established. Despite this, there is no widely accepted definition of pre-frailty to support its early identification and management. This study applied an international consensus approach to define and better understand pre-frailty.

Methods

A modified electronic two-round Delphi Consensus study was conducted. In all, 23 experts from 12 countries with different backgrounds participated. The questionnaire was developed following a systematic literature review. An online consensus meeting was conducted with eight Delphi participants and two external experts. Qualitative and quantitative methods were employed for data analysis. An agreement level of 70% was applied for accepting statements.

Results

A total of 71 statements were circulated in Round 1. Of these, 52.8% were accepted. Fifty-one statements were re-circulated in Round 2, of which 92.1% were accepted. The online consensus meeting produced a consensus statement describing the concept, multi-factorial nature, and mechanism of pre-frailty as well as assessment, prevention and management approaches. All experts agreed that physical and non-physical factors such as psychological and social capacity are involved in the development of pre-frailty, potentially adversely affecting health and health-related quality of life outcomes. Practitioners should regard pre-frailty as a multi-factorial, multi-dimensional, and non-linear process that does not inevitably lead to frailty. It might be reversed or attenuated by targeted interventions. Brief, feasible and validated tools are recommended for opportunistic screening or case-finding followed by confirmation with multi-dimensional assessment.

Conclusion

It is difficult to establish consensus on one compact definition of pre-frailty, which is a multi-dimensional concept not only associated with physical impairment, but also with cognitive, nutritional, socioeconomic and other aspects of frailty. However, it may be too early to agree on an operational definition of pre-frailty since none yet exists for frailty.

Interventions for maintenance of surgically induced remission in Crohn's disease: a network meta-analysis

BACKGROUND

Crohn's disease (CD) is a chronic disease of the gut. About 75% of people with CD undergo surgery at least once in their lifetime to induce remission. However, as there is no known cure for the disease, patients usually experience a recurrence even after surgery. Different interventions are routinely used in maintaining postsurgical remission. There is currently no consensus on which treatment is the most effective.

OBJECTIVES

To assess the effects and harms of interventions for the maintenance of surgically induced remission in Crohn's disease and rank the treatments in order of effectiveness.

SEARCH METHODS

We searched the Cochrane IBD Group Specialized Register, CENTRAL, MEDLINE, and Embase from inception to 15 January 2019. We also searched reference lists of relevant articles, abstracts from major gastroenterology meetings, ClinicalTrials.gov, and the WHO ICTRP. There was no restriction on language, date, or publication status.

SELECTION CRITERIA

We considered for inclusion randomised controlled trials (RCTs) that compared different interventions used for maintaining surgically induced remission in people with CD who were in postsurgical remission. Participants had to have received maintenance treatment for at least three months. We excluded studies assessing enteral diet, diet manipulation, herbal medicine, and nutritional supplementation.

DATA COLLECTION AND ANALYSIS

Two review authors independently selected relevant studies, extracted data, and assessed the risk of bias. Any disagreements were resolved by discussion or by arbitration of a third review author when necessary. We conducted a network meta-analysis (NMA) using a Bayesian approach through Markov Chain Monte Carlo (MCMC) simulation. For the pairwise comparisons carried out in Review Manager 5, we calculated risk ratios (RR) with their corresponding 95% confidence intervals (95% CI). For the NMA, we presented hazard ratios (HR) with corresponding 95% credible intervals (95% CrI) and reported ranking probabilities for each intervention. For the NMA, we focused on three main outcomes: clinical relapse, endoscopic relapse, and withdrawals due to adverse events. Data were insufficient to assess time to relapse and histologic relapse. Adverse events and serious adverse events were not sufficiently or objectively reported to permit an NMA. We used CINeMA (Confidence in Network Meta-Analysis) methods to evaluate our confidence in the findings within networks, and GRADE for entire networks.

MAIN RESULTS

We included 35 RCTs (3249 participants) in the review. The average age of study participants ranged between 33.6 and 38.8 years. Risk of bias was high in 18 studies, low in four studies, and unclear in 13 studies. Of the 35 included RCTs, 26 studies (2581 participants; 9 interventions) were considered eligible for inclusion in the NMA. The interventions studied included 5-aminosalicylic acid (5-ASA), adalimumab, antibiotics, budesonide, infliximab, probiotics, purine analogues, sulfasalazine, and a combination of sulfasalazine and prednisolone. This resulted in 30 direct contrasts, which informed 102 mixed-treatment contrasts.The evidence for the clinical relapse network (21 studies; 2245 participants) and endoscopic relapse (12 studies; 1128 participants) were of low certainty while the evidence for withdrawal due to adverse events (15 studies; 1498 participants) was of very low certainty. This assessment was due to high risk of bias in most of the studies, inconsistency, and imprecision across networks. We mainly judged individual contrasts as of low or very low certainty, except 5-ASA versus placebo, the evidence for which was judged as of moderate certainty.We ranked the treatments based on effectiveness and the certainty of the evidence. For clinical relapse, the five most highly ranked treatments were adalimumab, infliximab, budesonide, 5-ASA, and purine analogues. We found some evidence that adalimumab (HR 0.11, 95% Crl 0.02 to 0.33; low-certainty evidence) and 5-ASA may reduce the probability of clinical relapse compared to placebo (HR 0.69, 95% Crl 0.53 to 0.87; moderate-certainty evidence). However, budesonide may not be effective in preventing clinical relapse (HR 0.66, 95% CrI 0.27 to 1.34; low-certainty evidence). We are less confident about the effectiveness of infliximab (HR 0.36, 95% CrI 0.02 to 1.74; very low-certainty evidence) and purine analogues (HR 0.75, 95% CrI 0.55 to 1.00; low-certainty evidence). It was unclear whether the other interventions reduced the probability of a clinical relapse, as the certainty of the evidence was very low.Due to high risk of bias and limited data across the network, we are uncertain about the effectiveness of interventions for preventing endoscopic relapse. Whilst there might be some evidence of prevention of endoscopic relapse with adalimumab (HR 0.10, 95% CrI 0.01 to 0.32; low-certainty evidence), no other intervention studied appeared to be effective.Due to high risk of bias and limited data across the network, we are uncertain about the effectiveness of interventions for preventing withdrawal due to adverse events. Withdrawal due to adverse events appeared to be least likely with sulfasalazine (HR 1.96, 95% Crl 0.00 to 8.90; very low-certainty evidence) and most likely with antibiotics (HR 53.92, 95% Crl 0.43 to 259.80; very low-certainty evidence). When considering the network as a whole, two adverse events leading to study withdrawal (i.e. pancreatitis and leukopenia) occurred in more than 1% of participants treated with an intervention. Pancreatitis occurred in 2.8% (11/399) of purine analogue participants compared to 0.17% (2/1210) of all other groups studied. Leukopenia occurred in 2.5% (10/399) of purine analogue participants compared to 0.08% (1/1210) of all other groups studied.

AUTHORS' CONCLUSIONS

Due to low-certainty evidence in the networks, we are unable to draw conclusions on which treatment is most effective for preventing clinical relapse and endoscopic relapse. Evidence on the safety of the interventions was inconclusive, however cases of pancreatitis and leukopenia from purine analogues were evident in the studies. Larger trials are needed to further understand the effect of the interventions on endoscopic relapse.

The impact of frailty on healthcare resource use: a longitudinal analysis using the Clinical Practice Research Datalink in England

BACKGROUND

routine frailty identification and management is national policy in England, but there remains a lack of evidence on the impact of frailty on healthcare resource use. We evaluated the impact of frailty on the use and costs of general practice and hospital care.

METHODS

retrospective longitudinal analysis using linked routine primary care records for 95,863 patients aged 65-95 years registered with 125 UK general practices between 2003 and 2014. Baseline frailty was measured using the electronic Frailty Index (eFI) and classified in four categories (non, mild, moderate, severe). Negative binomial regressions and ordinary least squares regressions with multilevel mixed effects were applied on the use and costs of general practice and hospital care.

RESULTS

compared with non-frail status, annual general practitioner consultation incidence rate ratios (IRRs) were 1.24 (95% CI: 1.21-1.27) for mild, 1.41 (95% CI: 1.35-1.47) for moderate, and 1.52 (95% CI: 1.42-1.62) for severe frailty. For emergency hospital admissions, the respective IRRs were 1.64 (95% CI 1.60-1.68), 2.45 (95% CI 2.37-2.53) and 3.16 (95% CI: 3.00-3.33). Compared with non-frail people the IRR for inpatient days was 7.26 (95% CI 6.61-7.97) for severe frailty. Using 2013/14 reference costs, extra annual cost to the healthcare system per person was £561.05 for mild, £1,208.60 for moderate and £2,108.20 for severe frailty. This equates to a total additional cost of £5.8 billion per year across the UK.

CONCLUSIONS

increasing frailty is associated with substantial increases in healthcare costs, driven by increased hospital admissions, longer inpatient stay, and increased general practice consultations.

Is the association between blood pressure and mortality in older adults different with frailty? A systematic review and meta-analysis

OBJECTIVE

to investigate whether the association between blood pressure and clinical outcomes is different in older adults with and without frailty, using observational studies.

METHODS

MEDLINE, EMBASE and CINAHL were searched from 1st January 2000 to 13th June 2018. PROSPERO CRD42017081635. We included all observational studies reporting clinical outcomes in older adults with an average age over 65 years living in the community with and without treatment that measured blood pressure and frailty using validated methods. Two independent reviewers evaluated study quality and risk of bias using the ROBANS tool. We used generic inverse variance modelling to pool risks of all-cause mortality adjusted for age and sex.

RESULTS

nine observational studies involving 21,906 older adults were included, comparing all-cause mortality over a mean of six years. Fixed effects meta-analysis of six studies demonstrated that in people with frailty, there was no mortality difference associated with systolic blood pressure <140 mm Hg compared to systolic blood pressure >140 mm Hg (HR 1.02, 95% CI 0.90 to 1.16). In the absence of frailty, systolic blood pressure <140 mm Hg was associated with lower risk of death compared to systolic blood pressure >140 mm Hg (HR 0.86, 95% CI 0.77 to 0.96).

CONCLUSIONS

evidence from observational studies demonstrates no mortality difference for older people with frailty whose systolic blood pressure is <140 mm Hg, compared to those with a systolic blood pressure >140 mm Hg. Current evidence fails to capture the complexities of blood pressure measurement, and the association with non-fatal outcomes.

Current practice in the diagnosis and management of sarcopenia and frailty - results from a UK-wide survey

OBJECTIVES

Despite a rising clinical and research profile, there is limited information about how frailty and sarcopenia are diagnosed and managed in clinical practice. Our objective was to build a picture of current practice by conducting a survey of UK healthcare professionals.

METHODS

We surveyed healthcare professionals in NHS organisations, using a series of four questionnaires. These focussed on the diagnosis and management of sarcopenia, and the diagnosis and management of frailty in acute medical units, community settings and surgical units.

RESULTS

Response rates ranged from 49/177 (28%) organisations for the sarcopenia questionnaire to 104/177 (59%) for the surgical unit questionnaire. Less than half of responding organisations identified sarcopenia; few made the diagnosis using a recognised algorithm or offered resistance training. The commonest tools used to identify frailty were the Rockwood Clinical Frailty Scale or presence of a frailty syndrome. Comprehensive Geriatric Assessment was offered by the majority of organisations, but this included exercise therapy in less than half of cases, and medication review in only one-third to two-thirds of cases.

CONCLUSIONS

Opportunities exist to improve consistency of diagnosis and delivery of evidence-based interventions for both sarcopenia and frailty.

Quality of life is substantially worse for community-dwelling older people living with frailty: systematic review and meta-analysis

PURPOSE

Frailty is an important predictor of adverse health events in older people, and improving quality of life (QOL) is increasingly recognised as a focus for services in this population. This systematic review synthesised evidence of the relationship between frailty and QOL in community-dwelling older people, with an emphasis on how this relationship varied across QOL domains.

METHODS

We conducted a systematic review with meta-analysis. We searched five databases for reports of QOL in older people with frailty and included studies based on pre-defined criteria. We conducted meta-analyses comparing "frail" and "not frail" groups for each QOL scale where data were available. We compared pooled results to distribution-based and known-group differences to enhance interpretation. We summarised reported cross-sectional and longitudinal analyses.

RESULTS

Twenty-two studies (24,419 participants) were included. There were medium or larger standardised mean differences for 24 of 31 QOL scales between frail and not frail groups, with worse QOL for frail groups. These scales encompassed constructs of health-related quality of life as well as psychological and subjective well-being. There were similar findings from mean difference meta-analyses and within-study analyses.

CONCLUSIONS

The association between frailty and lower QOL across a range of constructs is clear and often substantial. Future research should establish whether causal mechanisms link the constructs, which aspects of QOL are most important to older people with frailty, and investigate their tractability. Services focused on measuring and improving QOL for older people with frailty should be introduced.

Correction to: A cross-sectional study examining convergent validity of a frailty index based on electronic medical records in a Canadian primary care program

Following the publication of this article [1], the authors reported a typesetting error in the "Results" section.

Frailty, inequality and resilience

Frailty is a common condition in later life in which minor stressors may result in major changes in health. While the biological mechanisms of frailty are increasingly understood, relationships with the wider determinants of health, health inequalities and the concept of resilience are less well-established and the role of the clinician in their modification is less well understood.The wider determinants are the modifiable conditions in which people are born, grow, work and live, and the wider set of systems shaping the conditions of daily life. They interact across the life course, driving a well-recognised social gradient in health. The wider determinants are closely linked to the concept of resilience, which is the process of effectively negotiating, adapting to or managing significant sources of stress or trauma. Better recognition of the relationship between frailty, the wider determinants, inequalities and resilience can enable a framework around which policy responses may be developed to build resilience in people living with frailty at an individual and community level as well as enabling clinicians to better identify how they may support their patients.

Growing research in geriatric medicine

Academic geriatric medicine activity lags behind the scale of clinical activity in the specialty. A meeting of UK academic geriatricians was convened in March 2018 to consider causes and solutions to this problem. The meeting highlighted a lack of research-active clinicians, a perception that research is not central to the practice of geriatric medicine and a failure to translate discovery science to clinical studies. Solutions proposed included better support for early-career clinical researchers, schemes to encourage non-University clinicians to be research-active, wider collaboration with organ specialists to broaden the funding envelope, and the need to co-produce research programmes with end-users. Solutions to grow academic geriatric medicine are essential if we are to provide the best care for the growing older population.

Frailty and co-morbidity predict first hospitalisation after heart failure diagnosis in primary care: population-based observational study in England

BACKGROUND

frailty has only recently been recognised as important in patients with heart failure (HF), but little has been done to predict the first hospitalisation after diagnosis in unselected primary care populations.

OBJECTIVES

to predict the first unplanned HF or all-cause admission after diagnosis, comparing the effects of co-morbidity and frailty, the latter measured by the recently validated electronic frailty index (eFI).

DESIGN

observational study.

SETTING

primary care in England.

SUBJECTS

all adult patients diagnosed with HF in primary care between 2010 and 2013.

METHODS

we used electronic health records of patients registered with primary care practices sending records to the Clinical Practice Research Datalink (CPRD) in England with linkage to national hospital admissions and death data. Competing-risk time-to-event analyses identified predictors of first unplanned hospitalisation for HF or for any condition after diagnosis.

RESULTS

of 6,360 patients, 9% had an emergency hospitalisation for their HF, and 39% had one for any cause within a year of diagnosis; 578 (9.1%) died within a year without having any emergency admission. The main predictors of HF admission were older age, elevated serum creatinine and not being on a beta-blocker. The main predictors of all-cause admission were age, co-morbidity, frailty, prior admission, not being on a beta-blocker, low haematocrit and living alone. Frailty effects were largest in patients aged under 85.

CONCLUSIONS

this study suggests that frailty has predictive power beyond its co-morbidity components. HF patients in the community should be assessed for frailty, which should be reflected in future HF guidelines.

A cross-sectional study examining convergent validity of a frailty index based on electronic medical records in a Canadian primary care program

Background

An electronic frailty index (eFI) has been developed and validated in the UK; it uses data from primary care electronic medical records (EMR) for effective frailty case-finding in primary care. This project examined the convergent validity of the eFI from Canadian primary care EMR data with a validated frailty index based on comprehensive geriatric assessment (FI-CGA), in order to understand its potential use in the Canadian context.

Methods

A cross-sectional validation study, using data from an integrated primary care research program for seniors living with frailty in Edmonton, AB. Eighty-five patients 65 years of age and older from six primary care physicians’ practices were recruited. Patients were excluded if they were under 65 years of age, did not provide consent to participate in the program, or were living in a long term care facility at the time of enrolment. We used scatter plots to assess linearity and Pearson correlation coefficients to examine correlations.

Results

Results indicate a strong statistically significant correlation between the eFI and FI-CGA (r = 0.72, 95% CI 0.60–0.81, p < 0.001). A simple linear regression showed good ability of the eFI scores to predict FI-CGA scores (F (1,83) = 89.06, p < .0001, R2 = 0.51). Both indices were also correlated with age, number of chronic conditions and number of medications.

Conclusions

The study findings support the convergent validity of the eFI, which further justifies implementation of a case-finding tool that uses routinely collected primary care data in the Canadian context.

Community ageing research 75+ study (CARE75+): an experimental ageing and frailty research cohort

INTRODUCTION

The Community Ageing Research 75+ Study (CARE75+) is a longitudinal cohort study collecting an extensive range of health, social and economic data, with a focus on frailty, independence and quality of life in older age. CARE75+ is the first international experimental frailty research cohort designed using Trial within Cohorts (TwiCs) methodology, to align applied epidemiological research with clinical trial evaluation of interventions to improve the health and well-being of older people living with frailty.

METHODS AND ANALYSIS

Prospective cohort study using a TwiCs design. One thousand community-dwelling older people (≥75 years) will be recruited from UK general practices. Nursing home residents, those with an estimated life expectancy of 3 months or less and people receiving palliative care will be excluded. Data collection assessments will be face to face in the person's home at baseline, 6 months, 12 months, 24 months and 48 months, including assessments of frailty, cognition, mood, health-related quality of life, comorbidity, medications, resilience, loneliness, pain and self-efficacy. A modified protocol for follow-up by telephone or web based will be offered at 6 months. Consent will be sought for data linkage and invitations to additional studies, including intervention studies using the TwiCs design. A blood sample biobank will be established for future basic science studies.

ETHICS AND DISSEMINATION

CARE75+ was approved by the NRES Committee Yorkshire and the Humber-Bradford Leeds 10 October 2014 (14/YH/1120). Formal written consent is sought if an individual is willing to participate and has capacity to provide informed consent. Consultee assent is sought if an individual lacks capacity.Study results will be disseminated in peer-reviewed scientific journals and scientific conferences. Key study results will be summarised and disseminated to all study participants via newsletters, local older people's publications and local engagement events. Results will be reported on a bespoke CARE75+ website.

TRIAL REGISTRATION NUMBER

ISRCTN16588124;Results stage.

Management of atrial fibrillation for older people with frailty: a systematic review and meta-analysis

BACKGROUND

despite a large and growing population of older people with frailty and atrial fibrillation (AF), there is a lack of guidance on optimal AF management in this high-risk group.

OBJECTIVE

to synthesise the existing evidence base on the association between frailty, AF and clinical outcomes.

METHODS

a systematic review of studies examining the association between validated measures of frailty, AF and clinical outcomes, and meta-analysis of the association between frailty and oral anticoagulation (OAC) prescription.

RESULTS

twenty studies (30,883 patients) were included, all observational. Fifteen were in hospital, four in the community, one in nursing care. Risk of bias was low-to-moderate. AF prevalence was 3%-38%. In people with AF, frailty was associated with increased stroke incidence, all-cause mortality, symptom severity and length of hospital stay.Meta-analysis of six studies showed frailty was associated with decreased OAC prescription at hospital admission (pooled adjusted OR 0.45 [95%CI 0.22-0.93], three studies), but not at discharge (pooled adjusted OR 0.40 [95%CI 0.13-1.23], three studies). A community-based study showed increased OAC prescription associated with frailty (OR 2.33 [95%CI 1.03-5.23]).

CONCLUSION

frailty is common, and associated with adverse clinical outcomes in patients with AF. There is evidence of an association between frailty status and OAC prescription, with different direction of effect in community compared with hospital cohorts. Despite the majority of care for older people being provided in the community, there is a lack of evidence on the association between frailty, AF, anticoagulation and clinical outcomes to guide optimal care in this setting.

Convergent validity of the electronic frailty index

Background

the electronic frailty index (eFI) has been developed and validated using routine primary care electronic health record data. The focus of the original big data study was on predictive validity as a form of criterion validation. Convergent validity is a subtype of construct validity and considered a core component of the validity of a test.

Objective

to investigate convergent validity between the eFI and research standard frailty measures.

Design

cross-sectional validation study using data from the Community Ageing Research 75+ (CARE 75+) cohort.

Setting

multi-site UK community-based cohort study.

Subjects

three hundred fifty-three community-dwelling older people (median age 80 years, IQR 77-84), excluding care home residents and people in the terminal stage of life. Median eFI score of participants was 0.22 (IQR 0.14-0.31).

Methods

convergent validities between the eFI and: a research standard frailty index (FI); the phenotype model of frailty; Clinical Frailty Scale (CFS) and Edmonton Frail Scale were assessed using scatter plots and Spearman's rank tests to estimate correlation coefficients (Spearman's rho, ρ) and 95% confidence intervals.

Results

results indicate strong correlation between the eFI and both the research standard FI (ρ = 0.68, 95% CI 0.62-0.74) and Edmonton Frail Scale (ρ = 0.63, 95% CI 0.57-0.69). There was evidence for moderate correlation between the eFI and both the CFS (ρ = 0.59, 95% CI 0.49-0.65) and phenotype model (ρ = 0.51, 95% CI 0.42-0.59).

Conclusions

This study provides evidence for convergent validity of the eFI, a core component of test validity.

Interventions for maintenance of surgically‐induced remission in Crohn’s disease: a network meta‐analysis

This is a protocol for a Cochrane Review (Intervention). The objectives are as follows:

To assess the effects and harms of interventions for the maintenance of surgically‐induced remission in Crohn's disease and to rank treatments in order of effectiveness.

The prevalence of frailty and its association with clinical outcomes in general surgery: a systematic review and meta-analysis

Objectives

to investigate the prevalence and impact of frailty for general surgical patients.

Research design and methods

we conducted a systematic review and meta-analysis. Studies published between 1 January 1980 and 31 August 2017 were searched from seven databases. Incidence of clinical outcomes (mortality at Days 30 and 90; readmission at Day 30, surgical complications and length of stay) were estimated by frailty subgroup (not-frail, pre-frail and frail).

Results

2,281 participants from nine observational studies were included, 49.3% (1013/2055) were males. Mean age ranged from 61 to 77 years old. Eight studies provided outcome data and were quality assessed and of fair or good quality, and one study only provided an estimate of prevalence and was not quality assessed. The prevalence estimate ranged between 31.3 and 45.8% for pre-frailty, and 10.4 and 37.0% for frailty. After pooling, Day 30 mortality was 8% (95% CI: 4-12%; I2 = 0%) for frail compared to 1% for non-frail patients (95% CI: 0-2%; I2 = 75%). Due to heterogeneity the Day 90 mortality was not pooled. Readmission rates were lower in the non-frail groups but were not pooled. Complications for the frail patients were 24%, (95% CI: 20-31%; I2 = 92%), pre-frail subgroup 9% (95% CI: 5-14%; I2 = 82%) and non-frail 5% (95% CI: 3-7%; I2 = 70%). The mean length of stay in frail people was 9.6 days (95% CI: 6.2-12.9) and 6.4 days (4.9-7.9) non-frail.

Conclusions

frailty is associated with adverse post-operative outcomes in general surgery.

Frailty and the endocrine system

Frailty is a condition characterised by loss of biological reserves, failure of homoeostatic mechanisms, and vulnerability to adverse outcomes. The endocrine system is considered particularly important in frailty, because of its complex inter-relationships with the brain, immune system, and skeletal muscle. This Review summarises evidence indicating a key role for the hypothalamic-pituitary axis in the pathogenesis of frailty through aberrant regulation of glucocorticoid secretion, insulin-like growth factor signalling, and androgen production. Evidence also indicates a potential role for vitamin D and insulin resistance in the pathogenesis of frailty. The role of thyroid hormones in the pathogenesis of frailty remains uncertain. Key convergent pathological effects of frailty include loss of muscle mass and strength, with consequent impact on mobility and activities of daily living. Future translational research should focus on the understanding of endocrine mechanisms, to identify potential biomarkers of the condition, modifiable targets for treatment, and novel pharmacological drugs targeted at the endocrine components of frailty.

Further Development and Validation of the electronic Frailty Index using the Secure Anonymised Information Linkage Databank

IntroductionAging populations with increasing frailty have major implications for health services internationally, and evidence-based treatment becomes increasingly important. The development of an electronic Frailty Index (eFI) using routine primary care data facilitates implementation of evidence-based interventions. However, the eFI does not account for time restrictions regarding when information was recorded. Objectives and ApproachOur aim is to implement and further validate the eFI using the Secure Anonymised Information Linkage (SAIL) databank, introducing refinements based on time restrictions. Our implementation of the eFI identifies frailty based on 1574 Read codes, which are mapped amongst 36 categories known as deficits. The eFI is based on the internationally established cumulative deficit model, and each deficit contributes equally to the eFI value. However, although each deficit is equally weighted, only one of them is currently time dependent. We therefore analyse the time at which each deficit is identified, and propose time dependent cut-points based on our findings. ResultsWe were able to successfully implement the eFI using data from over 400,000 individuals from the Welsh population using data held in the SAIL databank. Our results agree with the baseline characteristics and distributions of frailty found in the original development of the eFI. We also found that the percentage of individuals identified as frail increased as the number of years of records included was increased. Furthermore, the increase in percentage year by year was almost linear for a number of the deficits. This led to the identification of time bounds for particular deficits, which could help to refine future implementations of the eFI. Conclusion/ImplicationsOur work validates and refines the eFI, which is a particularly useful resource as it uses existing primary care data to identify frailty, meaning no additional resources are required. Furthermore, our implementation is readily available, meaning that future research related to frailty is easily reproducible and achievable by others.

Evaluating frailty scores to predict mortality in older adults using data from population based electronic health records: case control study

BACKGROUND

recognising that a patient is nearing the end of life is essential, to enable professional carers to discuss prognosis and preferences for end of life care.

OBJECTIVE

investigate whether an electronic frailty index (eFI) generated from routinely collected data, can be used to predict mortality at an individual level.

DESIGN

historical prospective case control study.

SETTING

UK primary care electronic health records.

SUBJECTS

13,149 individuals age 75 and over who died between 01/01/2015 and 01/01/2016, 1:1 matched by age and sex to individuals with no record of death in the same time period.

METHODS

two subsamples were randomly selected to enable development and validation of the association between eFI 3 months prior to death and mortality. Receiver operator characteristic (ROC) analyses were used to examine diagnostic accuracy of eFI at 3 months prior to death.

RESULTS

an eFI > 0.19 predicted mortality in the development sample at 75% sensitivity and 69% area under received operating curve (AUC). In the validation dataset this cut point gave 76% sensitivity, 53% specificity.

CONCLUSIONS

the eFI measured at a single time point has low predictive value for individual risk of death, even 3 months prior to death. Although the eFI is a strong predictor or mortality at a population level, its use for individuals is far less clear.

Routinely Identifying frailty: Implementing the electronic Frailty Index in the Secure Anonymised Information Linkage Databank

BackgroundAging populations with increasing frailty have major implications for health services, and evidence-based treatment becomes increasingly important. The development of the electronic Frailty Index (eFI) using routine primary care data facilitatesthe implementation of evidence-based interventions and care. MethodOur implementation of the eFI in the Secure Anonymised Information Linkage (SAIL) databank identifies frailty based on 1574 Read codes, which are mapped amongst 36 categories known as deficits. The eFI is based on a cumulative deficitmodel, and each deficit contributes equally to the eFI value. FindingsAlthough each deficit is equally weighted, only one is currently time dependent. We therefore analysed the cumulative prevalence of each deficit on a year-by-year basis. This led to the identification of time bounds for particular deficits, which willhelp to refine future implementations of the eFI. We also further validated the eFI using data from over 400,000 individuals held in SAIL. ConclusionThe eFI is particularly useful as it uses existing data to identify frailty, meaning no additional resources are required. Furthermore, our implementation is readily available, meaning that future research related to frailty is easily achievable by others.

Canagliflozin, dapagliflozin and empagliflozin monotherapy for treating type 2 diabetes: systematic review and economic evaluation

BACKGROUND

Most people with type 2 diabetes are overweight, so initial treatment is aimed at reducing weight and increasing physical activity. Even modest weight loss can improve control of blood glucose. If drug treatment is necessary, the drug of first choice is metformin. However, some people cannot tolerate metformin, which causes diarrhoea in about 10%, and it cannot be used in people with renal impairment. This review appraises three of the newest class of drugs for monotherapy when metformin cannot be used, the sodium-glucose co-transporter 2 (SGLT2) inhibitors.

OBJECTIVE

To review the clinical effectiveness and cost-effectiveness of dapagliflozin (Farxiga, Bristol-Myers Squibb, Luton, UK), canagliflozin (Invokana, Janssen, High Wycombe, UK) and empagliflozin (Jardiance, Merck & Co., Darmstadt, Germany), in monotherapy in people who cannot take metformin.

SOURCES

MEDLINE (1946 to February 2015) and EMBASE (1974 to February 2015) for randomised controlled trials lasting 24 weeks or more. For adverse events, a wider range of studies was used. Three manufacturers provided submissions.

METHODS

Systematic review and economic evaluation. A network meta-analysis was carried out involving the three SGLT2 inhibitors and key comparators. Critical appraisal of submissions from three manufacturers.

RESULTS

We included three trials of dapagliflozin and two each for canagliflozin and empagliflozin. The trials were of good quality. The canagliflozin and dapagliflozin trials compared them with placebo, but the two empagliflozin trials included active comparators. All three drugs were shown to be effective in improving glycaemic control, promoting weight loss and lowering blood pressure (BP).

LIMITATIONS

There were no head-to-head trials of the different flozins, and no long-term data on cardiovascular outcomes in this group of patients. Most trials were against placebo. The trials were done in patient groups that were not always comparable, for example in baseline glycated haemoglobin or body mass index. Data on elderly patients were lacking.

CONCLUSIONS

Dapagliflozin, canagliflozin and empagliflozin are effective in improving glycaemic control, with added benefits of some reductions in BP and weight. Adverse effects are urinary and genital tract infections in a small proportion of users. In monotherapy, the three drugs do not appear cost-effective compared with gliclazide or pioglitazone, but may be competitive against sitagliptin (Januvia, Boehringer Ingelheim, Bracknell, UK).

FUNDING

The National Institute for Health Research Health Technology Assessment programme.

Feasibility and reliability of frailty assessment in the critically ill: a systematic review

Background

For healthcare systems, an ageing population poses challenges in the delivery of equitable and effective care. Frailty assessment has the potential to improve care in the intensive care setting, but applying assessment tools in critical illness may be problematic. The aim of this systematic review was to evaluate evidence for the feasibility and reliability of frailty assessment in critical care.

Methods

Our primary search was conducted in Medline, Medline In-process, EMBASE, CINAHL, PsycINFO, AMED, Cochrane Database of Systematic Reviews, and Web of Science (January 2001 to October 2017). We included observational studies reporting data on feasibility and reliability of frailty assessment in the critical care setting in patients 16 years and older. Feasibility was assessed in terms of timing of evaluation, the background, training and expertise required for assessors, and reliance upon proxy input. Reliability was assessed in terms of inter-rater reliability.

Results

Data from 11 study publications are included, representing 8 study cohorts and 7761 patients. Proxy involvement in frailty assessment ranged from 58 to 100%. Feasibility data were not well-reported overall, but the exclusion rate due to lack of proxy availability ranged from 0 to 45%, the highest rate observed where family involvement was mandatory and the assessment tool relatively complex (frailty index, FI). Conventional elements of frailty phenotype (FP) assessment required modification prior to use in two studies. Clinical staff tended to use a simple judgement-based tool, the clinical frailty scale (CFS). Inter-rater reliability was reported in one study using the CFS and although a good level of agreement was observed between clinician assessments, this was a small and single-centre study.

Conclusion

Though of unproven reliability in the critically ill, CFS was the tool used most widely by critical care clinical staff. Conventional FP assessment required modification for general application in critical care, and an FI-based assessment may be difficult to deliver by the critical care team on a routine basis. There is a high reliance on proxies for frailty assessment, and the reliability of frailty assessment tools in critical care needs further evaluation.

Prospero registration number

CRD42016052073.

Corrigendum: Canagliflozin, dapagliflozin and empagliflozin monotherapy for treating type 2 diabetes: systematic review and economic evaluation

Empagliflozin (Jardiance, Merck & Co., Darmstadt, Germany) has been replaced with empagliflozin (Jardiance, Boehringer Ingelheim, Ingelheim, Germany/Eli Lilly and Company, Indianapolis, IN, USA).

Sitagliptin (Januvia, Boehringer Ingelheim, Bracknell, UK) has been replaced with sitagliptin (Januvia, Merck Sharp & Dohme Limited, Kenilworth, NJ, USA).

New horizons in multimorbidity in older adults

The concept of multimorbidity has attracted growing interest over recent years, and more latterly with the publication of specific guidelines on multimorbidity by the National Institute for Health and Care Excellence (NICE). Increasingly it is recognised that this is of particular relevance to practitioners caring for older adults, where multimorbidity may be more complex due to the overlap of physical and mental health disorders, frailty and polypharmacy. The overlap of frailty and multimorbidity in particular is likely to be due to the widespread health deficit accumulation, leading in some cases to functional impairment. The NICE guidelines identify 'target groups' who may benefit from a tailored approach to care that takes their multimorbidity into account, and make a number of research recommendations. Management includes a proactive individualised assessment and care plan, which improves quality of life by reducing treatment burden, adverse events, and unplanned or uncoordinated care.

Systematic Review and Meta-Analysis of Psychosocial Risk Factors for Stroke

Several studies have assessed the link between psychosocial risk factors and stroke; however, the results were inconsistent. We have conducted a systemic review and meta-analysis of cohort or case-control studies to ascertain the association between psychosocial risk factors (psychological, vocational, behavioral, interpersonal, and neuropsychological) and the risk of stroke. Systematic searches were undertaken in MEDLINE, EMBASE, CINAHL, PsycINFO, and the Cochrane Database of Systematic Reviews between 2000 and January 2017. Two reviewers independently screened titles, abstracts, and full texts. One reviewer assessed quality and extracted data, which was checked by a second reviewer. For studies that reported risk estimates, a meta-analysis was performed. We identified 41 cohort studies and 5 case-control studies. No neuropsychological papers were found. Overall, pooled adjusted estimates showed that all other psychosocial risk factors were independent risk factors for stroke. Psychological factors increased the risk of stroke by 39% (hazard ratio [HR], 1.39; 95% confidence interval [CI], 1.27–1.51), vocational by 35% (HR, 1.35; 95% CI, 1.20–1.51), and interpersonal by 16% (HR, 1.16; 95% CI, 1.03–1.31), and the effects of behavioral factors were equivocal (HR, 0.94; 95% CI, 0.20–4.31). The meta-analyses were affected by heterogeneity. Psychosocial risk factors are associated with an increased risk of stroke.

Screening for aspiration risk associated with dysphagia in acute stroke

This is a protocol for a Cochrane Review (Diagnostic test accuracy). The objectives are as follows:

To determine the diagnostic accuracy of bedside screening tools for detecting dysphagia, which is a predictor of aspiration, in people with acute stroke.

To assess the influence of the following potential sources of heterogeneity.

Patient demographics (e.g. age, gender, percentage of males in study, median age of study by gender). The time post‐stroke that the study was conducted (from admission to 48 hours) to ensure only hyperacute and acute stroke dysphagia screening tools are identified. Any significant change in the participant's condition between the index and reference tests being performed. The definition of dysphagia used by the study. Level of training of nursing staff, both grade and training in the screening tool. Low‐quality studies identified from the methodological quality checklist. Type of the index test and the threshold of the index test. Type of the reference test.