Prevalence and outcomes of frailty in unplanned hospital admissions: a systematic review and meta-analysis of hospital-wide and general (internal) medicine cohorts

Pre-Frailty and Frailty in Hospitalized Older Adults: A Comparison Study in People with and without a History of Cancer in an Acute Medical Unit

A prospective observational study was conducted in a cohort of older adults ≥65 years (n = 329), admitted to the acute medical unit (AMU) of a tertiary hospital, to describe and compare characteristics including frailty status and clinical outcomes. Multivariable models compared older adults with and without a history of cancer to determine characteristics associated with frailty and pre-frailty. An adjusted Poisson regression model was used to compare the length of hospital stay (LOS) between the two groups. About one-fifth (22%) of the cohort had a history of cancer. The most common cancer types were prostate (n = 20), breast (n = 13), lung (n = 8) and gastrointestinal (n = 8). There was no difference in the prevalence of pre-frailty/frailty among patients with or without a history of cancer (58% vs. 57%, p > 0.05). Pre-frailty/frailty was associated with polypharmacy (OR 8.26, 95% CI: 1.74 to 39.2) and malnutrition (OR 8.91, 95% CI: 2.15 to 36.9) in patients with a history of cancer. Adjusted analysis revealed that the risk of having a longer LOS was 24% higher in older adults with a history of cancer than those without (IRR 1.24, 95% CI 1.10 to 1.41, p < 0.001). Clinicians in the AMU should be aware that older adults with a history of cancer have a higher risk of a longer LOS compared to those without.

Protocol for the Development and Analysis of the Oxford and Reading Cognitive Comorbidity, Frailty and Ageing Research Database-Electronic Patient Records (ORCHARD-EPR)

BACKGROUND

Hospital electronic patient records (EPRs) offer the opportunity to exploit large-scale routinely acquired data at relatively low cost and without selection. EPRs provide considerably richer data, and in real-time, than retrospective administrative data sets in which clinical complexity is often poorly captured. With population ageing, a wide range of hospital specialties now manage older people with multimorbidity, frailty and associated poor outcomes. We, therefore, set-up the Oxford and Reading Cognitive Comorbidity, Frailty and Ageing Research Database-Electronic Patient Records (ORCHARD-EPR) to facilitate clinically meaningful research in older hospital patients, including algorithm development, and to aid medical decision-making, implementation of guidelines, and inform policy.

METHODS AND ANALYSIS

ORCHARD-EPR uses routinely acquired individual patient data on all patients aged ≥65 years with unplanned admission or Same Day Emergency Care unit attendance at four acute general hospitals serving a population of >800 000 (Oxfordshire, UK) with planned extension to the neighbouring Berkshire regional hospitals (>1 000 000). Data fields include diagnosis, comorbidities, nursing risk assessments, frailty, observations, illness acuity, laboratory tests and brain scan images. Importantly, ORCHARD-EPR contains the results from mandatory hospital-wide cognitive screening (≥70 years) comprising the 10-point Abbreviated-Mental-Test and dementia and delirium diagnosis (Confusion Assessment Method-CAM). Outcomes include length of stay, delayed transfers of care, discharge destination, readmissions and death. The rich multimodal data are further enhanced by linkage to secondary care electronic mental health records. Selection of appropriate subgroups or linkage to existing cohorts allows disease-specific studies. Over 200 000 patient episodes are included to date with data collection ongoing of which 129 248 are admissions with a length of stay ≥1 day in 64 641 unique patients.

ETHICS AND DISSEMINATION

ORCHARD-EPR is approved by the South Central Oxford C Research Ethics Committee (ref: 23/SC/0258). Results will be widely disseminated through peer-reviewed publications and presentations at conferences, and regional meetings to improve hospital data quality and clinical services.

Frailty in clinical drug trials: Frailty assessments, subgroup analyses and outcomes

With population ageing, drug trials are increasingly turning their attention to including older, frailer people. This review aimed to provide an overview of how frailty was assessed in published studies related to clinical pharmacological trials, and on the interaction of frailty on the efficacy of the treatments. We searched MEDLINE, EMBASE and Cochrane for clinical drug trials in older people. A total of 4031 abstracts were screened and 17 relevant studies were included in this review. We summarized the findings of these 17 trials into five main clinical areas: cardiovascular (eight studies), cognition (one study), vaccination (two studies), cancer (four studies) and other (two studies). Frailty was assessed retrospectively in most of the studies. Frailty was treated as an ordinal variable (with different levels of frailty) or binary variable (frail/non-frail) using cut-offs in some studies, and as a continuous in some other studies. The effect of frailty on the treatment efficacy was not consistent among the studies. While several trials, such as the Action in Diabetes and Vascular Disease-Preterax and Diamicron Modified Release Controlled Evaluation trials, the Systolic Blood Pressure Intervention Trial and the Aspirin in Reducing Events in the Elderly trial, showed some reduced effects of the treatment in frail patients, most of the trials showed that the benefits of the treatment are not affected by frailty. Some trials even showed that the benefits of the treatment were more significant in frailer patients (the Dapagliflozin and Prevention of Adverse Outcomes in Heart Failure and the Dapagliflozin Evaluation to Improve the Lives of Patients with Preserved Ejection Fraction Heart Failure trials). The results of this review suggest that routine measurement of frailty in participants in clinical drug trials would improve our knowledge of the effect of treatment in the frail and identify those who have more or least to gain from treatment.

Fried Frailty Phenotype in Elderly Patients with Chronic Coronary Syndrome: Prevalence, Associated Factors, and Impact on Hospitalization

Purpose

To investigate the prevalence and factors associated with frailty and impact of frailty on hospitalization due to any cause in elderly patients with chronic coronary syndrome (CCS).

Patients and Methods

We conducted a study wherein we assessed frailty using Fried frailty phenotype for outpatients aged ≥60 years with CCS. Logistic regression analysis was performed to assess the factors associated with frailty. Frailty was adjusted for demographic and geriatric variables and comorbidities to assess its impact on hospitalization.

Results

Overall, 420 patients (median age 70 years [interquartile range, 65-77]; men, 74.5%) who completed the 3-month follow-up period were analyzed. Coronary revascularization for > 1 year was the most common clinical scenario for CCS (59.8%; n = 251). The prevalence of non-frail, pre-frail, and frail patients were 22.4% (n = 94), 49.7% (n = 209), and 27.9% (n = 117), respectively. In the adjusted model, three factors associated with frailty were age ≥ 75 years (odds ratio [OR] 2.29, 95% confidence interval [CI] 1.39-3.75, P = 0.001), limitations in instrumental activity of daily living (OR 3.89, 95% CI 2.33-6.48, P < 0.001), and heart failure (OR 2.30, 95% CI 1.32-4.02, P = 0.003). The overall 3-month hospitalization rate was higher in frail patients than in non-frail patients (23.9% vs 13.5%, P = 0.012). Frailty was associated with hospitalization (OR 1.85, 95% CI 1.04-3.30, P = 0.037) but in a weak strength of association (r = 0.126).

Conclusion

The prevalence of frailty was 27.9% in the elderly patients with CCS. Age ≥ 75 years, limitations in functional status, and heart failure were associated with increased odds of frailty. Frailty was a predictor of 3-month all-cause hospitalization in these patients.

Association between Controlling Nutritional Status (CONUT) Score and Body Composition, Inflammation and Frailty in Hospitalized Elderly Patients

The Controlling Nutritional Status (CONUT) score has demonstrated its ability to identify patients with poor nutritional status and predict various clinical outcomes. Our objective was to assess the association between the CONUT score, inflammatory status, and body composition, as well as its ability to identify patients at risk of frailty in hospitalized elderly patients.

METHODS

a total of 361 patients were retrospectively recruited and divided into three groups based on the CONUT score.

RESULTS

patients with a score ≥5 exhibited significantly higher levels of inflammatory markers, such as erythrocyte sedimentation rate (ESR), C-reactive protein (CRP), Neutrophil/Lymphocytes ratio (NLR), main platelet volume (MPV), and ferritin, compared to those with a lower score. Furthermore, these patients showed unfavorable changes in body composition, including a lower percentage of skeletal muscle mass (MM) and fat-free mass (FFM) and a higher percentage of fatty mass (FM). A positive correlation was found between the CONUT score and inflammatory markers, Geriatric Depression Scale Short Form (GDS-SF), and FM. Conversely, the Mini Nutritional Assessment (MNA), Mini-Mental Status Examination, activity daily living (ADL), instrumental activity daily living (IADL), Barthel index, FFM, and MM showed a negative correlation. Frailty was highly prevalent among patients with a higher CONUT score. The receiver operating characteristic (ROC) curve demonstrated high accuracy in identifying frail patients (sensitivity).

CONCLUSIONS

a high CONUT score is associated with a pro-inflammatory status as well as with unfavorable body composition. Additionally, it is a good tool to identify frailty among hospitalized elderly patients.

Comprehensive Geriatric Assessment in the Emergency Department: A Prospective Cohort Study of Process, Clinical, and Patient-Reported Outcomes

Background

This study aimed to explore the process, clinical, and patient-reported outcomes of older adults who received an interdisciplinary Comprehensive Geriatric Assessment (CGA) in the emergency department (ED) over a six-month period after their initial ED attendance.

Patients and Methods

A prospective cohort study recruited older adults aged ≥65 years who presented to the ED of a university teaching hospital in Ireland. Baseline assessment data comprising a battery of demographic variables and validated indices were obtained at the index ED attendance. Telephone interviews were completed with participants at 30- and 180-day follow-up. The primary outcome was incidence of hospital admission following the index ED attendance. Secondary outcomes included participant satisfaction, incidence of functional decline, health-related quality of life, incidence of unscheduled ED re-attendance(s), hospital (re)admission(s), nursing home admission, and death.

Results

A total of 133 participants (mean age 82.43 years, standard deviation = 6.89 years; 71.4% female) were recruited; 21.8% of the cohort were admitted to hospital following the index ED attendance with a significant decline in function reported at hospital discharge (Z = 2.97, p = 0.003). Incidence of 30- and 180-day unscheduled ED re-attendance was 10.5% and 24.8%, respectively. The outcome at the index ED attendance was a significant predictor of adverse outcomes whereby those who were discharged home had significantly lower odds of multiple adverse process outcomes at 30- and 180-day follow-up, and significantly higher function and health-related quality of life at 30-day follow-up.

Conclusion

While this study was observational in nature, findings suggest CGA in the ED may improve outcomes by mitigating against the adverse effects of potentially avoidable hospital admissions and focusing on a longitudinal approach to healthcare delivery at the primary-secondary care interface. Future research should be underpinned by an experimental study design to address key limitations in this study.

Frailty Screening and Detection of Geriatric Syndromes in Acute Inpatient Care: Impact on Hospital Length of Stay and 30-Day Readmissions

BACKGROUND

Frailty is prevalent in acute care and is associated with negative outcomes. While a comprehensive geriatric assessment to identify geriatric syndromes is recommended after identifying frailty, more evidence is needed to support this approach in the inpatient setting. This study examined the association between frailty and geriatric syndromes and their impact on outcomes in acutely admitted older adults.

METHODS

A total of 733 individuals aged ≥65 years admitted to the General Surgery Service of a tertiary hospital were assessed for frailty using the Clinical Frailty Scale (CFS) and for geriatric syndromes using routine nursing admission assessments, including cognitive impairment, falls, incontinence, malnutrition, and poor oral health. Multinomial logistic regression and Cox regression were used to evaluate the associations between frailty and geriatric syndromes and their concomitant impact on hospital length of stay (LOS) and 30-day readmissions.

RESULTS

Greater frailty severity was associated with an increased likelihood of geriatric syndromes. Individuals categorized as CFS 4-6 and CFS 7-8 with concomitant geriatric syndromes had 29% and 35% increased risks of a longer LOS, respectively. CFS 4-6 was significantly associated with functional decline (relative risk ratio =1.46; 95% confidence interval [CI], 1.03-2.07) and 30-day readmission (hazare ratio=1.78; 95% CI, 1.04-3.04), whereas these associations were not significant for CFS 7-8.

CONCLUSION

Geriatric syndromes in frail individuals can be identified from routine nursing assessments and represent a potential approach for targeted interventions following frailty identification. Tailored interventions may be necessary to achieve optimal outcomes at different stages of frailty. Further research is required to evaluate interventions for older adults with frailty in a wider hospital context.

Exploring Frailty in the Intersection of Cardiovascular Disease and Cancer in Older People

Advances in cardiovascular therapies and cancer treatments have resulted in longer patient survival. The coexistence of cancer and cardiovascular disease has been recognized as a complex clinical scenario. In addition to cardiovascular disease, older people with cancer are at greater risk of experiencing multimorbidity and geriatric syndromes, such as frailty. In older people, the concurrent presence of cancer and cardiovascular disease increases the risk of mortality, and the presence of frailty can exacerbate their conditions and hinder treatment effectiveness. Given the significant intersection among frailty, cardiovascular disease, and cancer in older people, this paper aims to provide an overview of the current research in this field and identifies gaps in the research to understand the burden and impact of frailty in these populations. While many studies have examined the prevalence and impact of frailty on adverse outcomes in patients with cancer or cardiovascular disease, evidence of frailty in individuals with both conditions is lacking. There is no universally accepted definition of frailty, which leads to inconsistencies in identifying and measuring frailty in older adults with cardiovascular disease and cancer. The frailty index seems to be a preferred frailty definition in studies of patients with cancer, while the frailty phenotype seems to be more commonly used in cardiovascular research. However, differences in how the frailty index was categorized and in how patients were classified as 'frail' depending on the cut points may have a negative effect on understanding the impact of frailty in the studied populations. This makes it challenging to compare findings across different studies and limits our understanding of the prevalence and impact of frailty in these populations. Addressing these research gaps will contribute to our understanding of the burden of frailty in older people with cardiovascular disease and cancer, and improve clinical care protocols in this vulnerable population.

[Frailty phenotype and risk factor for disturbed sleep]

Regardless of the nature of its operationalization, frailty has significant negative consequences for the person concerned and the community. Even if a generally accepted definition of frailty is still missing, there is no doubt about the existence of this phenomenon. Pathophysiologically, a dysfunctional interaction between multiple complex systems is discussed. Therapeutic interventions show that frailty is a dynamic state that can be improved. The pathophysiological characteristics of frailty and sleep disturbances show numerous similarities. In addition, the risk of frailty is increased in individuals with sleep disturbances. As the majority of sleep disorders can usually be well treated, screening for sleep disorders should be integrated into a comprehensive concept of management of frailty.

Is the clinical frailty scale feasible to use in an emergency department setting? A mixed methods study

BACKGROUND

The Clinical Frailty Scale (CFS) is a frailty assessment tool used to identify frailty in older patients visiting the emergency department (ED). However, the current understanding of how it is used and accepted in ED clinical practice is limited. This study aimed to assess the feasibility of CFS in an ED setting.

METHODS

This was a prospective, mixed methods study conducted in three Swedish EDs where CFS had recently been introduced. We examined the completion rate of CFS assessments in relation to patient- and organisational factors. A survey on staff experience of using CFS was also conducted. All quantitative data were analysed descriptively, while free text comments underwent a qualitative content analysis.

RESULTS

A total of 4235 visits were analysed, and CFS assessments were performed in 47%. The completion rate exceeded 50% for patients over the age of 80. Patients with low triage priority were assessed to a low degree (24%). There was a diurnal variation with the highest completion rates seen for arrivals between 6 and 12 a.m. (58%). The survey response rate was 48%. The respondents rated the perceived relevance and the ease of use of the CFS with a median of 5 (IQR 2) on a scale with 7 being the highest. High workload, forgetfulness and critical illness were ranked as the top three barriers to assessment. The qualitative analysis showed that CFS assessments benefit from a clear routine and a sense of apparent relevance to emergency care.

CONCLUSION

Most emergency staff perceived CFS as relevant and easy to use, yet far from all older ED patients were assessed. The most common barrier to assessment was high workload. Measures to facilitate use may include clarifying the purpose of the assessment with explicit follow-up actions, as well as formulating a clear routine for the assessment.

REGISTRATION

The study was registered on ClinicalTrials.gov 2021-06-18 (identifier: NCT04931472).

Long-Term Survival of Ischemic Stroke Patients according to Prior Cognitive Status: Dijon Stroke Registry

INTRODUCTION

Understanding the influence of preexisting cognitive impairment on the poststroke outcome is a critical challenge in the context of current aging and growing population. This study aimed to assess long-term survival of patients with acute ischemic stroke (IS) according to their premorbid cognitive status and to identify contributing factors of death.

METHODS

Patients with IS were prospectively identified among residents of Dijon, France, using a population-based registry (2013-2017). The association between case fatality at 5 years and prestroke cognitive status was assessed by multivariable Cox models adjusted for other clinical characteristics and preexisting brain damage on the initial CT scan including leukoaraiosis, old vascular brain lesions, and cortical and central brain atrophy, as well as major arterial occlusion.

RESULTS

1,049 patients were included (mean age ± SD: 76.3 ± 15.2 years old, 54% women). Case fatality rates at 5 years were 38.1% in patients without cognitive impairment, 65.9% in patients with prior mild cognitive impairment (MCI, n = 132, 12.6%), and 86.6% in patients with dementia (n = 164, 15.6%) (p < 0.001). MCI (HR = 1.39; 95% CI: 1.06-1.81, p = 0.016) and dementia (HR = 1.89; 95% CI: 1.45-2.46, p < 0.001) were both independently associated with higher case fatality after adjustment for clinical variables. The association remained significant after further adjustment for preexisting brain damage and major arterial occlusion (HR = 1.47; 95% CI: 1.10-1.98, p = 0.009, for MCI and HR = 1.90; 95% CI: 1.43-2.53, p < 0.001, for dementia) among patients with available data on the CT scan (n = 916). Factors associated with death were roughly similar across groups.

CONCLUSION

This study highlighted a poor long-term survival of IS patients with preexisting cognitive impairment, independently of other contributing factors of death. It is critical to better understand the trajectory of IS patients with preexisting cognitive impairment and to identify prognostic markers to guide clinicians in their management strategies.

Association between the mental domain of the comprehensive geriatric assessment and prolonged length of stay in hospitalized older adults with mild to moderate frailty

Introduction

Previous researches have shown the risk factors of prolonged length of stay (PLOS) in hospitalized older adults, but it is unclear what are the risk factors of PLOS in hospitalized older adults with mild to moderate frailty.

Objective

To identify the risk factors of PLOS in hospitalized older adults with mild to moderate frailty.

Methods

We recruited adults aged ≥65 years old with mild to moderate frailty admitted to a tertiary medical center in the southern Taiwan from June 2018 to September 2018. Each individual underwent a structural questionnaire interview within 72 h after admission and 72 h after discharge. The data were collected face-to-face, including demographic characteristics, comorbidities, length of stay (LOS), and multiple domains of the comprehensive geriatric assessment. The main outcome was PLOS.

Results

Individuals who had two or more drugs, were female, did not have cognitive impairment and had a Geriatric Depression Scale score ≥ 1 had a higher risk of PLOS (probability = 0.81), and these individuals accounted for 29% of the overall study population. Among male individuals younger than 87 years old, those with cognitive impairment had a higher risk of PLOS (probability = 0.76), and among male individuals without cognitive impairment, living alone was associated with a higher risk of PLOS (probability = 0.88).

Conclusion

Early detection and management of mood and cognition in older adults, together with comprehensive discharge planning and transition care, may be an important part of reducing LOS in hospitalized older adults with mild to moderate frailty.