Application of an electronic Frailty Index in Australian primary care: data quality and feasibility assessment

Prognostic accuracy of 70 individual frailty biomarkers in predicting mortality in the Canadian Longitudinal Study on Aging

The frailty index (FI) uses a deficit accumulation approach to derive a single, comprehensive, and replicable indicator of age-related health status. Yet, many researchers continue to seek a single "frailty biomarker" to facilitate clinical screening. We investigated the prognostic accuracy of 70 individual biomarkers in predicting mortality, comparing each with a composite FI. A total of 29,341 individuals from the comprehensive cohort of the Canadian Longitudinal Study on Aging were included (mean, 59.4 ± 9.9 years; 50.3% female). Twenty-three blood-based biomarkers and 47 test-based biomarkers (e.g., physical, cardiac, cardiology) were examined. Two composite FIs were derived: FI-Blood and FI-Examination. Mortality status was ascertained using provincial vital statistics linkages and contact with next of kin. Areas under the curve were calculated to compare prognostic accuracy across models (i.e., age, sex, biomarker, FI) in predicting mortality. Compared to an age-sex only model, the addition of individual biomarkers demonstrated improved model fit for 24/70 biomarkers (11 blood, 13 test-based). Inclusion of FI-Blood or FI-Examination improved mortality prediction when compared to any of the 70 biomarker-age-sex models. Individual addition of seven biomarkers (walking speed, chair rise, time up and go, pulse, red blood cell distribution width, C-reactive protein, white blood cells) demonstrated an improved fit when added to the age-sex-FI model. FI scores had better mortality risk prediction than any biomarker. Although seven biomarkers demonstrated improved prognostic accuracy when considered alongside an FI score, all biomarkers had worse prognostic accuracy on their own. Rather than a single biomarker test, implementation of routine FI assessment in clinical settings may provide a more accurate and reliable screening tool to identify those at increased risk of adverse outcomes.

Combating Barriers to the Development of a Patient-Oriented Frailty Website

Unlabelled

This viewpoint article, which represents the opinions of the authors, discusses the barriers to developing a patient-oriented frailty website and potential solutions. A patient-oriented frailty website is a health resource where community-dwelling older adults can navigate to and answer a series of health-related questions to receive a frailty score and health summary. This information could then be shared with health care professionals to help with the understanding of health status prior to acute illness, as well as to screen and identify older adult individuals for frailty. Our viewpoints were drawn from 2 discussion sessions that included caregivers and care providers, as well as community-dwelling older adults. We found that barriers to a patient-oriented frailty website include, but are not limited to, its inherent restrictiveness to frail persons, concerns over data privacy, time commitment worries, and the need for health and lifestyle resources in addition to an assessment summary. For each barrier, we discuss potential solutions and caveats to those solutions, including assistance from caregivers, hosting the website on a trusted source, reducing the number of health questions that need to be answered, and providing resources tailored to each users' responses, respectively. In addition to screening and identifying frail older adults, a patient-oriented frailty website will help promote healthy aging in nonfrail adults, encourage aging in place, support real-time monitoring, and enable personalized and preventative care.

Effect of canakinumab on frailty: A post hoc analysis of the CANTOS trial

Although inflammation is strongly associated with frailty, whether medications that lower inflammation decrease frailty is unclear and randomized trial evidence is scant. We sought to test whether canakinumab, a therapeutic monoclonal antibody that inhibits IL-1β and reduces C-reactive protein (CRP), can lower frailty risk. This was a post hoc analysis of the Canakinumab ANti-inflammatory Thrombosis Outcome Study (CANTOS), a randomized double-blind placebo-controlled trial of 10,061 stable postmyocardial infarction patients randomized to subcutaneous canakinumab once every 3 months. Incident frailty was measured using a 34-item cumulative-deficit Frailty Index (FI). Time-to-event analysis using intent to treat. A total of 9942 CANTOS participants had data to calculate a baseline FI. Median age was 61 (IQR 54-68); 74% were male, 12% Asian, 3% Black, 80% White, and 16% Hispanic/Latino. At baseline, mean FI score was 0.12 and 13% were frail using a cutoff of 0.2. Over 5 years, 1080 participants (12.5%) became frail and mean FI scores increased to 0.14. There was no effect on frailty incidence according to randomization to any canakinumab dose versus placebo over time, HR 1.03 (0.91-1.17), p = 0.63. Results were similar using phenotypic frailty. Additionally, the primary findings of CANTOS in terms of canakinumab-associated cardiovascular event reduction were unchanged in analyses stratified by baseline frailty. In conclusion, among stable adult patients with atherosclerosis, random allocation to interleukin-1b inhibition with canakinumab versus placebo did not lower risk of incident frailty over 5 years. More randomized data are needed to understand the role of targeted anti-inflammatory medications for frailty prevention in older adults.

Validated frailty measures using electronic primary care records: a review of diagnostic test accuracy

INTRODUCTION

Identification of people who have or are at risk of frailty enables targeted interventions, and the use of tools that screen for frailty using electronic records (which we term as validated electronic frailty measures (VEFMs)) within primary care is incentivised by NHS England. We carried out a systematic review to establish the sensitivity and specificity of available primary care VEFMs when compared to a reference standard in-person assessment.

METHODS

Medline, Pubmed, CENTRAL, CINHAL and Embase searches identified studies comparing a primary care VEFM with in-person assessment. Studies were quality assessed using Quality Assessment of Diagnostic Accuracy Studies revised tool. Sensitivity and specificity values were extracted or were calculated and pooled using StatsDirect.

RESULTS

There were 2,245 titles screened, with 10 studies included. These described three different index tests: electronic frailty index (eFI), claims-based frailty index (cFI) and polypharmacy. Frailty Phenotype was the reference standard in each study. One study of 60 patients examined the eFI, reporting a sensitivity of 0.84 (95% CI = 0.55, 0.98) and a specificity of 0.78 (0.64, 0.89). Two studies of 7,679 patients examined cFI, with a pooled sensitivity of 0.48 (95% CI = 0.23, 0.74) and a specificity of 0.80 (0.53, 0.98). Seven studies of 34,328 patients examined a polypharmacy as a screening tool (defined as more than or equal to five medications) with a pooled sensitivity of 0.61 (95% CI = 0.50, 0.72) and a specificity of 0.66 (0.58, 0.73).

CONCLUSIONS

eFI is the best-performing VEFM; however, based on our analysis of an average UK GP practice, it would return a high number of false-positive results. In conclusion, existing electronic frailty tools may not be appropriate for primary care-based population screening.

Alzheimer's disease with frailty: Prevalence, screening, assessment, intervention strategies and challenges

Alzheimer's disease (AD) is a neurodegenerative disorder that affects millions worldwide and is expected to surge in prevalence due to aging populations. Frailty, characterized by muscle function decline, becomes more prevalent with age, imposing substantial burdens on patients and caregivers. This paper aimed to comprehensively review the current literature on AD coupled with frailty, encompassing prevalence, screening, assessment, and treatment while delving into the field's challenges and future trajectories. Frailty and AD coexist in more than 30% of cases, with hazard ratios above 120% indicating a mutually detrimental association.Various screening tools have emerged for both frailty and AD, including the Fried Frailty Phenotype (FP), FRAIL scale, Edmonton Frailty Scale (EFS), Mini-Mental State Examination (MMSE), Montreal Cognitive Assessment (MoCA), Clock Drawing Test (CDT), and General Practitioner Assessment of Cognition (GPCOG). However, none has solidified its role as the definitive gold standard. The convergence of electronic health records and brain aging biomarkers heralds a new era in AD with frailty screening and assessment. In terms of intervention, non-pharmacological strategies spanning nutrition, horticulture, exercise, and social interaction, along with pharmacological approaches involving acetylcholinesterase inhibitors (AChEIs), N-methyl-D-aspartate (NMDA) receptor antagonists, and anti-amyloid beta-protein medications, constituted cornerstones for treating AD coupled with frailty. Technological interventions like repetitive transcranial magnetic stimulation (rTMS) also entered the fold. Notably, multi-domain non-pharmacological interventions wield considerable potential in enhancing cognition and mitigating disability. However, the long-term efficacy and safety of pharmacological interventions necessitate further validation. Diagnosing and managing AD with frailty present several daunting challenges, encompassing low rates of early co-diagnosis, limited clinical trial evidence, and scarce integrated, pioneering service delivery models. These challenges demand heightened attention through robust research and pragmatic implementation.

Frailty detection among primary care older patients through the Primary Care Frailty Index (PC-FI)

The prompt identification of frailty in primary care is the first step to offer personalized care to older individuals. We aimed to detect and quantify frailty among primary care older patients, by developing and validating a primary care frailty index (PC-FI) based on routinely collected health records and providing sex-specific frailty charts. The PC-FI was developed using data from 308,280 primary care patients ≥ 60 years old part of the Health Search Database (HSD) in Italy (baseline 2013-2019) and validated in the Swedish National Study on Aging and Care in Kungsholmen (SNAC-K; baseline 2001-2004), a well-characterized population-based cohort including 3363 individuals ≥ 60 years old. Potential health deficits part of the PC-FI were identified through ICD-9, ATC, and exemption codes and selected through an optimization algorithm (i.e., genetic algorithm), using all-cause mortality as the main outcome for the PC-FI development. The PC-FI association at 1, 3 and 5 years, and discriminative ability for mortality and hospitalization were tested in Cox models. The convergent validity with frailty-related measures was verified in SNAC-K. The following cut-offs were used to define absent, mild, moderate and severe frailty: < 0.07, 0.07-0.14, 0.14-0.21, and ≥ 0.21. Mean age of HSD and SNAC-K participants was 71.0 years (55.4% females). The PC-FI included 25 health deficits and showed an independent association with mortality (hazard ratio range 2.03-2.27; p < 0.05) and hospitalization (hazard ratio range 1.25-1.64; p < 0.05) and a fair-to-good discriminative ability (c-statistics range 0.74-0.84 for mortality and 0.59-0.69 for hospitalization). In HSD 34.2%, 10.9% and 3.8% were deemed mildly, moderately, and severely frail, respectively. In the SNAC-K cohort, the associations between PC-FI and mortality and hospitalization were stronger than in the HSD and PC-FI scores were associated with physical frailty (odds ratio 4.25 for each 0.1 increase; p < 0.05; area under the curve 0.84), poor physical performance, disability, injurious falls, and dementia. Almost 15% of primary care patients ≥ 60 years old are affected by moderate or severe frailty in Italy. We propose a reliable, automated, and easily implementable frailty index that can be used to screen the primary care population for frailty.

Development and validation of risk prediction model for identifying 30-day frailty in older inpatients with undernutrition: A multicenter cohort study

Objective

To develop and externally validate a frailty prediction model integrating physical factors, psychological variables and routine laboratory test parameters to predict the 30-day frailty risk in older adults with undernutrition.

Methods

Based on an ongoing survey of geriatrics syndrome in elder adults across China (SGSE), this prognostic study identified the putative prognostic indicators for predicting the 30-day frailty risk of older adults with undernutrition. Using multivariable logistic regression analysis with backward elimination, the predictive model was subjected to internal (bootstrap) and external validation, and its calibration was evaluated by the calibration slope and its C statistic discriminative ability. The model derivation and model validation cohorts were collected between October 2018 and February 2019 from a prospective, large-scale cohort study of hospitalized older adults in tertiary hospitals in China. The modeling derivation cohort data (n = 2,194) were based on the SGSE data comprising southwest Sichuan Province, northern Beijing municipality, northwest Qinghai Province, northeast Heilongjiang Province, and eastern Zhejiang Province, with SGSE data from Hubei Province used to externally validate the model (validation cohort, n = 648).

Results

The incidence of frailty in the older undernutrition derivation cohort was 13.54% and 13.43% in the validation cohort. The final model developed to estimate the individual predicted risk of 30-day frailty was presented as a regression formula: predicted risk of 30-day frailty = [1/(1+e^-riskscore )], where riskscore = -0.106 + 0.034 × age + 0.796 × sex -0.361 × vision dysfunction + 0.373 × hearing dysfunction + 0.408 × urination dysfunction - 0.012 × ADL + 0.064 × depression - 0.139 × nutritional status - 0.007 × hemoglobin - 0.034 × serum albumin - 0.012 × (male: ADL). Area under the curve (AUC) of 0.71 in the derivation cohort, and discrimination of the model were similar in both cohorts, with a C statistic of nearly 0.7, with excellent calibration of observed and predicted risks.

Conclusion

A new prediction model that quantifies the absolute risk of frailty of older patients suffering from undernutrition was developed and externally validated. Based on physical, psychological, and biological variables, the model provides an important assessment tool to provide different healthcare needs at different times for undernutrition frailty patients.

Clinical trial registration

Chinese Clinical Trial Registry [ChiCTR1800017682].

The Feasibility of Deriving the Electronic Frailty Index from Australian General Practice Records

Purpose

Frailty is a prevalent condition in older adults. Identification of frailty using an electronic Frailty Index (eFI) has been successfully implemented across general practices in the United Kingdom. However, in Australia, the eFI remains understudied. Therefore, we aimed to (i) examine the feasibility of deriving an eFI from Australian general practice records and (ii) describe the prevalence of frailty as measured by the eFI and the prevalence with socioeconomic status and geographic remoteness.

Participants and Methods

This retrospective analysis included patients (≥70 years) attending any one of >700 general practices utilizing the Australian MedicineInsight data platform, 2017–2018. A 36-item eFI was derived using standard methodology, with frailty classified as mild (scores 0.13–0.24); moderate (0.25–0.36) or severe (≥0.37). Socioeconomic status (Socio-Economic Indexes for Areas (SEIFA) index)) and geographic remoteness (Australian Statistical Geography Standard (ASGC) remoteness areas) were also examined.

Results

In total, 79,251 patients (56% female) were included, mean age 80.0 years (SD 6.5); 37.4% (95% CI 37.0–37.7) were mildly frail, 16.7% (95% CI 16.4–16.9) moderately frail, 4.8% (95% CI 4.7–5.0) severely frail. Median eFI score was 0.14 (IQR 0.08 to 0.22); maximum eFI score was 0.69. Across all age groups, moderate and severe frailty was significantly more prevalent in females (P < 0.001). Frailty severity increased with increasing age (P < 0.001) and was strongly associated with socioeconomic disadvantage (P < 0.001) but not with geographic remoteness.

Conclusion

Frailty was identifiable from routinely collected general practice data. Frailty was more prevalent in socioeconomically disadvantaged groups, women and older patients and existed in all levels of remoteness. Routine implementation of an eFI could inform interventions to prevent or reduce frailty in all older adults, regardless of location.

The Future of Assessing Frailty in the Patient With Advanced Heart Failure: A Review of Current Literature

Frailty is becoming an important component of health care outcomes in patients with a diagnosis of heart failure. A literature search was completed to determine whether a best practice guideline existed to assess frailty in patients who were considering ventricular assist device placement. The literature search revealed that best practice guidelines did not exist. A second comprehensive literature search was completed specifically for frailty including the definition, criteria, assessment, and outcomes. The studies revealed that there were challenges with defining frailty, the age of frailty, assessments tools, and study designs. Cardiologists are primarily interested in screening for frailty, but other physician specialty practices are interested in a frailty screening tool as well. This article discusses the inconsistent research studies and the need for a valid and reliable tool to assess for frailty. It is important that nurse leaders and those working with heart failure patients determine the best practice guidelines for assessing frailty.

Effect of Vitamin D3 and Omega-3 Fatty Acid Supplementation on Risk of Frailty: An Ancillary Study of a Randomized Clinical Trial

IMPORTANCE

Preventive strategies for frailty are needed. Whether supplements with anti-inflammatory properties, such as vitamin D3 or marine omega-3 fatty acids, are useful for frailty prevention is unknown.

OBJECTIVE

To test the effects of vitamin D3 and omega-3 supplements on change in frailty in older individuals.

DESIGN, SETTING, AND PARTICIPANTS

This study was conducted in 2021, as a prespecified ancillary to the Vitamin D and Omega-3 (VITAL) trial, a 2 × 2 factorial randomized clinical trial. A total of 25 871 individuals (men aged ≥50 years and women aged ≥55 years), without cancer or cardiovascular disease and with data on frailty, were recruited across all 50 US states from November 2011 to March 2014 and followed up through December 31, 2017. Data analysis for the ancillary study was conducted from December 1, 2019, to March 30, 2022.

INTERVENTIONS

Vitamin D3, 2000 IU/d, and marine omega-3 fatty acids, 1 g/d.

MAIN OUTCOMES AND MEASURES

Frailty was measured using a validated 36-item frailty index that includes measures of function, cognition, mood, and comorbidities from annual questionnaires. Change in frailty score from baseline to year 5, according to randomization, using an intention-to-treat protocol, was assessed using repeated measures. Cox proportional hazards regression models assessed incident frailty. In subgroup analysis, an alternative frailty definition, the physical phenotype, was used as a sensitivity analysis.

RESULTS

Of 25 871 VITAL trial participants randomized, 25 057 had sufficient data to calculate a frailty index. Baseline mean (SD) age was 67.2 (7.0) years, and 12 698 (50.7.%) were women. Mean (SD) frailty score was 0.109 (0.090) (range, 0.00-0.685), and 3174 individuals (12.7%) were frail. During a median 5-year follow-up, mean (SD) frailty scores increased to 0.121 (0.099) (range, 0.00-0.792). Neither vitamin D3 nor omega-3 fatty acid supplementation affected mean frailty scores over time (mean difference at year 5: vitamin D3, -0.0002; P = .85; omega-3 fatty acid, -0.0001; P = .90) or rate of change in mean frailty score (interaction with time: vitamin D3; P = .98; omega-3 fatty acid; P = .13) Incident frailty remained similar over time (interaction with time: vitamin D3, P = .90; omega-3 fatty acid; P = .32). Results were unchanged using the frailty physical phenotype.

CONCLUSIONS AND RELEVANCE

In this ancillary study of the VITAL randomized clinical trial, treatment with vitamin D3 or omega-3 fatty acid supplementation, compared with placebo, did not affect the rate of frailty change or incidence over time. These results do not support routine use of either vitamin D3 or omega-3 fatty acid supplementation for frailty prevention in generally healthy community-dwelling older adults not selected for vitamin D3 deficiency.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT01169259.

Development and validation of the electronic screening index of frailty

BACKGROUND

primary care screening for frailty status is recommended in clinical guidelines, but is impeded by doctor and nurse workloads and the lack of valid, easy-to-use and time-saving screening tools.

AIM

to develop and validate a new electronic tool (the electronic screening index of frailty, e-SIF) using routinely available electronic health data to automatically and massively identify frailty status in the population aged ≥65 years.

METHODS

the e-SIF was developed in three steps: selection of clinical conditions; establishment of ICD-10 codes, criteria and algorithms for their definition; and electronic tool design and data extraction, transformation and load processes. The validation phase included an observational cohort study with retrospective data collection from computerised primary care medical records. The study population included inhabitants aged ≥65 years corresponding to three primary care centres (n = 9,315). Evaluated was the relationship between baseline e-SIF categories and mortality, institutionalisation, hospitalisation and health resource consumption after 2 years.

RESULTS

according to the e-SIF, which includes 42 clinical conditions, frailty prevalence increases with age and is slightly greater in women. The 2-year adjusted hazard ratios for pre-frail, frail and very frail subjects, respectively, were as follows: 2.23 (95% CI: 1.74-2.85), 3.34 (2.44-4.56) and 6.49 (4.30-9.78) for mortality; 2.80 (2.39-3.27), 5.53 (4.59-6.65) and 9.14 (7.06-11.8) for hospitalisation; and 1.02 (0.70-1.49), 1.93 (1.21-3.08) and 2.69 (1.34-5.40) for institutionalisation.

CONCLUSIONS

the e-SIF shows good agreement with mortality, institutionalisation, hospitalisation and health resource consumption, indicating satisfactory validity. More studies in larger populations are needed to corroborate our findings.

Practitioner perceptions of the feasibility of common frailty screening instruments within general practice settings: a mixed methods study

BACKGROUND

Frailty is a highly prevalent clinical syndrome increasing older people's vulnerability to risk of adverse outcomes. Better frailty identification through expanded screening implementation has been advocated within general practice settings, both internationally and within Australia. However, little is known about practitioner perceptions of the feasibility of specific instruments, and the underlying motivations behind those perceptions. Consequently, the purpose of this study was to explore the attitudes and perceptions of a convenience and volunteer sample of Australian general practitioners (GPs) and practice nurses (PNs) towards common frailty screening instruments.

METHODS

The feasibility of several frailty screening instruments (PRISMA-7 [P7], Edmonton Frail Scale [EFS], FRAIL Questionnaire [FQ], Gait Speed Test [GST], Groningen Frailty Indicator [GFI], Kihon Checklist [KC] and Timed Up and Go [TUG]) to 43 Australian GPs and PNs was assessed. The study adopted a concurrent embedded mixed-methods design incorporating quantitative (ranking exercise) and qualitative (content analysis) data collection integrated during the analysis phase.

RESULTS

Practitioners assessed multi-dimensional instruments (EFS, GFI, KC) as having relatively higher clinical utility, better integration into existing assessment processes and stronger links to intervention over uni-dimensional (GST, TUG) and simple (FQ, P7) instruments.

CONCLUSIONS

While existing frailty screening instruments show promise as an initial step in supporting better care for older people, all the included instruments were associated with perceived advantages and disadvantages. Ultimately, clinicians will need to weigh several factors in their selection of the optimal screening instrument. Further translational research, with a focus on contextual fit, is needed to support clinical decision-making on the selection of instruments for frailty screening.

Identifying Frail Patients by Using Electronic Health Records in Primary Care: Current Status and Future Directions

With the rapidly aging population, frailty, characterized by an increased risk of adverse outcomes, has become a major public health problem globally. Several frailty guidelines or consensuses recommend screening for frailty, especially in primary care settings. However, most of the frailty assessment tools are based on questionnaires or physical examinations, adding to the clinical workload, which is the major obstacle to converting frailty research into clinical practice. Medical data naturally generated by routine clinical work containing frailty indicators are stored in electronic health records (EHRs) (also called electronic health record (EHR) data), which provide resources and possibilities for frailty assessment. We reviewed several frailty assessment tools based on primary care EHRs and summarized the features and novel usage of these tools, as well as challenges and trends. Further research is needed to develop and validate frailty assessment tools based on EHRs in primary care in other parts of the world.

Validation of an electronic frailty index with electronic health records: eFRAGICAP index

Objective

To create an electronic frailty index (eFRAGICAP) using electronic health records (EHR) in Catalunya (Spain) and assess its predictive validity with a two-year follow-up of the outcomes: homecare need, institutionalization and mortality in the elderly. Additionally, to assess its concurrent validity compared to other standardized measures: the Clinical Frailty Scale (CFS) and the Risk Instrument for Screening in the Community (RISC).

Methods

The eFRAGICAP was based on the electronic frailty index (eFI) developed in United Kingdom, and includes 36 deficits identified through clinical diagnoses, prescriptions, physical examinations, and questionnaires registered in the EHR of primary health care centres (PHC). All subjects > 65 assigned to a PHC in Barcelona on 1st January, 2016 were included. Subjects were classified according to their eFRAGICAP index as: fit, mild, moderate or severe frailty. Predictive validity was assessed comparing results with the following outcomes: institutionalization, homecare need, and mortality at 24 months. Concurrent validation of the eFRAGICAP was performed with a sample of subjects (n = 333) drawn from the global cohort and the CFS and RISC. Discrimination and calibration measures for the outcomes of institutionalization, homecare need, and mortality and frailty scales were calculated.

Results

253,684 subjects had their eFRAGICAP index calculated. Mean age was 76.3 years (59.5% women). Of these, 41.1% were classified as fit, and 32.2% as presenting mild, 18.7% moderate, and 7.9% severe frailty. The mean age of the subjects included in the validation subsample (n = 333) was 79.9 years (57.7% women). Of these, 12.6% were classified as fit, and 31.5% presented mild, 39.6% moderate, and 16.2% severe frailty. Regarding the outcome analyses, the eFRAGICAP was good in the detection of subjects who were institutionalized, required homecare assistance, or died at 24 months (c-statistic of 0.841, 0.853, and 0.803, respectively). eFRAGICAP was also good in the detection of frail subjects compared to the CFS (AUC 0.821) and the RISC (AUC 0.848).

Conclusion

The eFRAGICAP has a good discriminative capacity to identify frail subjects compared to other frailty scales and predictive outcomes.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12877-022-03090-8.

Impacto de la fragilidad en la enfermedad por COVID-19 en una cohorte de gente mayor de la ciudad de Barcelona

Objetivo

Describir la incidencia y mortalidad de COVID-19, durante la primera ola, en la población de personas mayores de Barcelona, según sus niveles previos de fragilidad.

Diseño

Estudio de cohortes retrospectivo.

Emplazamiento y participantes

Población de 65 o más años asignada a los centros de Atención Primaria de Barcelona del Institut Català de la Salut, seguidos entre marzo y junio de 2020.

Mediciones principales

Fragilidad calculada al inicio a partir de la historia clínica informatizada. Resultados durante el seguimiento: diagnóstico de COVID-19, posible o confirmado con PCR y mortalidad por todas las causas.

Resultados

Se analizaron 251788 mayores de 64 años. Un 61,3% tenían algún nivel de fragilidad, 27,8% moderada o grave. La incidencia de COVID-19 fue de 3,13 casos por 100 habitantes (N = 7883) y la mortalidad por COVID-19 fue del 21,5% (N =1 691). Tanto la incidencia como la mortalidad por COVID-19 fueron superiores a mayor edad, en hombres, a mayor privación y a mayor nivel de fragilidad. Los individuos con fragilidad leve, moderada y grave tuvieron un hazard ratio ajustado de enfermedad por COVID-19 de 1,47, 2,08 y 3,50 respectivamente. Entre los sujetos con COVID-19, aquéllos con fragilidad leve, moderada y grave tuvieron un hazard ratio ajustado de mortalidad por COVID-19 de 1,44, 1,69 y 2,47 respectivamente.

Conclusiones

Consideramos necesario el abordaje de la fragilidad también en situación de pandemia, dado que es una condición tratable y a su vez factor de riesgo de COVID-19 más grave, donde el papel de la Atención Primaria es primordial, por su accesibilidad y longitudinalidad.

Frailty Factors and Outcomes in Patients Undergoing Orthopedic Surgery: Protocol for a Systematic Review and Meta-analysis

Background

Frailty is an aggregate expression of susceptibility to adverse health outcomes because of age- and disease-related deficits that accumulate across multiple domains. Previous studies have found the presence of preoperative frailty is associated with an increased risk of adverse outcomes. The number of older adults undergoing orthopedic surgery is rapidly increasing. However, there has been no evidence-based study on the relationship between frailty and outcomes in patients undergoing orthopedic surgery.

Objective

The aims of this study are to investigate the association between frailty and outcomes in patients who underwent orthopedic surgery as well as patient factors associated with frailty.

Methods

The methods to be used for this systematic review are reported according to the PRISMA-P (Preferred Reporting Items for Systematic Review and Meta-analysis Protocols) 2015 checklist. An extensive search will be conducted in PubMed, Embase, the Cochrane Library, and other mainstream databases. Any study where patients undergoing orthopedic surgery were assessed using a defined or validated measure of frailty and the association of frailty with patient factors and/or outcomes was reported will be included. A total of 2 researchers will independently screen articles for inclusion, with disagreements resolved by a third reviewer. We will perform a narrative synthesis of the factors associated with frailty, prevalence of frailty, effect of frailty on patient outcomes, and interventions for patients who are frail. A meta-analysis focusing on individual factors associated with frailty and the effect of frailty on patient outcomes will be performed, if applicable. The risk of bias will be evaluated. A subgroup analysis and sensitivity analysis will be performed.

Results

Literature searches were conducted in September 2021 and the review is anticipated to be completed by the end of July 2022.

Conclusions

This systematic review and meta-analysis will provide an overview of frailty and investigate the relationship between frailty and patient outcomes as well as the relationship between patient factors and frailty in patients undergoing orthopedic surgery. This study could potentially increase patients’ awareness of the outcomes associated with frailty, compel clinical specialties to further acknowledge the concept of frailty, and enhance the development of assessment instruments and tools for frailty.

Trial Registration

PROSPERO CRD42020181846; https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=181846

International Registered Report Identifier (IRRID)

DERR1-10.2196/28338

Prevalence of Undernutrition, Frailty and Sarcopenia in Community-Dwelling People Aged 50 Years and Above: Systematic Review and Meta-Analysis

The world’s population aged ≥65 is expected to rise from one in eleven in 2019 to one in six by 2050. People aged ≥65 are at a risk of undernutrition, frailty, and sarcopenia. The association between these conditions is investigated in a hospital setting. However, there is little understanding about the overlap and adverse health outcomes of these conditions in community-dwelling people. This systematic review aims to quantify the reported prevalence and incidence of undernutrition, frailty, and sarcopenia among older people aged ≥50 living in community dwellings. Searches were conducted using six databases (AMED, CENTRAL, EMBASE, Web of Science, MEDLINE, and CINAHL), and 37 studies were included. Meta-analyses produced weighted combined estimates of prevalence for each condition (Metaprop, Stata V16/MP). The combined undernutrition prevalence was 17% (95% CI 0.01, 0.46, studies n = 5; participants = 4214), frailty was 13% (95% CI 0.11, 0.17 studies n = 28; participants = 95,036), and sarcopenia was 14% (95% CI 0.09, 0.20, studies n = 9; participants = 7656). Four studies reported incidence rates, of which three included data on frailty. Nearly one in five of those aged ≥50 was considered either undernourished, frail, or sarcopenic, with a higher occurrence in women, which may reflect a longer life expectancy generally observed in females. Few studies measured incidence rates. Further work is required to understand population characteristics with these conditions and the overlap between them. PROSPERO registration No. CRD42019153806.

Commonly Used Screening Instruments to Identify Frailty Among Community-Dwelling Older People in a General Practice (Primary Care) Setting: A Study of Diagnostic Test Accuracy

BACKGROUND

Rapid frailty screening remains problematic in primary care. The diagnostic test accuracy (DTA) of several screening instruments has not been sufficiently established. We evaluated the DTA of several screening instruments against two reference standards: Fried's Frailty Phenotype [FP] and the Adelaide Frailty Index [AFI]), a self-reported questionnaire.

METHODS

DTA study within three general practices in South Australia. We randomly recruited 243 general practice patients aged 75+ years. Eligible participants were 75+ years, proficient in English and community-dwelling. We excluded those who were receiving palliative care, hospitalized or living in a residential care facility.We calculated sensitivity, specificity, predictive values, likelihood ratios, Youden Index and area under the curve (AUC) for: Edmonton Frail Scale [EFS], FRAIL Scale Questionnaire [FQ], Gait Speed Test [GST], Groningen Frailty Indicator [GFI], Kihon Checklist [KC], Polypharmacy [POLY], PRISMA-7 [P7], Reported Edmonton Frail Scale [REFS], Self-Rated Health [SRH] and Timed Up and Go [TUG]) against FP [3+ criteria] and AFI [>0.21].

RESULTS

We obtained valid data for 228 participants, with missing scores for index tests multiply imputed. Frailty prevalence was 17.5% frail, 56.6% prefrail [FP], and 48.7% frail, 29.0% prefrail [AFI]. Of the index tests KC (Se: 85.0% [70.2-94.3]; Sp: 73.4% [66.5-79.6]) and REFS (Se: 87.5% [73.2-95.8]; Sp: 75.5% [68.8-81.5]), both against FP, showed sufficient diagnostic accuracy according to our prespecified criteria.

CONCLUSIONS

Two screening instruments-the KC and REFS, show the most promise for wider implementation within general practice, enabling a personalized approach to care for older people with frailty.

Prevalence and associations of frailty in residents of Australian aged care facilities: findings from a retrospective cohort study

OBJECTIVES

Studies conducted among older people have shown that frailty is a common condition associated with an array of adverse outcomes. The aims of this study were to identify the prevalence and associations of frailty in older people residing in several aged care facilities located in Queensland, Australia.

METHODS

The database used for this study was drawn from the Aged Care Funding Instrument (ACFI) database of an Australian aged care provider, and contained data from ten aged care facilities in Queensland, Australia. A modification of an eFI originally developed by Clegg and colleagues and based on Rockwood's Frailty Index (FI) of cumulative deficits was used to identify frailty.

RESULTS

In total, 592 participants aged 75 years and over were included in the study (66.6% female). Median (IQR) age was 88.0 (9.0) years. Frailty prevalence among the sample was 43.6%, with 46.3% pre-frail and 10.1% not frail. In a multivariate logistic regression analysis incorporating three different models, frailty was significantly associated with three ACFI domains (Nutrition, Depression and Complex Health Care), along with facility size, consistently across two models. In the third model, frailty was also significantly associated with arthritis, diabetes, hypertension, osteoporosis and vision problems, along with male gender.

CONCLUSION

There is a need to develop frailty identification and management programs as part of standard care pathways for older adults residing in aged care facilities. Aged care facilities should consider regular frailty screening in residential aged care residents, along with interventions addressing specific issues such as dysphagia and depression.

Measuring Frailty in Health Care Databases for Clinical Care and Research

Considering the increasing burden and serious consequences of frailty in aging populations, there is increasing interest in measuring frailty in health care databases for clinical care and research. This review synthesizes the latest research on the development and application of 21 frailty measures for health care databases. Frailty measures varied widely in terms of target population (16 ambulatory, 1 long-term care, and 4 inpatient), data source (16 claims-based and 5 electronic health records [EHR]-based measures), assessment period (6 months to 36 months), data types (diagnosis codes required for 17 measures, health service codes for 7 measures, pharmacy data for 4 measures, and other information for 9 measures), and outcomes for validation (clinical frailty for 7 measures, disability for 7 measures, and mortality for 16 measures). These frailty measures may be useful to facilitate frailty screening in clinical care and quantify frailty for large database research in which clinical assessment is not feasible.

Feasibility and acceptability of commonly used screening instruments to identify frailty among community-dwelling older people: a mixed methods study

Background

Frailty exposes older people to an elevated risk of a range of negative outcomes. Emerging evidence that frailty can be effectively treated within community settings has stimulated calls for more proactive screening within primary care. Assessing feasibility is a critical preliminary step in assessing the efficacy of interventions such as screening. However, few studies have explored the feasibility and acceptability of administering frailty screening instruments within general practice, and even fewer have incorporated patient perspectives. Our study had three objectives: To 1) assess overall feasibility of the instruments (completion time and rate); 2) assess patient acceptability towards the instruments; and 3) assess the feasibility and acceptability of the instruments to administering nurses.

Methods

The feasibility and acceptability of several frailty screening instruments (PRISMA-7, Edmonton Frail Scale, FRAIL Scale Questionnaire, Gait Speed, Groningen Frailty Indicator, Reported Edmonton Frail Scale and Kihon Checklist) was explored within the context of a larger diagnostic test accuracy (DTA) study. Completion time and rate was collected for all participants (N = 243). A sub-sample of patients (n = 30) rated each instrument for ease of completion and provided comment on perceived acceptability. Lastly, five of six administering nurses involved in the DTA study participated in semi-structured face-to-face interviews, rating the instruments against several feasibility and acceptability criteria (time, space, equipment, skill required to implement, acceptability to patients and nurses, ease of scoring) and providing comment on their responses.

Results

The PRISMA-7 returned the highest overall feasibility and acceptability, requiring minimal space, equipment, skills and time to implement, and returning the fastest completion rate and highest patient and nurse acceptability rating. All screening instruments were faster to implement than the two reference standards (Fried’s Frailty Phenotype and Frailty Index). Self-administered instruments were subject to lower rates of completion than nurse-administered instruments.

Conclusions

This study has demonstrated that a number of commonly used frailty screening instruments are potentially feasible for implementation within general practice. Ultimately, more research is needed to determine how contextual factors, such as differences in individual patient and clinician preferences, setting and system factors, impact on the feasibility of screening in practice.

Safety and quality of perioperative anesthesia care-Ensuring safe care for older people living with frailty

The clinical concept of frailty as a detectable and improvable clinical condition has emerged in the field of geriatric medicine over the past two decades. Albeit frailty can be described as the rapid deterioration of organ function during the physiological aging process, this syndrome is not exclusively limited to the elderly. Recently, this concept has been introduced in the field of anesthesia and critical care as a means to better appraise perioperative risks and offer patient-centered individual treatment pathways. Extensive efforts have been invested into the research on tools for the detection and quantification of frailty. However, while multiple tools have been validated for the detection of frailty in different populations, no universal score or test has been validated to be universally applicable. Furthermore, it is unclear whether interventions capable of improving the detected degree of frailty may result in better outcomes. Ongoing and future research is aimed at developing automated systems that help in harnessing standard medical records for reliable frailty screening without additional user input. Further efforts are pointed at understanding the potential reversibility of frailty through interventions such as exercise or nutritional supplements. While the role of frailty detection, quantification, and treatment in anesthesia and critical care is limited today, it is likely that it may become a key element of perioperative care of older patients in the near future.

A Computerized Frailty Assessment Tool at Points-of-Care: Development of a Standalone Electronic Comprehensive Geriatric Assessment/Frailty Index (eFI-CGA)

Background: Frailty is characterized by loss of biological reserves and is associated with an increased risk of adverse health outcomes. Frailty can be operationalized using a Frailty Index (FI) based on the accumulation of health deficits; items under health evaluation in the well-established Comprehensive Geriatric Assessment (CGA) have been used to generate an FI-CGA. Traditionally, constructing the FI-CGA has relied on paper-based recording and manual data processing. As this can be time-consuming and error-prone, it limits widespread uptake of this proven type of frailty assessment. Here, we report the development of an electronic tool, the eFI-CGA, for use on personal computers by frontline healthcare providers, to collect CGA data and automate FI-CFA calculation. The ultimate goal is to support early identification and management of frailty at points-of-care, and make uptake in Electronic Medical Records (EMR) feasible and transparent. Methods: An electronic CGA (eCGA) form was implemented to operate on Microsoft's WinForms platform and coded using C# programming language. Users complete the eCGA form, from which items under the CGA evaluation are automatically retrieved and processed to output an eFI-CGA score. A user-friendly interface and secured data saving methods were implemented. The software was debugged and tested using systematically designed simulation data, addressing different logic, syntax, and application errors, and then tested with clinical assessment. The user manual and manual scoring were used as ground truth to compare eFI-CGA input and automated eFI score calculations. Frontline health-provider user feedback was incorporated to improve the end-user experience. Results: The Standalone eFI-CGA software tool was developed and optimized for use on personal computers. The user interface adapted the design of paper-based CGA form to facilitate familiarity for clinical users. Compared to known scores, the software tool generated eFI-CGA scores with 100% accuracy to four decimal places. The eFI-CGA allowed secure data storage and retrieval of multiple types, including user input, completed eCGA form, coded items, and calculated eFI-CGA scores. It also permitted recording of actions requiring clinical follow-up, facilitating care planning. Application bugs were identified and resolved at various stages of the implementation, resulting in efficient system performance. Discussion: Accurate, robust, and reliable computerized frailty assessments are needed to promote effective frailty assessment and management, as a key tool in health care systems facing up to frailty. Our research has enabled the delivery of the standalone eFI-CGA software technology to empower effective frailty assessment and management by various healthcare providers at points-of-care, facilitating integrated care of older adults.

Frailty: implications for clinical practice and public health

Frailty is an emerging global health burden, with major implications for clinical practice and public health. The prevalence of frailty is expected to rise alongside rapid growth in the ageing population. The course of frailty is characterised by a decline in functioning across multiple physiological systems, accompanied by an increased vulnerability to stressors. Having frailty places a person at increased risk of adverse outcomes, including falls, hospitalisation, and mortality. Studies have shown a clear pattern of increased health-care costs and use associated with frailty. All older adults are at risk of developing frailty, although risk levels are substantially higher among those with comorbidities, low socioeconomic position, poor diet, and sedentary lifestyles. Lifestyle and clinical risk factors are potentially modifiable by specific interventions and preventive actions. The concept of frailty is increasingly being used in primary, acute, and specialist care. However, despite efforts over the past three decades, agreement on a standard instrument to identify frailty has not yet been achieved. In this Series paper, we provide an overview of the global impact and burden of frailty, the usefulness of the frailty concept in clinical practice, potential targets for frailty prevention, and directions that need to be explored in the future.