Interventions for frail older inpatients: A systematic review of frailty measures and reported outcomes in randomised controlled trials

What patient-reported outcome measures may be suitable for research involving older adults with frailty? A scoping review

INTRODUCTION

The need to develop and evaluate frailty-related interventions is increasingly important, and inclusion of patient-reported outcomes is vital. Patient-reported outcomes can be defined as measures of health, quality of life or functional status reported directly by patients with no clinician interpretation. Numerous validated questionnaires can thus be considered patient-reported outcome measures (PROMs). This review aimed to identify existing PROMs currently used in quantitative research that may be suitable for older people with frailty.

METHOD

PubMed and Cochrane were searched up to 24/11/22. Inclusion criteria were quantitative studies, use of a PROM, and either measurement of frailty or inclusion of older adult participants. Criteria were created to distinguish PROMs from questionnaire-based clinical assessments. 197 papers were screened. PROMs were categorized according to the domain assessed, as derived from a published consensus 'Standard Set of Health Outcome Measures for Older People'.

RESULTS

88 studies were included. 112 unique PROMs were used 289 times, most frequently the SF-36 (n = 21), EQ-5D (n = 21) and Barthel Index (n = 14). The most frequently assessed outcome domains included Mood and Emotional Health and Activities of Daily Living, with fewer assessments of Participation in Decision-Making and Carer Burden.

CONCLUSIONS

PROM usage in frailty research is highly heterogeneous. Frequently used PROMs omit important outcomes identified by older adults. Further research should evaluate the importance of specific outcomes and identify PROMs relevant to people at different stages of frailty. Consistent and appropriate PROM use in frailty research would facilitate more effective comparisons and meaningful evaluation of frailty interventions.

Multicomponent perioperative interventions to improve outcomes for frail patients: a systematic review

BACKGROUND

Preoperative frailty is associated with increased risk of adverse outcomes. In 2017, McIsaac and colleagues' systematic review found that few interventions improved outcomes in this population and evidence was low-quality. We aimed to systematically review the evidence for multicomponent perioperative interventions in frail patients that has emerged since McIsaac et al.'s review.

METHODS

PUBMED, EMBASE, Cochrane, and CINAHL databases were searched for English-language studies published since January 1, 2016, that evaluated multicomponent perioperative interventions in patients identified as frail. Quality was assessed using the National Institute of Health Quality Assessment Tool. A narrative synthesis of the extracted data was conducted.

RESULTS

Of 2835 articles screened, five studies were included, all of which were conducted in elective oncologic gastrointestinal surgical populations. Four hundred and thirteen patients were included across the five studies and the mean/median age ranged from 70.1 to 87.0 years. Multicomponent interventions were all applied in the preoperative period. Two studies also applied interventions postoperatively. All interventions addressed exercise and nutritional domains with variability in timing, delivery, and adherence. Multicomponent interventions were associated with reduced postoperative complications, functional deterioration, length of stay, and mortality. Four studies reported on patient-centred outcomes. The quality of evidence was fair.

CONCLUSIONS

This systematic review provides evidence that frail surgical patients undergoing elective oncologic gastrointestinal surgery may benefit from targeted multicomponent perioperative interventions. Yet methodological issues and substantial heterogeneity of the interventions precludes drawing clear conclusions regarding the optimal model of care. Larger, low risk of bias studies are needed to evaluate optimal intervention delivery, effectiveness in other populations, implementation in health care settings and ascertain outcomes of importance for frail patients and their carers.

Are assessment measures for components of the International Classification of Functioning, Disability and Health reproducible for use on pre-frail and frail older adults? A systematic review

OBJECTIVE

To analyze the internal consistency, reliability and measurement error of assessment measures for body structure and function (postural balance, muscle strength, cardiorespiratory function and physical fitness), activity (walking and mobility) and participation (quality of life and social reintegration) outcomes for use on pre-frail and frail older adults.

METHODS

Searches were performed in six databases (Medline, Embase, ScienceDirect, Web of Science, The Cochrane Library and Lilacs) and reproducibility studies were included. Cronbach's alpha and the classification proposed by Terwee et al. (2007) were used for the interpretation of internal consistency. The intraclass correlation coefficient (ICC) and the Munro classification were used for the determination of reliability. The standard error of measurement (SEM), minimal detectable change (MDC) as well as percentages of error (SEM%) and change (MDC%) were calculated. Methodological quality of the studies was appraised using Boxes 4, 6 and 7 of the COSMIN Risk of Bias checklist.

RESULTS

Six studies were included in the present systematic review, with a total of 835 (82.4 years; 582 women and 253 men) pre-frail and frail older adults analyzed. Seven measures were identified for the assessment of body structure and function, activity and participation outcomes (Hierarchical Assessment of Balance and Mobility, Self-Assessment of Physical Fitness, Sarcopenia Quality of Life, Reintegration to Normal Living Index, Two-Minute Walking test, Six-Minute Walking test and Ten-Meter Walking test). The following measurement properties were identified: internal consistency = 0.84 (mean Cronbach's alpha); reliability = 0.87 (mean ICC); SEM range = 0.06 to 10.10; MDC range = 0.13 to 28.10; SEM% range = 5.2 % to 9.5 %; and MDC% range = 10.7 % to 28.5 %.

CONCLUSION

The present systematic review found adequate internal consistency, high reliability and an acceptable measurement error for assessment measures of body structure and function, activity and participation outcomes for use on pre-frail and frail older adults.

Frailty and pain in an acute private hospital: an observational point prevalence study

Frailty and pain in hospitalised patients are associated with adverse clinical outcomes. However, there is limited data on the associations between frailty and pain in this group of patients. Understanding the prevalence, distribution and interaction of frailty and pain in hospitals will help to determine the magnitude of this association and assist health care professionals to target interventions and develop resources to improve patient outcomes. This study reports the point prevalence concurrence of frailty and pain in adult patients in an acute hospital. A point prevalence, observational study of frailty and pain was conducted. All adult inpatients (excluding high dependency units) at an acute, private, 860-bed metropolitan hospital were eligible to participate. Frailty was assessed using the self-report modified Reported Edmonton Frail Scale. Current pain and worst pain in the last 24 h were self-reported using the standard 0-10 numeric rating scale. Pain scores were categorised by severity (none, mild, moderate, severe). Demographic and clinical information including admitting services (medical, mental health, rehabilitation, surgical) were collected. The STROBE checklist was followed. Data were collected from 251 participants (54.9% of eligible). The prevalence of frailty was 26.7%, prevalence of current pain was 68.1% and prevalence of pain in the last 24 h was 81.3%. After adjusting for age, sex, admitting service and pain severity, admitting services medical (AOR: 13.5 95% CI 5.7-32.8), mental health (AOR: 6.3, 95% CI 1. 9-20.9) and rehabilitation (AOR: 8.1, 95% CI 2.4-37.1) and moderate pain (AOR: 3.9, 95% CI 1. 6-9.8) were associated with increased frailty. The number of older patients identified in this study who were frail has implications for managing this group in a hospital setting. This indicates a need to focus on developing strategies including frailty assessment on admission, and the development of interventions to meet the care needs of these patients. The findings also highlight the need for increased pain assessment, particularly in those who are frail, for more effective pain management.Trial registration: The study was prospectively registered (ACTRN12620000904976; 14th September 2020).

Frailty and solid-organ transplant candidates: a scoping review

BACKGROUND

There is currently no consensus as to a standardized tool for frailty measurement in any patient population. In the solid-organ transplantation population, routinely identifying and quantifying frailty in potential transplant candidates would support patients and the multidisciplinary team to make well-informed, individualized, management decisions. The aim of this scoping review was to synthesise the literature regarding frailty measurement in solid-organ transplant (SOT) candidates.

METHODS

A search of four databases (Cochrane, Pubmed, EMBASE and CINAHL) yielded 3124 studies. 101 studies (including heart, kidney, liver, and lung transplant candidate populations) met the inclusion criteria.

RESULTS

We found that studies used a wide range of frailty tools (N = 22), including four 'established' frailty tools. The most commonly used tools were the Fried Frailty Phenotype and the Liver Frailty Index. Frailty prevalence estimates for this middle-aged, predominantly male, population varied between 2.7% and 100%. In the SOT candidate population, frailty was found to be associated with a range of adverse outcomes, with most evidence for increased mortality (including post-transplant and wait-list mortality), post-operative complications and prolonged hospitalisation. There is currently insufficient data to compare the predictive validity of frailty tools in the SOT population.

CONCLUSION

Overall, there is great variability in the approach to frailty measurement in this population. Preferably, a validated frailty measurement tool would be incorporated into SOT eligibility assessments internationally with a view to facilitating comparisons between patient sub-groups and national and international transplant services with the ultimate goal of improved patient care.

An Easy-to-Implement Clinical-Trial Frailty Index Based on Accumulation of Deficits: Validation in Zoster Vaccine Clinical Trials

Purpose

Despite being among those most in need of protection, frail older adults are often not well represented in clinical trials. Although frailty likely influences responses to treatments and vaccines, frailty may not be explicitly considered in trials even when frail participants are enrolled due to the perception that frailty is difficult to measure effectively and efficiently without adding to participant or data collection burden. We developed an easy-to-implement frailty index, the Clinical Trial-Frailty Index (CT-FI), based on baseline medical history and standard patient-reported outcomes using data from clinical trials of recombinant Zoster vaccine (the ZOE-50 and ZOE-70 studies). Our objective was to demonstrate that the CT-FI is a robust measure that may be used retrospectively or prospectively in clinical trials where sufficient patient data have been collected.

Methods

The CT-FI was based on baseline medical history and Quality of Life questionnaires (SF-36 and EQ-5D). Items meeting criteria for inclusion were scored from 0 to 1, then summed for each participant and divided by the total number of deficits considered. Validation analyses included descriptive verification of distribution and age- and sex-associations in relation to usual patterns of the frailty index, regressions in relation to outcomes hypothesized to be related to frailty, and resampling methods within the index.

Results

The CT-FI distribution was well represented by a gamma distribution with a range of 0–0.70. Deficit accumulation increased with chronological age and was higher for females. Multivariate Cox regression survival analysis showed that the CT-FI, age, and sex were significant predictors of mortality. Jackknife and Bootstrap resampling methods highlighted the robustness of the CT-FI, which was not sensitive to inclusion/exclusion of specific individual or groups of variables.

Conclusion

We have developed a reliable, robust and easy-to-implement CT-FI with potential retrospective or prospective application in other clinical trials.

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Frailty: understanding the difference between age and ageing

In the past, illness and dependence were viewed as inevitable consequences of old age. Now, we understand that there is a difference between age (the passing of chronological time) and ageing (the increased risk of adverse outcomes over time). Over the last 50 years, 'frailty' research has established that ageing is heterogeneous, variable and malleable. Significant advances have been made in frailty measurement (description of clinical features and development of clinical models), mechanisms (insights into pathogenesis) and management (development of interventions to reduce and/or prevent progression). Subsequently, the concept of frailty has informed health policy and clinical practice and started to change perceptions of older age held by the general public and the health sector. Here, we overview key achievements in frailty research and clinical practice and highlight the considerable number of known unknowns that may be addressed in the future.

Slow gait speed is associated with worse postoperative outcomes in cardiac surgery: A systematic review and meta-analysis

BACKGROUND

Frailty is associated with poorer outcomes in cardiac surgery, but the heterogeneity in frailty assessment tools makes it difficult to ascertain its true impact in cardiac surgery. Slow gait speed is a simple, validated, and reliable marker of frailty. We performed a systematic review and meta-analysis to examine the effect of slow gait speed on postoperative cardiac surgical patients.

METHODS

PubMED, MEDLINE, and EMBASE databases were searched from January 2000 to August 2021 for studies comparing slow gait speed and "normal" gait speed. Primary outcome was in-hospital mortality. Secondary outcomes were composite mortality and major morbidity, AKI, stroke, deep sternal wound infection, prolonged ventilation, discharge to a healthcare facility, and ICU length of stay.

RESULTS

There were seven eligible studies with 36,697 patients. Slow gait speed was associated with increased likelihood of in-hospital mortality (risk ratio [RR]: 2.32; 95% confidence interval [CI]: 1.87-2.87). Additionally, they were more likely to suffer from composite mortality and major morbidity (RR: 1.52; 95% CI: 1.38-1.66), AKI (RR: 2.81; 95% CI: 1.44-5.49), deep sternal wound infection (RR: 1.77; 95% CI: 1.59-1.98), prolonged ventilation >24 h (RR: 1.97; 95% CI: 1.48-2.63), reoperation (RR: 1.38; 95% CI: 1.05-1.82), institutional discharge (RR: 2.08; 95% CI: 1.61-2.69), and longer ICU length of stay (MD: 21.69; 95% CI: 17.32-26.05).

CONCLUSION

Slow gait speed is associated with poorer outcomes in cardiac surgery. Frail patients are twofold more likely to die during hospital admission than nonfrail counterparts and are at an increased risk of developing various perioperative complications.