Validity, Reliability and Feasibility of Tools to Identify Frail Older Patients in Inpatient Hospital Care: A Systematic Review

Multidimensional frailty as a predictor of mortality among older adults: a systematic review and meta-analysis

OBJECTIVE

This systematic review examined studies that assessed the relationship between mortality risk and multidimensional frailty. The pooled risk of mortality was estimated via a meta-analysis.

DESIGN

A systematic review and meta-analysis.

METHODS

A systematic search for potentially eligible literature was conducted on January 2, 2023, using five electronic databases: Web of Science, CINAHL, PubMed, the Cochrane Library and Embase. This review included cohort or longitudinal studies examining the association between multidimensional frailty/prefrailty and mortality in older adults. The quality of the included studies was evaluated via the Quality in Prognosis Studies (QUIPS) tool. Two independent researchers identified eligible studies and extracted the data. The data analyses were performed via STATA, version 15.0.

RESULTS

A total of 24 studies with 34,664 participants were included. The 24 studies were published between 2012 and 2022, with most studies being performed in Italy (n = 16). The sample sizes of the included studies ranged from 71 to 12,020. Most included studies were conducted in hospital settings. The QUIPS bias assessment results showed that the most frequent source of potential bias was study confounding. The meta-analysis results showed that multidimensional frailty was a significant predictor of mortality (HR = 5.48, 95% CI = 3.91-7.67, p < 0.001). In addition, multidimensional prefrailty was also a significant predictor of mortality (HR = 2.56, 95% CI = 2.17-3.02, p < 0.001). The results of the meta-analysis using the ORs revealed that multidimensional frailty was a risk factor for mortality in older people (OR = 4.59, 95% CI = 2.47-8.55, p < 0.05).

CONCLUSIONS AND IMPLICATIONS

This systematic review of the relationship between multidimensional frailty and mortality found that multidimensional frailty/prefrailty is a predictor of mortality. More studies should be conducted in community dwelling populations and nursing homes.

The Association between Circadian Syndrome and Frailty in US adults: a cross-sectional study of NHANES Data from 2007 to 2018

PURPOSE

Frailty and Circadian Syndrome (CircS) are prevalent among the elderly, yet the link between them remains underexplored. This study aims to examine the association between CircS and frailty, particularly focusing on the impact of various CircS components on frailty.

MATERIALS AND METHODS

We conducted a cross-sectional analysis using data from the National Health and Nutrition Examination Survey (NHANES) spanning 2007 to 2018. The 49-item Frailty Index (FI) was employed to assess frailty. To understand the prevalence of CircS in relation to frailty, we applied three multivariate logistic regression models. Additionally, subgroup and interaction analyses were performed to investigate potential modifying factors.

RESULTS

The study included 8,569 participants. In fully adjusted models, individuals with CircS showed a significantly higher risk of frailty compared to those without CircS (Odds Ratio [OR] = 2.18, 95% Confidence Interval [CI]: 1.91-2.49, p < 0.001). A trend of increasing frailty risk with greater CircS component was observed (trend test p < 0.001). Age (p = 0.01) and race (p = 0.02) interactions notably influenced this association, although the direction of effect was consistent across subgroups. Sensitivity analysis further confirmed the strength of this relationship.

CONCLUSION

This study identifies a strong positive correlation between CircS and frailty in the elderly. The risk of frailty escalates with an increasing number of CircS components. These findings highlight the intricate interplay between circadian syndrome and frailty in older adults, offering valuable insights for developing targeted prevention and intervention strategies.

Frailty and anticoagulants in older subjects with atrial fibrillation: the EUROSAF study

AIMS

Literature regarding anticoagulants in older people affected by atrial fibrillation (AF) is limited to retrospective studies, poorly considering the importance of multidimensional frailty. The main objective of this study is to evaluate in hospitalised older persons with AF the benefit/risk ratio of the anticoagulant treatments, considering the severity of frailty, determined by the multidimensional prognostic index (MPI).

METHODS

In this European, multicentre, prospective study, older hospitalised patients (≥65 years) with non-valvular AF were followed-up for 12 months. Anticoagulants' use at discharge ascertained using medical records. MPI was calculated using tools derived from comprehensive geriatric assessment, classifying participants in robust, pre-frail or frail. Mortality (primary outcome); vascular events, including ischemic heart disease or ischemic stroke, hemorrhagic stroke or gastrointestinal bleedings (secondary outcomes).

RESULTS

2,022 participants (mean age 82.9 years; females 56.6%) were included. Compared with people not taking anticoagulants (n = 823), people using vitamin K antagonists (n = 450) showed a decreased risk of mortality (hazard ratio, HR = 0.74; 95% CI: 0.59-0.93), more pronounced in patients using direct oral anticoagulants (DOACs) (n = 749) (HR = 0.46; 95% CI: 0.37-0.57). Only people taking DOACs reported a significantly lower risk of vascular events (HR = 0.55; 95% CI: 0.31-0.97). The efficacy of DOACs was present independently from frailty status. The risk of gastrointestinal bleedings and hemorrhagic stroke did not differ based on the anticoagulant treatments and by MPI values.

CONCLUSIONS

Anticoagulant treatment, particularly with DOACs, was associated with reduced mortality in older people, without increasing the risk of hemorrhagic events, overall suggesting the importance of treating with anticoagulants older people with AF.

Comparison of Glasgow Coma Scale and Full Outline of UnResponsiveness score for prediction of in-hospital mortality in traumatic brain injury patients: a systematic review and meta-analysis

BACKGROUND

Currently, Glasgow Coma Scale (GCS) is used to assess patients' level of consciousness. Although this tool is highly popular in clinical settings, it has various limitations that reduce its applicability in certain situations. This had led researchers to look for alternative scoring systems. This study aims to compare the value of GCS and Full Outline of UnResponsiveness (FOUR) score for prediction of mortality in traumatic brain injury (TBI) patients through a systematic review and meta-analysis.

METHOD

Online databases of Medline, Embase, Scopus, and Web of Science were searched until the end of July 2022 for studies that had compared GCS and FOUR score in TBI patients. Interested outcomes were mortality and unfavorable outcome (mortality + disability). Findings are reported as area under the curve (AUC) sensitivity, specificity, and diagnostic odds ratio.

RESULTS

20 articles (comprised of 2083 patients) were included in this study. AUC of GCS and FOUR score for prediction of in-hospital mortality after TBI was 0.92 (95% CI 0.80-0.91) and 0.91 (95% CI 0.88-0.93) respectively. The diagnostic odds ratio of the two scores for prediction of in-hospital mortality after TBI was 44.51 (95% CI 23.58-84.03) for GCS and 45.16 (95% CI 24.25-84.09) for FOUR score. As for prediction of unfavorable outcome after TBI, AUC of GCS and FOUR score were 0.95 (95% CI 0.93 to 0.97) and 0.93 (95% CI 0.91-0.95), respectively. The diagnostic odds ratios for prediction of unfavorable outcome after TBI were 66.31 (95% CI 35.05-125.45) for GCS and 45.39 (95% CI 23.09-89.23) for FOUR score.

CONCLUSION

Moderate level of evidence showed that the value of GCS and FOUR score in the prediction of in-hospital mortality and unfavorable outcome is comparable. The similar performance of these scores in assessment of TBI patients gives the medical staff the option to use either one of them according to the situation at hand.

Facilitators and Barriers to Nurses Screening for Frailty in Acute Care in a Provincial Health-Care System: a Survey Study Guided by the Theoretical Domains Framework

Background

Older adults living with frailty represent the largest population of hospitalized patients in Canada, but they do not always receive the quality of care needed. Nurses are well-positioned to screen for frailty, but current frailty screening practices are poorly understood.

Methods

A cross-sectional survey study was conducted over a six-week period with nurses from Alberta, Canada working in acute care with older adults. Demographics were descriptively reported. Frailty screening methods were quantified on 5-point frequency scales, reported descriptively and compared by practice area using linear regression. The top-five mean scores from a 43-item, 6-point Likert-type questionnaire based on the Theoretical Domains Framework were compared by practice area.

Results

Frailty screening by clinical impression was "usually" used (median = 4, IQR = 4-5), while tools were "rarely" used (median = 2, IQR = 1-3). Medical and/or surgical nursing had higher general frailty screening tool use (β = 0.81, r = .31, p < .001), but no significant (p > .05) differences for using clinical impression, or preference of screening method. The top facilitator was the disbelief that frailty screening negatively impacts relationships with older adults. The top barrier was belief that conducting frailty screening was routine. Nursing practice area influenced frailty screening beliefs.

Conclusions

There is an opportunity to implement frailty screening tools into the nursing practice of Alberta' nurses working in acute care. Frailty screening tools that become routine have greater likelihood for utilization. Nursing practice areas may have unique situations that require tailored approached to tool implementation.

Frailty Assessment and Perioperative Major Adverse Cardiovascular Events After Noncardiac Surgery

OBJECTIVE

Frailty is an emerging risk factor for adverse outcomes. However, perioperative frailty assessments derived from electronic health records have not been studied on a large scale. We aim to estimate the prevalence of frailty and the associated incidence of major adverse cardiovascular events (MACE) among adults hospitalized for noncardiac surgery.

METHODS

Adults aged ≥45 years hospitalized for noncardiac surgery from 2004-2014 were identified from the National Inpatient Sample. The validated Hospital Frailty Risk Score (HFRS) derived from International Classification of Diseases codes was used to classify patients as low (HFRS <5), medium (5-10), or high (>10) frailty risk. The primary outcome was MACE, defined as myocardial infarction, cardiac arrest, and in-hospital mortality. Multivariable logistic regression was used to estimate the adjusted odds of MACE stratified by age and HFRS.

RESULTS

A total of 55,349,978 hospitalizations were identified, of which 81.0%, 14.4%, and 4.6% had low, medium, and high HFRS, respectively. Patients with higher HFRS had more cardiovascular risk factors and comorbidities. MACE occurred during 2.5% of surgical hospitalizations and was common among patients with high frailty scores (high HFRS: 9.1%, medium: 6.9%, low: 1.3%, P < .001). Medium (adjusted odds ratio [aOR] 2.05; 95% confidence interval [CI], 2.02-2.08) and high (aOR 2.75; 95% CI, 2.70-2.79) HFRS were associated with greater odds of MACE vs low HFRS, with the greatest odds of MACE observed in younger individuals 45-64 years (interaction P value < .001).

CONCLUSIONS

The HFRS may identify frail surgical inpatients at risk for adverse perioperative cardiovascular outcomes.

Sensitivity and specificity of three screening tools for frailty in hospitalized older adults

AIM

To determine the test accuracy, including sensitivity, specificity, positive predictive value, negative predictive value and area under curve, of three frailty screening tools in identifying the risk of frail outcomes among hospitalized older patients.

DESIGN

Prospective longitudinal study.

METHODS

The screening tools [Frail-PPS (Frail-Physical, Psychological and Social), Frailty Assessment Measure (FAM), and Identification of seniors at-risk hospitalized patients (ISAR-HP)] were administered by ward nurses to patients aged 65 years and older within 24 h of admission to an acute hospital. Sensitivity, specificity, positive predictive value, negative predictive value and area under curve analysis of the three tools in the context of three frail outcomes, (a) functional decline at three months after discharge-defined as a decline of at least one point on the Katz Index, (ii) requiring a full-time caregiver upon discharge, and (iii) death by three months after discharge, was assessed.

RESULTS

Of 366 patients enrolled in the study, 78 (21.3%) experienced one or more frail outcomes, with 65 (17.76%) experiencing functional decline, 61 (16.67%) requiring a full-time caregiver upon discharge and 8 (2.19%) dying by three months. Frail-PPS had sensitivity 12.5% to 31.4% and specificity 91.2% to 94.8%, varying by the considered frail outcome. Similarly, FAM had sensitivity 12.5% to 29.4% and specificity 90.9% to 94.1%, and ISAR-HP had sensitivity 2.9% to 19.2% and specificity 92.2% to 99.1%. positive predictive value of the FAM, Frail-PPS and ISAR-HP ranged from 3.0 to 45.5%, 3.1 to 50.0% and 3.9 to 23.6% respectively, while their negative predictive value ranged from 87.1% to 97.9%, 87.7% to 97.9% and 92.2% to 99.4% respectively. The area under curve values were moderate for the Frail-PPS (0.56 to 0.75), FAM (0.58 to 0.70) and ISAR-HP (0.71 to 0.77) for the three outcomes.

CONCLUSIONS

With high specificity and negative predictive values, as well as low sensitivity, FAM and Frail-PPS may be beneficial in identifying older individuals who are not frail, minimizing unnecessary further assessment and intervention.

Older People Hospitalized for COVID-19: Prognostic Role of Multidimensional Prognostic Index and Other Prognostic Scores

During the SARS-CoV-2 pandemic, frailty and patients’ poor outcomes seem to be closely related. However, there is no clear indication of the significance of this connection and the most adequate risk index in clinical practice. In this study, we compared a short version of MPI (multidimensional prognostic index) and other two prognostic scores for COVID-19 as potential predictors of poor patient outcomes. The patients were consecutively enrolled in the hospital of Palermo for COVID-19. The accuracy of Brief-MPI, 4C score and COVID-GRAM score in points was evaluated using the area under the curve (AUC) with 95% CI, taking mortality or sub-ICU admission as outcome. The study included 112 participants (mean age 77.6, 55.4% males). During a mean of 16 days of hospitalization, Brief-MPI significantly increased by 0.03 ± 0.14 (p = 0.04), whilst COVID-GRAM did not. Brief-MPI, 4C score and COVID-GRAM scores had good accuracy in predicting negative outcomes (AUC > 0.70 for all three scores). Brief-MPI was significantly associated with an increased mortality/ICU admission risk, indicating the importance of multidimensional impairment in clinical decision-making with an accuracy similar to other prognostic scores commonly used in COVID-19 study, providing information regarding domains for which interventions can be proposed.

The role of prognostic stratification on prescription of anticoagulants in older patients with atrial fibrillation: a multicenter, observational, prospective European study (EUROSAF)

BACKGROUND

Literature suggests that different risks of mortality could influence physicians in prescribing or not anticoagulants in older patients with atrial fibrillation (AF). The Multidimensional Prognostic Index (MPI) can be considered a tool for the detection of multidimensional frailty. The aim of this cross-sectional study was to evaluate whether prescription patterns of oral anticoagulants exist, based on MPI values.

METHODS

Older hospitalised patients (age ≥ 65 years) with non-valvular AF were included across 24 European centres. MPI was calculated using validated and standardised tools derived from a comprehensive geriatric assessment. Other functional and clinical information were collected to calculate indexes specific for haemorrhagic and thromboembolic risk in AF.

RESULTS

Altogether, 2,012 participants affected by AF (mean age was 83.2 ± 7.5, range: 65-104 years), with a higher presence of women (57.0%), were included. Overall, 440 took vitamin K antagonists VKAs (22.0%), 667 (33.4%) direct oral anticoagulants (DOACs), whilst 44.6% did not take any anticoagulant treatment. Prescription of anticoagulants was associated with MPI values, with people taking anticoagulants having lower mean MPI values. Anticoagulant therapy was not used in 53.1% of the group with the highest risk of mortality, compared with 32.3% of those in the group with the lowest mortality risk. People with higher scores in MPI were less frequently treated with anticoagulant therapy, after adjusting for several potential confounders.

CONCLUSIONS

The EURopean study of Older Subjects with Atrial Fibrillation (EUROSAF) suggested that almost half of the older persons with AF do not receive anticoagulants and that MPI is an important determinant in prescribing or not anticoagulants. Trial Registration: https://clinicaltrials.gov/ct2/show/NCT02973984KEY POINTSAtrial fibrillation is a common condition in older people. The data regarding the use of anticoagulants is mainly derived from randomised controlled trials that do not include a sufficient number of older frail people.Our study suggests that a consistent part of older people affected by atrial fibrillation was not treated with anticoagulants, in particular, older frail patients; however, it is unclear if this choice is supported or not by evidence.The prognostic evaluation through the multidimensional prognostic index could be useful information for the choice in the prescription of anticoagulants in older people affected by atrial fibrillation.

Biomarkers of aging in real life: three questions on aging and the comprehensive geriatric assessment

Measuring intrinsic, biological age is a central question in medicine, which scientists have been trying to answer for decades. Age manifests itself differently in different individuals, and chronological age often does not reflect such heterogeneity of health and function. We discuss here the value of measuring age and aging using the comprehensive geriatric assessment (CGA), cornerstone of geriatric medicine, and operationalized assessment tools for prognosis. Specifically, we review the benefits of employing the multidimensional prognostic index (MPI), which collects information about eight domains relevant for the global assessment of the older person (functional and cognitive status, nutrition, mobility and risk of pressure sores, multi-morbidity, polypharmacy, and co-habitation), in the evaluation of the functional status, and in the prediction of health outcomes for older adults. Further integration of biological markers of aging into multidimensional prognostic tools is warranted, as well as actions which could facilitate prognostic assessments for older persons in all healthcare settings.

Prüfung des Screening-Tools GeriNOT

BACKGROUND

Geriatric-specific characteristics influence patient-relevant outcomes of inpatient hospital care in patients aged 70 years and older: prolonged length of stay, complications, increase in utilization of required services as well as mortality rates.

OBJECTIVE

The screening tool GeriNOT, identification of geriatric risk potential with 7 items, of which mobility and cognition are double-weighted, score 9 points, was tested for its predictive content and diagnostic quality.

MATERIAL AND METHODS

Diagnostic study from a retrospective, bicentric complete survey in all types of admission from 70 years with 2541 patient cases. Regression analyses in linked samples of the 7 items in GeriNOT and as noncombined end points: prolonged length of stay, complications, increase in need-based service at discharge and death.

RESULTS

Mean age ± SD: 77.0 ± 6.4 years. ROC analyses report at a cut-off value calculated using the Youden index of ≥ 4 points in 2541 cases: increase in need-based service at discharge (AUC = 0.693, 95% CI = 0.663-0.723, sensitivity 75.2%, specificity 59.7%), complications (AUC = 0.662, 95% CI = 0.636-0.688, sensitivity 64.2%, specificity 61.6%) and death (AUC = 0.734, 95% CI = 0.682-0.786, sensitivity 76.4%, specificity 57.5%). Possibly suitable for use as screening to identify geriatric risk potentials at a cut-off of ≥ 4 points.

DISCUSSION

Provide an initial filter screening with regard to mobility. Such identification could provide the involved persons with the opportunity for an improved treatment outcome by adapting the inpatient process. Prospective validation of GeriNOT needed.

The feasibility and reliability of frailty assessment tools applicable in acute in-hospital trauma patients: A systematic review

BACKGROUND

Assessing frailty in patients with an acute trauma can be challenging. To provide trustworthy results, tools should be feasible and reliable. This systematic review evaluated existing evidence on the feasibility and reliability of frailty assessment tools applied in acute in-hospital trauma patients.

METHODS

A systematic search was conducted in relevant databases until February 2020. Studies evaluating the feasibility and/or reliability of a multidimensional frailty assessment tool used to identify frail trauma patients were identified. The feasibility and reliability results and the risk of bias of included studies were assessed. This study was conducted and reported in line with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement and registered in Prospective Register of Systematic Reviews (ID: CRD42020175003).

RESULTS

Nineteen studies evaluating 12 frailty assessment tools were included. The risk of bias of the included studies was fair to good. The most frequently evaluated tool was the Clinical Frailty Scale (CFS) (n = 5). All studies evaluated feasibility in terms of the percentage of patients for whom frailty could be assessed; feasibility was high (median, 97%; range, 49-100%). Other feasibility aspects, including time needed for completion, tool availability and costs, availability of instructions, and necessity of training for users, were hardly reported. Reliability was only assessed in three studies, all evaluating the CFS. The interrater reliability varied between 42% and >90% agreement, with a Krippendorff α of 0.27 to 0.41.

CONCLUSION

Feasibility of most instruments was generally high. Other aspects were hardly reported. Reliability was only evaluated for the CFS with results varying from poor to good. The reliability of frailty assessment tools for acute trauma patients needs further critical evaluation to conclude whether assessment leads to trustworthy results that are useful in clinical practice.

LEVEL OF EVIDENCE

Systematic review, Level II.

Postoperative Dehydration Is Associated with Frailty and Decreased Survival in Older Patients with Hip Fracture

BACKGROUND

Hyperosmolar dehydration (HD) is a risk factor for severe complications in hip fracture in older patients. However, evidence for recommending screening of dehydration is insufficient and its relation with frailty and mortality is unclear. We tested the hypothesis that postoperative HD is associated with frailty and increased mortality.

METHODS

We recruited 625 older (>65 years) patients surgically treated for hip fracture and co-managed by an orthogeriatric team over one year in 2017. Pre- and postoperative HD (serum osmolarity > 300 mmol/L) was diagnosed. Frailty and associated mortality risk were assessed by the Multidimensional Prognostic Index (MPI).

RESULTS

The prevalence of preoperative HD was 20.4%. Compared with no-HD, MPI was similar in HD patients despite higher (p < 0.05) prevalence of polypharmacy, arterial hypertension, diabetes, chronic kidney disease and heart failure. After surgery the incidence of HD decreased to 16.5%, but increased (p = 0.003) in the MPI high-risk subgroup. Postoperative HD was associated with more complications and was an independent determinant of adjusted hospital length of stay (LOS) and of 60- to 365-days mortality.

CONCLUSIONS

Older frail patients with hip fracture are prone to developing postoperative HD, which independently predicts prolonged hospital LOS and mortality. Systematically screening older patients for frailty and dehydration is advisable to customize hydration management in high-risk individuals.

Predictors of short- and long-term mortality among acutely admitted older patients: role of inflammation and frailty

BACKGROUND

Frailty, demographic and clinical variables linked to incident diseases (e.g., dehydration, inflammation) contribute to poor outcomes in older patients acutely hospitalized. Their predictivity on short-, intermediate- and long-term mortality in a comprehensive model has been scarcely investigated.

AIMS

To test the performance of a predictive tool considering frailty and inflammation as well as age, sex and impaired hydration status on 1-year mortality in acutely admitted older patients.

METHODS

Retrospective observational study including 529 medical patients (age 84.6 ± 7.3 years). At hospital admission, frailty was assessed by the Multidimensional Prognostic Index (MPI). The Glasgow Prognostic Score (GPS) was used to grade systemic inflammation. Serum osmolarity was calculated to assess hydration.

RESULTS

After adjusting for age, sex, GPS and osmolarity, the severe-risk MPI was a strong predictor for 1-year mortality (OR 4.133; 95% CI 2.273-7.516; p < 0.001). Age > 85 years, male sex, GPS-2 and serum osmolarity > 300 mOsm/L were independent predictors of mortality in the same multivariable model. The MPI alone showed a moderate discrimination power (AUC 0.678; 95% CI 0.628-0.729; p < 0.001) on 1-year mortality, which increased by 12.5% after the addition of the above predictors in the fully adjusted regression model (AUC 0.763; 95% CI 0.719-0.807; p < 0.001). The severe-risk MPI adjusted for the same factors was also an independent predictor of mortality after 60 and 180 days since hospital admission.

DISCUSSION

Inflammation and impaired hydration are potentially modifiable risk factors for severe outcomes in older acutely hospitalized patients. A model combining GPS, age, gender, and plasma osmolarity improved the accuracy of MPI at admission in predicting long-term mortality.

Changing Hospital Care For Older Adults: The Case for Geriatric Hospitals in the United States

Hospital care of frail older adults is far from optimal. Although some geriatric models of care have been shown to improve outcomes, the effect size is small and models are difficult to fully implement, sustain and replicate. The two root causes for these shortcomings are competing interests (high revenue generating diseases, procedures and surgeries) and current hospital cultures (for example a culture of safety that emphasizes bed alarms and immobility rather than frequent ambulation). Geriatric hospitals would be hospitals completely dedicated to the care of frail older patients, a group which is most vulnerable to the negative consequences of a hospitalization. They would differ from a typical adult hospital because they could implement evidence based principles of successful geriatric models of care on a hospital wide basis, which would make them sustainable and allow for scaling up of proven outcomes. Innovative structural designs, unachievable in a typical adult hospital, would enhance mobility while maintaining safety. Financial viability and stability would be a challenge but should be feasible, likely through affiliation with larger health care systems with other hospitals because of cost savings associated with geriatric models of care (decreased length of stay, increased likelihood of discharge home, without increasing costs).

Frailty and In-Hospital Mortality Risk Using EHR Nursing Data

PurposeThe purpose of this study was to evaluate four definitions of a Frailty Risk Score (FRS) derived from EHR data that includes combinations of biopsychosocial risk factors using nursing flowsheet data or International Classification of Disease, 10th revision (ICD-10) codes and blood biomarkers and its predictive properties for in-hospital mortality in adults ≥50 years admitted to medical-surgical units. Methods In this retrospective observational study and secondary analysis of an EHR dataset, survival analysis and Cox regression models were performed with sociodemographic and clinical covariates. Integrated area under the ROC curve (iAUC) across follow-up time based on Cox modeling was estimated. Results The 46,645 patients averaged 1.5 hospitalizations (SD = 1.1) over the study period and 63.3% were emergent admissions. The average age was 70.4 years (SD = 11.4), 55.3% were female, 73.0% were non-Hispanic White (73.0%), mean comorbidity score was 3.9 (SD = 2.9), 80.5% were taking 1.5 high risk medications, and 42% recorded polypharmacy. The best performing FRS-NF-26-LABS included nursing flowsheet data and blood biomarkers (Adj. HR = 1.30, 95% CI [1.28, 1.33]), with good accuracy (iAUC = .794); the reduced model with age, sex, and FRS only demonstrated similar accuracy. The poorest performance was the ICD-10 code-based FRS. Conclusion The FRS captures information about the patient that increases risk for in-hospital mortality not accounted for by other factors. Identification of frailty enables providers to enhance various aspects of care, including increased monitoring, applying more intensive, individualized resources, and initiating more informed discussions about treatments and discharge planning.

Prevalence of multidimensional frailty and pre-frailty in older people in different settings: A systematic review and meta-analysis

Frailty is a common condition in older people. The epidemiological data available, however, are mainly based on the physical frailty phenotype. An extensive literature has suggested that frailty should be identified using a multidimensional approach. Based on these recommendations, we estimated the prevalence of frailty and pre-frailty in the older population, using the multidimensional prognostic index (MPI), a common tool for defining multidimensional frailty. We searched several databases until 10th May 2021 for studies reporting the prevalence of frailty according to MPI values. MPI was categorized, where possible, in < 0.33 (robustness), 0.33-0.66 (pre-frailty) and > 0.66 (frailty) or using a RECursive Partition and AMalgamation approach. A meta-analysis of the prevalence, with the correspondent 95% confidence intervals (CIs) of pre-frailty and frailty was performed stratified by setting (population-based, ambulatory, nursing home, and hospital). Among 177 papers initially screened, we included 57 studies for a total of 56,407 older people. The mean age was 78.6 years, with a slight prevalence of women (58%). The overall prevalence of multidimensional frailty (MPI-3) was 26.8% (95%CI: 22.1-31.5), being higher in nursing home setting (51.5%) and lower in population-based studies (13.3%). The prevalence of pre-frailty (MPI-2) was 36.4% (95%CI: 33.1-39.7), being higher in hospital setting (39.3%) and lower in nursing home (20%). In conclusion, frailty and pre-frailty, according to a multidimensional definition, are common in older people affecting, respectively, one person over four and one over three. Our work further strengths the importance of screening frailty in older people using a multidimensional approach.

The opinions and experiences of nurses on frailty screening among older hospitalized patients. An exploratory study

Background

Routine screening for frailty at admission by nurses may be useful to detect geriatric risks and problems at an early stage. However, the added value of this screening is not clear yet. Information about the opinions and attitudes of nurses towards this screening is also lacking. As they have a crucial role in conducting this screening, an exploratory study was performed to examine hospital nurses’ opinions and perspectives about this screening and how it influences their daily work.

Methods

A qualitative, exploratory approach was employed, using semi-structured interviews with 13 nurses working on different general medical wards (surgical and internal medicine) in three Dutch hospitals. Frailty screening had been implemented for several years in these hospitals.

Results

The participating nurses reported that frailty screening can be useful to structure their work, create more awareness of frail older patients and as starting point for pro-active nursing care. At the same time, they assess their clinical view as more important than the results of a standard screening tool. The nurses hardly used the overall screening scores, but were particularly interested in information regarding specific items, such as delirium or fall risk. Screening results are partly embedded systematically and in daily nursing care, e.g., in team briefings or during transfer of patients to other wards. The majority of the nurses had received little training about the background of frailty screening and the use of screening tools.

Conclusions

Most nurses stated that frailty screening tools are helpful in daily practice. However, nurses did not use the frailty screening tools in the referred way; tools were particularly used to evaluate patients on separate items of the tool instead of the summative score of the tool. When frailty screening tools are implemented in daily practice, training needs to be focused on. Additional research in this field is necessary to gain more insight into nurses’ opinions on frailty screening.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12877-021-02586-z.

The Multidimensional Prognostic Index as a Measure of Frailty in Elderly Patients with Head and Neck Cancer

Purpose

The multidimensional prognostic index (MPI) is a prognostic model derived from the comprehensive geriatric assessment (CGA) which can predict 1-year mortality risk in elderly individuals. We hypothesized that the MPI also reflects the degree of frailty and thus will correlate with established measures of frailty. Therefore, the aim of this study is to explore whether the MPI-score is a measure of frailty in older head and neck cancer patients and is associated with several physical functioning measurements.

Patients and Methods

From November 2019 to July 2020, a prospective cohort study enrolled patients with head and neck cancer aged ≥70 years, and patients <70 years with an abnormal G8 score. The MPI-score ranged from 0 to 1 and was categorized in MPI-stage 1 (≤0.33, non-frail); MPI-stage 2 (0.34-0.66, mildly frail), and MPI-stage 3 (≥0.67, severe frail). Pearson's correlation coefficient and multivariable linear regression were used to study the association between MPI-score and the physical functioning measurements handgrip strength, gait speed, and the timed up and go test (TUGT).

Results

A total of 163 patients were included. One hundred four (63.8%) patients were categorized as non-frail according MPI-stage 1, and 59 (36.2%) patients as mildly or severe frail (n=55 MPI-stage 2; n=4 MPI-stage 3, respectively). A higher MPI-score was significantly associated with lower hand grip strength (B -0.49 [95% CI -0.71; -0.28] p<0.001), lower gait speed (B -0.41 [95% CI -0.55; -0.25] p<0.001), and a slower TUGT (B 0.53 [95% CI 0.66; 0.85] p<0.001).

Conclusion

Almost one-third of the included patients with head and neck cancer was mild or severe frail. A higher MPI-score, indicating higher degree of frailty, was associated with worse physical performance by lower handgrip strength, gait speed, and a slower TUGT. Thus, the MPI reflects the degree of frailty.

The prognostic signature of health-related quality of life in older patients admitted to the emergency department: a 6-month follow-up study

BACKGROUND

The management of older and multimorbid patients with complex care requires a personalised and comprehensive approach. The main diagnosis is often registered as the cause of hospitalisation, yet poor health-related quality of life (HRQoL) as well as multimorbidity may represent the underlying cause and markedly influence prognosis.

AIMS

To analyse the association of HRQoL and clinical prognosis over time as assessed by a Comprehensive Geriatric Assessment (CGA)-based Multidimensional Prognostic Index (MPI) in older patients admitted to the emergency department (ED).

METHODS

We used data from the prospective MPI-HOPE (Influence of the MPI on the Hospitalisation of Older Patients admitted to the Emergency department) study. Data from 165 patients (≥ 75 years) admitted to the ED of the University Hospital of Cologne, Germany, between Oct 2017 and Jan 2018 were included. Clinical prognosis was calculated by the MPI and HRQoL by the EQ5D-5L. Follow-up interviews assessed HRQoL up to 6 months after discharge.

RESULTS

Most patients were multimorbid and presented with several geriatric syndromes. At admission, HRQoL was highest in patients with the best clinical prognosis. The MPI showed a negative correlation with the EQ-Index at admission (r_s(86) = - 0.50, p < 0.0001) and follow-up assessments after 3 and 6 months (r_s(86) = - 0.55 and r_s(86) = - 0.47, p < 0.0001).

DISCUSSION

Our results suggest that patients' self-perceived HRQoL in the ED is related to functional health status and clinical prognosis.

CONCLUSION

The MPI as a multidimensional snapshot provides information on clinical health indicators and informs about subjective HRQoL, thereby helping in identifying patients who would benefit from a specific treatment within the frame of a patient-centered, value-based care strategy geriatric treatment.

Multidimensional prognostic index (MPI) predicts successful application for disability social benefits in older people

AIM

The economic recognition of disability is of importance in daily practice, but the tools used in older people are still limited. Therefore, we aimed to investigate the effectiveness of the multidimensional prognostic index (MPI) to identify frail older subjects to be submitted to civil invalidity application for disability benefits including Attendance Allowance (AA) indemnity, Carer's Leave (Law 104) and/or Parking Card for people with disabilities.

METHODS

From March 2018 to January 2019, 80 older people were included. The MPI was calculated from comprehensive geriatric assessment information including eight different domains. Civil benefits included attendance allowance (AA) indemnity by the Local Medico-Legal Committee (MLC-NHS) and by the National Institute of Social Security Committee (INPS), Carer's Leave (Law 104), and Parking Card for people with disabilities.

RESULTS

MPI values were associated with an increased probability to obtain a 100% civil disability, AA indemnity, Carer's Leave and a parking card for people with disabilities. MPI score showed a very good accuracy in predicting the civil invalidity benefits with a area-under-curve (AUC) of 87.3 (95% CI 80.6-97.4) to predict the release of AA indemnity, 81.3 (95% CI 68.5-91.1) to predict Care's leave and 70.7 (95% CI 59.4-84.7) to predict the Parking Card release. Moreover, data showed that a cut-off score of MPI ≥ 0.75 could identify the 100% of older subjects who successfully obtained the indemnity release.

CONCLUSION

MPI is an excellent predictor of social benefits' release by local and national agencies.

Hospital Readmission Outcomes by Frailty Risk in Adults in Behavioral Health Acute Care

The purpose of the current retrospective study was to determine whether frailty is predictive of 30-day readmission in adults aged ≥50 years who were admitted with a psychiatric diagnosis to a behavioral health hospital from 2013 to 2017. A total of 1,063 patients were included. A 26-item frailty risk score (FRS-26-ICD) was constructed from electronic health record (EHR) data. There were 114 readmissions. Cox regression modeling for demographic characteristics, emergent admission, comorbidity, and FRS-26-ICD determined prediction of time to readmission was modest (incremental area under the receiver operating characteristic curve = 0.671). The FRS-26-ICD was a significant predictor of readmission alone and in models with demographics and emergent admission; however, only the Elixhauser Comorbidity Index was significantly related to hazard of readmission adjusting for other factors (adjusted hazard ratio = 1.26, 95% confidence interval [1.17, 1.37]; p < 0.001), whereas FRS-26-ICD became non-significant. Frailty is a relevant syndrome in behavioral health that should be further studied in risk prediction and incorporated into care planning to prevent hospital readmissions. [Journal of Psychosocial Nursing and Mental Health Services, xx(x), xx-xx.].

Supportive and Palliative Care Indicators Tool prognostic value in older hospitalised patients: a prospective multicentre study

BACKGROUND

An increasing number of older patients are hospitalised. Prognostic uncertainty causes hospital doctors to be reluctant to make the switch from cure to care. The Supportive and Palliative Care Indicators Tool (SPICT) has not been validated for prognostication in an older hospitalised population.

AIM

To validate SPICT as a prognostic tool for risk of dying within one year in older hospitalised patients.

DESIGN

Prospective multicentre study. Premorbid SPICT and 1-year survival and survival time were assessed.

SETTING/PARTICIPANTS

Patients 75 years and older admitted at acute geriatric (n=209) and cardiology units (CUs) (n=249) of four hospitals.

RESULTS

In total, 59.3% (124/209) was SPICT identified on acute geriatric vs 40.6% (101/249) on CUs (p<0.001). SPICT-identified patients in CUs reported more functional needs and more symptoms compared to SPICT non-identified patients. On acute geriatric units, SPICT-identified patients reported more functional needs only.The HR of dying was 2.9 (95% CI 1.1 to 8.7) in SPICT-identified versus non-identified after adjustment for hospital strata, age, gender and did not differ between units. One-year mortality was 24% and 22%, respectively, on acute geriatric versus CUs (p=0.488). Pooled average sensitivity, specificity and partial area under the curve differed significantly between acute geriatric and CUs (p<0.001), respectively, 0.82 (95%CI 0.66 to 0.91), 0.49 (95%CI 0.40 to 0.58) and 0.82 in geriatric vs 0.69 (95% CI 0.42 to 0.87), 0.66 (95% CI 0.55 to 0.77) and 0.65 in CUs.

CONCLUSIONS

SPICT may be used as a tool to identify older hospitalised patients at risk of dying within 1 year and who may benefit from a palliative care approach including advance care planning. The prognostic accuracy of SPICT is better in older patients admitted at the acute geriatric versus the CU.

Reliability, Validity, and Feasibility of the Frail-VIG Index

The study aimed to assess the reliability of the scores, evidence of validity, and feasibility of the Frail-VIG index. A validation study mixing hospitalized and community-dwelling older people was designed. Intraclass correlation coefficient (ICC) was used to assess the inter-rater agreement and the reliability. The construct validity of the Frail-VIG index with respect to the Frailty Phenotype (FP) was evaluated by calculating the area under the receiver operating characteristic curve (AUC-ROC). Convergent validity with the Clinical Frailty Scale (CFS) was assessed using Pearson's correlation coefficients. The feasibility was evaluated by calculating the average time required to administer the Frail-VIG index and the percentage of unanswered responses. A sample of 527 older people (mean age of 81.61, 56.2% female) was included. The inter-rater agreement and test-retest reliability were very strong: 0.941 (95% CI, 0.890 to 0.969) and 0.976 (95% CI, 0.958 to 0.986), respectively. Results indicated adequate convergent validity of the Frail-VIG index with respect to the FP, AUC-ROC 0.704 (95% CI, 0.622 to 0.786), and a moderate to strong positive correlation between the Frail-VIG index and CFS (r = 0.635, 95% CI, 0.54 to 0.71). The Frail-VIG index administration required an average of 5.01 min, with only 0.34% of unanswered responses. The Frail-VIG index is a reliable, feasible, and valid instrument to assess the degree of frailty in hospitalized and community-dwelling older people.

Mortality and readmission risk can be predicted by the record-based Multidimensional Prognostic Index: a cohort study of medical inpatients older than 75 years

PURPOSE

To examine the predictive value of the record-based Multidimensional Prognostic Index (MPI) on mortality, readmission and length of hospital stay (LOS) among older medical inpatients.

METHODS

A cohort of medical inpatients aged ≥ 75 years was rated using the record-based MPI to assess frailty retrospectively. 90-day and 1-year mortality hazard ratios (HRs) were calculated in a sex- and age-adjusted Cox proportional hazards model. 30-day readmission relative risk (RR) estimates were calculated in a binary regression model with mortality as a competing risk. Discrimination was expressed by the area under the receiver operating characteristic (ROC) curve. Median LOS was calculated using the non-parametric Kruskal-Wallis one-way ANOVA.

RESULTS

In total, 1190 patients with a median age of 83 years were included. 50% were male. 335 patients (28%) were categorized as non-frail (MPI score 0.0-0.33), 522 (44%) moderately frail (MPI score 0.34-0.66) and 333 (28%) severely frail (MPI score 0.67-1.0). 90-day mortality HR was 7.4 (95% confidence interval (CI) 2.9-18.6, p < 0.001) for the moderately frail and 18.5 (95% CI 7.5-46.1, p < 0.001) for the severely frail compared with the non-frail. ROC area was 0.76 (95% CI 0.72-0.80). Similarly, 1-year mortality HR was 3.3 (95% CI 2.2-5.0, p < 0.001) for the moderately frail and 7.1 (95% CI 4.7-10.6, p < 0.001) for the severely frail. 30-day readmission RR was 2.1 (95% CI 1.5-2.9, p < 0.001) for the moderately frail and 1.8 (95% CI 1.3-2.6, p = 0.001) for the severely frail. LOS was significantly longer with increasing MPI score (p < 0.001).

CONCLUSION

The record-based MPI assessed at discharge predicts dose-dependent post-discharge mortality and readmission risk and is associated with LOS in older medical inpatients.

Comparison of a Frailty Risk Score and Comorbidity Indices for Hospital Readmission Using Electronic Health Record Data

The purpose of the current study was to investigate the predictive properties of five definitions of a frailty risk score (FRS) and three comorbidity indices using data from electronic health records (EHRs) of hospitalized adults aged ≥50 years for 3-day, 7-day, and 30-day readmission, and to identify an optimal model for a FRS and comorbidity combination. Retrospective analysis of the EHR dataset was performed, and multivariable logistic regression and area under the curve (AUC) were used to examine readmission for frailty and comorbidity. The sample (N = 55,778) was mostly female (53%), non-Hispanic White (73%), married (53%), and on Medicare (55%). Mean FRSs ranged from 1.3 (SD = 1.5) to 4.3 (SD = 2.1). FRS and comorbidity were independently associated with readmission. Predictive accuracy for FRS and comorbidity combinations ranged from AUC of 0.75 to 0.77 (30-day readmission) to 0.84 to 0.85 (3-day readmission). FRS and comorbidity combinations performed similarly well, whereas comorbidity was always independently associated with readmission. FRS measures were more associated with 30-day readmission than 7-day and 3-day readmission. [Research in Gerontological Nursing, 14(2), 91-103.].

Patients in need of comprehensive geriatric assessment: The utility of the InterRAI emergency department screener

INTRODUCTION

The interRAI Emergency Department-Screener (ED-screener) is a risk stratification instrument incorporating functional and social aspects to identify older adults in EDs. The aim was to assess the construct validity and utility of the ED-screener in comparison with more established instruments.

METHODS

The ED-screener, Triage Risk Screening Tool (TRST) and Identification of Seniors at Risk (ISAR) were administered to older ED-patients. Construct validity was assessed by correlation with TRST and ISAR. The ED-screener scores that corresponded to the established cut-offs for ISAR and TRST were assessed with linear regression. The sensitivity and specificity of the ED-screener for mortality at 4-months were calculated.

RESULTS

Two hundred patients were included (mean age 78.5 years, 44% male). Majority (85%) lived at home, 43% lived alone and 53% received home care. The scores of 3.02 and 3.01 on ED-screener corresponded to the cut-off score of 2 on the other instruments. The correlation of the ED-screener with ISAR and TRST was 0.56 and 0.41 respectively. A score of 3 on the ED-screener was 100% sensitive and 28% specific for 4-month mortality.

CONCLUSION

These findings provide support for the construct validity of the ED-screener and its ability to predict outcomes in its intended setting.

[ISAR Score (Identification of Seniors At Risk) predicts mortality in patients older than 75 years admitted in Intensive Care]

BACKGROUND AND OBJECTIVES

Currently, the patient's baseline situation is a more important prognostic factor than age. The purpose of this study is to estimate the prognostic value of the ISAR score (Identification of Senior at Risk) in patients ≥75 years admitted to intensive care (ICU).

PATIENTS AND METHODS

Prospective multicenter study including patients ≥75 years admitted to the ICU > 24hours. On admission, 28 days and 6 months after discharge from the ICU, mortality and baseline were evaluated using the ISAR score, the Lawton and Brody scale (LB) and the Barthel index (BI), the Frail fragility scale. scale (FS), the Charlson comorbidity index (ICC), Dementia rating score (DRC).

RESULTS

38 of 94 patients (40%) were high risk (ISAR ≥ 3) and were characterized by BI 90 (65-100), LB 4 (3-5), and CDR 1 (0-2), ICC 7.5 (6-10). 58% had FS ≥ 3. In the long term, they were in a situation of dependency [BI 50 (2.5-77.5), LB 3 (0-4), CDR 1 (0-1.5)]. The ICU mortality at 28 days and 6 months was 18.4%, 25.7% and 35.3%, respectively, being statistically significant. The area under the ISAR score ROC curve was 0.749 to 0.797, in all the mortality periods studied, although the difference with other predictive variables was not significant, but the p value was the lowest.

CONCLUSIONS

The ISAR score predicts mortality in critically elderly patients with a discriminative capacity comparable to other predictive variables.

A Comparison of Frailty Assessment Instruments in Different Clinical and Social Care Settings: The Frailtools Project

OBJECTIVE

To determine which of 8 commonly employed frailty assessment tools demonstrate the most appropriate characteristics to be employed in different clinical and social settings.

DESIGN

Cross-sectional multicenter European-based study.

SETTING AND PARTICIPANTS

1440 patients aged ≥75 years evaluated in geriatric inpatient wards, geriatric outpatient clinics, primary care clinics, and nursing homes.

METHODS

The frailty instruments used were Frailty Phenotype, SHARE-FI, 3-item Frailty Trait Scale (FTS-3), 5-item Frailty Trait Scale (FTS-5), FRAIL, 35-item Frailty Index (FI-35), Gérontopôle Frailty Screening Tool (GFST), and Clinical Frailty Scale (CFS). The settings were geriatrics wards, outpatient clinics, primary care, and nursing homes. Suitability was evaluated by considering the feasibility (patients with the test fully completed), administration time (time spent for administering the test), and interscale agreement (Cohen kappa index among instruments to detect frailty).

RESULTS

The prevalence of frailty varied across settings and adopted tests. The scales with the mean highest feasibility were the FRAIL scale (99.4%), SHARE-FI (98.3%), and GFST (95.0%). The mean shortest administration times were obtained with CFS (24 seconds), GFST (72 seconds), and FRAIL scale (90 seconds). The interscale agreement between most of the tests was fair. CFS followed by FTS-5 agreed at least moderately with a greater number of scales overall and in almost all settings.

CONCLUSIONS AND IMPLICATIONS

Based on feasibility, time to undertake the tool, and agreement with other scales, different scales would be recommended according to the setting considered. Our findings suggest that most of the tools evaluated are actually assessing different frailty constructs.

Relationship between multidimensional prognostic index and incident depressive symptoms in older people: Findings from the Irish Longitudinal Study on Ageing

OBJECTIVES

The multidimensional prognostic index (MPI) is a useful prognostic tool for evaluating adverse health outcomes in older individuals. However, the association between MPI and depressive symptoms has never been explored, despite depression being a common condition in older people. We therefore aimed to evaluate whether MPI may predict incident depressive symptoms.

METHODS

Longitudinal, cohort study, with 2 years of follow-up (W1: October 2009-February 2011; W2: April 2012-January 2013), including people aged ≥65 years without depressive symptoms at baseline. A comprehensive geriatric assessment including information on functional, nutritional, cognitive status, mobility, comorbidities, medications, and cohabitation status was used to calculate the MPI dividing the participants into low, moderate, or severe risk. Those who scored ≥16/60 with the Center of Epidemiology Studies Depression (CES-D) tool were considered to have depressive symptoms. Multivariable logistic regression models were built to explore the association between MPI and incident depressive symptoms.

RESULTS

The sample consisted of 1854 participants (mean age: 72.8 ± SD 5.1 years; females: 52.1%). The prevalence of incident depressive symptoms by MPI tertiles at baseline were: low 2.5%, moderate 3.9%, and severe 6.7%. In multivariable analyses, baseline MPI values were significantly associated with incident depressive symptoms (increase in 0.1 points in MPI: odds ratio, OR = 1.47; 95% confidence intervals, CI: 1.17-1.85; MPI tertile severe vs low: OR = 2.96; 95%CI: 1.50-5.85).

CONCLUSION

Baseline MPI values were associated with incident depressive symptoms indicating that multidimensional assessment of older people may lead to early identification of individuals at increased risk of depression onset.

A multidimensional approach to frailty in older people

Frailty is an important factor determining a higher risk of adverse health outcomes in older adults. Although scientific community in the last two decades put a lot of effort for its definition, to date no consensus was reached on its assessment. The mainstream thinking describes frailty as a loss of physical functions or as accumulation of multiple deficits. Recently, a novel conceptual model of frailty has emerged based on the loss of harmonic interaction between multiple domains (also referred as dimensions) including genetic, biological, functional, cognitive, psychological and socio-economic domain that ultimately lead to homeostatic instability. Therefore, the multidimensional aspects of frailty condition could be captured by the comprehensive geriatric assessment (CGA) and its derived Multidimensional Prognostic Index (MPI). This instrument has been applied in different clinical settings and in several cohorts of older adults with specific acute and chronic diseases, showing always excellent accuracy in stratifying population according the mortality risk and other negative health outcomes, i.e. hospitalization, institutionalization or admission to homecare services. This MPI "plasticity" provides a single numerical prognostic index which could be helpful in clinical decision making for the management of frail older adults.

Frailty is associated with hospital readmission in geriatric patients: a prognostic study

PURPOSE

Targeting health care interventions requires valid measurements when predicting unplanned hospital readmission. The Multidimensional Prognostic Index (MPI) based on Comprehensive Geriatric Assessment (CGA) enables the prediction of mortality and length of stay (LOS) in older hospitalized patients. Our aim was to validate if the MPI as a frailty tool could predict unplanned hospital readmission in geriatric patients.

METHODS

This prognostic study was conducted in geriatric wards. The target population was 65 + -year-old patients hospitalized with acute illness. The MPI tool is derived from eight CGA domains by an interdisciplinary team: social aspects, number of drugs, activities of daily living (ADL), instrumental-ADL, cognitive status, severity of morbidity, risk of developing pressure sores, and nutritional status. Patients assessed were categorized into three groups: non-frail (MPI-1), moderate frail (MPI-2) or severe frail (MPI-3). Primary outcome was 30-day unplanned readmission and secondary LOS and 90-day mortality.

RESULTS

In total 1467 patients were included from January 1, 2018, to October 1, 2019. Mean age was 84.2 years (± 7.4) and 59% were women. 15.7% were readmitted. Hazard ratio (HR) for readmission in the MPI-2 group (n = 635) was 2.57; 95% confidence interval (CI) 1.25-5.29 (p = 0.01), and 2.60; 95% CI 1.27-5.33 (p = 0.009) in the MPI-3 group (n = 711) compared to the MPI-1 group (n = 121). MPI was a predictor of LOS and mortality.

CONCLUSION

Using the MPI tool to identify the frail and non-frail patients is applicable to predict unplanned hospital readmission in geriatric patients. The MPI is superior to the prognostic value of each single domain. MPI will be of great value to health professionals' decision-making.

Using the Multidimensional Prognostic Index (MPI) to improve cost-effectiveness of interventions in multimorbid frail older persons: results and final recommendations from the MPI_AGE European Project

MPI_AGE is a European Union co-funded research project aimed to use the Multidimensional Prognostic Index (MPI), a validated Comprehensive Geriatric Assessment (CGA)-based prognostic tool, to develop predictive rules that guide clinical and management decisions in older people in different European countries. A series of international studies performed in different settings have shown that the MPI is useful to predict mortality and risk of hospitalization in community-dwelling older subjects at population level. Furthermore, studies performed in older people who underwent a CGA before admission to a nursing home or receiving homecare services showed that the MPI successfully identified groups of persons who could benefit, in terms of reduced mortality, of specific therapies such as statins in diabetes mellitus and coronary artery disease, anticoagulants in atrial fibrillation and antidementia drugs in cognitive decline. A prospective trial carried out in nine hospitals in Europe and Australia demonstrated that the MPI was able to predict not only in-hospital and long-term mortality, but also institutionalization, re-hospitalization and receiving homecare services during the one-year follow-up after hospital discharge. The project also explored the association between MPI and mortality in hospitalized older patients in need of complex procedures such as transcatheter aortic valve implantation or enteral tube feeding. Evidence from these studies has prompted the MPI_AGE Investigators to formulate recommendations for healthcare providers, policy makers and the general population which may help to improve the cost-effectiveness of appropriate health care interventions for older patients.

Three-month mortality in permanently bedridden medical non-oncologic patients. The BECLAP study (permanently BEdridden, creatinine CLearance, albumin, previous hospital admissions study)

OBJECTIVE

To predict the 3-months mortality in permanently bedridden medical non-oncologic inpatients.

PATIENTS AND METHODS

2788 consecutive patients admitted in 5 Italian Internal Medicine units from January 2016 through January 2017 were prospectively screened; 644 oncologic patients were excluded; 2144 non-oncologic patients (1021 female) were followed-up for mortality for 6 months. Main outcome was 3-months mortality in permanently bedridden inpatients with at least 2 of: creatinine clearance <35 ml/min; albumin < 2.5 g/dl; at least 2 hospital admissions in the previous 6 months. Advanced dementia and dysphagia were also recorded.

RESULTS

Mean age of the 2144 patients was 73.9 (SD, 14.9) years; 374 (17%) were permanently bedridden, 435 (20%) had a creatinine clearance <35 ml/min, 217 (10%) albumin <2,5 g/dl, 112 (5%) at least 2 hospital admissions in the previous 6 months. Seventy-seven (4%) patients were permanently bedridden with at least 2 of the above mentioned items, and 48 of them died within 3 months (62%) (p < 0.001;95% CI 51-73%). Regression coefficients of the variables associated with 3-months mortality in multivariate analysis in 998 patients of unit 1 (training cohort) were used to create a simple score, which was validated in the 1146 patients of the other units (validation cohort) and performed well in predicting the 3-months mortality (https://www.ejcrim.com/beclap/).

CONCLUSIONS

Approximately two out of three non-oncologic medical patients permanently bedridden having 2 of the abovementioned items are dead 3 months after index admission; a simple score including bedridden status, creatinine clearance, albumin, dysphagia, age and sex may help discuss management priorities.

The prognostic significance of geriatric syndromes and resources

BACKGROUND

Geriatric syndromes (GS) do not fit into discrete disease categories and are often underdiagnosed in hospitalized older adults. Geriatric resources (GR) are also not routinely collected in clinical settings, although this may potentiate the beneficial effects of clinical decisions. The prognostic relevance of GS and GR has never been systematically evaluated through clinical tools developed for clinical decision purposes.

AIM

To ascertain the impact of common GS and GR on patients' prognosis as assessed by means of the comprehensive geriatric assessment (CGA)-based Multidimensional Prognostic Index (MPI).

METHODS

One hundred and thirty-five hospitalized patients aged 70 years and older underwent a CGA evaluation with calculation of the MPI on admission and discharge. Accordingly, patients were subdivided in low (MPI-1, score 0-0.33), moderate (MPI-2, score 0.34-0.66), and severe (MPI-3, score 0.67-1)-risk of mortality at 1 month and 1 year. Nine GR and 17 GS were identified and collected accordingly.

RESULTS

A lower number of GS and a higher number of GR were shown to be highly significantly correlated with a lower MPI, as well as years of education, grade of care, and number of medications independent of age, sex and number of GS or GR. Underweight and obesity according to the BMI were significantly correlated to higher number of GS. Patients with more GR had a significantly higher chance of being discharged home.

CONCLUSIONS

The MPI evaluation together with GS and GR in acute care for older patients should be encouraged to improve clinical decision-making.

Frailty screening in hospitalised older adults: How does the brief Dutch National Safety Management Program perform compared to a more extensive approach?

AIMS AND OBJECTIVES

To examine the predictive properties of the brief Dutch National Safety Management Program for the screening of frail hospitalised older patients (VMS) and to compare these with the more extensive Maastricht Frailty Screening Tool for Hospitalised Patients (MFST-HP).

BACKGROUND

Screening of older patients during admission may help to detect frailty and underlying geriatric conditions. The VMS screening assesses patients on four domains (i.e. functional decline, delirium risk, fall risk and nutrition). The 15-item MFST-HP assesses patients on three domains of frailty (physical, social and psychological).

DESIGN

Retrospective cohort study.

METHODS

Data of 2,573 hospitalised patients (70+) admitted in 2013 were included, and relative risks, sensitivity and specificity and area under the receiver operating characteristic (AUC) curve of the two tools were calculated for discharge destination, readmissions and mortality. The data were derived from the patients nursing files. A STARD checklist was completed.

RESULTS

Different proportions of frail patients were identified by means of both tools: 1,369 (53.2%) based on the VMS and 414 (16.1%) based on the MFST-HP. The specificity was low for the VMS, and the sensitivity was low for the MFST-HP. The overall AUC for the VMS varied from 0.50 to 0.76 and from 0.49 to 0.69 for the MFST-HP.

CONCLUSION

The predictive properties of the VMS and the more extended MFST-HP on the screening of frailty among older hospitalised patients are poor to moderate and not very promising.

RELEVANCE TO CLINICAL PRACTICE

The VMS labels a high proportion of older patients as potentially frail, while the MFST-HP labels over 80% as nonfrail. An extended tool did not increase the predictive ability of the VMS. However, information derived from the individual items of the screening tools may help nurses in daily practice to intervene on potential geriatric risks such as delirium risk or fall risk.

Older women are frailer, but less often die then men: a prospective study of older hospitalized people

OBJECTIVES

The association between frailty, mortality and sex is complex, but a limited literature is available on this topic, particularly for older hospitalized patients. Therefore, the objective of our study was to prospectively evaluate sex differences in frailty, assessed by the Multidimensional Prognostic Index (MPI) and mortality, institutionalization, and re-hospitalization in an international cohort of older people admitted to hospital.

STUDY DESIGN

We used data from nine public hospitals in Europe and Australia, to evaluate sex differences in mortality, frailty and the risk of institutionalization and re-hospitalization, during one year of follow-up.

MAIN OUTCOME MEASURES

People aged 65 years or more admitted to hospital for an acute medical condition or for a relapse of a chronic disease were included. A standardized comprehensive geriatric assessment, which evaluated functional, nutritional, and cognitive status, risk of pressure sores, comorbidities, medications and co-habitation status, was used to calculate the MPI to measure frailty in all hospitalized older people. Data regarding mortality, institutionalization and re-hospitalization were also recorded for one year.

RESULTS

Altogether, 1140 hospitalized patients (mean age = 84.2 years; 694 women = 60.9%) were included. The one-year mortality rate was 33.2%. In multivariate analysis, adjusted for age, MPI score, centre and diagnosis at baseline, although women had higher MPI scores than men, the latter had higher in-hospital (odds ratio, OR = 2.26; 95% confidence intervals, CI = 1.27-4.01) and one-year post-discharge mortality (OR = 2.04; 95%CI = 1.50-2.79). Furthermore, men were less frequently institutionalized in a care home than female patients (OR = 0.55; 95%CI: 0.34-0.91), but they were also more frequently re-hospitalized (OR = 1.42; 95%CI: 1.06-1.91) during the year after hospital discharge.

CONCLUSION

Older hospitalized men were less frail, but experienced higher in-hospital and one-year mortality than women. Women were admitted more frequently to nursing homes and experienced a lower risk of re-hospitalization. These findings suggest important differences between the sexes and extends the 'male-female health-survival paradox' to acutely ill patient groups.

Enteral tube feeding and mortality in hospitalized older patients: A multicenter longitudinal study

BACKGROUND & AIMS

The literature regarding enteral nutrition and mortality in older frail people is limited and still conflicting. Moreover, the potential role of comprehensive geriatric assessment is poorly explored. We therefore aimed to investigate whether the Multidimensional Prognostic Index (MPI), an established tool that assesses measures of frailty and predicts mortality, may help physicians in identifying patients in whom ETF (enteral tube feeding) is effective in terms of reduced mortality.

METHODS

Observational, longitudinal, multicenter study with one year of follow-up. Data regarding ETF were recorded through medical records. A standardized comprehensive geriatric assessment was used to calculate the MPI. Participants were divided in low (MPI-1), moderate (MPI-2) or severe (MPI-3) risk of mortality. Data regarding mortality were recorded through administrative information.

RESULTS

1064 patients were included, with 79 (13 in MPI 1-2 and 66 in MPI-3 class) receiving ETF. In multivariable analysis, patients receiving ETF experienced a higher risk of death (odds ratio, OR = 2.00; 95% confidence intervals, CI: 1.19-3.38). However, after stratifying for their MPI at admission, mortality was higher in MPI-3 class patients (OR = 2.03; 95%CI: 1.09-3.76), but not in MPI 1-2 class patients (OR = 1.51; 95%CI: 0.44-5.25). The use of propensity score confirmed these findings.

CONCLUSIONS

ETF is associated with a higher risk of death. However, this is limited to more frail patients, suggesting the importance of the MPI in the prognostic evaluation of ETF.

Rerouting Geriatric Medicine by Complementing Static Frailty Measures With Dynamic Resilience Indicators of Recovery Potential

Medicine is still very inadequate in forecasting recovery of tipping points in health and disease, especially in older adults. However, increasingly, diseases and invasive treatments unexpectedly push older patients with low resilience over their tipping points (TPs). These TPs are the points in human physiology that separate more healthy conditions from disease conditions or malfunctioning of the older human’s subsystems or organs, such as delirium, syncope and falls in old age, which threaten the functioning of the older person as a whole. Either the person may recover from the perturbation induced by such a subsystem TP and the balance of the whole system is restored, or the TP may set in motion a cascade of events driving the system down to a state of more decline, ultimately leading to death. A main unanswered question here is how to predict whether these older persons will recover or not. To improve this TP-recovery-forecasting, intriguing findings on measures of resilience found in other complex biological systems may be translated to humans. New dynamic resilience biomarkers for resilience can enrich clinical prediction for pathophysiological recovery and could test interventions for their effectiveness in improving resilience. Therefore, we hypothesize that dynamic, stimulus-response measures of recovery rate over time, observed after having received a minor stressor in a healthy condition, can be used to quantify recovery potential following subsystem TPs in disease and following invasive treatments in humans and thus the person’s resilience. Current static frailty prognostics can predict risks for death, institutionalization, delirium, falls, and other TP transitions, but it has not been proven that they can predict recovery. Our hypothesis on dynamic indicators of recovery is logical and timely, as it can now be studied with sensor technology to create a fundamentally different approach of variables that may be validated to forecast recovery potential. By generating dynamic measures of systemic resilience over various organ systems, we may subsequently model resilience generically across many chronic diseases, affecting different organ systems. Next, quantifying systemic resilience may reroute scientific and clinical pathways by predicting and preventing irreversible tipping points and by improving recovery by older adults.

Rehabilitation After Urgent or Elective Orthopedic Surgery: The Role of Resilience in Elderly Patients

PURPOSE

The aim of this investigation was to assess resilience within an elderly population during postacute rehabilitation for orthopedic surgery and to identify the role of resilience on rehabilitation outcomes by comparing hip fracture and elective patients (total knee and hip arthroplasty).

DESIGN

We conducted a prospective study in an orthopedic rehabilitation department.

METHODS

On admission and on discharge, 80 patients aged over 60 years underwent a multidimensional evaluation with the Resilience Scale, the Functional Independence Measure (FIM), the Multidimensional Prognostic Index, and the World Health Organization Quality of Life-BREF.

FINDINGS

Hip-fractured patients had a lower level of resilience. High-resilient fracture patients achieved higher FIM scores. For elective patients, no differences on FIM score occurred for different resilience levels.

CONCLUSIONS AND CLINICAL RELEVANCE

Resilience plays a significant role in reaching optimal functional recovery in hip-fractured elderly people. Results suggest the introduction of early routine assessment of resilience in future outcome studies in rehabilitation.

Multicomponent Frailty Assessment Tools for Older People with Psychiatric Disorders: A Systematic Review

OBJECTIVE

To review evidence evaluating the use of multicomponent frailty assessment tools in assessing frailty in older adults with psychiatric disorders.

METHODS

A systematic literature review was conducted to identify all multicomponent frailty assessment tools (ie, a tool that assesses two or more indicators of frailty). The items of each frailty assessment tool were compared with Diagnostic and Statistical Manual of Mental Disorders, 5th edition (DSM-5) diagnostic criteria for psychiatric disorders to assess construct overlap. Studies conducted in community, inpatient, and outpatient clinical settings were considered for inclusion.

PARTICIPANTS

Adults aged 60 years or older.

RESULTS

A total of 5639 records were identified following the removal of duplicates, from which 95 studies were included for review. Of the 48 multicomponent frailty assessment tools identified, no tool had been developed for, or validated in, older adult populations with a psychiatric disorder. Overall, 20 of 48 frailty assessment tools contained a psychological assessment domain, with 17 of 48 tools citing the presence of depressed mood and/or anxiety as a frailty indicator. Common areas of construct overlap in frailty assessment tools and DSM-5 diagnostic criteria included weight loss (29 of 48) and fatigue (21 of 48).

CONCLUSIONS

Significant construct overlap exists between the indicators of frailty as conceptualized in existing frailty assessment tools and DSM-5 diagnostic criteria for common psychiatric disorders including major depressive episode and generalized anxiety disorder that has the potential to confound frailty assessment results. Further research is necessary to establish a reliable and valid tool to assess frailty in this population. J Am Geriatr Soc 67:1085-1095, 2019.

Predicting 7-year mortality for use with evidence-based guidelines for Prostate-Specific Antigen (PSA) testing: findings from a large prospective study of 123 697 Australian men

OBJECTIVES

To develop and validate a prediction model for short-term mortality in Australian men aged ≥45years, using age and self-reported health variables, for use when implementing the Australian Clinical Practice Guidelines for Prostate-Specific Antigen (PSA) Testing and Early Management of Test-Detected Prostate Cancer. Implementation of one of the Guideline recommendations requires an estimate of 7-year mortality.

DESIGN

Prospective cohort study using questionnaire data linked to mortality data.

SETTING

Men aged ≥45years randomly sampled from the general population of New South Wales, Australia, participating in the 45 and Up Study.

PARTICIPANTS

123 697 men who completed the baseline postal questionnaire (distributed from 1 January 2006 to 31 December 2008) and gave informed consent for follow-up through linkage of their data to population health databases.

PRIMARY OUTCOME MEASURES

The primary outcome was all-cause mortality.

RESULTS

12 160 died during follow-up (median=5.9 years). Following age-adjustment, self-reported health was the strongest predictor of all-cause mortality (C-index: 0.827; 95% CI 0.824 to 0.831). Three prediction models for all-cause mortality were validated, with predictors: Model-1: age group and self-rated health; Model-2: variables common to the 45 and Up Study and the Australian Health Survey and subselected using stepwise regression and Model-3: all variables selected using stepwise regression. Final predictions calibrated well with observed all-cause mortality rates. The 90th percentile for the 7-year mortality risks ranged from 1.92% to 83.94% for ages 45-85 years.

CONCLUSIONS

We developed prediction scores for short-term mortality using age and self-reported health measures and validated the scores against national mortality rates. Along with age, simple measures such as self-rated health, which can be easily obtained without physical examination, were strong predictors of all-cause mortality in the 45 and Up Study. Seven-year mortality risk estimates from Model-3 suggest that the impact of the mortality risk prediction tool on men's decision making would be small in the recommended age (50-69 years) for PSA testing, but it may discourage testing at older ages.

Hospital Discharge Decisions Concerning Older Patients: Understanding the Underlying Process

ABSTRACTWe aimed to understand clinical decision-making processes that influence the orientation of older patients after hospital discharge. We compared discharge decisions (i.e., discharge home, or nursing home stay) of the hospital team with those of an expert panel. Both panel and hospital team made their decisions independently. The blind study included 102 patients (mean age: 83.13 ± 6.74). There is a statistically significant difference between expert and hospital team decisions (p &lt; .001; kappa coefficient: 0.468). Panel decisions were more closely associated with isolation (p = .018), reliable caregivers (p = .004), social problems (p = .001), and behavioural symptoms perceived as aggressive (p = .001). Both decision processes considered refusal of care (p = 0,025 and 0.016 respectively) and social problems (p = .001 and &lt; 0.001 respectively). Discharge planning models differ depending on the country, team and patient's condition. Our study suggests more precise evaluation of patients' needs.

New associations of the Multidimensional Prognostic Index

BACKGROUND

The multidimensional prognostic index (MPI) is a validated, sensitive, and specific prognosis estimation tool based on a comprehensive geriatric assessment (CGA). The MPI accurately predicts mortality after 1 month and 1 year in older, multimorbid patients with acute disease or relapse of chronic conditions.

OBJECTIVE

To evaluate whether the MPI predicts indicators of healthcare resources, i.e. grade of care (GC), length of hospital stay (LHS) and destination after hospital discharge in older patients in an acute medical setting.

MATERIAL AND METHODS

In this study 135 hospitalized patients aged 70 years and older underwent a CGA evaluation to calculate the MPI on admission and discharge. Accordingly, patients were subdivided in low (MPI‑1, score 0-0.33), moderate (MPI-2, score 0.34-0.66) and high (MPI-3, score 0.67-1) risk of mortality. The GC, LHS and the discharge allocation were also recorded.

RESULTS

The MPI score was significantly related to LHS (p = 0.011) and to GC (p < 0.001). In addition, MPI-3 patients were significantly more often transferred from other hospital settings (p = 0.007) as well as significantly less likely to be discharged home (p = 0.04) than other groups.

CONCLUSION

The CGA-based MPI values are significantly associated with use of indicators of healthcare resources, including GC, LHS and discharge allocation. These findings suggest that the MPI may be useful for resource planning in the care of older multimorbid patients admitted to hospital.