A comparison of two methods for identifying frail Medicare-aged persons

Understanding Frailty Screening: a Domain Mapping Exercise

Background

Many definitions and operationalisations of frailty exclude psychosocial factors, such as social isolation and mental health, despite considerable evidence of the links between frailty and these factors. This study aimed to investigate the health domains covered by frailty screening tools.

Methods

A systematic search of the literature was conducted in accordance with PRISMA guidelines. MEDLINE, CINAHL, EMBASE, and PsycInfo were searched from inception to December 31, 2018. Data related to the domains of each screening tool were extracted and mapped onto a framework based on the biopsychosocial model of Lehmans et al. (2009) and Wade & Halligans (2017).

Results

Sixty-seven frailty screening tools were captured in 79 articles. All screening tools assessed biological factors, 73% assessed psychological factors, 52% assessed social factors, and 78% assessed contextual factors. Under half (43%) of the tools evaluated all four domains, 33% evaluated three of four domains, 12% reported two of four domains, and 13% reported one domain (biological).

Conclusion

This review found considerable variation in the assessment domains covered by frailty screening tools. Frailty is a broad construct, and frailty screening tools need to cover a wide variety of domains to enhance screening and outcomes assessment.

Is It Time to Begin a Public Campaign Concerning Frailty and Pre-frailty? A Review Article

Frailty is a state that encompasses losses in physical, psychological or social domains. Therefore, frail people demonstrate a reduced potential to manage external stressors and to respond to life incidents. Consequently, such persons are prone to various adverse consequences such as falls, cognitive decline, infections, hospitalization, disability, institutionalization, and death. Pre-frailty is a condition predisposing and usually preceding the frailty state. Early detection of frailty (i.e., pre-frailty) may present an opportunity to introduce effective management to improve outcomes. Exercise training appears to be the basis of such management in addition to periodic monitoring of food intake and body weight. However, various nutritional supplements and other probable interventions, such as treatment with vitamin D or androgen, require further investigation. Notably, many societies are not conscious of frailty as a health problem. In fact, people generally do not realize that they can change this unfavorable trajectory to senility. As populations age, it is reasonable to begin treating frailty similarly to other population-affecting disorders (e.g., obesity, diabetes or cardiovascular diseases) and implement appropriate preventative measures. Social campaigns should inform societies about age-related frailty and pre-frailty and suggest appropriate lifestyles to avoid or delay these conditions. In this article, we review current information concerning therapeutic interventions in frailty and pre-frailty and discuss whether a greater public awareness of such conditions and some preventative and therapeutic measures may decrease their prevalence.

Integrated information for integrated care in the general practice setting in Italy: using social network analysis to go beyond the diagnosis of frailty in the elderly

BACKGROUND

Frailty has been defined in different ways and several diagnostic tools exist, but most of them are not applicable in routine primary care. Nonetheless, general practitioners (GPs) have a natural advantage in identifying frailty, due to their continued access to patients, patient-centered approach and training. GPs have also an advantage in conducting population-based evaluation as consequence of their role of gatekeepers of the health care system. This paper aims to identify those socio-demographic and clinical profiles and the relative information sources that, from the GPs' perspective, act as frailty markers, not solely as a diagnosis of state but as the ability to identify a patient's trajectory, over time, through the aging process.

METHODS

This study was performed as a survey within a population aged 75 and over, attending 148 GPs in Italy. A total of 23,996 patients were classified by GPs in distinct frailty status, without the use of a specific evaluation tool, but only referring to general indications. Co-morbidity was objectively assessed by a record-linkage with previous hospitalizations, in order to assess the occurrence of previous illnesses that could be associated with the likelihood of being identified as frails or at risk. The methodological approach is based on social network analysis (SNA), suited to explore relational aspects of complex phenomena.

RESULTS

Our findings reveal that GPs are able to perform low cost population-based evaluation, by exploiting the advantages of their approach to patients, combined with the information derived from their daily practice and from other sources currently available.

CONCLUSION

We believe that informative integration among different sources of available data can provide a comprehensive picture of the health state of patients in a shorter time and at lower cost. The identification of limited patient trajectories based on these observations can enable the development of critical biomarkers/diagnostics and prognostic indicators that will enhance patient care and potentially reduce inappropriate healthcare use. We also believe that network analysis is an extremely flexible research tool and a rich theoretical paradigm, and it may be used in the healthcare planning.

Self-reported severe memory problems as a screen for cognitive impairment and dementia

Undetected cognitive impairment (CI) and dementia are important clinical and epidemiological problems. This study addresses the effectiveness of using a single self-reported measure of severe memory problems (SMP) as a screen for CI and dementia. For the purposes of the study, 3220 elderly women participated in a mailed Health Survey Questionnaire and telephone interviews. Cognitive scores derived from the Telephone Interview for Cognitive Status–modified (TICSm) were calculated. Based on a multi-stage assessment strategy, all subjects were classified in one of three status categories: dementia, CI, or unimpaired. The SMP question was suggestive of cognitive problems in the majority of responders. t-tests found affirmative responders scored much lower on the cognitive test than negative responders. The SMP question had a sensitivity of .24 and a specificity of .99 for screening CI and dementia. While other assessment measures are needed, the SMP question is highly suggestive of CI and may serve as a first-stage screen in clinical and research settings.

Diagnostic test accuracy of simple instruments for identifying frailty in community-dwelling older people: a systematic review

BACKGROUND

frailty is a state of vulnerability to adverse outcomes. Routine identification of frailty is recommended in international guidance. This systematic review investigates the diagnostic test accuracy (DTA) of simple instruments for identifying frailty in community-dwelling older people.

METHODS

the review methodology followed Cochrane procedures. Databases were searched from January 1990 to October 2013. Prospective studies assessing the DTA of simple instruments for identifying frailty in community-dwelling older people (aged ≥65 years) as index tests against a reference standard phenotype model, cumulative deficit frailty index or comprehensive geriatric assessment were eligible for inclusion. Sensitivity, specificity, positive predictive value, negative predictive value and likelihood ratios were calculated for index tests. Risk of bias was assessed using the QUADAS-2 checklist.

RESULTS

three studies involving 3,261 participants were included. Median frailty prevalence was 10.5%. Seven index tests were assessed: gait speed, timed-up-and-go test, PRISMA 7 questionnaire, self-reported health, general practitioner clinical assessment, polypharmacy and Groningen Frailty Index. For a gait speed of <0.8 m/s, the sensitivity = 0.99 and specificity = 0.64. For the PRISMA 7, the sensitivity = 0.83 and specificity = 0.83. For the timed get-up-and-go test of 10 s, the sensitivity = 0.93 and specificity = 0.62. DTA was notably lower for all other index tests. All three studies were judged at unclear risk of bias.

DISCUSSION

slow gait speed, PRISMA 7 and the timed get-up-and-go test have high sensitivity for identifying frailty. However, limited specificity implies many false-positive results which means that these instruments cannot be used as accurate single tests to identify frailty.

Frailty in Older Adults: An Evolutionary Concept Analysis

The termfrailtyis often used to describe a subset of the older population with complex health issues. It is associated with dependence, disability, increased health care use, and mortality. An emergent problem is the lack of consensus as to the etiology and definition of frailty. The purpose of this concept analysis is to clarify the concept of frailty in the context of older adults and propose a definition of frailty that may be relevant to identification of frail older adults. The results from this analysis conclude frailty in older adults is a tenuous state of health that is the result of the complex interplay of physiological, psychosocial, and environmental stressors that increases an older adult’s susceptibility to adverse health outcomes.

Effects of home telemonitoring on transitions between frailty states and death for older adults: a randomized controlled trial

Background

Two primary objectives when caring for older adults are to slow the decline to a worsened frailty state and to prevent disability. Telemedicine may be one method of improving care in this population. We conducted a secondary analysis of the Tele-ERA study to evaluate the effect of home telemonitoring in reducing the rate of deterioration into a frailty state and death in older adults with comorbid health problems.

Methods

This trial involved 205 adults over the age of 60 years with a high risk of hospitalization and emergency department visits. For 12 months, the intervention group received usual medical care and telemonitoring case management, and the control group received usual care alone. The primary outcome was frailty, which was based on five criteria, ie, weight loss, weakness, exhaustion, low activity, and slow gait speed. Participants were classified as frail if they met three or more criteria; prefrail if they met 1–2 criteria; and not frail if they met no criteria. Both groups were assessed for frailty at baseline, and at 6 and 12 months. Frailty transition analyses were performed using a multiple logistic regression method. Kaplan–Meier and Cox proportional hazards methods were used to evaluate each frailty criteria for mortality and to compute unadjusted hazard ratios associated with being telemonitored, respectively. A retrospective power analysis was computed.

Results

During the first 6 months, 19 (25%) telemonitoring participants declined in frailty status or died, compared with 17 (19%) in usual care (odds ratio 1.41, 95% confidence interval [CI] 0.65–3.06, P = 0.38). In the subsequent 6 months, there was no transition to a frailty state, but seven (7%) participants from the telemonitoring and one (1%) from usual care group died (odds ratio 5.94, 95% CI 0.52–68.48, P = 0.15). Gait speed (hazards ratio 3.49, 95% CI 1.42–8.58) and low activity (hazards ratio 3.10, 95% CI 1.25–7.71) were shown to predict mortality.

Conclusion

This study did not provide sufficient evidence to show that the telemonitoring group did better than usual care in reducing the decline of frailty states and death. Transitions occurred primarily in the first 6 months.

The Lausanne cohort Lc65+: a population-based prospective study of the manifestations, determinants and outcomes of frailty

Background

Frailty is a relatively new geriatric concept referring to an increased vulnerability to stressors. Various definitions have been proposed, as well as a range of multidimensional instruments for its measurement. More recently, a frailty phenotype that predicts a range of adverse outcomes has been described. Understanding frailty is a particular challenge both from a clinical and a public health perspective because it may be a reversible precursor of functional dependence. The Lausanne cohort Lc65+ is a longitudinal study specifically designed to investigate the manifestations of frailty from its first signs in the youngest old, identify medical and psychosocial determinants, and describe its evolution and related outcomes.

Methods/Design

The Lc65+ cohort was launched in 2004 with the random selection of 3054 eligible individuals aged 65 to 70 (birth year 1934–1938) in the non-institutionalized population of Lausanne (Switzerland). The baseline data collection was completed among 1422 participants in 2004–2005 through questionnaires, examination and performance tests. It comprised a wide range of medical and psychosocial dimensions, including a life course history of adverse events. Outcomes measures comprise subjective health, limitations in activities of daily living, mobility impairments, development of medical conditions or chronic health problems, falls, institutionalization, health services utilization, and death. Two additional random samples of 65–70 years old subjects will be surveyed in 2009 (birth year 1939–1943) and in 2014 (birth year 1944–1948).

Discussion

The Lc65+ study focuses on the sequence "Determinants → Components → Consequences" of frailty. It currently provides information on health in the youngest old and will allow comparisons to be made between the profiles of aging individuals born before, during and at the end of the Second World War.

PRISMA-7: A case-finding tool to identify older adults with moderate to severe disabilities

Many comprehensive rating scales have been developed to assess disabilities. These assessments, which require significant amounts of time, are usually performed by trained professionals. A simple case-finding instrument is needed to quickly identify older persons with potential disabilities, who then should undergo comprehensive assessments. In a cross-sectional study of 594 community-dwelling older subjects, we developed a questionnaire from an initial list of 23 yes/no questions, and compared it with an existing one to determine their relative ability to identify older persons with moderate to severe disabilities. Initially designed to identify older people with any disability, the existing seven-question tool also provided to be a good marker of significant disabilities, with a cut-off score of three or more positive answers. The sensitivity and specificity of this cut-off are 78.3% and 74.7%, respectively. These validity indices support the use of this questionnaire in identifying older persons with potential moderate to severe disabilities with a view to referring them for more comprehensive assessment.

Advanced illness index: Predictive modeling to stratify elders using self-report data

OBJECTIVES

Develop a prediction model to identify persons who have an increased risk of dying within the next 36 months, in order to focus additional resources and assessment in areas related to advanced care planning.

DESIGN

Retrospective study with a 3-year observation period.

SETTING

Integrated, not-for-profit managed care organization.

PARTICIPANTS

Beneficiaries aged 65-105 responding to an annual survey (n = 4888).

MEASUREMENTS

Survey instrument includes physical function, geriatric syndromes, health care utilization, special equipment use, self-care deficits, caregiving responsibilities, and general health problems.

RESULTS

An 11-variable model changed the baseline chi2 from 315.71 (df = 1) to 742.511 (df = 11). The percent of subjects correctly classified was 74.3% and the negative predictive value was 92.2%.

CONCLUSION

Advanced Illness Index (AII) model is stable. Characteristic variables used are not easily reversed: the 1997 cohort classified as at-risk consistently remained at risk or died in the subsequent years (1998, 92%; and 1999, 96%) and 92% of those not at-risk survived the next 36 months. Persons at high risk should at a minimum be made aware of the types of integrated home and community-based services available to them should it be needed. They also should be targeted for elicitation of treatment preferences, values, designation of health care proxy, planning, and advanced care directives.

Leveraging the Trusted Clinician: Documenting Disease Management Program Enrollment

The objective of this study was to test the hypothesis that an integrated disease management (IDM) protocol (patent-pending), which combines telephonic-delivered disease management (TDM) with a worksite-based primary care center and pharmacy delivery, would yield higher contact and enrollment rates than traditional remote disease management alone. IDM is characterized by the combination of standard TDM with a worksite-based primary care and pharmacy delivery protocol led by trusted clinicians. This prospective cohort study tracks contact and enrollment rates for persons assigned to either IDM or traditional TDM protocols, and compares them on contact and enrollment efficiency. The IDM protocol showed a significant improvement in contact and enrollment rates over traditional TDM. Integrating a worksite-based primary care and pharmacy delivery system led by trusted clinicians with traditional TDM increases contact and enrollment rates, resulting in higher patient engagement. The IDM protocol should be adopted by employers seeking higher returns on their investment in disease management programming.

Risk factors for medication misadventure among residents in sheltered housing complexes

AIM

To identify risk factors for unplanned hospitalizations among residents of sheltered housing complexes (SHCs).

METHODS

Medication-related risk factors for health outcomes among residents of SHCs in Aberdeen (n = 1137) were assessed using a postal questionnaire. Predictors of unplanned hospitalization/emergency department (ED) visit were identified using logistic regression.

RESULTS

Of the 695 (61.1%) responses received, 645 were from residents (mean age 78.2 years) using prescribed medications. One or more risk factors for medication-related problems was seen in 467 (72.4%) respondents; 488 (75.7%) were using medications with high potential for adverse drug reactions (ADRs) in the elderly. Unplanned hospitalizations/ED visits (n = 230) were found to be associated with use of drugs of narrow therapeutic index [P < 0.001; odds ratio (OR) 2.98, 95% confidence interval (CI) 1.69, 5.28]; use of five or more different medications (P = 0.001; OR 2.10, 95% CI 1.34, 3.31); and greater disability (Townsend score) (P = 0.005; OR 1.06, 95% CI 1.02, 1.11).

CONCLUSION

Residents of SHCs using drugs of narrow therapeutic index, using five or more different medications, and with greater disability warrant periodic monitoring.

Use of comprehensive geriatric assessment in older cancer patients: recommendations from the task force on CGA of the International Society of Geriatric Oncology (SIOG)

BACKGROUND

As more and more cancers occur in elderly people, oncologists are increasingly confronted with the necessity of integrating geriatric parameters in the treatment of their patients.

METHODS

The International Society of Geriatric Oncology (SIOG) created a task force to review the evidence on the use of a comprehensive geriatric assessment (CGA) in cancer patients. A systematic review of the evidence was conducted.

RESULTS

Several biological and clinical correlates of aging have been identified. Their relative weight and clinical usefulness is still poorly defined. There is strong evidence that a CGA detects many problems missed by a regular assessment in general geriatric and in cancer patients. There is also strong evidence that a CGA improves function and reduces hospitalization in the elderly. There is heterogeneous evidence that it improves survival and that it is cost-effective. There is corroborative evidence from a few studies conducted in cancer patients. Screening tools exist and were successfully used in settings such as the emergency room, but globally were poorly tested. The article contains recommendations for the use of CGA in research and clinical care for older cancer patients.

CONCLUSIONS

A CGA, with or without screening, and with follow-up, should be used in older cancer patients, in order to detect unaddressed problems, improve their functional status, and possibly their survival. The task force cannot recommend any specific tool or approach above others at this point and general geriatric experience should be used.

Usefulness of a single item in a mail survey to identify persons with possible dementia: a new strategy for finding high-risk elders

The objective of this study was to examine the characteristics of elderly persons who responded positively to a question about "severe memory problems" on a mailed health questionnaire yet were missed by the existing health risk algorithm to identify vulnerable elderly persons. A total of 324,471 respondents aged 65 and older completed a primary care health status questionnaire that gathered clinical information to quickly identify members with functional impairment, multiple chronic diseases, and higher medical care needs. The respondents were part of a large, integrated, not-for-profit managed care organization that implemented a model of care for elders using a uniform risk identification method across eight regions. Respondents with severe memory problems were compared to general respondents by morbidity, geriatric syndromes, functional impairments, service utilization, sensory impairments, sociodemographic characteristics, and activities of daily living. Of the respondents, 13,902 persons (4.3%) reported severe memory problems; the existing health risk algorithm missed 47.1% of these. When severe memory problems were included in the risk algorithm, identification increased from 11% to 13%, and risk prevalence by age groups ranged from 4.4% to 40.5%; one third had severe memory problems, a finding that was fairly consistent within age groups (28.4% to 36.5%). A question about severe memory problems should be incorporated into population risk-identification techniques. While false-negative rates are unknown, the false-positive rate of a self-report mail survey appears to be minimal. Persons reporting severe memory problems clearly have multiple comorbidities, higher prevalence of geriatric syndromes, and greater functional and sensory impairments.

Follow up of people aged 65 and over with a history of emergency admissions: analysis of routine admission data

OBJECTIVE

To determine the subsequent pattern of emergency admissions in older people with a history of frequent emergency admissions.

DESIGN

Analysis of routine admissions data from NHS hospitals using hospital episode statistics (HES) in England.

SUBJECTS

Individual patients aged > or = 65, > or = 75, and > or = 85 who had at least two emergency admissions in 1997-8.

MAIN OUTCOME MEASURES

Emergency admissions and bed use in this "high risk" cohort of patients were counted for the next five years and compared with the general population of the same age. No account was taken of mortality as the analysis was designed to estimate the future use of beds in this high risk cohort.

RESULTS

Over four to five years, admission rates and bed use in the high risk cohorts fell to the mean rate for older people. Although patients > or = 65 with two or more such admissions were responsible for 38% of admissions in the index year, they were responsible for fewer than 10% of admissions in the following year and just over 3% five years later.

CONCLUSION

Patients with multiple emergency admissions are often identified as a high risk group for subsequent admission and substantial claims are made for interventions designed to avoid emergency admission in such patients. Simply monitoring admission rates cannot assess interventions designed to reduce admission among frail older people as rates fall without any intervention. Comparison with a matched control group is necessary. Wider benefits than reduced admissions should be considered when introducing intensive case management of older people.

Framework for assessing causality in disease management programs: principles

To credibly state that a disease management (DM) program "caused" a specific outcome it is required that metrics observed in the DM population be compared with metrics that would have been expected in the absence of a DM intervention. That requirement can be very difficult to achieve, and epidemiologists and others have developed guiding principles of causality by which credible estimates of DM impact can be made. This paper introduces those key principles. First, DM program metrics must be compared with metrics from a "reference population." This population should be "equivalent" to the DM intervention population on all factors that could independently impact the outcome. In addition, the metrics used in both groups should use the same defining criteria (ie, they must be "comparable" to each other). The degree to which these populations fulfill the "equivalent" assumption and metrics fulfill the "comparability" assumption should be stated. Second, when "equivalence" or "comparability" is not achieved, the DM managers should acknowledge this fact and, where possible, "control" for those factors that may impact the outcome(s). Finally, it is highly unlikely that one study will provide definitive proof of any specific DM program value for all time; thus, we strongly recommend that studies be ongoing, at multiple points in time, and at multiple sites, and, when observational study designs are employed, that more than one type of study design be utilized. Methodologically sophisticated studies that follow these "principles of causality" will greatly enhance the reputation of the important and growing efforts in DM.

Depression, functional status, treatment for psychiatric problems, and the health-related practices of elderly HMO members

PURPOSE

To study relationships between depression, functional limitations, psychiatric treatment, and the health-related practices of elderly individuals.

DESIGN

Cross-sectional, observational study based on survey data (response rate = 90%) analyzed using multiple linear and logistic regression models.

SETTING

Kaiser Permanente Northwest, a large nonprofit HMO.

SUBJECTS

Medicare members (4615) aged 65-103 years who responded to a health status survey.

MEASURES

Depression, health and functional status, frequency of alcohol consumption, smoking status, advance medical directive completion, influenza or pneumonia vaccinations, mammograms, recent psychiatric treatment, and attempts to lose weight or increase exercise.

RESULTS

Self-reported depression was related to a greater risk of smoking (odds ratio [OR] = 1.54). Health-related functional limitations were related to fewer attempts to change health behaviors and less preventive service use (significant ORs ranged from 0.84 to 0.94). Minority group membership and Supplemental Security Income were negatively associated with better health practices and with completing advance medical directives (ORs 0.41 and 0.79, respectively). Falls in the prior year, more prescription medications, and psychiatric treatment were positively associated with better health practices (significant ORs ranged from 1.12 to 1.88).

CONCLUSIONS

Depression and smoking are associated among elderly individuals, as are psychiatric treatment and attempts to lose weight. Those with functional limitations, minority status, or Supplemental Security Income use fewer preventive services; the latter two groups are less likely to complete advance medical directives. Older adults with these characteristics might need assistance in improving health-related practices.