Translating Frailty Research Into Clinical Practice: Insights From the Successful Aging and Frailty Evaluation Clinic

Implementing a Frailty-Specific Postoperative Order Set to Improve Postoperative Outcomes in Frail Adults After Elective Thoracic Surgery

BACKGROUND

Frailty is independently associated with adverse patient outcomes after surgery. The current standards of postoperative care rarely consider frailty status.

LOCAL PROBLEM

There was no standardized protocol to optimize specialized postoperative care for frail patients at an academic medical center.

METHODS

A quasi-experimental pre-/postimplementation study design, using the Reach, Effectiveness, Adoption, Implementation, Maintenance implementation framework, was utilized.

INTERVENTIONS

A frailty-specific postoperative order set (FPOS) was developed, including tailored nursing care, activity levels, and nutritional goals.

RESULTS

There were significant improvements in nurse's self-reported familiarity with frailty (P = .003) and FPOS awareness (P < .001). The number of orders for delirium prevention, elimination, nutrition, sleep promotion, and sensory support increased (P < .001).

CONCLUSIONS

Implementing an FPOS showed improvements in nurse frailty knowledge, awareness, and order set utilization.

Comprehensive geriatric assessment predicts listing for kidney transplant in patients with end-stage renal disease: a retrospective cohort study

BACKGROUND

Comprehensive geriatric assessment (CGA) involves a formal broad approach to assess frailty and creating a plan for management. However, the impact of CGA and its components on listing for kidney transplant in older adults has not been investigated.

METHODS

We performed a single-center retrospective study of patients with end-stage renal disease who underwent CGA during kidney transplant candidacy evaluation between 2017 and 2021. All patients ≥ 65 years old and those under 65 with any team member concern for frailty were referred for CGA, which included measurements of healthcare utilization, comorbidities, social support, short physical performance battery, Montreal Cognitive Assessment (MoCA), and Physical Frailty Phenotype (FPP), and estimate of surgical risk by the geriatrician.

RESULTS

Two hundred and thirty patients underwent baseline CGA evaluation; 58.7% (135) had high CGA ("Excellent" or "Good" rating for transplant candidacy) and 41.3% (95) had low CGA ratings ("Borderline," "Fair," or "Poor"). High CGA rating (OR 8.46; p < 0.05), greater number of CGA visits (OR 4.93; p = 0.05), younger age (OR 0.88; p < 0.05), higher MoCA scores (OR 1.17; p < 0.05), and high physical activity (OR 4.41; p < 0.05) were all associated with listing on transplant waitlist.

CONCLUSIONS

The CGA is a useful, comprehensive tool to help select older adults for kidney transplantation. Further study is needed to better understand the predictive value of CGA in predicting post-operative outcomes.

Prevalence and feasibility of assessing the frailty phenotype among hemodialysis patients in a dialysis unit

BACKGROUND

Frailty increases risk of morbidity and mortality in hemodialysis patients. Frailty assessments could trigger risk reduction interventions if broadly adopted in clinical practice. We aimed to assess the clinical feasibility of frailty assessment among Veteran hemodialysis patients.

METHODS

Hemodialysis patients' ≥50 years were recruited from a single dialysis unit between 9/1/2021 and 3/31/2022.Patients who consented underwent a frailty phenotype assessment by clinical staff. Five criteria were assessed: unintentional weight loss, low grip strength, self-reported exhaustion, slow gait speed, and low physical activity. Participants were classified as frail (3-5 points), pre-frail (1-2 points) or non-frail (0 points). Feasibility was determined by the number of eligible participants completing the assessment.

RESULTS

Among 82 unique dialysis patients, 45 (52%) completed the assessment, 13 (16%) refused, 18 (23%) were not offered the assessment due to death, transfers, or switch to transplant or peritoneal dialysis, and 6 patients were excluded because they did not meet mobility criteria. Among assessed patients, 40(88%) patients were identified as pre-frail (46.6%) or frail (42.2%). Low grip strength was most common (90%). Those who refused were more likely to have peripheral vascular disease (p = 0.001), low albumin (p = 0.0187), low sodium (p = 0.0422), and ineligible for kidney transplant (p = 0.005).

CONCLUSIONS

Just over half of eligible hemodialysis patients completed the frailty assessment suggesting difficulty with broad clinical adoption expectations. Among those assessed, frailty and pre-frailty prevalence was high. Given patients who were not tested were clinically high risk, our reported prevalence likely underestimates true frailty prevalence. Providing frailty reduction interventions to all hemodialysis patients could have high impact for this group.

Higher baseline resting metabolic rate is associated with 1-year frailty decline among older adults residing in an urban area

BACKGROUND

Dysregulated energy metabolism is one hypothesized mechanism underlying frailty. Resting energy expenditure, as reflected by resting metabolic rate (RMR), makes up the largest component of total energy expenditure. Prior work relating RMR to frailty has largely been done in cross section with mixed results. We investigated whether and how RMR related to 1-year frailty change while adjusting for body composition.

METHODS

N = 116 urban, predominantly African-American older adults were recruited between 2011 and 2019. One-year frailty phenotype (0-5) was regressed on baseline RMR, frailty phenotype, demographics and body composition (DEXA) in an ordinal logistic regression model. Multimorbidity (Charlson comorbidity scale, polypharmacy) and cognitive function (Montreal Cognitive Assessment) were separately added to the model to assess for change to the RMR-frailty relationship. The model was then stratified by baseline frailty status (non-frail, pre-frail) to explore differential RMR effects across frailty.

RESULTS

Higher baseline RMR was associated with worse 1-year frailty (odds ratio = 1.006 for each kcal/day, p = 0.001) independent of baseline frailty, demographics, and body composition. Lower fat-free mass (odds ratio = 0.88 per kg mass, p = 0.008) was independently associated with worse 1-year frailty scores. Neither multimorbidity nor cognitive function altered these relationships. The associations between worse 1-year frailty and higher baseline RMR (odds ratio = 1.009, p < 0.001) and lower baseline fat-free mass (odds ratio = 0.81, p = 0.006) were strongest among those who were pre-frail at baseline.

DISCUSSION

We are among the first to relate RMR to 1-year change in frailty scores. Those with higher baseline RMR and lower fat-free mass had worse 1-year frailty scores, but these relationships were strongest among adults who were pre-frail at baseline. These relationships were not explained by chronic disease or impaired cognition. These results provide new evidence suggesting higher resting energy expenditure is associated with accelerate frailty decline.

Racial differences in phenotypic frailty assessment among general thoracic surgery patients

Objectives

The American Association for Thoracic Surgery recommends using frailty assessments to identify patients at higher risk of perioperative morbidity and mortality. We evaluated what patient factors are associated with frailty in a thoracic surgery patient population.

Methods

New patients aged more than 50 years who were evaluated in a thoracic surgery clinic underwent routine frailty screening with a modified Fried's Frailty Phenotype. Differences in demographics and comorbid conditions among frailty status groups were assessed with chi-square and Student t tests. Logistic regressions performed with binomial distribution assessed the association of demographic and clinical characteristics with nonfrail, frail, prefrail, and any frailty (prefrail/frail) status.

Results

The study population included 317 patients screened over 19 months. Of patients screened, 198 (62.5%) were frail or prefrail. Frail patients undergoing thoracic surgery were older, were more likely single or never married, had lower median income, and had lower percent predicted diffusion capacity of the lungs for carbon monoxide and forced expiratory volume during 1 second (all P < .05). More non-Hispanic Black patients were frail and prefrail compared with non-Hispanic White patients (P = .003) and were more likely to score at least 1 point on Fried's Frailty Phenotype (adjusted odds ratio, 3.77; P = .02) when controlling for age, sex, number of comorbidities, median income, diffusion capacity of the lungs for carbon monoxide, and forced expiratory volume during 1 second. Non-Hispanic Black patients were more likely than non-Hispanic White patients to score points for slow gait and low activity (both P < .05).

Conclusions

Non-Hispanic Black patients undergoing thoracic surgery are more likely to score as frail or prefrail than non-Hispanic White patients. This disparity stems from differences in activity and gait speed. Frailty tools should be examined for factors contributing to this disparity, including bias.

Recent developments in frailty identification, management, risk factors and prevention: A narrative review of leading journals in geriatrics and gerontology

Frailty is an age-related clinical condition characterised by an increased susceptibility to stressors and an elevated risk of adverse outcomes such as mortality. In the light of global population ageing, the prevalence of frailty is expected to soar in coming decades. This narrative review provides critical insights into recent developments and emerging practices in frailty research regarding identification, management, risk factors, and prevention. We searched journals in the top two quartiles of geriatrics and gerontology (from Clarivate Journal Citation Reports) for articles published between 01 January 2018 and 20 December 2022. Several recent developments were identified, including new biomarkers and biomarker panels for frailty screening and diagnosis, using artificial intelligence to identify frailty, and investigating the altered response to medications by older adults with frailty. Other areas with novel developments included exercise (including technology-based exercise), multidimensional interventions, person-centred and integrated care, assistive technologies, analysis of frailty transitions, risk-factors, clinical guidelines, COVID-19, and potential future treatments. This review identified a strong need for the implementation and evaluation of cost-effective, community-based interventions to manage and prevent frailty. Our findings highlight the need to better identify and support older adults with frailty and involve those with frailty in shared decision-making regarding their care.

The effect of frailty on in-hospital and medium-term mortality of patients with COronaVIrus Disease-19: the FRACOVID study

BACKGROUND

Older persons hospitalized for COVID-19 are at highest risk of death. Frailty Assessment can detect heterogeneity in risk among people of the same chronological age. We investigated the association between frailty and in-hospital and medium-term mortality in middleaged and older adults with COVID-19 during the first two pandemic waves.

METHODS

Observational multicenter study. We recorded sociodemographic factors (age, sex), smoking status, date of symptom onset, biological data, need for supplemental oxygen, comorbidities, cognitive and functional status, in-hospital mortality. We calculated a Frailty Index (FI) as the ratio between deficits presented and total deficits considered for each patient (theoretical range 0-1). We also assessed the Clinical Frailty Scale (CFS). Mortality at follow-up was ascertained from a regional registry.

RESULTS

In total, 1344 patients were included; median age 68 years (Q1-Q3, 56-79); 857 (64%) were men. Median CFS score was 3 (Q1-Q3 2-5) and was lower in younger vs older patients. Median FI was 0.06 (Q1-Q3 0.03-0.09) and increased with increasing age. Overall, 244 (18%) patients died in-hospital and 288 (22%) over a median follow-up of 253 days. FI and CFS were significantly associated with risk of death. In two different models using the same covariates, each increment of 0.1 in FI increased the overall hazard of death by 35% (HR= 1.35, 95%CI 1.23-1.48), similar to the hazard for each increment of CFS (HR=1.37, 95%CI 1.25-1.50).

CONCLUSIONS

Frailty, assessed with the FI or CFS, predicts in-hospital and medium-term mortality and may help estimate vulnerability in middle-aged and older COVID-19 patients.

Validation of the revised 9-scale clinical frailty scale (CFS) in Greek language

BACKGROUND

Among many screening tools that have been developed to detect frailty in older adults, Clinical Frailty Scale (CFS) is a valid, reliable and easy-to-use tool that has been translated in several languages. The aim of this study was to develop a valid and reliable version of the CFS to the Greek language.

METHODS

A Greek version was obtained by translation (English to Greek) and back translation (Greek to English). The "known-group" construct validity of the CFS was determined by using test for trends. Criterion concurrent validity was assessed by evaluating the extent that CFS relates to Barthel Index, using Pearson's correlation coefficient. Both inter-rater and test-retest reliability were assessed using intraclass correlation coefficient.

RESULTS

Known groups comparison supports the construct validity of the CFS. The strong negative correlation between CFS and Barthel Index (rs = - 0,725, p ≤ 0.001), supports the criterion concurrent validity of the instrument. The intraclass correlation was good for both inter-rater (0.87, 95%CI: 0.82-0.90) and test-retest reliability (0.89: 95%CI: 0.85-0.92).

CONCLUSION

The Greek version of the CFS is a valid and reliable instrument for the identification of frailty in the Greek population.

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.

Frailty Assessment in Clinical Practice: Opportunity in the Midst of a Pandemic

Emerging evidence from studies of older adults hospitalised with COVID-19 suggests that there is a high prevalence of frailty in this patient group. We reflect on the measurement of frailty in older patients hospitalized as an emergency and the translation of frailty from a research to a clinical concept. We consider whether, despite the contemporary challenges in the care of older adults as a result of COVID-19, there are opportunities for care quality improvement during a pandemic.

Enhancing Functional Risk Stratification in Contemporary Cardiac Rehabilitation: RESPONDING TO PATIENTS WHO ARE INCREASINGLY OLDER AND MORE PHYSICALLY IMPAIRED

PURPOSE

Current American Association of Cardiovascular and Pulmonary Rehabilitation guidelines rely primarily on cardiovascular disease (CVD)-centered metrics to stratify risk and guide care. Yet, contemporary CVD patients are often older and are more likely to have risks attributable to rudimentary functional impairments that can have disproportionate bearing on management and prognosis. In this study, we stratified risk using novel indices of physical function as well as traditional indices of CVD in patients enrolling in phase II cardiac rehabilitation (CR). We hypothesized that risk stratification (RS) using functional criteria would be nonconcordant with CVD RS in a significant number of patients, thus inferring the conceptual value of CR management priorities that are better tailored for distinctive functional risks in many patients.

METHODS

This was a retrospective analysis of a comprehensive quality improvement database with 489 patients. Risk stratification using novel functional indices (ie, gait speed, Timed Up and Go, hand grip, sit to stand, tandem stand, and a 6-min walk test) was compared with RS using traditional CVD criteria.

RESULTS

Using functional RS, 97 patients were determined to be high risk versus 235 at low risk. Using CVD RS in the same cohort, 227 patients had high risk versus 161 who had low risk. Functional RS was consistent with CVD RS only 42.9% of the time.

CONCLUSION

Functional RS and CVD RS varied in the same patients. Enhanced assessment of functional risks adds important prognostic refinement and greater potential to tailor exercise therapy, nutrition, and other CR caregiving priorities.

Predicting Mortality and Adverse Outcomes: Comparing the Frailty Index to General Prognostic Indices

BACKGROUND

Mortality prediction models are useful to guide clinical decision-making based on prognosis. The frailty index, which allows prognostication and personalized care planning, has not been directly compared with validated prognostic models.

OBJECTIVE

To compare the discrimination of mortality, disability, falls, and hospitalization between a frailty index and validated prognostic indices.

DESIGN

Secondary Analysis of the National Health and Aging Trends Study.

PARTICIPANTS

Seven thousand thirty-three Medicare beneficiaries 65 years or older.

MEASUREMENTS

We measured a deficit-accumulation frailty index, Schonberg index, and Lee index at the 2011 baseline assessment. Primary outcome was mortality at 5 years. Secondary outcomes were decline in activities of daily living (ADL), decline in instrumental activities of daily living (IADL), fall, and hospitalization at 1 year. We used C-statistics to compare discrimination between indices, adjusting for age and sex.

RESULTS

The study population included 4146 (44.8%) with age ≥ 75 years, with a median frailty index of 0.15 (interquartile range 0.09-0.25). A total of 1385 participants died (14.7%) and 2386 (35.2%) were lost to follow-up. Frailty, Schonberg, and Lee indices predicted mortality similarly: C-statistics (95% confidence interval) were 0.78 (0.77-0.80) for frailty index; 0.79 (0.78-0.81) for Schonberg index; and 0.78 (0.77-0.80) for Lee index. The frailty index had higher C-statistics for decline in ADL function (frailty index, 0.80 [0.78-0.83]; Schonberg, 0.74 [0.72-0.76]; Lee, 0.74 [0.71-0.77]) and falls (frailty index, 0.66 [0.65-0.68]; Schonberg, 0.61 [0.58-0.63]; Lee, 0.61 [0.59-0.63]). C-statistics were similar for decline in IADL function (frailty index, 0.61 [0.59-0.63]; Schonberg, 0.60 [0.59-0.62]; Lee, 0.60 [0.58-0.62]) and hospitalizations (frailty index, 0.68 [0.66-0.70]; Schonberg, 0.68 [0.66-0.69]; Lee, 0.65 [0.63-0.67]).

CONCLUSIONS

A deficit-accumulation frailty index performs as well as prognostic indices for mortality prediction, and better predicts ADL disability and falls in community-dwelling older adults. Frailty assessment offers a unifying approach to risk stratification for key health outcomes relevant to older adults.

Changes in Predictive Performance of a Frailty Index with Availability of Clinical Domains

OBJECTIVES

Determine the effects of missing data in frailty identification and risk prediction.

DESIGN

Analysis of the National Health in Aging Trends Study.

SETTING

Community.

PARTICIPANTS

About 6206 older adults.

MEASUREMENTS

A 41-variable frailty index (FI) was constructed with the following domains: comorbidities, activities of daily living (ADLs), instrumental activities of daily living, self-reported physical limitations, physical performance, and neuropsychiatric tests. We evaluated discrimination after removing single and multiple domains, comparing C-statistics for predicting 5-year risk of mortality and 1-year risks of disability and falls.

RESULTS

The full FI yielded a mean of .18 and C-statistics of .72 (95% confidence interval, .70-.74) for mortality, .80 (.77-.82) for disability, and .66 (.64-.68) for falls. Removal of any single domain shifted the FI distribution, resulting in a mean FI ranging from .13 (removing comorbidities) to .20 (removing ADLs) and frailty prevalence (FI ≥ .25) from 16.0% to 28.7%. Among robust participants models missing ADLs misclassified most often, (19% as pre-frail). Among pre-frail and frail participants missing comorbidities misclassified most often(69.2% from pre-frail to robust, 24% from frail to pre-frail, and 4.9% from frail to robust). Removal of any single domain minimally changed C-statistics: mortality, .71-.73; disability, .79-.80; and falls, .64-.66. Removing neuropsychiatric testing and physical performance yielded comparable C-statistics of .70, .78, and .66 for mortality, ADLs, and falls, respectively. However, removal of three or four domains based on likely availability decreased C-statistics for mortality (.69, .66),disability (.75, .70), and falls (.64, .63), respectively.

CONCLUSION

While FI discrimination is robust to missing information in any single domain, risk prediction is affected by absence of multiple domains. This work informs the application of FI as a clinical and research tool. J Am Geriatr Soc 68:1771-1777, 2020.