Frailty in primary care: a review of its conceptualization and implications for practice

Frailty in Persons with Down Syndrome: Results from the REVIVIS Study

OBJECTIVES

To determine frailty prevalence and identify possible nonclinical factors associated with this condition in community-dwelling individuals with Down syndrome (DS).

DESIGN

Cross-sectional analysis of the registry study REVIVIS, a single-center, prospective study on the geriatric management of persons with DS.

SETTING AND PARTICIPANTS

Individuals with DS (n = 139) referred to a geriatric clinic.

METHODS

Frailty was assessed through a 38-item Frailty Index (FI). A multivariable linear regression model was performed to assess the relationship between frailty and different variables of interest: age, number of prescribed drugs, and employment status (unemployed vs employed).

RESULTS

Among 139 subjects (54.5% male), mean (SD) aged 42.9 (6.9) years, the median (interquartile range) FI was 0.24 (0.16-0.30) with 60 participants (43.2%) classified as frail. The number of prescribed medications was associated with higher FI levels (P < .001), whereas being employed was associated with lower FI levels (P < .001) compared with being unemployed. No association was found between chronological age and FI.

CONCLUSIONS AND IMPLICATIONS

Our findings suggest that chronological age is insufficient to encompass the complexity of a subject with DS, underscoring the importance of a standardized evaluation of the FI among this population. Access to geriatric care might become an important opportunity for people with DS, a population characterized by high vulnerability (or frailty).

M, M. V, B. M, J. H, D. H, D. I, L. L, R. V, J. Z, J. B, V. M, T. P. Improvements in upper extremity isometric muscle strength, dexterity, and self-care independence during the sub-acute phase of stroke recovery: an observational study on the effects of intensive comprehensive rehabilitation

Background

Stroke often impairs upper extremity motor function, with recovery in the sub-acute phase being crucial for regaining independence. This study examines changes in isometric muscle strength, dexterity, and self-care independence during this period, and evaluates the effects of a comprehensive intensive rehabilitation (COMIRESTROKE).

Methods

Individuals in sub-acute stroke recovery and age- and sex-matched controls were assessed for pre- and post-rehabilitation differences in primary outcomes (grip/pinch strength, Nine Hole Peg Test [NHPT], Action Research Arm Test [ARAT]). COMIRESTROKE's effects on primary and secondary outcomes (National Institute of Health Stroke Scale [NIHSS], Modified Rankin Scale [MRS], Functional Independence Measure [FIM]) were evaluated. Outcomes were analyzed for dominant and non-dominant limbs, both regardless of impairment and with a focus on impaired limbs.

Results

Fifty-two individuals with stroke (NIHSS 7.51 ± 5.71, age 70.25 ± 12.66 years, 21.36 ± 12.06 days post-stroke) and forty-six controls participated. At baseline, individuals with stroke showed significantly lower strength (dominant grip, key pinch, tip-tip pinch, p adj < 0.05), higher NHPT scores (p adj < 0.05), and lower ARAT scores (p adj < 0.001). COMIRESTROKE led to improvements in dominant key pinch, non-dominant tip-tip pinch, NHPT, and both dominant and non-dominant ARAT (p adj < 0.05). Notably, non-dominant key pinch improved significantly when considering only impaired hands. Pre- and post-test differences between groups were significant only for ARAT (both limbs), even after adjustment (p adj < 0.05). All secondary outcomes (NIHSS, MRS, FIM) showed significant improvement post-COMIRESTROKE (p adj < 0.001).

Conclusion

Individuals with stroke exhibit reduced muscle strength and dexterity, impairing independence. However, comprehensive intensive rehabilitation significantly improves these functions. Data are available from the corresponding author upon request and are part of a sub-study of NCT05323916.

The application of machine learning for identifying frailty in older patients during hospital admission

BACKGROUND

Early identification of frail patients and early interventional treatment can minimize the frailty-related medical burden. This study investigated the use of machine learning (ML) to detect frailty in hospitalized older adults with acute illnesses.

METHODS

We enrolled inpatients of the geriatric medicine ward at Taichung veterans general hospital between 2012 and 2022. We compared four ML models including logistic regression, random forest (RF), extreme gradient boosting, and support vector machine (SVM) for the prediction of frailty. The feature window as well as the prediction window was set as half a year before admission. Furthermore, Shapley additive explanation plots and partial dependence plots were used to identify Fried's frailty phenotype for interpreting the model across various levels including domain, feature, and individual aspects.

RESULTS

We enrolled 3367 patients. Of these, 2843 were frail. We used 21 features to train the prediction model. Of the 4 tested algorithms, SVM yielded the highest AUROC, precision and F1-score (78.05%, 94.53% and 82.10%). Of the 21 features, age, gender, multimorbidity frailty index, triage, hemoglobin, neutrophil ratio, estimated glomerular filtration rate, blood urea nitrogen, and potassium were identified as more impactful due to their absolute values.

CONCLUSIONS

Our results demonstrated that some easily accessed parameters from the hospital clinical data system can be used to predict frailty in older hospitalized patients using supervised ML methods.

Direct Oral Anticoagulants for Pulmonary Embolism

Venous thromboembolism (VTE) is the third most common cardiovascular disease. For most patients, the standard of treatment has long consisted on low-molecular-weight heparin followed by vitamin K antagonists, but a number of clinical trials and, subsequently, post-marketing studies have shown that direct oral anticoagulants (DOACs) with or without lead-in heparin therapy are effective alternatives with fewer adverse effects. This evidence has led to important changes in the guidelines on the treatment of VTE, including pulmonary embolism (PE), with the DOACs being now recommended as the first therapeutic choice. Additional research has contributed to identifying low-risk PE patients who can benefit from outpatient management or from early discharge from the emergency department with DOAC treatment. There is evidence to support the use of DOACs in intermediate-risk PE patients as well as in high-risk patients receiving thrombolytic treatment. The use of DOACs has also been proven to be safe and effective in special populations of PE patients, such as patients with renal impairment, liver impairment, and cancer.

Outpatient geriatric health care in the German federal state of Mecklenburg-Western Pomerania: a population-based spatial analysis of claims data

BACKGROUND

Due to unidentified geriatric needs, elderly patients have a higher risk for developing chronic conditions and acute medical complications. Early geriatric screenings and assessments help to identify geriatric needs. Holistic and coordinated therapeutic approaches addressing those needs maintain the independence of elderly patients and avoid adverse effects. General practitioners are important for the timely identification of geriatric needs. The aims of this study are to examine the spatial distribution of the utilization of outpatient geriatric services in the very rural Federal State of Mecklenburg-Western Pomerania in the Northeast of Germany and to identify regional disparities.

METHODS

Geographical analysis and cartographic visualization of the spatial distribution of outpatient geriatric services of patients who are eligible to receive basic geriatric care (BGC) or specialized geriatric care (SGC) were carried out. Claims data of the Association of Statutory Health Insurance Physicians in Mecklenburg-Western Pomerania were analysed on the level of postcode areas for the quarter periods between 01/2014 and 04/2017. A Moran's I analysis was carried out to identify clusters of utilization rates.

RESULTS

Of all patients who were eligible for BGC in 2017, 58.3% (n = 129,283/221,654) received at least one BCG service. 77.2% (n = 73,442/95,171) of the patients who were eligible for SGC, received any geriatric service (BGC or SGC). 0.4% (n = 414/95,171) of the patients eligible for SGC, received SGC services. Among the postcode areas in the study region, the proportion of patients who received a basic geriatric assessment ranged from 3.4 to 86.7%. Several regions with statistically significant Clusters of utilization rates were identified.

CONCLUSIONS

The widely varying utilization rates and the local segregation of high and low rates indicate that the provision of outpatient geriatric care may depend to a large extent on local structures (e.g., multiprofessional, integrated networks or innovative projects or initiatives). The great overall variation in the provision of BGC services implicates that the identification of geriatric needs in GPs' practices should be more standardized. In order to reduce regional disparities in the provision of BGC and SGC services, innovative solutions and a promotion of specialized geriatric networks or healthcare providers are necessary.

Effect of frailty on postoperative complications, mortality, and survival in older patients with non-metastatic colon cancer: A systematic review and meta-analysis

INTRODUCTION

New evidence has emerged on the impact of frailty on prognosis in colon cancer, but the findings are not always consistent and conclusive. The aim of this systematic review was to assess the effect of frailty on postoperative complications and mortality in patients with non-metastatic colon cancer (CC) aged 65 years and older.

MATERIALS AND METHODS

We systematically searched for original studies published in the PubMed and Web of Science databases up to June 2021. Two independent reviewers selected the studies and extracted predefined data. A meta-analysis was performed using the random effects model to assess the effect of frailty on 30-day, 3- to 6-month and 1-year mortality, survival, and postoperative complications.

RESULTS

The search yielded 313 articles, of which 14 were included in this systematic review. The meta-analysis showed an effect for frailty on 30-day, 3- to 6-month, and 1-year mortality with respective pooled odds ratios (ORs) of 3.67 (95% confidence interval [CI] 1.53-8.79, p = 0.004), 8.73 (95% CI 4.03-18.94, p < 0.0001), and 3.99 (95% CI 2.12-7.52, p < 0.0001). Frailty also had an effect on survival, with a pooled hazard ratio of 2.99 (95% CI 1.70-5.25. p < 0.0001), and on overall and severe postoperative complications with pooled ORs of 2.34 (95% CI 1.75-3.15; p < 0.0001) and 2.43 (95% CI 1.72-3.43; p < 0.0001), respectively.

DISCUSSION

Frailty in older patients with CC is a risk factor for postoperative complications and mortality in the short term (30 days), medium term (3-6 months), and long term (1 year).

Current frailty knowledge, awareness, and practices among physicians following the 2022 European consensus document on Frailty in Cardiology

Aims

Aging-related cardiovascular disease and frailty burdens are anticipated to rise with global aging. In response to directions from major cardiovascular societies, we investigated frailty knowledge, awareness, and practices among cardiologists as key stakeholders in this emerging paradigm a year after the European Frailty in Cardiology consensus document was published.

Methods and results

We launched a prospective multinational web-based survey via social networks to broad cardiology communities representing multiple World Health Organization regions, including Western Pacific and Southeast Asia regions. Overall, 578 respondents [38.2% female; ages 35-49 years (55.2%) and 50-64 years (34.4%)] across subspecialties, including interventionists (43.3%), general cardiologists (30.6%), and heart failure specialists (HFSs) (10.9%), were surveyed. Nearly half had read the consensus document (38.9%). Non-interventionists had better perceived knowledge of frailty assessment instruments (fully or vaguely aware, 57.2% vs. 45%, adj. P = 0.0002), exercise programmes (well aware, 12.9% vs. 6.0%, adj. P = 0.001), and engaged more in multidisciplinary team care (frequently or occasionally, 52.6% vs. 41%, adj. P = 0.002) than interventionists. Heart failure specialists more often addressed pre-procedural frailty (frequently or occasionally, 43.5% vs. 28.2%, P = 0.004) and polypharmacy (frequently or occasionally, 85.5% vs. 71%, adj. P = 0.014) and had consistently better composite knowledge (39.3% vs. 21.6%, adj. P = 0.001) and practice responses (21% vs. 11.1%, adj. P = 0.018) than non-HFSs. Respondents with better knowledge responses also had better frailty practices (40.3% vs. 3.6%, adj. P < 0.001).

Conclusion

Distinct response differences suggest that future strategies strengthening frailty principles should address practices peculiar to subspecialties, such as pre-procedural frailty strategies for interventionists and rehabilitation interventions for HFSs.

Perspectives on the representation of frailty in the electronic frailty index

BACKGROUND

Frailty is a state of increased vulnerability from physical, social, and cognitive factors resulting in greater risk of negative health-related outcomes and increased healthcare expenditure. A 36-factor electronic frailty index (eFI) developed in the United Kingdom calculates frailty scores using electronic medical record data. There is currently no standardization of frailty screening in Canadian primary care. In order to implement the eFI in a Canadian context, adaptation of the tool is necessary because frailty is represented by different clinical terminologies in the UK and Canada. In considering the promise of implementing an eFI in British Columbia, Canada, we first looked at the content validation of the 36-factor eFI. Our research question was: Does the eFI represent frailty from the perspectives of primary care clinicians and older adults in British Columbia?

METHODS

A modified Delphi using three rounds of questionnaires with a panel of 23 experts (five family physicians, five nurse practitioners, five nurses, four allied health professionals, four older adults) reviewed and provided feedback on the 36-factor eFI. These professional groups were chosen because they closely work as interprofessional teams within primary care settings with older adults. Older adults provide real life context and experiences. Questionnaires involved rating the importance of each frailty factor on a 0-10 scale and providing rationale for ratings. Panelists were also given the opportunity to suggest additional factors that ought to be included in the screening tool. Suggested factors were similarly rated in two Delphi rounds.

RESULTS

Thirty-three of the 36 eFI factors achieved consensus (> 80% of panelists provided a rating of ≥ 8). Factors that did not achieve consensus were hypertension, thyroid disorder and peptic ulcer. These factors were perceived as easily treatable or manageable and/or not considered reflective of frailty on their own. Additional factors suggested by panelists that achieved consensus included: cancer, challenges to healthcare access, chronic pain, communication challenges, fecal incontinence, food insecurity, liver failure/cirrhosis, mental health challenges, medication noncompliance, poverty/financial difficulties, race/ethnic disparity, sedentary/low activity levels, and substance use/misuse. There was a 100% retention rate in each of the three Delphi rounds.

CONCLUSIONS AND NEXT STEPS

Three key findings emerged from this study: the conceptualization of frailty varied across participants, identification of frailty in community/primary care remains challenging, and social determinants of health affect clinicians' assessments and perceptions of frailty status. This study will inform the next phase of a broader mixed-method sequential study to build a frailty screening tool that could ultimately become a standard of practice for frailty screening in Canadian primary care. Early detection of frailty can help tailor decision making, frame discussions about goals of care, prevent advancement on the frailty trajectory, and ultimately decrease health expenditures, leading to improved patient and system level outcomes.

The association between patients' frailty status, multimorbidity, and demographic characteristics and changes in primary care for chronic conditions during the COVID-19 pandemic: a pre-post study

BACKGROUND

The purpose of this study was to assess the impact of SARS-COV-2 (Severe acute respiratory syndrome coronavirus 2) pandemic on primary care management (frequency of monitoring activities, regular prescriptions, and test results) of older adults with common chronic conditions (diabetes, hypertension, and chronic kidney disease) and to examine whether any changes were associated with age, sex, neighbourhood income, multimorbidity, and frailty.

METHODS

A research database from a sub-set of McMaster University Sentinel and Information Collaboration family practices was used to identify patients ≥65 years of age with a frailty assessment and 1 or more of the conditions. Patient demographics, chronic conditions, and chronic disease management information were retrieved. Changes from 14 months pre to 14 months since the pandemic were described and associations between patient characteristics and changes in monitoring, prescriptions, and test results were analysed using regression models.

RESULTS

The mean age of the 658 patients was 75 years. While the frequency of monitoring activities and prescriptions related to chronic conditions decreased overall, there were no clear trends across sub-groups of age, sex, frailty level, neighbourhood income, or number of conditions. The mean values of disease monitoring parameters (e.g. blood pressure) did not considerably change. The only significant regression model demonstrated that when controlling for all other variables, patients with 2 chronic conditions and those with 4 or more conditions were twice as likely to have reduced numbers of eGFR (Estimated glomerular filtration rate) measures compared to those with only 1 condition ((OR (odds ratio) = 2.40, 95% CI [1.19, 4.87]); (OR = 2.19, 95% CI [1.12, 4.25]), respectively).

CONCLUSION

In the first 14 months of the pandemic, the frequency of common elements of chronic condition care did not notably change overall or among higher-risk patients.

Association of Preoperative Frailty with Inferior Outcomes for Patients Undergoing Lower Extremity Bypass for Chronic Limb Threatening Ischemia: A Systematic Review

BACKGROUND

Frailty is a risk factor associated with adverse postoperative outcomes following lower extremity bypass (LEB) surgery in patients with peripheral arterial disease (PAD). Chronic limb threatening ischemia (CLTI) represents the worst form of PAD, and frailty is common among patients presenting with CLTI. Multiple frailty assessment scores have been developed for the past 2 decades; however, a universal clinical assessment tool for measuring frailty has not yet been established due to the complexity of the concept. This systematic review aimed to evaluate the use of a frailty index as a predictor of postoperative outcomes in patients undergoing LEB.

METHODS

The review protocol was registered in the international prospective register of systematic reviews (PROSPERO) database (CRD42022358888). A systematic literature search was conducted using the PubMed and Scopus databases. The review followed the preferred reporting items for systematic reviews and metaanalyses (PRISMA) guidelines. The risk of bias was evaluated using the Risk of Bias in Non-randomized Studies of Interventions (ROBINS-I) tool. A total of 3,929 studies were initially selected originally and were eventually left with 6 studies that met the inclusion criteria of this systematic review.

RESULTS

Six studies were examined that assessed the relationship between frailty index and long-term mortality following LEB for CLTI were screened. All analyses were published between 2017 and 2020 and included a broad spectrum of patients who underwent LEB. The results of these studies showed inconsistencies in the reporting of postoperative outcomes and the time endpoint of these events. However, all correlated with higher frailty index and increased mortality rate.

CONCLUSIONS

Higher frailty index preoperatively is associated with an increased likelihood of postoperative comorbidities after undergoing LEB. Identifying and addressing the preoperative frailty index of these patients may be a practical approach to reducing postoperative adverse outcomes. A thorough review of the frailty spectrum and standardized reporting of outcomes in the context of frailty could be helpful to have a more comprehensive understanding of this subject.

Is waist-calf circumference ratio associated with frailty in older adults? Findings from a cohort study

BACKGROUND

The waist-calf circumference ratio (WCR) has been suggested as a potential indicator of visceral adiposity. Nevertheless, the relationship between WCR and the risk of frailty remains unclear. Therefore, our study aimed to investigate the association between WCR and longitudinal changes in WCR with frailty risk in older adults.

METHODS

We included 2359 participants aged ≥ 65 years without frailty (frailty index [FI] ≤ 0.21) from the Chinese Longitudinal Healthy Longevity Survey in the 2014 wave. The follow-up was conducted in 2018. We investigated the relationship of WCR, waist circumference (WC), and calf circumference (CC) with frailty using both the Cox proportional hazards model and the generalized estimating equation (GEE).

RESULTS

During a median follow-up of 4.0 years, 668 (28.2%) frailty occurred. Those with higher WCR and WC had a significantly increased risk of frailty (fifth quintile compared with first quintile: hazard ratio [HR] = 1.59, 95% confidence interval [CI] 1.24-2.04 for WCR; HR = 1.69, 95% CI 1.27-2.24 for WC), whereas those in the fourth quintile of CC had a lower likelihood of developing frailty compared to those in the first quintile (HR = 0.67, 95% CI 0.50-0.89). Interaction analyses showed that the effects of WCR on frailty were more pronounced in females (P-interaction = 0.016). GEE analyses revealed that increased WCR and WC were associated with a higher risk of frailty (odds ratio [OR] = 1.74, 95% CI 1.43-2.12 for WCR; OR = 1.03, 95% CI 1.02-1.04 for WC), while CC showed opposite results (OR = 0.95, 95% CI 0.93-0.97).

CONCLUSIONS

A higher WCR and WC, as well as a lower CC, were significantly associated with higher frailty. Of these measures, WCR demonstrated the strongest association with frailty, suggesting that having a combination of high central fat and low lean body mass may increase the risk of developing frailty.

'Frailty as an adjective rather than a diagnosis'-identification of frailty in primary care: a qualitative interview study

INTRODUCTION

In 2017, NHS England introduced proactive identification of frailty into the General Practitioners (GP) contract. There is currently little information as to how this policy has been operationalised by front-line clinicians, their working understanding of frailty and impact of recognition on patient care. We aimed to explore the conceptualisation and identification of frailty by multidisciplinary primary care clinicians in England.

METHODS

Qualitative semi-structured interviews were conducted with primary care staff across England including GPs, physician associates, nurse practitioners, paramedics and pharmacists. Thematic analysis was facilitated through NVivo (Version 12).

RESULTS

Totally, 31 clinicians participated. Frailty was seen as difficult to define, with uncertainty about its value as a medical diagnosis. Clinicians conceptualised frailty differently, dependant on job-role, experience and training. Identification of frailty was most commonly informal and opportunistic, through pattern recognition of a frailty phenotype. Some practices had embedded population screening and structured reviews. Visual assessment and continuity of care were important factors in recognition. Most clinicians were familiar with the electronic frailty index, but described poor accuracy and uncertainty as to how to interpret and use this tool. There were different perspectives amongst professional groups as to whether frailty should be more routinely identified, with concerns of capacity and feasibility in the current climate of primary care workload.

CONCLUSIONS

Concepts of frailty in primary care differ. Identification is predominantly ad hoc and opportunistic. A more cohesive approach to frailty, relevant to primary care, together with better diagnostic tools and resource allocation, may encourage wider recognition.

Prognostic Association Between Frailty and Post-Arrest Health Outcomes in Patients Receiving Home Care: A Population-Based Retrospective Cohort Study

AIM

To evaluate the association between frailty and post-cardiac arrest survival, functional decline, and cognitive decline, among patients receiving home care METHODS: Frailty was measured using the Clinical Frailty Scale (CFS) and a valid frailty index. We used multivariable logistic regression to measure the association between frailty and post-arrest outcomes after adjusting for age, sex, and arrest setting. Functional independence and cognitive performance were measured using the interRAI ADL Long-Form and Cognitive Performance Scale, respectively. We conducted sub-group analytics of in-hospital and out-of-hospital arrests RESULTS: Our cohort consisted of 7,901 home care clients; most patients arrested out-of-hospital (55.4%) and were 75 years or older (66.3%). Most of the cohort was classified as frail (94.2%), with a CFS score of 5 or greater. The 30-day survival rate was higher for in-hospital (26.6%) than out-of-hospital cardiac arrests (5.2%). Most patients who survived to discharge had declines in post-arrest functional independence (65.8%) and cognitive performance (46.5%). A one-point increase in the CFS decreased the odds of 30-day survival by 8% (aOR=0.92; 95%CI = 0.87-0.97). A 0.1 unit increase in the frailty index reduced 30-day survival odds by 9% (aOR = 0.91; 95%CI = 0.86-0.96). The frailty index was associated with declines in functional independence (OR = 1.16; 95%CI = 1.02-1.31) and cognitive performance (OR = 1.24; 95%CI = 1.09-1.42), while the CFS was not.

CONCLUSION

Frailty is associated with cardiac arrest survival and post-arrest cognitive and functional status in patients receiving home care. Post-cardiac arrest cognitive and functional status are best predicted using more comprehensive frailty indices.

Using electronic consultation (eConsult) to identify frailty in provider-to-provider communication: a feasibility and validation study

BACKGROUND

Frailty is a complex age-related clinical condition that increases vulnerability to stressors. Early recognition of frailty is challenging. While primary care providers (PCPs) serve as the first point of contact for most older adults, convenient tools for identifying frailty in primary care are lacking. Electronic consultation (eConsult), a platform connecting PCPs to specialists, is a rich source of provider-to-provider communication data. Text-based patient descriptions on eConsult may provide opportunities for earlier identification of frailty. We sought to explore the feasibility and validity of identifying frailty status using eConsult data.

METHODS

eConsult cases closed in 2019 and submitted on behalf of long-term care (LTC) residents or community-dwelling older adults were sampled. A list of frailty-related terms was compiled through a review of the literature and consultation with experts. To identify frailty, eConsult text was parsed to measure the frequency of frailty-related terms. Feasibility of this approach was assessed by examining the availability of frailty-related terms in eConsult communication logs, and by asking clinicians to indicate whether they can assess likelihood of frailty by reviewing the cases. Construct validity was assessed by comparing the number of frailty-related terms in cases about LTC residents with those about community-dwelling older adults. Criterion validity was assessed by comparing clinicians' ratings of frailty to the frequency of frailty-related terms.

RESULTS

One hundred thirteen LTC and 112 community cases were included. Frailty-related terms identified per case averaged 4.55 ± 3.95 in LTC and 1.96 ± 2.68 in the community (p < .001). Clinicians consistently rated cases with ≥ 5 frailty-related terms as highly likely of living with frailty.

CONCLUSIONS

The availability of frailty-related terms establishes the feasibility of using provider-to-provider communication on eConsult to identify patients with high likelihood of living with this condition. The higher average of frailty-related terms in LTC (versus community) cases, and agreement between clinician-provided frailty ratings and the frequency of frailty-related terms, support the validity of an eConsult-based approach to identifying frailty. There is potential for eConsult to be used as a case-finding tool in primary care for early recognition and proactive initiation of care processes for older patients living with frailty.

Association between frailty, chronic conditions and socioeconomic status in community-dwelling older adults attending primary care: a cross-sectional study using practice-based research network data

OBJECTIVES

Frailty is a multidimensional syndrome of loss of reserves in energy, physical ability, cognition and general health. Primary care is key in preventing and managing frailty, mindful of the social dimensions that contribute to its risk, prognosis and appropriate patient support. We studied associations between frailty levels and both chronic conditions and socioeconomic status (SES).

DESIGN

Cross-sectional cohort study SETTING: A practice-based research network (PBRN) in Ontario, Canada, providing primary care to 38 000 patients. The PBRN hosts a regularly updated database containing deidentified, longitudinal, primary care practice data.

PARTICIPANTS

Patients aged 65 years or older, with a recent encounter, rostered to family physicians at the PBRN.

INTERVENTION

Physicians assigned a frailty score to patients using the 9-point Clinical Frailty Scale. We linked frailty scores to chronic conditions and neighbourhood-level SES to examine associations between these three domains.

RESULTS

Among 2043 patients assessed, the prevalence of low (scoring 1-3), medium (scoring 4-6) and high (scoring 7-9) frailty was 55.8%, 40.3%, and 3.8%, respectively. The prevalence of five or more chronic diseases was 11% among low-frailty, 26% among medium-frailty and 44% among high-frailty groups (χ²=137.92, df 2, p<0.001). More disabling conditions appeared in the top 50% of conditions in the highest-frailty group compared with the low and medium groups. Increasing frailty was significantly associated with lower neighbourhood income (χ²=61.42, df 8, p<0.001) and higher neighbourhood material deprivation (χ²=55.24, df 8, p<0.001).

CONCLUSION

This study demonstrates the triple disadvantage of frailty, disease burden and socioeconomic disadvantage. Frailty care needs a health equity approach: we demonstrate the utility and feasibility of collecting patient-level data within primary care. Such data can relate social risk factors, frailty and chronic disease towards flagging patients with the greatest need and creating targeted interventions.

COMIRESTROKE—A clinical study protocol for monitoring clinical effect and molecular biological readouts of COMprehensive Intensive REhabilitation program after STROKE: A four-arm parallel-group randomized double blinded controlled trial with a longitudinal design

Introduction

While the role of physiotherapy as part of a comprehensive inpatient rehabilitation is indisputable, clear evidence concerning the effectiveness of different rehabilitation managements [interdisciplinary implementing the International Classification of Functioning, disability and health (ICF) vs. multidisciplinary model] and physiotherapy categories (neuroproprioceptive “facilitation, inhibition” vs. motor/skill acquisitions using technologies) are still lacking. In this study, four kinds of comprehensive inpatient rehabilitation with different management and content of physical therapy will be compared. Moreover, focus will be placed on the identification of novel biological molecules reflective of effective rehabilitation. Long non-coding RNAs (lncRNAs) are transcripts (&gt;200 bps) of limited coding potential, which have recently been recognized as key factors in neuronal signaling pathways in ischemic stroke and as such, may provide a valuable readout of patient recovery and neuroprotection during therapeutic progression.

Methods and analysis

Adults after the first ischemic stroke in an early sub-acute phase with motor disability will be randomly assigned to one of four groups and undergo a 3 weeks comprehensive inpatient rehabilitation of different types: interdisciplinary team work using ICF model as a guide; multidisciplinary teamwork implementing neuroproprioceptive “facilitation and inhibition” physiotherapy; multidisciplinary teamwork implementing technology-based physiotherapy; and standard multidisciplinary teamwork. Primary (the Goal Attainment Scale, the Patient-Reported Outcomes Measurement Information System, and the World Health Organization Disability Assessment Schedule) and secondary (motor, cognitive, psychological, speech and swallowing functions, functional independence) outcomes will be measured. A blood sample will be obtained upon consent (20 mls; representing pre-rehabilitation molecular) before and after the inpatient program. Primary outcomes will be followed up again 3 and 12 months after the end of the program. The overarching aim of this study is to determine the effectiveness of various rehabilitation managements and physiotherapeutic categories implemented by patients post ischemic stroke via analysis of primary, secondary and long non-coding RNA readouts. This clinical trial will offer an innovative approach not previously tested and will provide new complex analysis along with public assessable molecular biological evidence of various rehabilitation methodology for the alleviation of the effects of ischemic stroke.

Clinical trial registration

NCT05323916, https://clinicaltrials.gov/ct2/show/NCT05323916.

Agreement between standard and self-reported assessments of physical frailty syndrome and its components in a registry of community-dwelling older adults

BACKGROUND

The ability to identify frail older adults using a self-reported version of the physical frailty phenotype (PFP) that has been validated with the standard PFP could facilitate physical frailty detection in clinical settings.

METHODS

We collected data from volunteers (N = 182), ages 65 years and older, in an aging research registry in Baltimore, Maryland. Measurements included: standard PFP (walking speed, grip strength, weight loss, activity, exhaustion); and self-reported questions about walking and handgrip strength. We compared objectively-measured gait speed and grip strength to self-reported questions using Cohen's Kappa and diagnostic accuracy tests. We used these measures to compare the standard PFP with self-reported versions of the PFP, focusing on a dichotomized identification of frail versus pre- or non-frail participants.

RESULTS

Self-reported slowness had fair-to-moderate agreement (Kappa(k) = 0.34-0.56) with measured slowness; self-reported and objective weakness had slight-to-borderline-fair agreement (k = 0.10-0.21). Combining three self-reported slowness questions had highest sensitivity (81%) and negative predictive value (NPV; 91%). For weakness, three questions combined had highest sensitivity (72%), while all combinations had comparable NPV. Follow-up questions on level of difficulty led to minimal changes in agreement and decreased sensitivity. Substituting subjective for objective measures in our PFP model dichotomized by frail versus non/pre-frail, we found substantial (k = 0.76-0.78) agreement between standard and self-reported PFPs. We found highest sensitivity (86.4%) and NPV (98.7%) when comparing the dichotomized standard PFP to a self-reported version combining all slowness and weakness questions. Substitutions in a three-level model (frail, vs pre-frail, vs. non-frail) resulted in fair-to-moderate agreement (k = 0.33-0.50) with the standard PFP.

CONCLUSIONS

Our results show potential utility as well as challenges of using certain self-reported questions in a modified frailty phenotype. A self-reported PFP with high agreement to the standard phenotype could be a valuable frailty screening assessment in clinical settings.

Associations between loneliness and frailty among older adults: Evidence from the China Health and Retirement Longitudinal Study

Background

Previous studies have demonstrated the associations between loneliness and frailty in late life. However, there is a lack of consensus on the direction of the relationship. The present study aimed to examine the interdependencies between loneliness and frailty over time.

Methods

Data on participants aged 60 years old and above were collected from the 2011, 2013, and 2015 samples of the China Health and Retirement Longitudinal Study (CHARLS). Loneliness was measured by a single question from the Centre for Epidemiological Studies Depression scale, and frailty was assessed by the Physical Frailty Phenotype (PFP) scale. Cross-lagged panel models were utilized to examine the potential bidirectional relationship between loneliness and frailty.

Results

Reciprocal associations were found between loneliness and frailty. Furthermore, we found that baseline frailty and early change in frailty had a significant predictive effect on late change in loneliness. Higher baseline loneliness in older adults may create a potentially vicious cycle that influenced early change in frailty and continued to cause late change in loneliness.

Conclusion

A bidirectional relationship may exist between loneliness and frailty among older Chinese adults over 60 years old. Lonely older adults should be alerted to the potential self-reinforcing cycle of loneliness that affects their health.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12877-022-03044-0.

Frailty and Potentially Inappropriate Prescribing in Older People with Polypharmacy: A Bi-Directional Relationship?

Frail older adults commonly experience multiple co-morbid illnesses and other risk factors for potentially inappropriate prescribing. However, determination of frailty varies depending on the frailty instrument used. Older people’s degree of frailty often influences their care and treatment priorities. Research investigating the association between frailty and potentially inappropriate prescribing is hindered by a wide variety of frailty definitions and measurement tools. We undertook a narrative review of selected articles of PubMed and Google Scholar databases. Articles were selected on the basis of relevance to the core themes of frailty and potentially inappropriate prescribing. We identified observational studies that clearly link potentially inappropriate prescribing, potential prescribing omissions, and adverse drug reactions with frailty in older adults. Equally, the literature illustrates that measured frailty in older adults predisposes to inappropriate polypharmacy and associated adverse drug reactions and events. In essence, there is a bi-directional relationship between frailty and potentially inappropriate prescribing, the underlying substrates being multimorbidity and inappropriate polypharmacy. We conclude that there is a need for consensus on rapid and accurate identification of frailty in older people using appropriate and user-friendly methods for routine clinical practice as a means of identifying older multimorbid patients at risk of potentially inappropriate prescribing. Detection of frailty should, we contend, lead to structured screening for inappropriate prescribing in this high-risk population. Of equal importance, detection of potentially inappropriate prescribing in older people should trigger screening for frailty. All clinicians undertaking a medication review of multimorbid patients with associated polypharmacy should take account of the important interaction between frailty and potentially inappropriate prescribing in the interest of minimizing patient harm.

A Home-Based Individual Cognitive Stimulation Program for Older Adults With Cognitive Impairment: A Randomized Controlled Trial

Objective: This study aims to assess the feasibility and meaningfulness of a home-based individual cognitive stimulation (iCS) program delivered by caregivers to persons with cognitive impairment (PwCIs). It also aims to assess whether the older adults receiving this program improved their cognitive, neuropsychiatric, and depressive symptoms and quality of life and whether their caregivers improved their mental and physical health.

Methods: A randomized controlled trial (RCT) was conducted with PwCI-caregiver dyads recruited from the community. Participants were allocated to two groups: intervention (n = 28) and control (n = 24). The intervention group received the European Portuguese version of the Individual Cognitive Stimulation Program—Making a Difference 3 (MD3-P). The control group received usual care. The iCS therapy program was implemented three times a week for 12 weeks. Caregivers were supported by the researchers to deliver the sessions at home. Participants were assessed at baseline and at the end of the intervention (week 13). Feasibility and meaningfulness were assessed through the attrition rate, adherence, and degree of satisfaction with the sessions. Four interviews were conducted (after week 13) to understand participants’ experiences.

Results: The attrition rate was 23.1%. The dyads reported that they did not have high expectations about the iCS program before starting the study. Nevertheless, as the program evolved, caregivers noted that their family members had improved some areas of functioning. Intention-to-treat analysis based on group differences revealed a significant improvement in PwCIs’ cognition, specifically in their orientation and ability to follow commands. The intervention had no impact on other variables such as caregivers’ physical and mental health.

Conclusion: The iCS program implemented by caregivers showed promising results in improving PwCIs’ cognition. The participants who completed the intervention attributed a positive meaning to the MD3-P, confirming it as a valid non-pharmacological therapeutic approach to reducing frailty in PwCIs in community settings.

Clinical Trial Registration:www.ClinicalTrials.gov, identifier [NCT03514095].

Frailty Triage: Is Rationing Intensive Medical Treatment on the Grounds of Frailty Ethical?

In early 2020, a number of countries developed and published intensive care triage guidelines for the pandemic. Several of those guidelines, especially in the UK, encouraged the explicit assessment of clinical frailty as part of triage. Frailty is relevant to resource allocation in at least three separate ways, through its impact on probability of survival, longevity and quality of life (though not a fourth-length of intensive care stay). I review and reject claims that frailty-based triage would represent unjust discrimination on the grounds of age or disability. I outline three important steps to improve the ethical incorporation of frailty into triage. Triage criteria (ie frailty) should be assessed consistently in all patients referred to the intensive care unit. Guidelines must make explicit the ethical basis for the triage decision. This can then be applied, using the concept of triage equivalence, to other (non-frail) patients referred to intensive care.

Communicating with older adults with long-term conditions about self-management goals: A systematic review and thematic synthesis

OBJECTIVE

To synthesise a body of fine-grained observational research on communication between healthcare professionals (HCPs), older adults, and carers regarding self-management goals and actions.

METHODS

We conducted a systematic review, searching nine electronic databases and the grey literature. Two reviewers independently selected for inclusion following a two-stage process and studies and discrepancies were resolved through consultation with the review team.

RESULTS

898 records were retrieved, and eight studies were included in the review. Aggregative thematic analysis resulted in 13 categories of communication practices across three decision-making domains: (1) initiating: actions occurring prior to the commitment point; (2) proposing: putting forward a course of action; and (3) committing and closing: committing (or not) to the course of action.

CONCLUSIONS

Despite an increasing emphasis on the importance of personalised care planning and shared decision-making (SDM) to support older people's health and wellbeing, HCPs did not consistently practice this approach and, in some cases, worked in opposition to it.

PRACTICE IMPLICATIONS

We encourage HCPs to prepare older adults to engage actively with SDM and the goal setting process by employing patient-centred communication resources. These could assist with identifying different types of goals that are realistic and relevant to patients in daily life.

Machine learning for identification of frailty in Canadian primary care practices

Introduction

Frailty is a medical syndrome, commonly affecting people aged 65 years and over and is characterized by a greater risk of adverse outcomes following illness or injury. Electronic medical records contain a large amount of longitudinal data that can be used for primary care research. Machine learning can fully utilize this wide breadth of data for the detection of diseases and syndromes. The creation of a frailty case definition using machine learning may facilitate early intervention, inform advanced screening tests, and allow for surveillance.

Objectives

The objective of this study was to develop a validated case definition of frailty for the primary care context, using machine learning.

Methods

Physicians participating in the Canadian Primary Care Sentinel Surveillance Network across Canada were asked to retrospectively identify the level of frailty present in a sample of their own patients (total n = 5,466), collected from 2015–2019. Frailty levels were dichotomized using a cut-off of 5. Extracted features included previously prescribed medications, billing codes, and other routinely collected primary care data. We used eight supervised machine learning algorithms, with performance assessed using a hold-out test set. A balanced training dataset was also created by oversampling. Sensitivity analyses considered two alternative dichotomization cut-offs. Model performance was evaluated using area under the receiver-operating characteristic curve, F1, accuracy, sensitivity, specificity, negative predictive value and positive predictive value.

Results

The prevalence of frailty within our sample was 18.4%. Of the eight models developed to identify frail patients, an XGBoost model achieved the highest sensitivity (78.14%) and specificity (74.41%). The balanced training dataset did not improve classification performance. Sensitivity analyses did not show improved performance for cut-offs other than 5.

Conclusion

Supervised machine learning was able to create well performing classification models for frailty. Future research is needed to assess frailty inter-rater reliability, and link multiple data sources for frailty identification.

Dietary Pattern Accompanied with a High Food Variety Score Is Negatively Associated with Frailty in Older Adults

Proper nutrition is a modifiable factor in preventing frailty. This study was conducted to identify the association between dietary patterns and frailty in the older adult population. The cross-sectional analysis was performed on 4632 subjects aged ≥65 years enrolled in the Korea National Health and Nutrition Examination Survey from 2014–2018. Food variety score (FVS) was defined as the number of foods items consumed over a day. Three dietary patterns were identified using factor analysis: “white rice and salted vegetables,” “vegetables, oils, and fish,” and “noodles and meat.” The higher “white rice and salted vegetables” pattern score was related to significantly lower FVS, whereas higher “vegetables, oils, and fish” and “noodles and meat” pattern scores were associated with a higher FVS. Participants with higher FVS showed a low risk of frailty (odds ratio (OR) (95% confidence interval, CI) = 0.44 (0.31–0.61), p-trend = 0.0001) than those with lower FVS. Moreover, the “vegetables, oils, and fish” pattern score was significantly associated with a low risk of frailty (OR (95% CI) = 0.55 (0.40–0.75), p-trend = 0.0002). These results suggested that consuming a dietary pattern based on vegetables, oils, and fish with high FVS might ameliorate frailty in older adults.

Relationship between frailty and mortality after gastrectomy in older patients with gastric cancer

OBJECTIVES

Frail older adults with gastric cancer are at an increased risk of poor postoperative outcomes. We assessed whether geriatric frailty assessed using the Study of Osteoporotic Fractures (SOF) index could predict post-gastrectomy mortality.

MATERIALS AND METHODS

We retrospectively assessed older adults (age ≥ 65 years) who underwent gastrectomy for gastric cancer between April 2012 and September 2015. Frailty status was assessed using the SOF index (range, 0-3) and categorized as robust (0), pre-frail (1), and frail (2-3). The Kaplan-Meier method and log-rank tests were used to compare survival between frailty groups. Univariate and multivariate analyses were used to identify mortality-associated risk factors.

RESULTS

Among 231 patients (the median age 72.04 years and 140 (60.6%) men), 138 (59.7%) were robust, 58 (25.1%) were pre-frail, and 35 (15.2%) were frail. The mortality rate was 14.5% among robust patients, 20.7% among pre-frail patients, and 20.0% among frail patients (log-rank test, P = 0.032). Frail patients had more than a 3-fold increased risk of mortality compared with robust patients (adjusted HR = 3.331; 95% CI, 1.161-9.559). Multivariate analysis revealed that the SOF index and TNM stage were associated with increased mortality.

CONCLUSIONS

SOF index predicted post-gastrectomy mortality among older patients independently of age, sex, TNM stage, type of approach, gastrectomy type, and extent of lymph node dissection. SOF index may be used with ease to assess frailty status among older patients with gastric cancer in busy clinics and subgroups that may benefit from targeted frailty interventions before cancer treatments.

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.

Transforming primary care for older Canadians living with frailty: mixed methods study protocol for a complex primary care intervention

INTRODUCTION

Older Canadians living with frailty are high users of healthcare services; however, the healthcare system is not well designed to meet the complex needs of many older adults. Older persons look to their primary care practitioners to assess their needs and coordinate their care. They may need care from a variety of providers and services, but often this care is not well coordinated. Older adults and their family caregivers are the experts in their own needs and preferences, but often do not have a chance to participate fully in treatment decisions or care planning. As a result, older adults may have health problems that are not properly assessed, managed or treated, resulting in poorer health outcomes and higher economic and social costs. We will be implementing enhanced primary healthcare approaches for older patients, including risk screening, patient engagement and shared decision making and care coordination. These interventions will be tailored to the needs and circumstances of the primary care study sites. In this article, we describe our study protocol for implementing and testing these approaches.

METHODS AND ANALYSIS

Nine primary care sites in three Canadian provinces will participate in a multi-phase mixed methods study. In phase 1, baseline information will be collected through questionnaires and interviews with patients and healthcare providers (HCPs). In phase 2, HCPs and patients will be consulted to tailor the evidence-based interventions to site-specific needs and circumstances. In phase 3, sites will implement the tailored care model. Evaluation of the care model will include measures of patient and provider experience, a quality of life measure, qualitative interviews and economic evaluation.

ETHICS AND DISSEMINATION

This study has received ethics clearance from the host academic institutions: University of Calgary (REB17-0617), University of Waterloo (ORE#22446) and Université Laval (#MP-13-2019-1500 and 2017-2018-12-MP). Results will be disseminated through traditional means, including peer-reviewed publications and conferences and through an extensive network of knowledge user partners.

TRIAL REGISTRATION NUMBER

NCT03442426;Pre-results.

Perceptions, attitudes and training needs of primary healthcare professionals in identifying and managing frailty: a qualitative study

PURPOSE

Although frailty can be delayed or prevented by appropriate interventions, these are often not available in countries lacking formal education and infrastructure in geriatrics. The aim of this study was to: (a) explore ideas, perceptions and attitudes of primary health care (PHC) professionals towards frailty in a country where geriatrics is not recognised as a specialty; (b) explore PHC professionals' training needs in frailty; and (c) define components of a frailty educational programme in PHC.

METHODS

Qualitative design, using two focus groups with PHC professionals conducted in Thessaloniki, Greece. Focus groups were audio recorded and transcribed. Data were analysed with thematic analysis.

RESULTS

In total 31 PHC professionals (mean age: 46 years; gender distribution: 27 females, 4 males) participated in the study (physicians n = 17; nurses n = 12; health visitors n = 2). Four main themes were identified: (1) Perceptions and understanding of frailty; (2) Facilitators and barriers to frailty identification and management; (3) Motivation to participate in a frailty training programme; (4) Education and training. The main barriers for the identification and management of frailty were associated with the healthcare system, including duration of appointments, a focus on prescribing, and problems with staffing of allied health professionals, but also a lack of education. Training opportunities were scarce and entirely based on personal incentive. Professionals were receptive to training either face-to-face or online. A focus on learning practical skills was key.

CONCLUSION

Education and training of professionals and interdisciplinary collaboration are essential and much needed for the delivery of person-centred care for people with frailty living in the community.

Is proactive frailty identification a good idea? A qualitative interview study

Background

In England, GPs are independent contractors working to a national contract. Since 2017, the contract requires GPs to use electronic tools to proactively identify moderate and severe frailty in people aged ≥65 years, and offer interventions to help those identified to stay well and maintain independent living. Little is currently known about GPs’ views of this contractual requirement.

Aim

To explore GPs’ views of identifying frailty and offering interventions for those living with moderate or severe frailty.

Design and setting

A sequential mixed-methods study of GPs in the East Midlands region of England — namely Derbyshire, Leicestershire, Lincolnshire, Nottinghamshire, and Northamptonshire — undertaken between January and May 2019.

Method

GPs were made aware of the study via professional organisations’ newsletters and bulletins, GP email lists, and social media, and were invited to complete an online questionnaire. Responses were analysed using descriptive statistics and, based on those survey responses, GPs with a range of GP and practice characteristics, as well as views on identifying frailty, were selected to participate in a semi-structured telephone interview. Interview transcripts were analysed using framework analysis.

Results

In total, 188 out of 3058 (6.1%) GPs responded to the survey and 18 GPs were interviewed. GPs were broadly supportive of identifying frailty, but felt risk-stratification tools lacked sensitivity and specificity, and wanted evidence showing clinical benefit. Frailty identification increased workload and was under-resourced, with limited time for, and access to, necessary interventions. GPs felt they lacked knowledge about frailty and more education was required to better understand it.

Conclusion

Proactively identifying and responding to frailty in primary care requires GP education, highly sensitive and specific risk-stratification tools, better access to interventions to lessen the impact of frailty, and adequate resourcing to achieve potential clinical impact.

Feasibility and impact of a short training course on frailty destined for primary health care professionals

BACKGROUND

There is an unmet need for training primary health care professionals on frailty, especially in countries where geriatrics is still emerging.

PURPOSE

We aimed to evaluate the feasibility and efficacy of a training course for primary health care professionals on the detection, assessment, and management of frailty.

METHODS

A single-day training course, developed and facilitated by three physicians trained in geriatrics abroad, was organized by the Aristotle University of Thessaloniki Primary Hearth Care Research Network. Primary health care professionals' attitudes, knowledge, and everyday practices regarding frailty were assessed by self-administered anonymous questionnaires (using Likert-type scales) at three time-points (before, upon completion of the training course, and 3 months afterward).

RESULTS

Out of 31 participants (17 physicians, 12 nurses, 2 health visitors; 87.1% women; mean age 46.4 years), 31(100%) filled in the first, 30(97%) the second, and 25(81%) the third questionnaire. Improvements were reported in familiarization with the frailty syndrome (p = 0.041) and in self-perception of knowledge and skills to detect (p < 0.001) and manage (p < 0.001) frailty, that were also sustained 3 months afterward (p = 0.001 and p = 0.003 respectively). Improvement was also observed in the attitude that frailty is an inevitable consequence of aging (p = 0.007) and in the frequency of application of screening (but not management) strategies, 3 months following the workshop compared to baseline (p = 0.014). Participants reported less disagreement with the statement that systematic screening for frailty was unfeasible in their daily practice at 3 months compared to baseline (p = 0.006), mainly due to time restrictions.

CONCLUSION

A short skill-oriented training course can significantly and sustainably improve primary health care professionals' attitudes and practices regarding frailty.

Fatores associados à piora da autopercepção de saúde em idosos: estudo longitudinal

Resumo Objetivo identificar os fatores associados à piora da autopercepção de saúde em idosos residentes na comunidade ao longo do tempo. Método Trata-se de um estudo longitudinal prospectivo e analítico. Na linha de base a coleta de dados ocorreu no domicílio a partir de uma amostragem aleatória, por conglomerados. A segunda coleta de dados foi realizada após um período médio de 42 meses. Foram analisadas variáveis sociodemográficas, relativas à saúde e uso de serviços de saúde. A autopercepção de saúde foi investigada pela questão: “Como o(a) Sr.(a) classificaria seu estado de saúde?”. Os resultados da classificação de saúde de cada pessoa idosa foram comparados entre os dois momentos do estudo (primeira onda e linha de base) definindo a variável dependente. As razões de prevalências ajustadas foram obtidas por análise múltipla de regressão de Poisson com variância robusta. Resultados participaram das duas etapas do estudo 394 idosos, 21,1% pioraram a autopercepção de saúde, 26,7% melhoraram e 52,2% não apresentaram alteração. As variáveis que se mantiveram estatisticamente associadas à transição para uma avaliação pior de autopercepção de saúde foram: asma, hipertensão arterial sistêmica e fragilidade. Conclusão a autopercepção de saúde é caracterizada por transição entre níveis de autoavaliação de saúde. Doenças crônicas e fragilidade mostraram associação longitudinal com a piora da autopercepção de saúde.

Additional Functional Performance Gains After 24-Week Unstable Strength Training With Cognitive Training in Community-Dwelling Healthy Older Adults: A Randomized Trial

The authors investigated the effects of unstable strength training (UST) without or with cognitive training (C+UST) on functional performance in community-dwelling older adults. A total of 50 participants were randomly assigned (1:1) to either 24 weeks of thrice-weekly UST (n = 25) or C+UST (n = 25). All participants performed moderate-intensity strength exercises using unstable surfaces, and C+UST participants simultaneously received cognitive training in addition to UST. Primary outcomes included measures of functional performance: single- and dual-task timed up and go tests. Secondary outcomes included dynamic balance, mobility, handgrip strength, flexibility, quality of life, and concern about falling. The authors observed similar improvements on functional performance through the interventions. The C+UST group experienced additional gains at completion (single-task timed up and go: -0.90 s, 95% confidence interval [-2.38, -0.03]; dual-task timed up and go: -4.80 s, 95% confidence interval [-8.65, -0.95]) compared with the UST group. Moreover, significant differences were observed in mobility (sitting-rising test: -1.34, 95% confidence interval [-2.00, -0.20]) at 24 weeks. Both exercise modes improved single-task functional performance, while adding cognitive-training-optimized dual-task functional performance gains.

Frailty in community-dwelling older people: comparing screening instruments

OBJECTIVE:

To compare the Edmonton Frail Scale (EFS) and Clinical-Functional Vulnerability Index-20 (CFVI-20) instruments regarding degree of agreement and correlation and compare descriptive models with frailty-associated variables in community-dwelling older people in Brazil.

METHODS:

Cross-sectional study, nested in a population-based and household cohort. Baseline sampling was calculated based on a probabilistic approach by conglomerate in two stages. In the first stage, census tract was used as sampling unit. In the second, the number of households was defined according to the population density of individuals aged ≥ 60 years. The Kappa statistic evaluated the agreement between instruments and Pearson's coefficient their correlation. Factors associated with frailty and high risk of clinical-functional vulnerability were identified by multiple analysis of Poisson regression with robust variance.

RESULTS:

Kappa statistics was 0.599 and Pearson's correlation coefficient 0.755 (p < 0.001). The EFS found a 28.2% prevalence of frailty, and the CFVI-20 found a 19.5% prevalence of high risk of clinical-functional vulnerability. Age equal to or greater than 80 years, history of stroke, polypharmacy, negative self-perceived health, fall in the past 12 months, and hospitalization in the past 12 months were variables associated with frailty in both instruments after multiple analysis. Less than four years of education, osteoarticular disease, and weight loss were associated with frailty only by EFS, and having a caregiver was associated with a high risk of clinical-functional vulnerability only by CFVI-20.

CONCLUSIONS:

Although the analyses show moderate agreement and strong positive correlation between the instruments, the indicated prevalence of frailty is discrepant. Our results attest the need to standardize the instrument for assessing frailty in community-dwelling older people.

Blood pressure in frail older adults: associations with cardiovascular outcomes and all-cause mortality

Background

Blood pressure (BP) management in frail older people is challenging. An randomised controlled trial of largely non-frail older people found cardiovascular and mortality benefit with systolic (S) BP target <120 mmHg. However, all-cause mortality by attained BP in routine care in frail adults aged above 75 is unclear.

Objectives

To estimate observational associations between baseline BP and mortality/cardiovascular outcomes in a primary-care population aged above 75, stratified by frailty.

Methods

Prospective observational analysis using electronic health records (clinical practice research datalink, n = 415,980). We tested BP associations with cardiovascular events and mortality using competing and Cox proportional-hazards models respectively (follow-up ≤10 years), stratified by baseline electronic frailty index (eFI: fit (non-frail), mild, moderate, severe frailty), with sensitivity analyses on co-morbidity, cardiovascular risk and BP trajectory.

Results

Risks of cardiovascular outcomes increased with SBPs >150 mmHg. Associations with mortality varied between non-frail <85 and frail 75–84-year-olds and all above 85 years. SBPs above the 130–139-mmHg reference were associated with lower mortality risk, particularly in moderate to severe frailty or above 85 years (e.g. 75–84 years: 150–159 mmHg Hazard Ratio (HR) mortality compared to 130–139: non-frail HR = 0.94, 0.92–0.97; moderate/severe frailty HR = 0.84, 0.77–0.92). SBP <130 mmHg and Diastolic(D)BP <80 mmHg were consistently associated with excess mortality, independent of BP trajectory toward the end of life.

Conclusions

In representative primary-care patients aged ≥75, BP <130/80 was associated with excess mortality. Hypertension was not associated with increased mortality at ages above 85 or at ages 75–84 with moderate/severe frailty, perhaps due to complexities of co-existing morbidities. The priority given to aggressive BP reduction in frail older people requires further evaluation.

Can Linked Electronic Medical Record and Administrative Data Help Us Identify Those Living with Frailty?

Introduction

Frailty is a complex condition that affects many aspects of patients’ wellbeing and health outcomes.

Objectives

We used available Electronic Medical Record (EMR) and administrative data to determine definitions of frailty. We also examined whether there were differences in demographics or health conditions among those identified as frail in either the EMR or administrative data.

Methods

EMR and administrative data were linked in British Columbia (BC) and Manitoba (MB) to identify those aged 65 years and older who were frail. The EMR data were obtained from the Canadian Primary Care Sentinel Surveillance Network (CPCSSN) and the administrative data (e.g. billing, hospitalizations) was obtained from Population Data BC and the Manitoba Population Research Data Repository. Sociodemographic characteristics, risk factors, prescribed medications, use and costs of healthcare are described for those identified as frail.

Results

Sociodemographic and utilization differences were found among those identified as frail from the EMR compared to those in the administrative data. Among those who were >65 years, who had a record in both EMR and administrative data, 5%-8% (n=191 of 3,553, BC; n=2,396 of 29,382, MB) were identified as frail. There was a higher likelihood of being frail with increasing age and being a woman. In BC and MB, those identified as frail in both data sources have approximately twice the number of contacts with primary care (n=20 vs. n=10) and more days in hospital (n=7.2 vs. n=1.9 in BC; n=9.8 vs. n=2.8 in MB) compared to those who are not frail; 27% (BC) and 14% (MB) of those identified as frail in 2014 died in 2015.

Conclusions

Identifying frailty using EMR data is particularly challenging because many functional deficits are not routinely recorded in structured data fields. Our results suggest frailty can be captured along a continuum using both EMR and administrative data.

Diagnosis and Management of Frailty in Primary Health Care

Disability in older adults has become a significant burden, both individually and socially, due to the rapidly aging population in Korea. It is important to manage both frailty and chronic diseases to delay disability. Frailty, which is considered to be a transition phase between healthy status and disability, is defined as a significant decline in functional reserves of multiple organ systems and the resultant extreme vulnerability to stressors, leading to a higher risk of adverse health-related outcomes. The frailty phenotype and frailty index are the most commonly used methods to diagnose frailty. Frailty is related to physical, psychological, cognitive, and social dysfunction, and is sometimes caused by chronic disease. Therefore, primary care providers are ideally situated to incorporate the concept of frailty into their practice, as they are champions in comprehensive care. Although the identification and treatment of frailty is not yet standard practice in primary care, primary care physicians must use the electronic frailty index to identify frailty in all the patients aged ≥65 years in the United Kingdom. In Canada, some insurance companies and governments are using a similar program, which is called the Community Actions and Resources Empowering Seniors model. The clinical practice guidelines of the International Conference of Frailty and Sarcopenia Research, as well as some additional references, will be introduced. Here, we review the current literature on how to diagnose and manage frailty in primary care.

Development of Korean Frailty Index for Primary Care (KFI-PC) and Its Criterion Validity

BACKGROUND

The objective of this study was to develop and validate the Korean Frailty Index for Primary Care (KFI-PC) based on a comprehensive geriatric assessment.

METHODS

We developed a 54-item KFI-PC comprising 10 standard domains: cognitive status including delirium or dementia; mood; communication including vision, hearing, and speech; mobility; balance; bowel function; bladder function; ability to carry out activities of daily living; nutrition; and social resources. To test its validity, we applied KFI-PC to participants of the Korean Frailty Aging and Cohort Study (KFACS). We analyzed 1,242 participants (mean age, 77.9±3.9 years; 47.2% men) from the KFACS who visited 10 study centers in 2018, after excluding 32 participants with missing data required to assess Fried's physical frailty phenotype.

RESULTS

The mean KFI-PC score was 0.17±0.08, ranging from 0.02 to 0.52. The median KFI-PC score was higher in women than in men, and there was a trend toward higher values in older age groups. The prevalence of frailty when applying a generally used frailty index cutoff point of >0.25 was 17.5% in the whole study sample. As a construct validation of KFI-PC, the area under the receiver operating characteristic curve for Fried's physical frailty was 0.921, and the optimal cutoff value to predict frailty phenotype was 0.23. The KFI-PC score also correlated well with physical, cognitive, and psychological functions; nutritional status; disability in activities of daily living; and instrumental activities of daily living. The Cronbach's alpha coefficient of the 54 total items was 0.737.

CONCLUSION

We developed KFI-PC with 53 deficits, including comprehensive geriatric assessment components, and demonstrated the acceptable construct validity and internal consistency of KFI-PC.

Feasibility and acceptability of commonly used screening instruments to identify frailty among community-dwelling older people: a mixed methods study

Background

Frailty exposes older people to an elevated risk of a range of negative outcomes. Emerging evidence that frailty can be effectively treated within community settings has stimulated calls for more proactive screening within primary care. Assessing feasibility is a critical preliminary step in assessing the efficacy of interventions such as screening. However, few studies have explored the feasibility and acceptability of administering frailty screening instruments within general practice, and even fewer have incorporated patient perspectives. Our study had three objectives: To 1) assess overall feasibility of the instruments (completion time and rate); 2) assess patient acceptability towards the instruments; and 3) assess the feasibility and acceptability of the instruments to administering nurses.

Methods

The feasibility and acceptability of several frailty screening instruments (PRISMA-7, Edmonton Frail Scale, FRAIL Scale Questionnaire, Gait Speed, Groningen Frailty Indicator, Reported Edmonton Frail Scale and Kihon Checklist) was explored within the context of a larger diagnostic test accuracy (DTA) study. Completion time and rate was collected for all participants (N = 243). A sub-sample of patients (n = 30) rated each instrument for ease of completion and provided comment on perceived acceptability. Lastly, five of six administering nurses involved in the DTA study participated in semi-structured face-to-face interviews, rating the instruments against several feasibility and acceptability criteria (time, space, equipment, skill required to implement, acceptability to patients and nurses, ease of scoring) and providing comment on their responses.

Results

The PRISMA-7 returned the highest overall feasibility and acceptability, requiring minimal space, equipment, skills and time to implement, and returning the fastest completion rate and highest patient and nurse acceptability rating. All screening instruments were faster to implement than the two reference standards (Fried’s Frailty Phenotype and Frailty Index). Self-administered instruments were subject to lower rates of completion than nurse-administered instruments.

Conclusions

This study has demonstrated that a number of commonly used frailty screening instruments are potentially feasible for implementation within general practice. Ultimately, more research is needed to determine how contextual factors, such as differences in individual patient and clinician preferences, setting and system factors, impact on the feasibility of screening in practice.

A Computerized Frailty Assessment Tool at Points-of-Care: Development of a Standalone Electronic Comprehensive Geriatric Assessment/Frailty Index (eFI-CGA)

Background: Frailty is characterized by loss of biological reserves and is associated with an increased risk of adverse health outcomes. Frailty can be operationalized using a Frailty Index (FI) based on the accumulation of health deficits; items under health evaluation in the well-established Comprehensive Geriatric Assessment (CGA) have been used to generate an FI-CGA. Traditionally, constructing the FI-CGA has relied on paper-based recording and manual data processing. As this can be time-consuming and error-prone, it limits widespread uptake of this proven type of frailty assessment. Here, we report the development of an electronic tool, the eFI-CGA, for use on personal computers by frontline healthcare providers, to collect CGA data and automate FI-CFA calculation. The ultimate goal is to support early identification and management of frailty at points-of-care, and make uptake in Electronic Medical Records (EMR) feasible and transparent. Methods: An electronic CGA (eCGA) form was implemented to operate on Microsoft's WinForms platform and coded using C# programming language. Users complete the eCGA form, from which items under the CGA evaluation are automatically retrieved and processed to output an eFI-CGA score. A user-friendly interface and secured data saving methods were implemented. The software was debugged and tested using systematically designed simulation data, addressing different logic, syntax, and application errors, and then tested with clinical assessment. The user manual and manual scoring were used as ground truth to compare eFI-CGA input and automated eFI score calculations. Frontline health-provider user feedback was incorporated to improve the end-user experience. Results: The Standalone eFI-CGA software tool was developed and optimized for use on personal computers. The user interface adapted the design of paper-based CGA form to facilitate familiarity for clinical users. Compared to known scores, the software tool generated eFI-CGA scores with 100% accuracy to four decimal places. The eFI-CGA allowed secure data storage and retrieval of multiple types, including user input, completed eCGA form, coded items, and calculated eFI-CGA scores. It also permitted recording of actions requiring clinical follow-up, facilitating care planning. Application bugs were identified and resolved at various stages of the implementation, resulting in efficient system performance. Discussion: Accurate, robust, and reliable computerized frailty assessments are needed to promote effective frailty assessment and management, as a key tool in health care systems facing up to frailty. Our research has enabled the delivery of the standalone eFI-CGA software technology to empower effective frailty assessment and management by various healthcare providers at points-of-care, facilitating integrated care of older adults.

Negative self-perception of health: prevalence and associated factors among elderly assisted in a reference center

The negative self-perception of health is a relevant construct for the analysis of the elderly population health conditions and should be recognized as a guiding tool for health promotion actions. We aimed to verify the prevalence and the associated factors to a negative self-perception of health by elderly assisted in a reference center. This is an analytical cross-sectional study with convenience sampling conducted in 2015. The negative self-perception association with health-related sociodemographic variables was investigated. Bivariate analysis followed by multiple analysis by Poisson regression was performed to verify the variables associated with the outcome. Three hundred sixty elderly were evaluated. The negative self-perception of health prevalence was 60.5%. The following associated factors were identified in the final model: age range 65-79 years (PR=1; CI95%=0.648-0.974; p=0.027); frailty (PR=1.28; CI95%=1.07-1.54; p=0.007); depressive symptoms (PR=1.40; CI95%=1.19-1.67; p=0.000); and providing care to someone (PR=1.49; CI95%=1.18-1.88; p=0.001). The elevated prevalence of negative self-perception of health and the associated factors point to the need for effective health promotion actions and more specific care for the elderly assisted in the reference center.

Factors influencing communication about frailty in primary care: A scoping review

OBJECTIVE

To summarise the available evidence on the factors influencing communication about frailty in the primary care setting.

METHODS

We conducted a scoping review, searching five electronic databases (PubMed, Scopus, CINAHL, PsycINFO, and ProQuest) for studies addressing communication about frailty in primary care practice. Reference list and grey literature searching was conducted to identify additional articles. A narrative descriptive method was used to synthesise the findings.

RESULTS

The search identified 3185 articles and 37 were included in the review. We identified five categories of factors influencing communication about frailty at the consumer, healthcare provider, and system levels: (1) consumer perceptions, information needs, and communication preferences; (2) healthcare providers' knowledge, capacities, and attitudes; (3) clinical communication skills and training; (4) availability of information and communication technologies; and (5) care coordination, collaboration, and case management.

CONCLUSION

Findings offer considerations for the design and delivery of initiatives to improve communication about frailty in primary care both at the local clinical level and at the broader level of healthcare service delivery.

PRACTICE IMPLICATIONS

Healthcare providers and systems require practical, evidence-informed guidance regarding the development of a systematic approach to the quality and timing of communication about frailty in healthcare encounters.

A Simple Questionnaire as a First-Step Tool to Detect Specific Frailty Profiles: The Lorraine Frailty-Profiling Screening Scale

OBJECTIVES

To propose a simple frailty screening tool able to identify frailty profiles.

DESIGN

Cross-sectional observational study.

SETTING

Participants were recruited in 3 different clinical settings: a primary care outpatient clinic (RURAL population, N=591), a geriatric day clinic (DAY-CLINIC population, N=76) and healthy volunteers (URBAN population, N=147).

PARTICIPANTS

A total of 817 older adults (>70 years old) living at home were included.

INTERVENTION

A 9-item questionnaire (Lorraine Frailty Profiling Screening Scale, LoFProSS), constructed by an experts' working group, was administered to participants by health professionals.

MEASUREMENTS

A Multiple Correspondence Analysis (MCA) followed by a hierarchical clustering of the results of the MCA performed in each population was conducted to identify participant profiles based on their answers to LoFProSS. A response pattern algorithm was resultantly identified in the RURAL (main) population and subsequently applied to the URBAN and DAY-CLINIC populations and, in these populations, the two classification methods were compared. Finally, clinically-relevant profiles were generated and compared for their ability to similarly classify subjects.

RESULTS

The response pattern differed between the 3 sub-populations for all 9 items, revealing significant intergroup differences (1.2±1.4 positive responses for URBAN vs. 2.1±1.3 for RURAL vs. 3.1±2.1 for DAY-CLINIC, all p<0.05). Five clusters were highlighted in the main RURAL population: "non-frail", "hospitalizations", "physical problems", "social isolation" and "behavioral", with similar clusters highlighted in the remaining two populations. Identification of the response pattern algorithm in the RURAL population yielded a second classification approach, with 83% of tested participants classified in the same cluster using the 2 different approaches. Three clinically-relevant profiles ("non-frail" profile, "physical frailty and diseases" profile and "cognitive-psychological frailty" profile) were subsequently generated from the 5 clusters. A similar double classification approach as above was applied to these 3 profiles revealing a very high percentage (95.6%) of similar profile classifications using both methods.

CONCLUSION

The present results demonstrate the ability of LoFProSS to highlight 3 frailty-related profiles, in a consistent manner, among different older populations living at home. Such scale could represent an added value as a simple frailty screening tool for accelerated and better-targeted investigations and interventions.

Anticholinergic Burden, Sleep Quality and Health Outcomes in Malaysian Aged Care Home Residents

The use of anticholinergic medications by residents in aged care homes is associated with increased risk of adverse effects. These include cognitive impairment, sleep disturbances, and falls, and necessitate increased healthcare visits and the associated burden on healthcare systems. The objective of this study was to investigate associations between anticholinergic burden and health outcomes such as independence in activities for daily living, frailty, quality of life, and sleep quality. The study was conducted among residents in Malaysian aged care homes, aged 60 years and above. Anticholinergic burden was calculated using the Anticholinergic Cognitive Burden (ACB) scale. Health outcome measures included independence, assessed using the Katz Activities for Daily Living scale (Katz ADL); quality of life, assessed using the Older People’s Quality of Life Questionnaire (OPQOL); frailty, assessed using the Groningen Frailty Index (GFI); and sleep quality, measured using the Pittsburg Sleep Quality Index (PSQI). Just over one-third (36%) of the study population was exposed to at least one medication with anticholinergic effect. An increased anticholinergic cognitive burden was associated with frailty (p = 0.031), sleep latency (p = 0.007), and sleep disturbances (p = 0.015). Further studies are required to assess the effect of prolonged exposure to anticholinergic medications on health outcomes.

Frailty in older people: a principle-based concept analysis

Frailty is a term that presents many difficulties for policy makers and clinicians due to the lack of consensus in defining frailty in a way that meets the needs of older people. A principle-based concept analysis was used to examine the scientific literature across four perspectives: medicine, nursing, social sciences, and occupational and physiotherapy. The purpose was to identify the conceptual components of frailty as revealed by analysis of the literature, and to develop a theoretical definition of frailty. The findings exposed commonalities in implied meanings both within and across perspectives. The strengths of frailty as a concept are revealed in the implications for clinical practice and relevance to health professionals. The limitations reflect a concept that is still evolving and further research is recommended but this should not stop health professionals engaging in this process. The definition developed in this study will enhance existing knowledge and promote a shared understanding to unite different disciplines in recognising frailty as an important concept.

Frailty, profile and cognition of elderly residents in a highly socially vulnerability area

This study aimed to associate frailty with sociodemographic profile and cognition of elderly people living in highly socially vulnerable contexts registered at a Social Assistance Referral Centers in a city of inland São Paulo. This is a cross-sectional and quantitative study with 48 elderly. Data was collected with a sociodemographic interview, the Edmonton Frail Scale and the Montreal Cognitive Assessment, and was analyzed with the Jonckheere-Terpstra test, Spearman's correlation and logistic regression (α = 5.0%). This study was approved under Opinion Nº 72182. Of the 48 elderly interviewed, 33.4% were non-frail, 20.8% were apparently vulnerable and 45.8% were frail at some level (mild, moderate or severe). Women (OR = 4.64) and nonwhites (OR = 3.99) were more likely of being frail. The realms with the greatest influence in the determination of frailty were cognition, independence and functional performance, general health and mood, although gender (p = 0.0373) and ethnicity (p = 0.0284) had a significant association. Worth highlighting is that considering the frailty profile of the elderly warrants the development of specific care strategies for this segment of the population in a vulnerable area, preventing futures complications.