Frailty, thy name is…

Assessing Physiologic Reserve and Frailty in the Older Emergency Department Patient: Should the Paradigm Change?

Older patients are more vulnerable to acute illness or injury because of reduced physiologic reserve associated with aging. Therefore, their assessment in the emergency department (ED) should include not only vital signs and their baseline values but also changes that reflect physiologic reserve, such as mobility, mental status, and frailty. Combining aggregated vitals sign scores and frailty might improve risk stratification in the ED. Implementing these changes in ED assessment may require the introduction of senior-friendly processes to ensure ED treatment is appropriate to the older patients' immediate discomfort, personal goals, and likely prognosis.

Older women's view on frailty and an Emergency Department evidence-based Frailty Intervention Team (FIT) program: An evaluation using the Reach, Effectiveness, Adoption, Implementation, Maintenance RE-AIM framework

BACKGROUND

Older women have higher levels of frailty resulting in disability and reduced quality of life. Presentation to an Emergency Department (ED) is an opportunity to address frailty and provide tailored interventions to promote function. An ED allied health team integrated frailty assessment and interventions into care through a 'Frailty Intervention Team' (FIT) program.

METHODS

A prospective study informed by the Reach, Effectiveness, Adoption, Implementation, Maintenance (RE-AIM) framework to evaluate the FIT program tailored to female older adults. The purpose of this project was to evaluate the FIT program over a three-month period and use the findings to further develop the intervention.

RESULTS

Over three-months, 192 older females (>70 years) were identified with mild frailty and discharged directly home. Ninety percent were offered the FIT program with 83.3 % accepting all recommended frailty management strategies. Ninety percent of patients were satisfied with the FIT program, however staff and patient barriers to provision of frailty services were identified.

CONCLUSIONS

The FIT program was largely adopted by staff and accepted by older female patients with mild frailty in the ED. However, program effectiveness was limited by gaps in communication about frailty in the ED and implementation of frailty management strategies after discharge.

Around the EQUATOR with clinician-scientists transdisciplinary aging research (Clin-STAR) principles: Implementation science challenges and opportunities

The Institute of Medicine and the National Institute on Aging increasingly understand that knowledge alone is necessary but insufficient to improve healthcare outcomes. Adapting the behaviors of clinicians, patients, and stakeholders to new standards of evidence-based clinical practice is often significantly delayed. In response, over the past twenty years, Implementation Science has developed as the study of methods and strategies that facilitate the uptake of evidence-based practice into regular use by practitioners and policymakers. One important advance in Implementation Science research was the development of Standards for Reporting Implementation Studies (StaRI), which provided a 27-item checklist for researchers to consistently report essential elements of the implementation and intervention strategies. Using StaRI as a framework, this review discusses specific Implementation Science challenges for research with older adults, provides solutions for those obstacles, and opportunities to improve the value of this evolving approach to reduce the knowledge translation losses that exist between published research and clinical practice.

Clinical Frailty Scale as a predictor of short-term mortality: A systematic review and meta-analysis of studies on diagnostic test accuracy

BACKGROUND

The Clinical Frailty Scale (CFS) is a representative frailty assessment tool in medicine. This systematic review and meta-analysis aimed to examine whether frailty defined based on the CFS could adequately predict short-term mortality in emergency department (ED) patients.

METHODS

The PubMed, EMBASE, and Cochrane libraries were searched for eligible studies until December 23, 2021. We included studies in which frailty was measured by the CFS and short-term mortality was reported for ED patients. All studies were screened by two independent researchers. Sensitivity, specificity, positive likelihood ratio (PLR), and negative likelihood ratio (NLR) values were calculated based on the data extracted from each study. Additionally, the diagnostic odds ratio (DOR) was calculated for effect size analysis, and the area under the curve (AUC) of summary receiver operating characteristics was calculated. Outcomes were in-hospital and 1-month mortality rate for patients with the CFS scores of ≥5, ≥6, and ≥7.

RESULTS

Overall, 17 studies (n = 45,022) were included. Although there was no evidence of publication bias, a high degree of heterogeneity was observed. For the CFS score of ≥5, the PLR, NLR, and DOR values for in-hospital mortality were 1.446 (95% confidence interval [CI] 1.325-1.578), 0.563 (95% CI 0.355-0.893), and 2.728 (95% CI 1.872-3.976), respectively. In addition, the pooled statistics for 1-month mortality were 1.566 (95% CI 1.241-1.976), 0.582 (95% CI 0.430-0.789), and 2.696 (95% CI 1.673-4.345), respectively. Subgroup analysis of trauma patients revealed that the CFS score of ≥5 could adequately predict in-hospital mortality (PLR 1.641, 95% CI 1.242-2.170; NLR 0.580, 95% CI 0.461-0.729; DOR 2.883, 95% CI 1.994-4.168). The AUC values represented sufficient to good diagnostic accuracy.

CONCLUSIONS

Evidence that is published to date suggests that the CFS is an accurate and reliable tool for predicting short-term mortality in emergency patients.

Emergency presentations of older patients living with frailty: Presenting symptoms compared with non-frail patients

BACKGROUND AND OBJECTIVE

Symptoms may differ between frail and non-frail patients presenting to Emergency Departments (ED). However, the association between frailty status and type of presenting symptoms has not been investigated. We aimed to systematically analyse presenting symptoms in frail and non-frail older emergency patients and hypothesized that frailty may be associated with nonspecific complaints (NSC), such as generalised weakness.

METHODS

Secondary analysis of a prospective, single centre, observational all-comer cohort study conducted in the ED of a Swiss tertiary care hospital. All presentations of patients aged 65 years and older were analysed. At triage, presenting symptoms and frailty were systematically assessed using a questionnaire. Patients with a Clinical Frailty Scale (CFS) > 4 were considered frail. Presenting symptoms, stratified by frailty status, were analysed. The association between frailty and generalised weakness was tested by logistic regression.

RESULTS

Overall, 2'416 presentations of patients 65 years and older were analysed. Mean age was 78.9 (SD 8.4) years, 1'228 (50.8%) patients were female, and 885 (36.6%) patients were frail (CFS > 4). Generalised weakness, dyspnea, localised weakness, speech disorder, loss of consciousness and gait disturbance were recorded more often in frail patients, whereas chest pain was reported more often by non-frail patients. Generalised weakness was reported as presenting symptom in 166 (18.8%) frail patients and in 153 (10.0%) non-frail patients. Frailty was associated with generalised weakness after adjusting for age, gender and elevated National Early Warning Score 2 (NEWS) ≥ 3 (OR 1.19, CI 1.10-1.29, p < 0.001).

CONCLUSION

Presenting symptoms differ in frail and non-frail patients. Frailty is associated with generalised weakness at ED presentation.

The clinical frailty scale predicts 1-year mortality in emergency department patients aged 65 years and older

OBJECTIVE

To validate the Clinical Frailty Scale (CFS) for prediction of 1-year all-cause mortality in the emergency department (ED) and compare its performance to the Emergency Severity Index (ESI).

METHODS

Prospective cohort study at the ED of a tertiary care center in Northwestern Switzerland. All patients aged ≥65 years were included from March 18 to May 20, 2019, after informed consent. Frailty status was assessed using CFS, excluding level 9 (palliative). Acuity level was assessed using ESI. Both CFS and ESI were adjusted for age, sex and presenting condition in multivariable logistic regression. Prognostic performance was assessed for discrimination and calibration separately. Estimates were internally validated by Bootstrapping. Restricted mean survival time (RMST) was determined for all levels of CFS.

RESULTS

In the final study population of 2191 patients, 1-year all-cause mortality was 17% (n = 372). RMST values ranged from 219 days for CFS 8 to 365 days for CFS 1. The adjusted CFS model had an area under receiver operating characteristic of 0.767 (95% confidence interval [CI]: 0.741-0.793), compared to 0.703 (95% CI: 0.673-0.732) for the adjusted ESI model.

CONCLUSION

The CFS predicts 1-year all-cause mortality for older ED patients and predicts survival time in a graded manner. The CFS is superior to the ESI when adjusted for age, sex, and presenting condition.

Admission Braden Scale Score as an Early Independent Predictor of In-Hospital Mortality Among Inpatients With COVID-19: A Retrospective Cohort Study

Background

The COVID‐19 pandemic has put a strain on health systems. Predictors of adverse outcomes need to be investigated to properly manage COVID‐19 patients. The Braden Scale (BS), commonly used for the assessment of pressure ulcer risk, has recently been proposed to identify frailty.

Objective

To investigate the predictive utility of the BS for prediction of in‐hospital mortality in a cohort of COVID‐19 patients admitted to non‐ICU wards.

Methods

We conducted a retrospective single‐center cohort study evaluating all patients with SARS‐CoV‐2 infection consecutively admitted over a 2‐month period (from March 6 to May 7, 2020) to the COVID‐19 general wards of our institution. Demographic, clinical, and nursing assessment data, including admission BS, were extracted from electronic medical records. Univariable and multivariable logistic regression models were used to explore the association between the BS score and in‐hospital death.

Results

Braden Scale was assessed in 146 patients (mean age 74.7 years; 52% males). On admission, 46 had a BS ≤ 15, and 100 patients had a BS > 15. Mortality among patients with BS ≤ 15 was significantly higher than in patients with BS > 15 (45.7% vs. 16%; p < .001). On multivariable regression analysis, adjusting for potentials confounders (age, Barthel scale, chronic kidney disease, atrial fibrillation, and hypertension), the admission BS remained inversely associated with the risk of in‐hospital mortality (OR = 0.76; 95% CI [0.60, 0.96]; p = .020).

Linking Evidence to Action

Admission BS could be used as a simple bedside predictive tool able to early identify non‐ICU COVID‐19 patients with poor prognosis who might benefit from specific and timely interventions.

Population Pharmacokinetic Study of Ceftriaxone in Elderly Patients, Using Cystatin C-Based Estimates of Renal Function To Account for Frailty

Ceftriaxone is widely used for respiratory and urinary infections in elderly and frail patients, but there are few pharmacokinetic studies. A prospective population pharmacokinetic study of ceftriaxone in adults over 65 years old was undertaken. Dried blood spots collected at baseline (predose) and 0.5, 1, 4, 8, and 24 h after administration of 1 g of ceftriaxone were assayed using a validated liquid chromatography-mass spectroscopy analytical method. Frailty was classified using the Edmonton frailty scale and grip strength via a hand dynamometer. Estimates of glomerular filtration rate were determined using creatinine-based and cystatin C-based equations. Of 26 patients recruited, 23 (88%) were vulnerable or very frail. Estimates of drug clearance improved significantly with a cystatin C-based estimate of renal function that accounted for frailty. Simulations indicate that the combined effects of ranges of size and renal function resulted in a 6-fold range in peak ceftriaxone concentrations and 9-fold range in total exposure (area under the concentration-time curve [AUC]). For elderly patients with moderate or severe renal impairment, 48-h dosing results in greater trough concentrations and total exposure than the trough concentrations and total exposure in patients with normal renal function receiving 24-h dosing. Cystatin C-based measures of renal function improved predictions of ceftriaxone clearance in elderly patients.

Validation of the Clinical Frailty Scale for Prediction of Thirty-Day Mortality in the Emergency Department

STUDY OBJECTIVE

We validate the Clinical Frailty Scale by examining its independent predictive validity for 30-day mortality, ICU admission, and hospitalization and by determining its reliability. We also determine frailty prevalence in our emergency department (ED) as measured with the Clinical Frailty Scale.

METHODS

This was a prospective observational study including consecutive ED patients aged 65 years or older, from a single tertiary care center during a 9-week period. To examine predictive validity, association with mortality was investigated through a Cox proportional hazards regression; hospitalization and ICU transfer were investigated through multivariable logistic regression. We assessed reliability by calculating Cohen's weighted κ for agreement of experts who independently assigned Clinical Frailty Scale levels, compared with trained study assistants. Frailty was defined as a Clinical Frailty Scale score of 5 and higher.

RESULTS

A total of 2,393 patients were analyzed in this study, of whom 128 died. Higher frailty levels were associated with higher hazards for death independent of age, sex, and condition (medical versus surgical). The area under the curve for 30-day mortality prediction was 0.81 (95% confidence interval [CI] 0.77 to 0.85), for hospitalization 0.72 (95% CI 0.70 to 0.74), and for ICU admission 0.69 (95% CI 0.66 to 0.73). Interrater reliability between the reference standard and the study team was good (weighted Cohen's κ was 0.74; 95% CI 0.64 to 0.85). Frailty prevalence was 36.8% (n=880).

CONCLUSION

The Clinical Frailty Scale appears to be a valid and reliable instrument to identify frailty in the ED. It might provide ED clinicians with useful information for decisionmaking in regard to triage, disposition, and treatment.

Frailty and Associated Outcomes and Resource Utilization Among Older ICU Patients With Suspected Infection

OBJECTIVES

Suspected infection and sepsis are common conditions seen among older ICU patients. Frailty has prognostic importance among critically ill patients, but its impact on outcomes and resource utilization in older patients with suspected infection is unknown. We sought to evaluate the association between patient frailty (defined as a Clinical Frailty Scale ≥ 5) and outcomes of critically ill patients with suspected infection. We also evaluated the association between frailty and the quick Sequential Organ Failure Assessment score.

DESIGN

Analysis of a prospectively collected registry.

SETTING

Two hospitals within a single tertiary care level hospital system between 2011 and 2016.

PATIENTS

We analyzed 1,510 patients 65 years old or older (at the time of ICU admission) and with suspected infection at the time of ICU admission. Of these, 507 (33.6%) were categorized as "frail" (Clinical Frailty Scale ≥ 5).

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

The primary outcome was in-hospital mortality. A total of 558 patients (37.0%) died in-hospital. Frailty was associated with increased risk of in-hospital death (adjusted odds ratio, 1.81 [95% CIs, 1.34-2.49]). Frailty was also associated with higher likelihood of discharge to long-term care (adjusted odds ratio, 2.06 [95% CI, 1.50-2.64]) and higher likelihood of readmission within 30 days (adjusted odds ratio, 1.83 [95% CI, 1.38-2.34]). Frail patients had increased ICU resource utilization and total costs. The combination of frailty and quick Sequential Organ Failure Assessment greater than or equal to 2 further increased the risk of death (adjusted odds ratio, 7.54 [95% CI, 5.82-9.90]).

CONCLUSIONS

The presence of frailty among older ICU patients with suspected infection is associated with increased mortality, discharge to long-term care, hospital readmission, resource utilization, and costs. This work highlights the importance of clinical frailty in risk stratification of older ICU patients with suspected infection.

Frailty and invasive mechanical ventilation: association with outcomes, extubation failure, and tracheostomy

PURPOSE

Invasive mechanical ventilation is a common form of life support provided to critically ill patients. Frailty is an emerging prognostic factor for poor outcome in the Intensive Care Unit (ICU); however, its association with adverse outcomes following invasive mechanical ventilation is unknown. We sought to evaluate the association between frailty, defined by the Clinical Frailty Scale (CFS), and outcomes of ICU patients receiving invasive mechanical ventilation.

METHODS

We performed a retrospective analysis (2011-2016) of a prospectively collected registry from two hospitals of consecutive ICU patients ≥ 18 years of age receiving invasive mechanical ventilation. CFS scores were based on recorded pre-admission function at the time of hospital admission. The primary outcome was hospital mortality. Secondary outcomes included discharge to long-term care, extubation failure at time of first liberation attempt, and tracheostomy.

RESULTS

We included 8110 patients, and 2529 (31.2%) had frailty (CFS ≥ 5). Frailty was associated with increased odds of hospital death (adjusted odds ratio [aOR]: 1.24 [95% confidence interval [CI] 1.10-1.40) and discharge to long-term care (aOR 1.21 [95% CI 1.13-1.35]). As compared to patients without frailty, patients with frailty had increased odds of extubation failure (aOR 1.17 [95% CI 1.04-1.37]), hospital death following extubation failure (aOR 1.18 [95% CI 1.07-1.28]), tracheostomy (aOR 1.17 [95% CI 1.01-1.36]), and hospital death following tracheostomy (aOR 1.14 [95% CI 1.03-1.25]).

CONCLUSIONS

The presence of frailty among patients receiving mechanical ventilation is associated with increased odds of hospital mortality, discharge to long-term care, extubation failure, and need for tracheostomy.

Do frailty and comorbidity indices improve risk prediction of 28-day ED reattendance? Reanalysis of an ED discharge nomogram for older people

BACKGROUND

In older people, quantification of risk of reattendance after emergency department (ED) discharge is important to provide adequate post ED discharge care in the community to appropriately targeted patients at risk.

METHODS

We reanalysed data from a prospective observational study, previously used for derivation of a nomogram for stratifying people aged 65 and older at risk for ED reattendance. We investigated the potential effect of comorbidity load and frailty by adding the Charlson or Elixhauser comorbidity index and a ten-item frailty measure from our data to develop four new nomograms. Model I and model F built on the original nomogram by including the frailty measure with and without the addition of the Charlson comorbidity score; model E adapted for efficiency in the time-constrained environment of ED was without the frailty measure; and model P manually constructed in a purposeful stepwise manner and including only statistically significant variables. Areas under the ROC curve of models were compared. The primary outcome was any ED reattendance within 28 days of discharge.

RESULTS

Data from 1357 patients were used. The point estimate of the respective areas under ROC were 0.63 (O), 0.63 (I), 0.68 (E), 0.71 (P) and 0.63 (F).

CONCLUSION

Addition of a comorbidity index to our previous model improves stratifying elderly at risk of ED reattendance. Our frailty measure did not demonstrate any additional predictive benefit.

Geospatial modelling of the prevalence and changing distribution of frailty in Australia - 2011 to 2027

BACKGROUND AND OBJECTIVES

Detailed information about the current and future geographic distribution of Australia's frail population provides critical evidence to inform policy, resource allocation and planning initiatives that aim to treat and reverse frailty. Frailty is associated with poor health outcomes, including disability and death. It is also characterised by increased health care usage and costs. Understanding the distribution and growth of frailty is important for planning and budgeting service provision and health interventions aimed to support the needs of Australia's growing ageing population. The objective of this research is to provide baseline mapping and area level population estimates of Australia's current and future frail and pre-frail populations.

RESEARCH DESIGN AND METHODS

Geospatial modelling was applied to national frailty prevalence rates to provide estimates of the size, distribution and potential growth of Australia's frail and pre-frail population.

RESULTS

It is estimated that in 2016 approximately 415,769 people living in Australia aged 65 years or more are frail and almost 1.7 million people are pre-frail. In future years, as the population ages, these figures will increase rapidly, reaching 609,306 frail and 2,248,977 pre-frail by 2027, if prevalence continues at current levels. The geographic distribution of this projected growth is not uniform and while the largest frail populations will continue to be located in the major cities, the fastest growth will be in the outer metropolitan, regional and remote areas.

DISCUSSION AND IMPLICATIONS

The projected growth of frail populations in outer metropolitan, regional and remote areas may be reduced by targeting health interventions in these areas and improving access to support services. Frailty is a dynamic condition that is amenable to intervention. Reducing frailty will lead to benefits in wellbeing for older Australians in addition to reductions in health care costs.