The role of frailty in predicting mortality and readmission in older adults in acute care wards: a prospective study

The adverse inpatient medication event and frailty (AIME-frail) risk prediction model

BACKGROUND

Medication harm affects between 5 and 15% of hospitalised patients, with approximately half of the harm events considered preventable through timely intervention. The Adverse Inpatient Medication Event (AIME) risk prediction model was previously developed to guide a systematic approach to patient prioritisation for targeted clinician review, but frailty was not tested as a candidate predictor variable.

AIM

To evaluate the predictive performance of an updated AIME model, incorporating a measure of frailty, when applied to a new multisite cohort of hospitalised adult inpatients.

METHODS

A retrospective cohort study was conducted at two tertiary Australian hospitals on patients discharged between 1st January and April 31, 2020. Data were extracted from electronic medical records (EMRs) and clinical coding databases. Medication harm was identified using ICD-10 Y-codes and confirmed by senior pharmacist review of medical records. The Hospital Frailty Risk Score (HFRS) was calculated for each patient. Logistic regression analysis was used to construct a modified AIME model. Candidate variables of the original AIME model, together with new variables including HFRS were tested. Performance of the final model was reported using area under the curve (AUC) and decision curve analysis (DCA).

RESULTS

A total of 4089 patient admissions were included, with a mean age ± standard deviation (SD) of 64 years (±19 years), 2050 patients (50%) were males, and mean HFRS was 6.2 (±5.9). 184 patients (4.5%) experienced one or more medication harm events during hospitalisation. The new AIME-Frail risk model incorporated 5 of the original variables: length of stay (LOS), anti-psychotics, antiarrhythmics, immunosuppressants, and INR greater than 3, as well as 5 new variables: HFRS, anticoagulants, antibiotics, insulin, and opioid use. The AUC was 0.79 (95% CI: 0.76-0.83) which was superior to the original model (AUC = 0.70, 95% CI: 0.65-0.74) with a sensitivity of 69%, specificity of 81%, positive predictive value of 0.14 (95% CI: 0.10-0.17) and negative predictive value of 0.98 (95% CI: 0.97-0.99). The DCA identified the model as having potential clinical utility between the probability thresholds of 0.05-0.4.

CONCLUSION

The inclusion of a frailty measure improved the predictive performance of the AIME model. Screening inpatients using the AIME-Frail tool could identify more patients at high-risk of medication harm who warrant timely clinician review.

Acute frailty services: results of a national day of care survey

INTRODUCTION

Older people living with frailty are at high risk of emergency hospital admission and often have complex care needs which may not be adequately met by conventional models of acute care. This has driven the introduction of adaptations to acute care pathways designed to improve outcomes in this patient group. The identification of differences in the organisational approach to frailty may highlight opportunities for quality improvement.

METHODS

The Society for Acute Medicine Benchmarking audit is a national service evaluation which uses a single day-of-care methodology to record patient and organisational level data. All acute hospitals in the United Kingdom are eligible to participate. Emergency admissions referred to acute medical services between 00:00 and 23:59 on Thursday 23rd June 2022 were recorded. Information on the structure and operational design of acute frailty services was collected. The use of a validated frailty assessment tool, clinical frailty scale within the first 24 h of admission, assessment by an acute frailty service and clinical outcomes were reported in patients aged 70 year and above. A mixed effect generalised linear model was used to determine factors associated same-day discharge without overnight stay in patients with frailty.

RESULTS

A total of 152 hospitals participated. There was significant heterogeneity in the operational design and staffing model of acute frailty services. The presence of an acute frailty unit was reported in 57 (42.2%) hospitals. The use of validated frailty assessment tools was reported in 117 (90.0%) hospitals, of which 107 (91.5%) used the clinical frailty scale. Patient-level data were recorded for 3604 patients aged 70 years and above. At the patient level, 1626 (45.1%) were assessed using a validated tool during the admission process. Assessment by acute frailty services was associated with an increased likelihood of same-day discharge (adjusted OR 1.55, 95%CI 1.03- 2.39).

CONCLUSION

There is significant variation in the provision of acute frailty services. Frailty-related policies and services are common at the organisational level but implemented inconsistently at the patient level. Older people with frailty or geriatric syndromes assessed by acute frailty services were more likely to be discharged without the need for overnight bed-based admission.

Examining the Longitudinal Relationship Between Olfactory Dysfunction and Frailty in Community-Dwelling, older US Adults

OBJECTIVE

Olfactory dysfunction is a "canary in the coalmine" for aging conditions. We evaluated olfactory dysfunction as a biomarker of early frailty in older adults living in the United States.

STUDY DESIGN

Prospective, longitudinal, nationally representative study.

SETTING

National Social Life, Health and Aging Project (NSHAP).

METHODS

We examined data from 1061 community-dwelling older US adults. Odor identification (5-item Sniffin' Stick) and frailty scores were measured at baseline and 5-year follow-up. Multivariate logistic regressions evaluated the association between olfactory dysfunction and frailty at baseline in cross-section and over time in the transition from robust to prefrail to frail, adjusting for confounding factors measured at baseline.

RESULTS

Older US adults who were anosmic at baseline were more likely to be frail 5 years later compared to normosmic peers (odds ratio [OR]: 3.83, 95% confidence interval [CI]: 1.10-13.31, P = .035). Examining changes in frailty stage over time, we found that anosmics were more likely to transition from prefrail to frail over 5 years (OR: 3.25, 95% CI: 1.31-8.08, P = .011). Interestingly, hyposmics did not show a similar trajectory toward frailty (P > .05). In contrast, olfactory dysfunction was not associated with frailty in cross-section (OR: 0.90, 95% CI: 0.43-1.89, P = .787, hyposmia; OR: 0.72, 95% CI: 0.15-3.35, P = .673, anosmia).

CONCLUSION

Older US adults with anosmia face higher odds of becoming frail over 5 years, especially those in the prefrail stage. Olfactory dysfunction may serve as a surrogate marker for early-stage neurodegenerative diseases, which are strong contributors to frailty.

Frailty in the cardiac intensive care unit: assessment and impact

Frailty, a clinical syndrome of increased vulnerability, due to diminished cognitive, physical, and physiological reserves is a growing concern in the cardiac intensive care unit (CICU). It contributes to morbidity, mortality, and complications and often exerts a bidirectional association with cardiovascular disease. Although it predominately affects older adults, frailty can also be observed in younger patients <65 years of age, with approximately 30% of those admitted in CICU are frail. Acute cardiovascular illness can also impair physical and cognitive functioning among survivors and these survivors often suffer from frailty and functional declines post-CICU discharge. Patients with frailty in the CICU often have higher comorbidity burden, and they are less likely to receive optimal therapy for their acute cardiovascular conditions. Given the significance of this geriatric syndrome, this review will focus on assessment, clinical outcomes, and interventions, in an attempt to establish appropriate assessment, management, and resource utilization in frail patients during and after CICU admission.

Proof-of-concept for an automatable mortality prediction scoring in hospitalised older adults

Introduction

It is challenging to prognosticate hospitalised older adults. Delayed recognition of end-of-life leads to failure in delivering appropriate palliative care and increases healthcare utilisation. Most mortality prediction tools specific for older adults require additional manual input, resulting in poor uptake. By leveraging on electronic health records, we aim to create an automatable mortality prediction tool for hospitalised older adults.

Methods

We retrospectively reviewed electronic records of general medicine patients ≥75 years at a tertiary hospital between April-September 2021. Demographics, comorbidities, ICD-codes, age-adjusted Charlson Comorbidity Index (CCI), Hospital Frailty Risk Score, mortality and resource utilization were collected. We defined early deaths, late deaths and survivors as patients who died within 30 days, 1 year, and lived beyond 1 year of admission, respectively. Multivariate logistic regression analyses were adjusted for age, gender, race, frailty, and CCI. The final prediction model was created using a stepwise logistic regression.

Results

Of 1,224 patients, 168 (13.7%) died early and 370 (30.2%) died late. From adjusted multivariate regression, risk of early death was significantly associated with ≥85 years, intermediate or high frail risk, CCI > 6, cardiovascular risk factors, AMI and pneumonia. For late death, risk factors included ≥85 years, intermediate frail risk, CCI >6, delirium, diabetes, AMI and pneumonia. Our mortality prediction tool which scores 1 point each for age, pneumonia and AMI had an AUC of 0.752 for early death and 0.691 for late death.

Conclusion

Our mortality prediction model is a proof-of-concept demonstrating the potential for automated medical alerts to guide physicians towards personalised care for hospitalised older adults.

Patient Frailty is Correlated With Increased Adverse Events and Costs After Revision Knee Arthroplasty

BACKGROUND

Frailty can predict adverse outcomes after various orthopaedic procedures, but is not well-studied in revision total knee arthroplasty (rTKA). We investigated the correlation between the Hospital Frailty Risk Score (HFRS) and post-rTKA outcomes.

METHODS

Using the Nationwide Readmissions Database, we identified rTKA patients discharged from January 2017 to November 2019 for the most common diagnoses (mechanical loosening, infection, and instability). Using HFRS, we compared 30-day readmission rate, length of stay, and hospitalization cost between frail and nonfrail patients with multivariate and binomial regressions. The 30-day complication and reoperation rates were compared using univariate analyses. We identified 25,177 mechanical loosening patients, 12,712 infection patients, and 9,458 instability patients.

RESULTS

Frail patients had higher rates of 30-day readmission (7.8 versus 3.7% for loosening, 13.5 versus 8.1% for infection, 8.7 versus 3.9% for instability; P < .01), longer length of stay (4.1 versus 2.4 days for loosening, 8.1 versus 4.4 days for infection, 4.9 versus 2.4 days for instability; P < .01), and greater cost ($32,082 versus $27,582 for loosening, $32,898 versus $28,115 for infection, $29,790 versus $24,164 for instability; P < .01). Frail loosening patients had higher 30-day complication (6.8 versus 2.9%, P < .01) and reoperation rates (1.8 versus 1.2%, P = .01). Frail infection patients had higher 30-day complication rates (14.0 versus 8.3%, P < .01). Frail instability patients had higher 30-day complication (8.0 versus 3.5%, P < .01) and reoperation rates (3.2 versus 1.6%, P < .01).

CONCLUSIONS

The HFRS may identify patients at risk for adverse events and increased costs after rTKA. Further research is needed to determine causation and mitigate complications and costs.

The predictive ability of ABSI compared to BMI for mortality and frailty among older adults

Introduction

To study the utility of A Body Shape Index (ABSI) alongside body mass index (BMI) to predict mortality and frailty in an aging community population.

Materials and methods

Participants (n = 1,580) were drawn from the first Israeli national health and nutrition survey of older adults ("Mabat Zahav") conducted from 2005 to 2006, constituting adults aged ≥65 years. Socio-demographic, clinical, behavioral, and psychosocial data were collected. Baseline weight, height, and waist circumference (WC) were measured and expressed as the allometric indices BMI (kg/m2) and ABSI, a BMI-independent measure of abdominal obesity [WC/(BMI2/3*m1/2)]. Mortality follow-up lasted through 2019. Frailty was assessed in 2017-2019 by the Fried Biological Phenotype in a sub-cohort of 554 survivors. Cox and logistic regression models assessed associations of BMI and ABSI with mortality and frailty.

Results

At baseline, mean [SD] age was 74.5 [6.1] years, and 52.4% were women. The correlation between BMI and WC Z scores was 0.71, reduced to -0.11 for BMI and ABSI. Over a median follow-up of 13 years, 757 deaths occurred. The multivariable-adjusted hazard ratios (95% CIs) for mortality per standard deviation increase in BMI and ABSI were 1.07 (0.99;1.17) and 1.13 (1.05;1.21), respectively. Among participants assessed for frailty, 77 (14%) met the frailty criteria. After multivariable adjustment, the odds ratios (95% CIs) for frailty were 0.83 (0.69-1.01) for BMI and 1.55 (1.34-1.79) for ABSI.

Discussion

In a nationwide cohort of older adults, ABSI was independently associated with mortality risk. Furthermore, ABSI, but not BMI, was a strong predictor of frailty.

Characterizing Aging-Related Health in Older Women with a History of Incarceration: Multimorbidity, Polypharmacy, Mortality, Frailty, and Depression

OBJECTIVE

To characterize aging-related health in women with past CLSI and compare with women with no-CLSI.

METHOD

Health and Retirement Study Wave 11 and 12 data from women age >50 with CLSI were compared with data from women age >50 with no-CLSI. Generalized linear models were estimated for aging-related health outcomes.

RESULTS

The group with CLSI (n = 230) was significantly younger than the no-CLSI group (n = 8035) yet had more physical, functional, and mental health challenges and fewer resources. Incarceration significantly predicted aging-related outcomes of multimorbidity, polypharmacy, mortality, frailty, and depression.

DISCUSSION

Earlier onset of physical and functional health conditions in women with past CLSI has implications for health education and promotion, clinical practice, and intervention design.

Frailty before and during austerity: A time series analysis of the English Longitudinal Study of Ageing 2002-2018

BACKGROUND

Frailty is characterised by a reduced resilience to adversity. In this analysis we examined changes in frailty in people aged 50+ before and during a period of austere public spending in England.

METHODS

Data from the English Longitudinal Study of Ageing 2002-2018 were analysed. Associations between austerity and frailty were examined using (1) Multilevel interrupted times series analysis (ITSA); and (2) Accelerated longitudinal modelling comparing frailty trajectories in people of the same age in 2002 and 2012.

RESULTS

The analysis included 16,410 people (mean age 67 years, 55% women), with mean frailty index score of 0.16. Mean scores in women (0.16) where higher than in men (mean 0.14), and higher in the poorest tertile (mean 0.20) than the richest (mean 0.12). In the ITSA, frailty index scores increased more quickly during austerity than before, with the additional increase in frailty 2012-2018 being similar in magnitude to the difference in mean frailty score between people aged 65-69 and 70-74 years. Steeper increases in frailty after 2012 were experienced across the wealth-spectrum and in both sexes but were greater in the very oldest (80+). In the accelerated longitudinal analysis, frailty was lower in 2012 than 2002, but increased more rapidly in the 2012 cohort compared to the 2002 cohort; markedly so in people aged 80+.

CONCLUSION

The period of austerity politics was associated with steeper increases in frailty with age compared to the pre-austerity period, consistent with previously observed increases in mortality.

Modified Frailty Index Predicts Postoperative Complications Following Parastomal Hernia Repair

BACKGROUND

The 5-factor frailty index (5-mFI), validated frailty index with Spearmen rho correlation of .95 and C statistic >.7 for predicting postoperative complications, can be preoperatively used to stratify patients prior to parastomal hernia repairs.

METHODS

Retrospective review of the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database identified patients from 2015 to 2020. 5-mFI scores were calculated by adding one point for each comorbidity present: diabetes mellitus, congestive heart failure (CHF), hypertension requiring medication, severe chronic obstructive pulmonary disease (COPD), non-independent functional status. Primary endpoint was 30-day overall complications; secondary endpoints were 30-day readmission, reoperation, and discharge to care facility.

RESULTS

2924 (52.2% female) patients underwent elective parastomal hernia repair. Univariate analysis showed 5-mFI > 2 had higher rates of overall (P = .008), pulmonary (P = .002), cardiovascular (P = .003)), hematologic (P = .003), and renal (P = .002) complications and higher rates of readmission (P = .009), reoperation (P = .001), discharge to care facility (P < .001), and death (P < .001). Multivariate analysis identified a 5-mFI of 2 or more as an independent risk factor for overall complications [OR: 1.40, 1.03-1.78; P = .032], pulmonary complications [2.97, 1.63-5.39; P < .001], hematological complications [1.60, 1.03-2.47; P = .035], renal complications [2.04, 1.19-3.46; P = .009], readmission [1.54, 1.19-1.99; P < .001], and discharge to facility [2.50, 1.66-3.77; P < .001]. Reoperation was not signification on multivariate analysis.

CONCLUSIONS

Parastomal hernia repair patients with 5-mFI score of >2 had higher risk of renal, cardiovascular, pulmonary, and hematologic complications, readmissions, longer hospitalization, discharge to care facility, and mortality, and can be useful during preoperative risk stratification.

The hospital frailty risk score as a predictor of readmission after ERCP

BACKGROUND AND AIMS

The 30-day readmission rate is a nationally recognized quality measure with nearly one-fifth of patients being readmitted. This study aims to evaluate frailty, as measured by the hospital frailty risk score (HFRS), as a prognostic indicator for 30-day readmission after inpatient ERCP.

METHODS

We analyzed weighted discharge records from the 2017 Nationwide Readmissions Database (NRD) to identify patients undergoing ERCP between 01/01/2017 and 11/30/2017. Our primary outcome was the 30-day unplanned readmission rate in frail (defined as HFRS > 5) against non-frail (HFRS < 5) patients. A mixed effects multivariable logistic regression method was employed.

RESULTS

Among 68,206 weighted hospitalized patients undergoing ERCP, 31.3% were frail. Frailty was associated with higher 30-day readmission (OR 1.23, 95% CI [1.16-1.30]). Multivariable analysis showed a greater risk of readmission with cirrhosis (OR 1.26, 95% CI [1.10-1.45]), liver transplantation (OR 1.36, 95% CI [1.08-1.71]), cancer (OR 1.58, 95% CI [1.48-1.69]), and male gender (OR 1.24, 95% CI [1.18-1.31]). Frail patients also had higher mortality rate (1.8% vs 0.6%, p < 0.01)], longer LOS during readmission (6.7 vs 5.6 days, p < 0.01), and incurred more charges from both hospitalizations ($175,620 vs $132,519, p < 0.01). Sepsis was the most common primary indication for both frail and non-frail readmissions but accounted for a greater percentage of frail readmissions (17.9% vs 12.4%, p < 0.01).

CONCLUSIONS

Frailty is associated with higher readmission rates, mortality, LOS, and hospital charges for admitted patients undergoing ERCP. Sepsis is the leading cause for readmission. Independent risk factors for readmission include liver transplantation, cancer, cirrhosis, and male gender.

Acute care models for older people living with frailty: a systematic review and taxonomy

BACKGROUND

The need to improve the acute care pathway to meet the care needs of older people living with frailty is a strategic priority for many healthcare systems. The optimal care model for this patient group is unclear.

METHODS

A systematic review was conducted to derive a taxonomy of acute care models for older people with acute medical illness and describe the outcomes used to assess their effectiveness. Care models providing time-limited episodes of care (up to 14 days) within 48 h of presentation to patients over the age of 65 with acute medical illness were included. Care models based in hospital and community settings were eligible. Searches were undertaken in Medline, Embase, CINAHL and Cochrane databases. Interventions were described and classified in detail using a modified version of the TIDIeR checklist for complex interventions. Outcomes were described and classified using the Core Outcome Measures in Effectiveness Trials (COMET) taxonomy. Risk of bias was assessed using RoB2 and ROBINS-I.

RESULTS

The inclusion criteria were met by 103 articles. Four classes of acute care model were identified, acute-bed based care, hospital at home, emergency department in-reach and care home models. The field is dominated by small single centre randomised and non-randomised studies. Most studies were judged to be at risk of bias. A range of outcome measures were reported with little consistency between studies. Evidence of effectiveness was limited.

CONCLUSION

Acute care models for older people living with frailty are heterogenous. The clinical effectiveness of these models cannot be conclusively established from the available evidence.

TRIAL REGISTRATION

PROSPERO registration (CRD42021279131).

Network analysis of frailty indicators in hospitalized elderly patients: unveiling the role of depression and hemoglobin as core factors

BACKGROUND

Frailty is a significant concern among hospitalized older adults, influenced by multiple factors. Understanding the complex interactions between these variables can be facilitated through a network perspective.

AIM

This study aimed to identify the core factor and physiological indicator of frailty in hospitalized elderly patients and visualize their interactions within the network structure.

METHODS

Frailty was assessed using the Tilburg Frailty Indicators, with a score of 5 or higher indicating frailty. Additional variables related to sociodemographic, physical and clinical, psychological and cognitive aspects, as well as physiological indicators, were extracted from electronic health records. A partial correlation network analysis was conducted using an adaptive LASSO algorithm, based on univariate correlation and logistic regression, to examine the network structure and identify influential nodes.

RESULTS

The average age of participants was 70.74 ± 7.52 years, with 24.27% classified as frail. Frailty was associated with 38 of 145 initially included variables (P < 0.05). The network analysis revealed depression as the most central node, followed by drugs used, sleep disorders, loneliness, masticatory obstacles, drinking, and number of teeth missing. Hemoglobin emerged as the most central biochemical indicator in the network, based on network center index analysis (Strength = 4.858, Betweenness = 223, Closeness = 0.034).

CONCLUSIONS

Frailty in hospitalized older adults is influenced by various social, physical, and psychological factors, with depression as the core factor of utmost importance. Changes in hemoglobin levels could serve as an essential indicator. This innovative network approach provides insights into the multidimensional structure and relationships in real-world settings.

The impact of frailty and geriatric syndromes on metrics of acute care performance: results of a national day of care survey

Background

Frailty is associated with a range of adverse clinical outcomes in the acute hospital setting. We sought to determine whether frailty and related factors affected clinical processes such as time to assessment during emergency hospital admission within the National Health Service (NHS) in the UK.

Methods

The Society for Acute Medicine Benchmarking Audit (SAMBA) is an annual cross-sectional day of care survey. SAMBA 2022 was conducted on Thursday 23rd June 2022. We assessed whether the Clinical Frailty Scale (CFS) and presence of a geriatric syndrome affected performance against nationally recognised clinical quality indicators based on time to initial assessment and time to consultant review. CFS was graded into robust (CFS1-3), mild (CFS 4-5), moderate (CFS 6), severe (CFS7-8) and terminal illness (CFS 9). Plausible values were created for missing variables using multi-level multiple imputation. The association was described using mixed effect generalised linear models adjusting for initial National Early Warning Score 2 (NEWS2) and time of arrival.

Findings

A total of 152 hospitals provided patient level data relating to 7248 emergency medical admissions. Patients with mild, moderate and severe frailty were less likely to be assessed within 4 h of arrival (adjusted OR, mild 0.79, 95% CI 0.68-0.96, moderate 0.67 95% CI 0.53-0.84, severe, 0.75 95% CI 0.58-0.96, terminally ill 0.59 95% CI 0.23-1.43) and less likely to be achieve the clinical quality indicator for consultant review (adjusted OR, mild 0.69 95% CI 0.58-0.83, moderate 0.55 95% CI 0.44-0.70, severe 0.54 95% CI 0.41-0.69, terminally ill 0.76 95% CI 0.42-1.5). Patients with geriatric syndromes were also less likely to be assessed within 4 h of arrival (adjusted OR 0.66 95% CI 0.56-0.76) or by a consultant within the recommended time frame (adjusted OR 0.45 95% CI 0.39-0.51). The difference was partially explained by differential use of SDEC pathways. Sub-group analysis of 5148 patients assessed outside of SDEC areas demonstrated patients with geriatric syndromes (adjusted OR 0.71, 95% CI 0.60-0.83), but not frailty defined by CFS were less likely to be assessed within 4 h of arrival. Moderate and severe frailty and the presence of a geriatric syndrome were associated with a decreased likelihood of achieving the consultant review standard (moderate, adjusted OR 0.75, 95% CI 0.59-0.94, severe adjusted OR 0.75 95% CI 0.58-0.96, geriatric syndrome adjusted OR 0.59, 95% CI 0.50-0.69).

Interpretation

Frailty is associated with delayed clinical assessment. This association may suggest a systemic issue with clinical prioritisation, with important implications for acute care policy.

Funding

The database for SAMBA is funded by the Society for Acute Medicine.

Frailty trajectories in ICU survivors: A comparison between the clinical frailty scale and the Tilburg frailty Indicator and association with 1 year mortality

PURPOSE

To test the agreement of the Clinical Frailty Scale (CFS) and the Tilburg Frailty Indicator (TFI), their association with 3, 6 months and 1-year mortality and the trajectory of frailty in a mixed population of ICU survivors.

MATERIAL AND METHODS

This is a prospective, multicenter, longitudinal study on ICU survivors ≥18 years old with an ICU stay >72 h. For each patient, sociodemographic and clinical data were collected. Frailty was assessed during ICU stay and at 3, 6, 12 months after ICU discharge, through both CFS and TFI.

RESULTS

124 patients with a mean age of 66 years old were enrolled. The baseline prevalence of frailty was 15.3% by CFS and 44.4% by TFI. Baseline CFS and TFI correlated but showed low agreement (Cohen's K = 0.23, p < 0.001). Baseline CFS score, but not TFI, was significantly associated to 1 year mortality. Moreover, CFS score during the follow-up was independently associated 1-year mortality (OR = 1.43; 95% CI: 1.18-1.73).

CONCLUSIONS

CFS and TFI identify different populations of frail ICU survivors. Frail patients before ICU according to CFS have a significantly higher mortality after ICU discharge. The CFS during follow-up is an independent negative prognostic factor of long-term mortality in the ICU population.

Reversing frailty in older adults: a scoping review

BACKGROUND

Individuals 65 years or older are presumably more susceptible to becoming frail, which increases their risk of multiple adverse health outcomes. Reversing frailty has received recent attention; however, little is understood about what it means and how to achieve it. Thus, the purpose of this scoping review is to synthesize the evidence regarding the impact of frail-related interventions on older adults living with frailty, identify what interventions resulted in frailty reversal and clarify the concept of reverse frailty.

METHODS

We followed Arksey and O'Malley's five-stage scoping review approach and conducted searches in CINAHL, EMBASE, PubMed, and Web of Science. We hand-searched the reference list of included studies and conducted a grey literature search. Two independent reviewers completed the title, abstract screenings, and full-text review using the eligibility criteria, and independently extracted approximately 10% of the studies. We critically appraised studies using Joanna Briggs critical appraisal checklist/tool, and we used a descriptive and narrative method to synthesize and analyze data.

RESULTS

Of 7499 articles, thirty met the criteria and three studies were identified in the references of included studies. Seventeen studies (56.7%) framed frailty as a reversible condition, with 11 studies (36.7%) selecting it as their primary outcome. Reversing frailty varied from either frail to pre-frail, frail to non-frail, and severe to mild frailty. We identified different types of single and multi-component interventions each targeting various domains of frailty. The physical domain was most frequently targeted (n = 32, 97%). Interventions also varied in their frequencies of delivery, intensities, and durations, and targeted participants from different settings, most commonly from community dwellings (n = 23; 69.7%).

CONCLUSION

Some studies indicated that it is possible to reverse frailty. However, this depended on how the researchers assessed or measured frailty. The current understanding of reverse frailty is a shift from a frail or severely frail state to at least a pre-frail or mildly frail state. To gain further insight into reversing frailty, we recommend a concept analysis. Furthermore, we recommend more primary studies considering the participant's lived experiences to guide intervention delivery.

Effectiveness of holistic assessment-based interventions for adults with multiple long-term conditions and frailty: an umbrella review of systematic reviews

Holistic assessment-based interventions (HABIs) are effective in older people admitted to hospital, but it is unclear whether similar interventions are effective in adults with multiple long-term conditions or frailty in the community. We conducted an umbrella review to comprehensively evaluate the literature on HABIs for adults (aged ≥18 years) with multiple long-term conditions, and frailty. We searched eight databases for systematic reviews reporting on experimental or quasi-experimental studies. Of 9803 titles screened, we identified 29 eligible reviews (14 with meta-analysis) reporting on 14 types of HABIs. The evidence for the effectiveness of HABIs was largely inconsistent across different types of interventions, settings, and outcomes. We found evidence of no benefit from hospital HABIs on health-related quality of life (HRQoL) and emergency department re-attendance, and evidence of no benefit from community HABIs on overall health-care utilisation rates, emergency department attendance, nursing home admissions, and mortality. The best evidence of effectiveness was for hospital comprehensive geriatric assessment (CGA) on nursing home admissions, keeping patients alive and in their own homes. There was some evidence of benefit from community CGA on hospital admissions, and from CGA spanning community and hospital settings on HRQoL. Patient-centred medical homes had beneficial effects on HRQoL, mental health, self-management, and hospital admissions.

Association between the Neutrophil-to-Lymphocyte Ratio and Inpatient Mortality in Hospitalized Older Veterans with COVID-19 Infection

OBJECTIVES

Determine the association of high neutrophil-to-lymphocyte ratio (NLR) values with inpatient mortality and other outcomes in older veterans hospitalized with coronavirus disease 2019 (COVID-19).

METHODS

This was a retrospective, multicenter, cohort study of hospitalized adults, with laboratory-confirmed COVID-19 infection who were studied for 1 year after discharge or until death. The NLR was categorized into tertiles, and we determined frailty status with the 31-item Veterans Affairs Frailty Index. Multivariate logistic regression and adjusted odds ratios (aORs) with 95% confidence intervals (CIs) were performed to assess the association between NLR and clinical outcomes.

RESULTS

The study included 615 hospitalized adult veterans, mean age 66.12 (standard deviation 14.79) years, 93.82% (n = 577) male, 57.56% (n = 354) White, 81.0% (n = 498) non-Hispanic, median body mass index of 30.70 (interquartile range 25.64-34.99, standard deviation 7.13), and median length of stay of 8 days (interquartile range 3-15). Individuals in the middle and upper tertile groups had higher inpatient mortality (8.37%, n = 17 and 18.36%, n = 38, respectively) as compared with the lower tertile (2.93%, n = 6, P < 0.001). Compared with the lowest tertile, the middle and upper tertiles had a higher risk of inpatient mortality (aOR 3.75, 95% CI 1.38-10.21, P = 0.01, and aOR 8.13, 95% CI 3.18-20.84, P < 0.001, respectively). The highest tertile had a higher odds of intensive care unit admission (aOR 4.47, 95% CI 2.33-8.58, P < 0.001) and intensive care unit transfer (aOR 3.54, 95% CI 1.84-6.81, P < 0.001).

CONCLUSIONS

The NLR score is a clinically useful tool to predict in-hospital mortality in older patients with COVID-19.

Short-Term, Community-Based, Slow-Stream Rehabilitation Program for Older Adults Transitioning from Hospital to Home: A Mixed Methods Program Evaluation

Introduction

Shortened hospital stays have shifted the burden of care for older adults to community, informal (ie, family, caregiver) and formal post-acute care and services, highlighting the need for effective post-hospital stay services and programs. As there is a dearth of information related to community-based, slow-stream rehabilitation program models for older adults transitioning from hospital to home in the Canadian context, the paper describes a mixed methods evaluation of such a program.

Materials and Methods

A mixed methods program evaluation, with process- and outcome-related elements, included 1) review and analysis of program documents; 2) observations to examine fidelity. Observation data were coded and summarized using descriptive statistics. Coded information and data were compared to document review data; 3) quantitative assessment of pre-post changes in physical, social, and psychological outcome measure and instrument scores using descriptive statistics, paired t-tests and confidence intervals (p = 0.05); and 4) exploration of acceptability through interviews and focus groups with 41 of the older adult participants and 17 family caregivers. Thematic analysis was used to examine focus group and interview transcripts.

Results

Observational data indicated alignment with the program document information overall. Statistically and clinically significant positive trends in improvement for physical outcome measure scores were observed (6-minute Walk Test, Life Space Assessment, Short Physical Performance Battery, Rapid Assessment of Physical Activity). Participants and family caregivers identified several positives and benefits of the program, ie, improvement in physical, social and mental well-being, decreased caregiver burden; and areas for improvement ie, need for more information about the program prior to enrollment and individualization, several of which aligned with the observation and quantitative data.

Discussion/Conclusion

This mixed methods program evaluation provided a detailed description of a community-based, slow-stream rehabilitation program for older adults who are transitioning to home post-hospital stay and its participants. Evidence of program fidelity, acceptability, and positive trends in improvement in physical outcome measure scores were found. Information about program strengths and areas for improvement can be used by stakeholders to inform program refinement and enhancement.

How does hospitalization affect the frailty status of geriatric patients? Prospective study from internal medicine wards of a university hospital

OBJECTIVES

Frailty is a dynamic process. Frailty in the baseline, discharge, and post-discharge are important in the management of patients. We aimed to see how hospitalization affects frailty and to evaluate its effects on health outcomes.

METHODS

It was conducted with patients aged 65 and over who were hospitalized in the internal medicine wards of a university hospital. Frailty was evaluated by Clinical Frailty Scale within the first 24 h of hospitalization, within 24 h before discharge, and at third months after discharge.

RESULTS

Ninety-six (57.8%) of patients at baseline, 79 (50.6%) at discharge, and 68 (47.9%) at 3 months were frail. According to baseline, 12 (7.7%) patients changed from frail to non-frail at discharge, while 4 (2.6%) patients became frail (p = 0.08). According to the baseline, 18 (12.5%) patients went from frail to non-frail at 3 months, while 7 (4.9%) patients turned frail (p = 0.04). In regression analysis, living with frailty at discharge and low education level increased re-hospitalization. Five or more are considered living with frailty.

DISCUSSION

Hospitalization may have positive effects on frailty in older adult patients hospitalized in internal medicine wards, the main effect is seen to be more significant in the post-discharge follow-up.

Prediction of adverse health outcomes using an electronic frailty index among nonfrail and prefrail community elders

BACKGROUND

Early recognition of older people at risk of undesirable clinical outcomes is vital in preventing future disabling conditions. Here, we report the prognostic performance of an electronic frailty index (eFI) in comparison with traditional tools among nonfrail and prefrail community-dwelling older adults. The study is to investigate the predictive utility of a deficit-accumulation eFI in community elders without overt frailty.

METHODS

Participants aged 65-80 years with a Clinical Frailty Scale of 1-3 points were recruited and followed for 2 years. The eFI score and Fried's frailty scale were determined by using a semiautomated platform of self-reported questionnaires and objective measurements which yielded cumulative deficits and physical phenotypes from 80 items of risk variables. Kaplan-Meier method and Cox proportional hazards regression were used to analyze the severity of frailty in relation to adverse outcomes of falls, emergency room (ER) visits and hospitalizations during 2 years' follow-up.

RESULTS

A total of 427 older adults were evaluated and dichotomized by the median FI score. Two hundred and sixty (60.9%) and 167 (39.1%) elders were stratified into the low- (eFI ≤ 0.075) and the high-risk (eFI > 0.075) groups, respectively. During the follow-up, 77 (47.0%) individuals developed adverse events in the high-risk group, compared with 79 (30.5%) in the low-risk group (x2, p = 0.0006). In multivariable models adjusted for age and sex, the increased risk of all three events combined in the high- vs. low-risk group remained significant (adjusted hazard ratio (aHR) = 3.08, 95% confidence interval (CI): 1.87-5.07). For individual adverse event, the aHRs were 2.20 (CI: 1.44-3.36) for falls; 1.67 (CI: 1.03-2.70) for ER visits; and 2.84 (CI: 1.73-4.67) for hospitalizations. Compared with the traditional tools, the eFI stratification (high- vs. low-risk) showed better predictive performance than either CFS rating (managing well vs. fit to very fit; not discriminative in hospitalizations) or Fried's scale (prefrail to frail vs. nonfrail; not discriminative in ER visits).

CONCLUSION

The eFI system is a useful frailty tool which effectively predicts the risk of adverse healthcare outcomes in nonfrail and/or prefrail older adults over a period of 2 years.

Frailty at death: An examination of multiple causes of death in four low mortality countries in 2017

BACKGROUND

The increasing prevalence of frailty in aging populations represents a major social and public health challenge which warrants a better understanding of the contribution of frailty to the morbid process.

OBJECTIVE

To examine frailty-related mortality as reported on the death certificate in France, Italy, Spain and the United States in 2017.

METHODS

We identify frailty at death for the population aged 50 years and over in France, Italy, Spain and the United States. We estimate the proportions of deaths by sex, age group and country with specific frailty-related ICD-codes on the death certificate 1) as the underlying cause of death (UC), 2) elsewhere in Part I (sequence of diseases or conditions or events leading directly to death), and 3) anywhere in Part II (conditions that do not belong in Part I but whose presence contributed to death).

RESULTS

The age-standardized proportion of deaths with frailty at ages 50 and over is highest in Italy (25.0%), then in France (24.1%) and Spain (17.3%), and lowest in the United States (14.0%). Cross-country differences are smaller when frailty-related codes are either the underlying cause of the death or reported in Part II. Frailty-related mortality increases with age and is higher among females than males. Dementia is the most frequently reported frailty-related code.

CONCLUSIONS

Notable cross-country differences were found in the prevalence and the type of frailty-related symptoms at death even after adjusting for differential age distributions.

Predicting Short-Term Mortality in Older Patients Discharged from Acute Hospitalizations Lasting Less Than 24 Hours

Purpose

Over coming decades, a rise in the number of short, acute hospitalizations of older people is to be expected. To help physicians identify high-risk patients prior to discharge, we aimed to develop a model capable of predicting the risk of 30-day mortality for older patients discharged from short, acute hospitalizations and to examine how model performance changed with an increasing amount of information.

Methods

This registry-based study included acute hospitalizations in Denmark for 2016-2018 lasting ≤24 hours where patients were permanent residents, ≥65 years old, and discharged alive. Utilizing many different predictor variables, we developed random forest models with an increasing amount of information, compared their performance, and examined important variables.

Results

We included 107,132 patients with a median age of 75 years. Of these, 3.3% (n=3575) died within 30 days of discharge. Model performance improved especially with the addition of laboratory results and information on prior acute admissions (AUROC 0.835), and again with comorbidities and number of prescription drugs (AUROC 0.860). Model performance did not improve with the addition of sociodemographic variables (AUROC 0.861), apart from age and sex. Important variables included age, dementia, number of prescription drugs, C-reactive protein, and eGFR.

Conclusion

The best model accurately estimated the risk of short-term mortality for older patients following short, acute hospitalizations. Trained on a large and heterogeneous dataset, the model is applicable to most acute clinical settings and could be a useful tool for physicians prior to discharge.

Adherence to the Mediterranean diet and risk of frailty and pre-frailty in elderly adults: A systematic review and dose-response meta-analysis with GRADE assessment

BACKGROUND

Several studies have explored the association between Mediterranean diet and frailty, but reported inconsistent results. This systematic review and dose-response meta-analysis summarized the existing evidence on the relationship between Mediterranean diet and risk of frailty and pre-frailty in elderly adults.

METHODS

A systematic search on MEDLINE (PubMed), Scopus, Institute for Scientific Information (ISI) Web of Science and Google Scholar was conducted up to January 2023. Study selection and data extraction were performed by two reviewers working in parallel. Epidemiologic studies reporting relative risks (RRs) or odds ratios (ORs) with 95% confidence intervals (CIs) for frailty/pre-frailty in relation to Mediterranean diet (as a priori dietary pattern) were considered. The overall effect size was determined using a random effects model. The body of evidence was assessed by the GRADE approach.

RESULTS

A total of 19 studies (12 cohorts and 7 cross-sectionals) were included. In cohort studies (89,608 participants/ 12,866 cases), the highest versus lowest category of Mediterranean diet was inversely associated with frailty (RR: 0.66; 95%CI: 0.55, 0.78; I²:52.4%, P_Q-test=0.02). This association was also significant in cross-sectional studies with 1093 cases among 13,581 participants (OR: 0.44; 95%CI: 0.28, 0.70; I²:81.8%, P_Q-test<0.001). Moreover, each 2-point increase in Mediterranean diet score was related to decreased risk of frailty in cohort (RR: 0.86; 95%CI: 0.80, 0.93) and cross-sectional (OR: 0.79; 95%CI: 0.65, 0.95) studies. Nonlinear association showed a decreasing slope in curve, sharper at high scores for cohort studies and a steadily reduction for cross-sectional studies. The certainty of the evidence was graded as high in both cohort and cross-sectional studies. Combining 4 effect sizes of 4 studies (12,745 participants/ 4363 cases), the highest adherence to Mediterranean diet was linked to a lower risk of pre-frailty, as well (pooled OR: 0.73; 95%CI: 0.61, 0.86; I²:40.9%, P_Q-test=0.17).

CONCLUSION

Adherence to Mediterranean diet is inversely associated with risk of frailty and pre-frailty in older adults and thus, has a considerable impact on health of this population.

Sarcopenia as a Predictor of the Functional Outcome in Patients with Intracranial Aneurysms

INTRODUCTION

Radiological indicators in head computed tomography (CT) scan have emerged as tools to evaluate sarcopenia using the sectional area and thickness of the temporal muscle. They can be obtained by standardized measurements in preoperative image assessment of patients with brain aneurysms. We aimed to evaluate the association between functional outcomes after interventions for intracranial aneurysms (IAs) and temporal muscle thickness (TMT) and area (TMA), as surrogates of sarcopenia.

METHODS

This is a prospective observational cohort study in patients who underwent microsurgery or embolization for ruptured or unruptured IA between January 2018 and December 2019, with a 6-month follow-up. Preoperative CT scans were analyzed to measure TMT and TMA. The functional outcome was assessed by the modified Rankin Scale (mRS). The main outcome was the relationship between sarcopenia and the postoperative functional outcome.

RESULTS

A total of 361 patients were included, of whom 199 (55.1%) had ruptured and 162 (44.9%) had unruptured lesions. Larger TMA significantly predicted better functional outcomes at discharge. TMT was associated with functional outcomes at both discharge and 6 months, adjusted for rupture and hypertension. Maximizing the sum sensitivity-specificity, an optimal TMT cutoff of 6.25 mm can predict unfavorable outcomes. Maximizing the positive predictive value × negative predictive value of a product, the cutpoint was 3.55 mm.

CONCLUSIONS

Sarcopenia, represented by TMT and TMA, is associated with poorer functional results at discharge and 6-month follow-up in IA surgery. TMT below 6.25 mm was associated with unfavorable functional outcomes. These easily obtainable measurements may improve the decision-making process for patients with IAs.

Hospital frailty risk score predicts worse outcomes in patients with chronic pancreatitis

Background

Chronic pancreatitis (CP) is a pathological fibroinflammatory response to persistent inflammation or stress to the pancreas. The effect of frailty on outcomes in patients with CP has not been previously examined. In this study, we examined the effect of frailty on outcomes in hospitalized patients with CP.

Methods

Records of patients with a primary or secondary discharge diagnosis of CP (ICD10-CM codes K86.0, K86.1) between January 2016 and December 2019 were obtained from the National Inpatient Sample database. Data were collected on patient demographics, hospital characteristics, comorbidities, and etiology of CP. The relationship between frailty and outcomes, including mortality, intensive care unit (ICU) admission, sepsis, shock, length of stay (LOS), and total hospitalization charges (THC), were analyzed using multivariate analysis.

Results

722,160 patients were included in the analysis. Patients with a high hospital frailty risk score had a higher mortality risk (adjusted odds ratio [aOR] 12.57, 95% confidence interval [CI] 10.42-15.16; P<0.001) compared to patients with low frailty scores. Patients with high frailty scores also had a higher risk of sepsis (aOR 5.75, 95%CI 4.97-6.66; P<0.001), shock (aOR- 26.25, 95%CI-22.83-30.19; P<0.001), ICU admission (aOR 25.86, 95% CI-22.58-29.62; P<0.001), and acute kidney injury (aOR 24.4, 95%CI 22.39-26.66; P<0.001). They also had a longer LOS (7.04 days, 95%CI 6.57-7.52; P<0.001) and higher THC ($72,200, 95%CI 65,904.52-78,496.66; P<0.001).

Conclusions

Frail patients, as determined by their hospital frailty risk score, are at high risk of worse outcomes. This data suggests opportunities for physicians to risk-stratify patients and predict outcomes.

Association of Baseline and Longitudinal Changes in Frailty Burden and Risk of Heart Failure in Type 2 Diabetes-Findings from the Look AHEAD Trial

BACKGROUND

Individuals with diabetes have a high frailty burden and increased risk of heart failure (HF). In this study, we evaluated the association of baseline and longitudinal changes in frailty with risk of HF and its subtypes: HF with preserved ejection fraction (HFpEF), and HF with reduced ejection fraction (HFrEF).

METHODS

Participants (age: 45-76 years) of the Look AHEAD trial without prevalent HF were included. The frailty index (FI) was used to assess frailty burden using a 35-variable deficit model. The association between baseline and longitudinal changes (1- and 4-year follow-up) in FI with risk of overall HF, HFpEF (ejection fraction [EF] ≥ 50%), and HFrEF (EF < 50%) independent of other risk factors and cardiorespiratory fitness was assessed using adjusted Cox models.

RESULTS

The study included 5 100 participants with type 2 diabetes mellitus, of which 257 developed HF. In adjusted analysis, higher frailty burden was significantly associated with a greater risk of overall HF. Among HF subtypes, higher baseline FI was significantly associated with risk of HFpEF (hazard ratio [HR] [95% CI] per 1-SD higher FI: 1.37 [1.15-1.63]) but not HFrEF (HR [95% CI]: 1.19 [0.96-1.46]) after adjustment for potential confounders, including traditional HF risk factors. Among participants with repeat measures of FI at 1- and 4-year follow-up, an increase in frailty burden was associated with a higher risk of HFpEF (HR [95% CI] per 1-SD increase in FI at 4 years: 1.78 [1.35-2.34]) but not HFrEF after adjustment for other confounders.

CONCLUSIONS

Among individuals with type 2 diabetes mellitus, higher baseline frailty and worsening frailty burden over time were independently associated with higher risk of HF, particularly HFpEF after adjustment for other confounders.

Prediction of 30-Day Readmission in Hospitalized Older Adults Using Comprehensive Geriatric Assessment and LACE Index and HOSPITAL Score

(1) Background: Elders have higher rates of rehospitalization, especially those with functional decline. We aimed to investigate potential predictors of 30-day readmission risk by comprehensive geriatric assessment (CGA) in hospitalized patients aged 65 years or older and to examine the predictive ability of the LACE index and HOSPITAL score in older patients with a combination of malnutrition and physical dysfunction. (2) Methods: We included patients admitted to a geriatric ward in a tertiary hospital from July 2012 to August 2018. CGA components including cognitive, functional, nutritional, and social parameters were assessed at admission and recorded, as well as clinical information. The association factors with 30-day hospital readmission were analyzed by multivariate logistic regression analysis. The predictive ability of the LACE and HOSPITAL score was assessed using receiver operator characteristic curve analysis. (3) Results: During the study period, 1509 patients admitted to a ward were recorded. Of these patients, 233 (15.4%) were readmitted within 30 days. Those who were readmitted presented with higher comorbidity numbers and poorer performance of CGA, including gait ability, activities of daily living (ADL), and nutritional status. Multivariate regression analysis showed that male gender and moderately impaired gait ability were independently correlated with 30-day hospital readmissions, while other components such as functional impairment (as ADL) and nutritional status were not associated with 30-day rehospitalization. The receiver operating characteristics for the LACE index and HOSPITAL score showed that both predicting scores performed poorly at predicting 30-day hospital readmission (C-statistic = 0.59) and did not perform better in any of the subgroups. (4) Conclusions: Our study showed that only some components of CGA, mobile disability, and gender were independently associated with increased risk of readmission. However, the LACE index and HOSPITAL score had a poor discriminating ability for predicting 30-day hospitalization in all and subgroup patients. Further identifiers are required to better estimate the 30-day readmission rates in this patient population.

Frailty: Pathophysiology, Theoretical and Operational Definition(s), Impact, Prevalence, Management and Prevention, in an Increasingly Economically Developed and Ageing World

The world's population is ageing, and most older adults experience a later life burdened with disease and disability. Frailty is a multidimensional and dynamic condition characterized by declines in reserve and function across multiple physiological systems, such that the ability to cope with every day or acute stressors becomes compromised. It is projected to become one of the most serious public health challenges economically developed societies will face in the coming century. This review provides a comprehensive overview of frailty, exploring its pathophysiology, theoretical and operational definition(s), impact, prevalence, management, and prevention, within the context of its emergence as a major public health challenge, in an increasingly economically developed and ageing world. Further, this review discusses the major limitations, deficiencies, and knowledge gaps presently within the field, and future research directions pertinent to the advancement of frailty research and the promotion of healthy longevity among the increasing global population of older adults.

Associations of poor sleep quality, chronic pain and depressive symptoms with frailty in older patients: is there a sex difference?

Background

Sleep disturbance, chronic pain and depressive symptoms later in life are modifiable risk factors and may contribute to frailty. However, much less is known about sex differences in the association between these concurrent symptoms and frailty in older patients. Therefore, we conducted this study to explore the associations of poor sleep quality, chronic pain, and depressive symptoms with frailty in older patients, and the sex-specific associations.

Methods

In an observational population-based study, 540 older hospitalized patients from Zhejiang Hospital in China were enrolled. We collected data on poor sleep quality, pain, depressive symptoms and frailty using the Pittsburgh Sleep Quality Index, the Numerical Rating Scale, the 15-item Geriatric Depression Scale, and the Clinical Frailty Scale. Multivariate logistic regression models were used to explore the total sample and sex-specific associations among symptom burdens, symptom combination patterns and symptom counts, and frailty.

Results

After adjusting for the potential covariates, concurrent poor sleep quality and depressive symptoms (OR = 4.02, 95% CI 1.57–10.26), concurrent poor sleep quality and chronic pain (OR = 2.05, 95% CI 1.04–4.05), and having three symptoms (OR = 3.52, 95% CI 1.19–10.44) were associated with a higher likelihood of frailty in older inpatients. In addition, older patients with 2 or 3 symptoms (2 and 3 vs. 0 symptoms) had a higher risk of frailty, and the odds ratios were 2.40 and 3.51, respectively. Interaction analysis and sex-stratified associations exhibited conflicting results. The nonsignificant effect of the interaction of sex and symptoms on frailty, but not the sex-stratified associations, showed that individual symptoms, symptom combination patterns, and symptom counts were associated with elevated risks of frailty in older male patients, but not in older female patients.

Conclusions

Increased symptom burdens were associated with a higher risk of frailty in older inpatients, especially in those with poor sleep quality concurrent with at least one of the other two symptoms. Thus, a multidisciplinary program addressing these common symptoms is required to reduce adverse outcomes.

Which anticoagulant is safest for frail elderly patients with nonvalvular A-fib?

In a retrospective study comparing direct oral anticoagulants vs warfarin in this population, apixaban's adverse event rate was lower regardless of frailty status.

Factors Related to Hospital Readmission of Frail Older Adults in Korea

PURPOSE

Frail older adults have a higher risk of hospital readmission due to decline in physical, functional, and psychological health status. The impact of readmission on individuals, families, or the healthcare system is tremendously devastating. This study aimed to investigate factors associated with hospital readmission of frail older adults.

MATERIALS AND METHODS

This was a retrospective descriptive study based on multi-professional health assessments found in electronic medical records of patients from a university-affiliated hospital in Seoul, Korea. The participants were 141 older adults who were admitted to the geriatric department with medical problems. Frailty, components of the comprehensive geriatric assessment including nutrition, physical functions, psychological and cognitive status, clinical data including length of hospital stay, and readmission within 30, 90, and 180 days were collected. Survival analysis was performed, and Cox proportional hazard regression model was used to investigate the risk factors for readmission.

RESULTS

The statistically significant variables at each time point were slightly different. However, at most time points, disease-related problems (i.e., comorbidities and medications) and body functions (i.e., grip strength and physical activity) were included. The median duration until readmission was 27 days, and grip strength was found to be significantly related to readmission (p=0.020).

CONCLUSION

After discharge, both medical services to manage the medical condition and intervention to maintain physical function are needed to prevent frail older adults from being readmitted to the hospital.

Risk of all-cause mortality in subjects with varying degrees of renal impairment with or without dietary protein restriction

BACKGROUND AND OBJECTIVE

Low-protein diet (less than 0.8g/kg/day) has been practiced in the management of chronic kidney disease (estimated glomerular filtration rate [eGFR]<60ml/min/1.73m² or urine albumin-to-creatinine ratios [UACR] ≥30mg/g) for decades. However, its effect on all-cause mortality is unclear. We investigated the association between a low-protein intake and all-cause mortality in subjects with varying degrees of renal impairment.

MATERIALS AND METHODS

We analyzed participants in the National Health and Nutrition Examination Survey (NHANES) from 2003 to 2010. They were divided into four groups according to their eGFR (≥60 or <60ml/min/1.73m²) and UACR (≥30 or <30mg/g). Daily protein intake of the NHANES participants could be assessed using information from the dietary interview questionnaires. The mortality data was retrieved by linking to the National Death Index till the end of 2011. The hazard ratios for all-cause mortality were evaluated by the weighted Cox proportional hazards regression models.

RESULTS

A total of 8093 participants were analyzed. During a median follow-up of 4.7 years, participants with UACR≥30mg/g (with or without eGFR<60ml/min/1.73m²) had a higher risk of all-cause mortality compared with those having UACR<30mg/g and eGFR≥60ml/min/1.73m² (reference group). The higher risk of mortality in participants with UACR≥30mg/g was consistently observed in those with or without a low-protein intake.

CONCLUSIONS

A low-protein intake was not associated with a lower risk of all-cause mortality in subjects with varying degrees of renal impairment.

Social frailty increases the risk of all-cause mortality: A longitudinal analysis of the English Longitudinal Study of Ageing

OBJECTIVES

Social frailty is a common condition in older people, but its consequences are largely unknown. Therefore, in this longitudinal analysis, we aimed to investigate the association between social frailty and risk of all-cause mortality in a large sample of older people.

DESIGN

Longitudinal, cohort.

SETTINGS AND PARTICIPANTS

Older people participating to the English Longitudinal Study of Ageing (ELSA).

METHODS

Social frailty was defined based on financial difficulty, household status, social activity, and contacts with other people: social frailty was defined as ≥2 points, social pre-frailty (1 point), and robustness (0 points). Survival status during ten years of follow-up was assessed using administrative data. Cox proportional hazard models were used to estimate adjusted hazard ratios (HR) and 95 % confidence intervals (95 % CI) of the association between social frailty status and all-cause mortality.

RESULTS

At baseline, compared to social robust participants, social frail subjects reported a significant higher presence of potential risk factors for all-cause mortality. During the ten years of follow-up, after adjusting for 10 potential confounders, social frailty at baseline (vs. robustness) was associated with a significantly higher risk of death (HR = 1.31; 95 % CI: 1.04-1.64; p = 0.02), whilst social pre-frail was not. Among the single factors contributing to social frailty, poverty increased the risk of all-cause mortality by approximately 60 % (HR = 1.60; 95 % CI: 1.33-1.93; p < 0.0001) as well as living alone (HR = 1.46; 95 % CI: 1.10-1.94; p = 0.009).

CONCLUSIONS AND IMPLICATIONS

Social frailty was significantly associated with all-cause mortality in a large cohort of older people, highlighting the importance of identifying this phenomenon in older adults to inform targeted intervention efforts.

Association of a modified laboratory frailty index with adverse outcomes in geriatric rehabilitation inpatients: RESORT

A higher number of laboratory measurements is associated with mortality in patients admitted to hospital, but is not part of the frailty index based on laboratory tests (FILab). This study aimed to modify the FI-Lab (mFI-Lab) by accounting for the number of laboratory measurements and compare its validity to predict institutionalization and mortality at three-month post-discharge with the clinical frailty scale (CFS) in geriatric rehabilitation inpatients. In 1819 patients (median age 83.3 [77.6-88.3], 56.6% female), a higher FI-Lab was not associated with institutionalization but a higher risk of mortality. A higher mFI-Lab was associated with lower odds of institutionalization but a higher risk of mortality. A higher CFS was associated with institutionalization and higher mortality. The Akaike information criterion value was lowest for the CFS, followed by the mFI-Lab and the FI-Lab. The CFS is better than the mFI-Lab predicting short-term adverse outcomes in geriatric rehabilitation inpatients. When using laboratory data to estimate frailty, the mFI-Lab rather than the FI-Lab should be used.

Development of an electronic frailty index for hospitalized older adults in Sweden

BACKGROUND

Frailty assessment in the Swedish health system relies on the Clinical Frailty Scale (CFS), but it requires training, in-person evaluation, and is often missing in medical records. We aimed to develop an electronic frailty index (eFI) from routinely collected electronic health records (EHRs) and assess its association with adverse outcomes in hospitalized older adults.

METHODS

EHRs were extracted for 18,225 patients with unplanned admissions between 1 March 2020 and 17 June 2021 from nine geriatric clinics in Stockholm, Sweden. A 48-item eFI was constructed using diagnostic codes, functioning and other health indicators, and laboratory data. The CFS, Hospital Frailty Risk Score, and Charlson Comorbidity Index were used for comparative assessment of the eFI. We modelled in-hospital mortality and 30-day readmission using logistic regression; 30-day and 6-month mortality using Cox regression; and length of stay using linear regression.

RESULTS

13,188 patients were included in analyses (mean age 83.1 years). A 0.03 increment in the eFI was associated with higher risks of in-hospital (odds ratio: 1.65; 95% confidence interval: 1.54-1.78), 30-day (hazard ratio [HR]: 1.43; 1.38-1.48), and 6-month mortality (HR: 1.34; 1.31-1.37) adjusted for age and sex. Of the frailty and comorbidity measures, the eFI had the highest area under receiver operating characteristic curve for in-hospital mortality of 0.813. Higher eFI was associated with longer length of stay, but had a rather poor discrimination for 30-day readmission.

CONCLUSIONS

An EHR-based eFI has robust associations with adverse outcomes, suggesting that it can be used in risk stratification in hospitalized older adults.

Preclinical frailty assessments: Phenotype and frailty index identify frailty in different mice and are variably affected by chronic medications

Use of different objective frailty assessment tools may improve understanding of the biology of frailty and allow evaluation of effects of interventions on frailty. Polypharmacy is associated with increased risk of frailty in epidemiologic studies, regardless of frailty definition, but the pathophysiology of the association is not well understood. This study aims to (1) assess and compare the prevalence of frailty from middle to old age following control, chronic polypharmacy or monotherapy treatment, when measured using the clinical frailty index assessment and the mouse frailty phenotype tools; and (2) to evaluate and compare the effects of chronic polypharmacy regimens with zero, low and high Drug Burden Index (DBI) and monotherapies from middle to old age on the rate of deficit accumulation on the frailty index, mean number of phenotype criteria, odds of being frail assessed by the frailty index or phenotype, and the time to onset of frailty assessed by the frailty index or phenotype. In a longitudinal study, middle-aged (12 months) male C57BL/6J(B6) mice were administered non medicated control feed and water, or therapeutic doses of different polypharmacy combinations or monotherapies in feed and/or water. Frailty assessments were performed at 12, 15, 18, 21 and 24 months. There was limited overlap between animals identified as frail using different frailty assessments. Polypharmacy has measurable and different effects on each frailty assessment. Long-term chronic administration of some polypharmacy and monotherapy therapeutic drug regimens increased the number of frailty deficits (clinical frailty index: low DBI polypharmacy (15 and 21 months), high DBI polypharmacy (15-21 months), oxycodone (15-18 months), oxybutynin (15-18 months), citalopram (15-21 months) and metoprolol monotherapy (15 months) and modified frailty phenotype assessment (over the whole duration of treatment, low DBI polypharmacy (adjusted Risk Ratio(aRR) = 1.97, 95% confidence interval (CI) 1.43-2.72), high DBI polypharmacy (aRR = 1.88; 95% CI 1.36-2.60), oxybutynin (aRR = 1.48; 95% CI 1.01-2.16) and citalopram monotherapy (aRR = 1.96; 95% CI 1.41-2.74), p < 0.05) . The odds of developing frailty measured with the clinical frailty index increased with high DBI polypharmacy (adjusted odds ratio (aOR) = 3.13; 95% CI 1.01-9.66) and when measured with the frailty phenotype assessment increased with low DBI polypharmacy (aOR = 4.38, 95% CI 1.40-13.74), high DBI polypharmacy (aOR = 3.43; 95% CI 1.12-10.50) and citalopram monotherapy (aOR = 4.63; 95% CI 1.39-15.54)). No treatment affected time to frailty using either frailty assessment. Analysis of the number of deficits on the frailty index or number of positive criteria on the frailty phenotype allows analysis of rate of change and provides greater sensitivity, while the odds of being frail analysis provided a clinically relevant indicator of whether mice had greater chance of reaching a cut-off for becoming frail with medication exposure than without. Our results are consistent with clinical studies, demonstrating that certain polypharmacy regimens induce frailty, with different relationships observed when using different frailty assessments and analyses.

Associations of social isolation, social participation, and loneliness with frailty in older adults in Singapore: a panel data analysis

BACKGROUND

There is a shortage of research evidence about how social isolation, social participation, and loneliness were longitudinally associated with frailty. This study was to 1) examine the associations of social isolation, social participation, and loneliness with level of frailty among community-dwelling older adults using panel data, and 2) explore the moderating effect of gender on the association of social isolation, social participation and loneliness with frailty.

METHODS

The study included 606 participants aged 60 years and above from the longitudinal Population Health Index Survey conducted in Singapore. At each timepoint, level of frailty was determined using the Clinical Frailty Scale. Social isolation was assessed by the Lubben Social Network Scale-6, and loneliness was assessed using the three-item UCLA Loneliness Scale. Fixed-effects ordinal logistic regressions were conducted with level of frailty as the dependent variable and social isolation and loneliness as the independent variables, adjusting for time-varying socio-demographic, lifestyle, and health-related factors.

RESULTS

Increase in social participation was associated with lower level of frailty (odds ratio: 0.96, 95% confidence interval: 0.93-0.99) and feeling lonely was associated with higher level of frailty (odds ratio: 2.90, 95% confidence interval: 1.44-5.84). Social isolation was not associated with frailty. Gender did not have moderating effect on these associations.

CONCLUSIONS

This study observed that social isolation and loneliness had differential longitudinal association with level of frailty among community-dwelling older adults and suggested that loneliness and frailty should be measured and addressed concurrently among community-dwelling older adults.

Frailty assessment and acute frailty service provision in the UK: results of a national 'day of care' survey

Background

The incorporation of acute frailty services into the acute care pathway is increasingly common. The prevalence and impact of acute frailty services in the UK are currently unclear.

Methods

The Society for Acute Medicine Benchmarking Audit (SAMBA) is a day of care survey undertaken annually within the UK. SAMBA 2019 (SAMBA19) took place on Thursday 27th June 2019. A questionnaire was used to collect hospital and patient-level data on the structure and organisation of acute care delivery. SAMBA19 sought to establish the frequency of frailty assessment tool use and describe acute frailty services nationally. Hospitals were classified based on the presence of acute frailty services and metrics of performance compared.

Results

A total of 3218 patients aged ≥70 admitted to 129 hospitals were recorded in SAMBA19. The use of frailty assessment tools was reported in 80 (62.0%) hospitals. The proportion of patients assessed for the presence of frailty in individual hospitals ranged from 2.2 to 100%. Bedded Acute Frailty Units were reported in 65 (50.3%) hospitals. There was significant variation in admission rates between hospitals. This was not explained by the presence of a frailty screening policy or presence of a dedicated frailty unit.

Conclusion

Two fifths of participating UK hospitals did not have a routine frailty screening policy: where this existed, rates of assessment for frailty were variable and most at-risk patients were not assessed. Responses to positive results were poorly defined. The provision of acute frailty services is variable throughout the UK. Improvement is needed for the aspirations of national policy to be fully realised.

High Rates of Mortality in Geriatric Patients Admitted for Inflammatory Bowel Disease Management

GOAL

The goal of this study was to evaluate the inpatient mortality risk among geriatric patients with inflammatory bowel disease (IBD).

BACKGROUND

The challenges of caring for elderly patients with IBD will increase with the aging of the US population. Given the complications of hospitalization, we set to examine if elderly patients age older than 65 were at higher risk of mortality.

MATERIALS AND METHODS

All patients with ulcerative colitis (UC) or Crohn's disease (CD) in the National Inpatient Sample (NIS) from 2016 and 2017 as the primary diagnosis or secondary diagnosis with an IBD-related cause of admission were included. Outcomes for patients aged above 65 were compared with below 65 using multivariable survey-adjusted regression. CD and UC were analyzed separately.

RESULTS

In 2016-2017, there were an estimated 162,800 admissions for CD and related complications compared with 96,450 for UC. In total, 30% of UC and 20% of CD admissions were geriatric. Geriatric status was associated with higher odds of mortality for CD [odds ratio (OR)=3.47, 95% confidence interval (CI): 2.72-4.44] and UC (OR=2.75, 95% CI: 2.16-3.49) after adjustment for comorbidities, admission type, hospital type, inpatient surgery, and IBD subtype. The cause of death was ∼80% infectious in both CD and UC in all groups. An average of 0.19 days (95% CI: 0.05-0.34) and $2467 (95% CI: 545-4388) increase was seen for geriatric CD patients. No significant change was seen for UC.

CONCLUSIONS

Age over 65 was independently associated with higher odds of death in both UC and CD patients, even after appropriate adjustment. Further research is needed to optimize care for this growing patient population.

Frailty and In-Hospital Mortality Risk Using EHR Nursing Data

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

How frail is frail? A systematic scoping review and synthesis of high impact studies

AIMS

While the frailty index (FI) is a continuous variable, an FI score of 0.25 has construct and predictive validity to categorise community-dwelling older adults as frail or non-frail. Our study aimed to explore which FI categories (FI scores and labels) were being used in high impact studies of adults across different care settings and why these categories were being chosen by study authors.

METHODS

For this systematic scoping review, Medline, Cochrane and EMBASE databases were searched for studies that measured and categorised an FI. Of 1314 articles screened, 303 met the eligibility criteria (community: N = 205; residential aged care: N = 24; acute care: N = 74). For each setting, the 10 studies with the highest field-weighted citation impact (FWCI) were identified and data, including FI scores and labels and justification provided, were extracted and analysed.

RESULTS

FI scores used to distinguish frail and non-frail participants varied from 0.12 to 0.45 with 0.21 and 0.25 used most frequently. Additional categories such as mildly, moderately and severely frail were defined inconsistently. The rationale for selecting particular FI scores and labels were reported in most studies, but were not always relevant.

CONCLUSIONS

High impact studies vary in the way they categorise the FI and while there is some evidence in the community-dweller literature, FI categories have not been well validated in acute and residential aged care. For the time being, in those settings, the FI should be reported as a continuous variable wherever possible. It is important to continue working towards defining frailty categories as variability in FI categorisation impacts the ability to synthesise results and to translate findings into clinical practice.

Factors associated with 14-day hospital readmission in frail older patients: A case-control study

Frailty is a key predictor of readmission among older patients. However, studies on the factors associated with readmission of frail older patients are lacking. This study aims to examine factors associated with 14-day hospital readmission in frail older patients. A retrospective case-control study was conducted. Patients were eligible for inclusion if they were age 65 and over and if their Clinical Frailty Scale (CFS) score was above 4. A total of 210 frail older patients were included. Patients who had partners, experienced a fall within 6 months before hospitalization, had pressure injuries, received surgery or chemotherapy, and received rehabilitation therapy from a physical therapist during hospitalization had increased odds of being readmitted to the hospital within 14 days. Moreover, patients receiving comprehensive geriatric assessment (CGA) services during hospitalization showed a significantly reduced risk of readmission. Adapting CGA and developing continuity care plans from hospitals to the community are crucial.

Transitional care from hospital to home for frail older adults: A systematic review and meta-analysis

Frail older adults are vulnerable to hospitalization and transitional care is needed to maintain care continuity; however, there exists no review regarding transitional care focusing on frailty. This study aimed to investigate transitional care for frail older adults and its effectiveness. Search terms were (P) frail older adults; (I) transitional care initiated before discharge; (C) usual care; (O) all health outcomes. Fourteen trials were identified. The most measured outcome was readmission (n = 13), followed by mortality (n = 9), function (n = 7), quality of life (n = 5), and self-rated health (n = 5). Statistical significance effects were reported in the followings: n = 6, readmission; n = 0, mortality; n = 3, function; n = 2, quality of life; and n = 4, self-rated health. The meta-analysis demonstrated that transitional care reduced readmission at six months but not other time points nor mortality or quality of life. The intervention effectiveness was inconclusive; therefore, an evidence-based yet novel approach is necessary to establish an adequate transitional care intervention for frail older adults.

Clinical characteristics and risk factors of preventable hospital readmissions within 30 days

Knowledge regarding preventable hospital readmissions is scarce. Our aim was to compare the clinical characteristics of potentially preventable readmissions (PPRs) with non-PPRs. Additionally, we aimed to identify risk factors for PPRs. Our study included readmissions within 30 days after discharge from 1 of 7 hospital departments. Preventability was assessed by multidisciplinary meetings. Characteristics of the readmissions were collected and 23 risk factors were analyzed. Of the 1120 readmissions, 125 (11%) were PPRs. PPRs occurred equally among different departments (p = 0.21). 29.6% of PPRs were readmitted by a practitioner of a different medical specialty than the initial admission (IA) specialist. The PPR group had more readmissions within 7 days (PPR 54% vs. non-PPR 44%, p = 0.03). The median LOS was 1 day longer for PPRs (p = 0.16). Factors associated with PPR were higher age (p = 0.004), higher socio-economic status (p = 0.049), fewer prior hospital admissions (p = 0.004), and no outpatient visit prior to readmission (p = 0.025). This study found that PPRs can occur at any department in the hospital. There is not a single type of patient that can easily be pinpointed to be at risk of a PPR, probably due to the multifactorial nature of PPRs.

Predicting readmission and death after hospital discharge: a comparison of conventional frailty measurement with an electronic health record-based score

BACKGROUND

frailty measurement may identify patients at risk of decline after hospital discharge, but many measures require specialist review and/or additional testing.

OBJECTIVE

to compare validated frailty tools with routine electronic health record (EHR) data at hospital discharge, for associations with readmission or death.

DESIGN

observational cohort study.

SETTING

hospital ward.

SUBJECTS

consented cardiology inpatients ≥70 years old within 24 hours of discharge.

METHODS

patients underwent Fried, Short Physical Performance Battery (SPPB), PRISMA-7 and Clinical Frailty Scale (CFS) assessments. An EHR risk score was derived from the proportion of 31 possible frailty markers present. Electronic follow-up was completed for a primary outcome of 90-day readmission or death. Secondary outcomes were mortality and days alive at home ('home time') at 12 months.

RESULTS

in total, 186 patients were included (79 ± 6 years old, 64% males). The primary outcome occurred in 55 (30%) patients. Fried (hazard ratio [HR] 1.47 per standard deviation [SD] increase, 95% confidence interval [CI] 1.18-1.81, P < 0.001), CFS (HR 1.24 per SD increase, 95% CI 1.01-1.51, P = 0.04) and EHR risk scores (HR 1.35 per SD increase, 95% CI 1.02-1.78, P = 0.04) were independently associated with the primary outcome after adjustment for age, sex and co-morbidity, but the SPPB and PRISMA-7 were not. The EHR risk score was independently associated with mortality and home time at 12 months.

CONCLUSIONS

frailty measurement at hospital discharge identifies patients at risk of poorer outcomes. An EHR-based risk score appeared equivalent to validated frailty tools and may be automated to screen patients at scale, but this requires further validation.