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.