Predictive validity of PRISMA-7 as a screening instrument for frailty in a hospital setting

Not All Frailty Assessments Are Created Equal: Comparability of Electronic Health Data-Based Frailty Assessments in Assessing Older People in Residential Care

Objectives: To evaluate the comparability of frailty assessment tools - the electronic frailty index (eFI), retrospective electronic frailty index (reFI), and clinical frailty scale (CFS) - in older residents of care facilities. Methods: Data from 813 individuals aged 65 or older, with frailty and co-morbidities, collected between 2022 and 2023, were analysed using various statistical methods. Results: The results showed significant differences in frailty classification among the tools: 78.3% were identified as moderately to severely frail by eFI, 59.6% by reFI, and 92.1% by CFS. Statistical tests confirmed significant differences (p < .05) in their assessments, indicating variability in measurement methods. Discussion: This study advances the understanding of frailty assessment within aged-care settings, highlighting the differences in the efficacy of these assessment tools. It underscores the challenges in frailty assessments and emphasizes the need for continuous refinement of assessment methods to address the diverse facets of frailty in aged care.

External validation of the TFC (triage frailty and comorbidity) tool: a prospective observational study

Assessing patient frailty during triage evaluations has become increasingly relevant in Emergency Departments (ED). This study aimed to externally validating the Triage Frailty and Comorbidity (TFC) tool. This prospective study was conducted from June 1 to December 31, 2023. During this period, 12 triage nurses applied the TFC tool during triage evaluation of ED patients. We used receiver operating characteristic (ROC) curves and Decision Curve Analysis to assess the predictive ability of the TFC tool for a 90-day mortality (the same endpoint used during tool development) and a 30-day mortality. 1270 patients were included and 56 of them died within 90 days. The TFC tool had an AUROC of 0.894 (0.858-0.929) for 90-day mortality and 0.885 (0.834-0.938) for 30-day mortality. In Decision Curve Analysis, it yielded higher net benefits up to a threshold probability of 0.30. The externally validated TFC tool appears very effective at identifying patients with increased risk of 90-day mortality after ED attendance. It could be implemented in clinical practice and enhance the predictive ability of standard triage systems.

Research Progress on Frailty in Elderly People

Global aging is rapidly accelerating, which significantly influences the health systems worldwide. Frailty emerges as the most conspicuous hallmark of aging, imposing novel global health challenges. Characterized by a multifaceted decline across physiological system, frailty diminishes an individual's capacity to maintain equilibrium in the presence of stressors, which leads to adverse outcomes such as falls, delirium, and disability. Several screening tools and interventions have been developed to mitigate the harm caused by frailty to human health, but research on frailty in mainland China commences belatedly with scant studies conducted. Therefore, it is imperative to explore screening methods and treatment modalities tailored to the Chinese context, thereby enhancing the older adults' quality of life and advancing social medicine. This review aims to elucidate the evolution, diagnosis, and management of frailty, alongside the challenges it poses, with the overarching goal of guiding future diagnostic and therapeutic endeavors. Specifically, we summarized the mechanisms of frailty and intervention strategies in elderly people, and meanwhile, we evaluated the advantages and disadvantages of different measurement tools.

Frailty as an Independent Predictor of Adverse Outcomes in Patients Undergoing Direct Myocardial Revascularization

The aim of this study was to analyze the incidence and anamnestic characteristics of frail patients with stable coronary artery disease (CAD) and to evaluate the role of frailty in the development of complications and adverse outcomes in the perioperative period and early survival period after coronary artery bypass grafting (CABG).

MATERIAL AND METHODS

The study included 387 patients admitted to the clinic for a scheduled primary CABG. A seven-item questionnaire, "PRISMA-7", was used to identify frail elderly patients before the procedure. We divided the study sample into two groups, taking into account the results of the survey: patients without frailty, n0 = 300 (77.5%), and patients with frailty, n1 = 87 (22.5%). The anamnestic and laboratory data, outcome of the surgical intervention, perioperative and early complications, and adverse outcomes were analyzed.

RESULTS

We detected frailty in 22.5% of the patients with CAD before the procedure. According to the anamnestic data and paraclinical and intraoperative findings, the groups of patients with and without frailty were comparable. The differences were revealed in the intraoperative and early postoperative periods of CABG. Thus, postoperative rhythm disturbances (19.5% vs. 10.5%, p = 0.025, V = 0.115, respectively) and transient ischemic attacks/stroke (5.7% vs. 1.3%, p = 0.031, V = 0.122, respectively) occurred significantly more often among the frail patients. There were no significant differences between the groups in the frequency of other intraoperative and early postoperative complications. In the group of frail patients, four fatal outcomes due to early postoperative ischemia were recorded, and among patients without frailty, one fatal outcome was recorded (4.5% vs. 0.3%, p = 0.010, V = 0.156, respectively). At the 1-year follow-up visit, the presence of frailty in history served as a predictor of mortality (11.5% vs. 0.6%, p ˂ 0.001, V = 0.290, respectively).

CONCLUSION

The presence of frailty can be used as an independent predictor of an unfavorable prognosis in patients with CAD, both in the perioperative and early survival period after CABG. It should be taken into account during surgical risk assessment.

Measurement and optimization of perioperative risk among patients undergoing surgery for esophageal cancer

Esophagectomy is an exemplar of complex oncological surgery and is associated with a relatively high risk of major morbidity and mortality. In the modern era, where specific complications are targeted in prevention and treatment pathways, and where the principles of enhanced recovery after surgery are espoused, optimum outcomes are targeted via a number of approaches. These include comprehensive clinical and physiological risk assessment, specialist perioperative care by a high-volume team, and multimodal inputs throughout the patient journey that aim to preserve or restore nutritional deficits, muscle mass and function.

Contribution of reduced skeletal muscle perfusion reserve to exercise intolerance in heart failure with preserved ejection fraction

BACKGROUND

Skeletal muscle (SM)-associated mechanisms of exercise intolerance in HFpEF are insufficiently defined, and inadequate augmentation of SM blood flow during physical effort may be one of the contributors. Therefore, we sought to investigate the association of SM perfusion response to exertion with exercise capacity in this clinical condition.

METHODS

Echocardiography and SM microvascular perfusion by contrast-enhanced ultrasound were performed at rest and immediately post-exercise test in 77 HFpEF patients in NYHA class II and III, and in 25 subjects with normal exercise tolerance (stage B). Exercise reserve of cardiac function and SM perfusion was calculated by subtracting resting value from exercise value.

RESULTS

In addition to decreased cardiac functional reserve, HFpEF patients demonstrated significantly reduced SM perfusion reserve as compared to HF stage B, with the degree of impairment being greater in the subgroup with more profound left ventricular (LV) diastolic abnormalities (E/e' > 15 and TRV > 2.8 m/s). SM perfusion reserve was significantly associated with exercise capacity (beta = 0.33; SE 0.11; p = 0.003), cardiac output reserve (beta = 0.24; SE 0.12; p = 0.039), resting E/e' (beta = -0.33; SE 0.11; p = 0.006), and patient frailty expressed by the PRISMA 7 score (beta = -0.30; SE 0.11; p = 0.008). In multivariable analysis including clinical, demographic and cardiac functional variables, SM perfusion reserve was in addition to patient frailty, sex and LV longitudinal strain reserve among the independent correlates of exercise capacity.

CONCLUSIONS

SM perfusion reserve is impaired in HFpEF, and is associated with reduced exercise capacity independent of clinical, demographic and "central" cardiac factors. This supports the need to consider the SM domain in patient management strategies in HFpEF.

Cohort profile: Evaluation of the Methods and Management of Acute Coronary Events (EMMACE) Longitudinal Cohort

AIMS

The Evaluation of the Methods and Management of Acute Coronary Events (EMMACE) longitudinal cohort study aims to investigate health trajectories of individuals following hospitalization for myocardial infarction (MI).

METHODS AND RESULTS

EMMACE is a linked multicentre prospective cohort study of 14 899 patients with MI admitted to 77 hospitals in England who participated in the EMMACE-3 and -4 studies between 1st November 2011 and 24th June 2015. Long-term follow-up of the EMMACE cohorts was conducted through the EMMACE-XL (27th September 2020 to 31st March 2022) and EMMACE-XXL (1st July 2021 to 1st July 2023) studies. EMMACE collected individual participant data for health-related quality of life (HRQoL) measured by three-level EuroQol five-dimension and visual analogy scale at admission, 1 month, 6 months, 12 months, and 10 years follow-up, as well as medications, medication adherence, beliefs about medicines, Satisfaction with Information about Medicines Scale, and illness perceptions. Participant data were deterministically linked to the Myocardial Infarction National Audit Project (MINAP) for information on baseline treatments and comorbidities, Hospital Episode Statistics Admitted Patient Care (for cause-specific hospitalization data), and the Office for National Statistics (for mortality data) up to 2020.

CONCLUSION

EMMACE is a nationwide prospective cohort that will provide unique insights into fatal and non-fatal outcomes, medication adherence, and HRQoL following MI.Trial registration: ClinicalTrials.gov NCT01808027 and NCT01819103.

Relationship between frailty, according to three frail scores, and clinical and laboratory parameters of the geriatric patients with type 2 Diabetes Mellitus

OBJECTIVE:

Type 2 diabetes mellitus is associated with significant morbidity and mortality. The term “frailty in the elderly” has become increasingly important with the increase of the elderly population, especially in diabetic subjects. Frailty is established by various scoring scales, such as Edmonton, Frail, and Prisma-7 scores. We aimed to evaluate the association between frailty and clinical and laboratory parameters of the geriatric type 2 diabetic patients.

METHODS:

Diabetic patients over 65 years of age who presented to outpatient internal medicine clinics of our institution between June 2020 and January 2021 were enrolled to the study. Edmonton, Frail, and Prisma-7 scores were administered to the subjects. Study parameters were compared between well-controlled and poorly controlled diabetic groups according to diabetes control level and between frail and non-frail groups, according to each frailty scores.

RESULTS:

Frailty according to Edmonton score was associated with increased risks of hospitalization (p=0.005) and mortality (p=0.02). Frailty according to frail score was associated with increased risk of hospitalization (p=0.009). Frailty according to Prisma-7 score was associated with increased risk of mortality (p<0.001).

CONCLUSION:

We suggest that Edmonton frail score is superior to Frail and Prisma-7 scores in determining frailty in geriatric patients with type 2 diabetes mellitus, since it is associated with both increased risk of hospitalization and mortality within 6 months.

The role of the district nurse in screening and assessment for frailty

An ageing population is leading to greater demands on healthcare services; investments are being made to allow complex care to be given in patient's homes by community care staff, as highlighted in the NHS Long Term Plan (2019). Frailty is often identified in secondary care when acute crisis is hit; frailty does not suddenly occur and will happen over time. This article aims to explore community screening, the assessment processes of frailty and the role the district nurse has. It also addresses how working collaboratively with the wider multidisciplinary team to earlier identify service users with frailty can assist in improving patient outcomes by empowering and supporting service users to remain at home. Recognising continual improvement to service users' care and changes in practice should be considered and disseminated. based upon best available evidence.

Risk factors and disease profile of post-vaccination SARS-CoV-2 infection in UK users of the COVID Symptom Study app: a prospective, community-based, nested, case-control study

BACKGROUND

COVID-19 vaccines show excellent efficacy in clinical trials and effectiveness in real-world data, but some people still become infected with SARS-CoV-2 after vaccination. This study aimed to identify risk factors for post-vaccination SARS-CoV-2 infection and describe the characteristics of post-vaccination illness.

METHODS

This prospective, community-based, nested, case-control study used self-reported data (eg, on demographics, geographical location, health risk factors, and COVID-19 test results, symptoms, and vaccinations) from UK-based, adult (≥18 years) users of the COVID Symptom Study mobile phone app. For the risk factor analysis, cases had received a first or second dose of a COVID-19 vaccine between Dec 8, 2020, and July 4, 2021; had either a positive COVID-19 test at least 14 days after their first vaccination (but before their second; cases 1) or a positive test at least 7 days after their second vaccination (cases 2); and had no positive test before vaccination. Two control groups were selected (who also had not tested positive for SARS-CoV-2 before vaccination): users reporting a negative test at least 14 days after their first vaccination but before their second (controls 1) and users reporting a negative test at least 7 days after their second vaccination (controls 2). Controls 1 and controls 2 were matched (1:1) with cases 1 and cases 2, respectively, by the date of the post-vaccination test, health-care worker status, and sex. In the disease profile analysis, we sub-selected participants from cases 1 and cases 2 who had used the app for at least 14 consecutive days after testing positive for SARS-CoV-2 (cases 3 and cases 4, respectively). Controls 3 and controls 4 were unvaccinated participants reporting a positive SARS-CoV-2 test who had used the app for at least 14 consecutive days after the test, and were matched (1:1) with cases 3 and 4, respectively, by the date of the positive test, health-care worker status, sex, body-mass index (BMI), and age. We used univariate logistic regression models (adjusted for age, BMI, and sex) to analyse the associations between risk factors and post-vaccination infection, and the associations of individual symptoms, overall disease duration, and disease severity with vaccination status.

FINDINGS

Between Dec 8, 2020, and July 4, 2021, 1 240 009 COVID Symptom Study app users reported a first vaccine dose, of whom 6030 (0·5%) subsequently tested positive for SARS-CoV-2 (cases 1), and 971 504 reported a second dose, of whom 2370 (0·2%) subsequently tested positive for SARS-CoV-2 (cases 2). In the risk factor analysis, frailty was associated with post-vaccination infection in older adults (≥60 years) after their first vaccine dose (odds ratio [OR] 1·93, 95% CI 1·50-2·48; p<0·0001), and individuals living in highly deprived areas had increased odds of post-vaccination infection following their first vaccine dose (OR 1·11, 95% CI 1·01-1·23; p=0·039). Individuals without obesity (BMI <30 kg/m2) had lower odds of infection following their first vaccine dose (OR 0·84, 95% CI 0·75-0·94; p=0·0030). For the disease profile analysis, 3825 users from cases 1 were included in cases 3 and 906 users from cases 2 were included in cases 4. Vaccination (compared with no vaccination) was associated with reduced odds of hospitalisation or having more than five symptoms in the first week of illness following the first or second dose, and long-duration (≥28 days) symptoms following the second dose. Almost all symptoms were reported less frequently in infected vaccinated individuals than in infected unvaccinated individuals, and vaccinated participants were more likely to be completely asymptomatic, especially if they were 60 years or older.

INTERPRETATION

To minimise SARS-CoV-2 infection, at-risk populations must be targeted in efforts to boost vaccine effectiveness and infection control measures. Our findings might support caution around relaxing physical distancing and other personal protective measures in the post-vaccination era, particularly around frail older adults and individuals living in more deprived areas, even if these individuals are vaccinated, and might have implications for strategies such as booster vaccinations.

FUNDING

ZOE, the UK Government Department of Health and Social Care, the Wellcome Trust, the UK Engineering and Physical Sciences Research Council, UK Research and Innovation London Medical Imaging and Artificial Intelligence Centre for Value Based Healthcare, the UK National Institute for Health Research, the UK Medical Research Council, the British Heart Foundation, and the Alzheimer's Society.

Interventions to improve medicines optimisation in frail older patients in secondary and acute care settings: a systematic review of randomised controlled trials and non-randomised studies

Background: Frailty is a geriatric syndrome in which physiological systems have decreased reserve and resistance against stressors. Frailty is associated with polypharmacy, inappropriate prescribing and unfavourable clinical outcomes. Aim: To identify and evaluate randomised controlled trials (RCTs) and non-randomised studies of interventions designed to optimise the medications of frail older patients, aged 65 years and over, in secondary or acute care settings. Method: Literature searches were conducted across seven electronic databases and three trial registries from the date of inception to October 2021. All types of interventional studies were included. Study selection, data extraction, risk of bias and quality assessment were conducted by two independent reviewers. Results: Three RCTs were eligible for inclusion; two employed deprescribing as the intervention, and one used comprehensive geriatric assessment. All reported significant improvements in prescribing appropriateness. One study investigated the effect of the intervention on clinical outcomes including hospital presentations, falls, fracture, quality of life and mortality, and reported no significant differences in these outcomes, but did report a significant reduction in monthly medication cost. Two of the included studies were assessed as having ‘some concerns’ of bias, and one was judged to be at ‘high risk’ of bias. Conclusion: This systematic review demonstrates that medicines optimisation interventions may improve medication appropriateness in frail older inpatients. However, it highlights the paucity of high-quality evidence that examines the impact of medicines optimisation on quality of prescribing and clinical outcomes for frail older inpatients. High-quality studies are needed to address this gap.

Exercise interventions for older people at risk for frailty: A protocol for systematic review and meta-analysis

BACKGROUND

Frailty is a state of age-related reduced physiological reserve characterized by an increased risk of adverse clinical outcomes. Studies have shown that exercise can improve frailty in older people. However, it remains to be seen which exercises will most improve the fitness of older people with frailty or those at the risk for frailty.Objective: This protocol aims to determine whether physical exercise can improve frailty in older people, and if which methods are most effective.

METHODS

We searched the following databases for relevant articles published between January 1, 2012 and January 1, 2021: PubMed, EMBASE, the Cochrane Library, Wanfang, the China National Knowledge Infrastructure, Clinical Trials Database, and the Science Network. Two independent reviewers will carry out data extraction, discuss and resolve differences, and obtain consensus from the third author. We will select randomized control trials (RCTs) according to the preformulated inclusion criteria. The main outcomes in this study are scores from Fried Frailty Phenotype Criteria; the Frailty Trait Scale-short form; the SHARE Frailty Instrument; the FRAIL scale; the Gérontopôle Frailty Screening Tool; the Clinical Frailty Scale, the Rockwood and Mitnitsky Frailty Index; the Study of Osteoporotic Fractures Index; the Edmonton Frailty Scale; the Fatigue, Resistance, Ambulation, Illness and Loss of Weight Index; the Multidimensional Prognostic Index; the Tilburg Frailty Indicator; PRISMA-7; the Groningen Frailty Indicator; the Sherbrooke Postal Questionnaire; and the Kihon Checklist. Secondary outcomes are muscle strength, gait velocity, stair-climbing power, and level of spontaneous physical activity. If the heterogeneity test shows slight or no statistical heterogeneity, a fixed effects model will be used for data synthesis; otherwise, a random effects model will be used. We will develop a unified data extraction table that includes a number of parameters. The Cochrane Cooperative Bias Risk Tool will be used to evaluate the methodological quality of the selected RCTs. RevMan Manager 5.3 and STATA 14.0 will be used for data analysis if enough RCTs (more than 10) are identified and selected.

RESULT

The final results will provide information on the effectiveness of intervention programs for frail older adul and further demonstrate which exercise programs are more effective and which methods can significantly improve frailty.

CONCLUSION

This protocol will contribute to the development of more effective interventions for elderly individuals with frailty.

ETHICS AND DISSEMINATION

This study applies existing literature references; therefore, ethical approval is not required.

INPLASY REGISTRATION NUMBER

INPLASY202130107.