Relationship between clinical outcomes and Dutch frailty score among elderly patients who underwent surgery for hip fracture

Association of frailty with adverse outcomes in surgically treated geriatric patients with hip fracture: A meta-analysis and trial sequential analysis

OBJECTIVE

Some studies have associated frailty and prognostic outcomes in geriatric hip fracture patients, but whether frailty can predict postoperative outcomes remains controversial. This review aims to assess the relationship between frailty and adverse postoperative outcomes in geriatric patients with hip fracture.

METHODS

Based on electronic databases, including PubMed, Embase, Web of Science, Cumulative Index to Nursing and Allied Health Literature, the Cochrane Library, Chinese National Knowledge Infrastructure, and WanFang Data, we systematically searched for studies that investigated the association between frailty and adverse outcomes among patients aged 60 or over after hip fracture surgery. Stata 17.0 and Trial Sequential Analysis viewer software were used to obtain pooled estimates and verify whether the sample size was sufficient and the evidence robust.

RESULTS

Twenty-one studies involving 49,196 patients were included for quantitative analysis. Compared with nonfrail patients, frail patients had a higher risk of inpatient mortality (risk ratio [RR] = 1.93, 95% confidence interval [CI]: 1.66-2.23), 30-day mortality (RR = 2.13, 95% CI: 1.23-3.70), and 1-year mortality (RR = 2.44, 95% CI: 1.47-4.04). Frailty can significantly predict postoperative complications (RR = 1.76, 95% CI: 1.38-2.23), including delirium, pneumonia, cardiac complications, urinary tract infection, and surgical site infection; the association between frailty and deep venous thrombosis/pulmonary embolism and acute kidney injury needs further analysis. Trial sequential analysis showed that the findings regarding mortality were reliable and robust.

CONCLUSION

This meta-analysis provides detailed information indicating that frailty is a substantial predictor of mortality and selected postoperative complications.

Value of the Safety Management System (VMS) frailty instrument as a frailty screener in care for older hospital patients: a systematic review

BACKGROUND

Dutch hospitals are required to screen older patients for the risk of developing functional decline using the Safety Management System (VMS) which assesses four domains associated with functional decline; fall risk, risk of delirium, malnutrition, and physical impairment.

PURPOSE

The aim is twofold, first to compare the VMS frailty instrument as a frailty screener with existing frailty instruments and second to provide an overview of the available evidence.

METHODS

We performed a literature search to identify studies that used the VMS instrument as frailty screener to asses frailty or to predict adverse health outcomes in older hospitalized patients. Pubmed, Cinahl, and Embase were searched from January 1st 2008 to December 11th 2023.

RESULTS

Our search yielded 603 articles, of which 17 studies with heterogenous populations and settings were included. Using the VMS, frailty was scored in six different ways. The agreement between VMS and other frailty instruments ranged from 57 to 87%. The highest sensitivity and specificity of VMS for frailty were 90% and 67%, respectively. The association of the VMS with outcomes was studied in 14 studies, VMS was predictive for complications, delirium, falls, length of stay, and adverse events. Conflicting results were found for hospital (re)admission, complications, change in living situation, functional decline, and mortality.

CONCLUSION

The VMS frailty instrument were studied as a frailty screening instrument in various populations and settings. The value of the VMS instrument as a frailty screener looks promising. Our results suggest that the scoring method of the VMS could be adapted to specific requirements of settings or populations.

The Clinical Frailty Scale is a Strong Predictor of 1-Year Mortality in Surgically Managed Hip Periprosthetic Fracture: An Analysis From a High-Volume Institution

BACKGROUND

Hip periprosthetic fractures (PPFs) after primary total hip arthroplasty are increasing with the number of primary implants and aging population. Mortality has been reported up to 34% at 1-year. The aim of this study was to evaluate the association of Clinical Frailty Scale (CFS) and 1-year mortality, complication rate, and length of stay (LOS) in surgically managed hip PPFs.

METHODS

This was a retrospective study of prospectively collected data from January 2008 to January 2021. A total of 282 surgically managed hip PPFs were identified. Mean age was 79 years (range, 42 to 106). Preoperative scores were analyzed through linear regression to identify significant association with mortality, complication and LOS. Receiver operating characteristic curve and Area Under the Curve (AUC) were generated to evaluate the quality of the models and the discriminatory ability of each clinical score. Significance was considered at P values < .05.

RESULTS

Mortality was 7.8% at 3-months and 15.7% at 1-year. Complication rate requiring surgery was 19.5% and mean LOS was 8.9 ± 7 days. The CFS was significantly associated with 3-month (odds ratio 2.23, P < .001) and 1-year mortality (odds ratio 2.01, P < .001). The receiver operating characteristic curve test for 1-year mortality showed a greater AUC for the CFS when compared with American Society for Anesthesiologists score and age-adjusted Charlson Comorbidity Index (AUC 0.80 versus 0.68 versus 0.72, respectively).

CONCLUSIONS

Frailty is a syndrome with increased risk of mortality after surgically managed PPF. The CFS can be easily assessed at the time of admission and could be considered as a strong and reliable predictor of 1-year mortality with a greater AUC than the conventionally used American Society for Anesthesiologists score.

The prognostic value of a geriatric risk score for older patients undergoing emergency surgery of colorectal cancer: A retrospective cohort study

INTRODUCTION

Emergency surgery of colorectal cancer is associated with high mortality rates in older patients. We investigated whether information on four geriatric domains has prognostic value for 30-day mortality and postoperative morbidity including severe complications.

MATERIALS AND METHODS

All consecutive patients aged 70 years or older who underwent emergency colorectal cancer surgery in six Dutch hospitals (2014-2017) were studied. Presence of geriatric risk factors was scored prior to surgery as either 0 (risk absent) or 1 (risk present) in each of four geriatric domains and summed up to calculate a sumscore with a value between 0 and 4. In addition, we separately investigated the use of a mobility aid. Primary outcome was 30-day mortality. Secondary outcomes were any postoperative complications and severe complications. Multivariable logistic regression model was used to evaluate the sumscore and outcomes.

RESULTS

Two hundred seven patients were included. Median age was 79.4 years. One hundred seventy-five patients (76%) presented with obstruction, 22 (11%) with a perforation, and 17 (8%) with severe anemia. Mortality rates were 2.9%, 13.6%, and 29.6% for patients with a sumscore of 0, 1-2, and 3-4 respectively, with odds ratio (OR) 4.8 [95% confidence interval (CI) 1.03-22.95] and OR 10.6 [95% CI 1.99-56.34] for a sumscore of 1-2 and 3-4 respectively. Use of a mobility aid was associated with increased mortality OR 8.0 [95% CI 2.74-23.43] and severe complications OR 2.31 [95% CI 1.17-4.55].

DISCUSSION

This geriatric sumscore and the use of a mobility aid have strong association with 30-day mortality after emergency surgery of colorectal cancer. This could provide better insight into surgical risk and help select high-risk patients for alternative strategies.

Association of Vulnerability Screening on Hospital Admission with Discharge to Rehabilitation-Oriented Care after Acute Hospital Stay

BACKGROUND

We assessed the vulnerability of patients aged ≥70 years during hospital admission based on the Short Dutch Safety Management Screening (DSMS). Screening of four geriatric domains aims to prevent adverse outcomes and may support targeted discharge planning for post-acute care. We explored whether the DSMS criteria for acutely admitted patients were associated with rehabilitation-oriented care needs.

METHODS

This retrospective cohort study included community-dwelling patients aged ≥70 years acutely admitted to a tertiary hospital. We recorded patient demographics, morbidity, functional status, malnutrition, fall risk, and delirium and used descriptive analysis to calculate the risks by comparing the discharge destination groups.

RESULTS

Among 491 hospital discharges, 349 patients (71.1%) returned home, 60 (12.2%) were referred for geriatric rehabilitation, and 82 (16.7%) to other inpatient post-acute care. Non-home referrals increased with age from 21% (70-80 years) to 61% (>90 years). A surgical diagnosis (odds ratio [OR]=4.92; 95% confidence interval [CI], 2.03-11.95), functional decline represented by Katz-activities of daily living positive screening (OR=3.79; 95% CI, 1.76-8.14), and positive fall risk (OR=2.87; 95% CI, 1.31-6.30) were associated with non-home discharge. The Charlson Comorbidity Index did not differ significantly between the groups.

CONCLUSION

Admission diagnosis and vulnerability screening outcomes were associated with discharge to rehabilitation-oriented care in patients >70 years of age. The usual care data from DSMS vulnerability screening can raise awareness of discharge complexity and provide opportunities to support timely and personalized transitional care.

Exercise to Prevent and Manage Frailty and Fragility Fractures

PURPOSE OF REVIEW

This review identifies exercise-based recommendations to prevent and manage frailty and fragility fractures from current clinical practice guidelines. We also critically assess recently published literature in relation to exercise interventions to mitigate frailty and fragility fractures.

RECENT FINDINGS

Most guidelines presented similar recommendations that included the prescription of individually tailored, multicomponent exercise programs, discouragement of prolonged sitting and inactivity, and combining exercise with optimal nutrition. To target frailty, guidelines recommend supervised progressive resistance training (PRT). For osteoporosis and fragility fractures, exercise should include weight-bearing impact activities and PRT to target bone mineral density (BMD) at the hip and spine, and also incorporate balance and mobility training, posture exercises, and functional exercise relevant to activities of daily living to reduce falls risk. Walking as a singular intervention has limited benefits for frailty and fragility fracture prevention and management. Current evidence-based clinical practice guidelines for frailty, osteoporosis, and fracture prevention recommend a multifaceted and targeted approach to optimise muscle mass, strength, power, and functional mobility as well as BMD.

Prognostic significance of frailty in older patients with hip fracture: a systematic review and meta-analysis

PURPOSE

Hip fracture (HF) has become a major healthcare concern associated with higher mortality in older patients. Frailty is one of the most important problems in aging population but its prognostic value in HF remains susceptible. This systematic review and meta-analysis aimed to evaluate the association between frailty and adverse outcomes in older patients with HF.

METHODS

We systematically searched electrical databases including PubMed and Embase to find eligible literature with end-search restriction of February 20, 2021. The main endpoints were all-cause mortality, peri-operative complications, abnormal discharge, and length of stay (LOS). Pooled effect size was calculated by random-effects or fixed-effect model according to study heterogeneity. Three subgroup analyses based on follow-up times, study design, and frailty criteria were conducted.

RESULTS

We screened 22 studies out of 1599 identified studies in our analysis. Compared with normal patients, frail ones had a higher risk of mortality both before (OR = 3.48, 95% CI: 2.50-4.85, I² = 87.2%, P < 0.001) and after (OR = 1.87, 95% CI: 1.44-2.44, I² = 85.5%, P < 0.001) adjustment. The incidence of peri-operative complications, abnormal discharge, and prolonged LOS also significantly increased in frail subjects. There was no publication bias observed and the pooled results were stable based on sensitivity analysis.

CONCLUSION

Overall, more attention needs to be paid to the prognostic effects caused by frailty in seniors with HF. Better understanding of the association between frailty and adverse outcomes in HF could help doctors perform co-management across orthopaedic and geriatric departments.

Interaction between geriatric syndromes in predicting three months mortality risk

OBJECTIVES

Capturing frailty using a quick tool has proven to be challenging. We hypothesise that this is due to the complex interactions between frailty domains. We aimed to identify these interactions and assess whether adding interactions between domains improves mortality predictability.

METHODS

In this retrospective cohort study, we selected all patients aged 70 or older who were admitted to one Dutch hospital between April 2015 and April 2016. Patient characteristics, frailty screening (using VMS (Safety Management System), a screening tool used in Dutch hospital care), length of stay, and mortality within three months were retrospectively collected from electronic medical records. To identify predictive interactions between the frailty domains, we constructed a classification tree with mortality as the outcome using five variables: the four VMS-domains (delirium risk, fall risk, malnutrition, physical impairment) and their sum. To determine if any domain interactions were predictive for three-month mortality, we performed a multivariable logistic regression analysis.

RESULTS

We included 4,478 patients. (median age: 79 years; maximum age: 101 years; 44.8% male) The highest risk for three-month mortality included patients that were physically impaired and malnourished (23% (95%-CI 19.0-27.4%)). Subgroups had comparable three-month mortality risks based on different domains: malnutrition without physical impairment (15.2% (96%-CI 12.4-18.6%)) and physical impairment and delirium risk without malnutrition (16.3% (95%-CI 13.7-19.2%)).

DISCUSSION

We showed that taking interactions between domains into account improves the predictability of three-month mortality risk. Therefore, when screening for frailty, simply adding up domains with a cut-off score results in loss of valuable information.

Prognosis and institutionalization of frail community-dwelling older patients following a proximal femoral fracture: a multicenter retrospective cohort study

Hip fractures are a serious public health issue with major consequences, especially for frail community dwellers. This study found a poor prognosis at 6 months post-trauma with regard to life expectancy and rehabilitation to pre-fracture independency levels. It should be realized that recovery to pre-trauma functioning is not a certainty for frail community-dwelling patients.

INTRODUCTION

Proximal femoral fractures are a serious public health issue in the older patient. Although a significant rise in frail community-dwelling elderly is expected because of progressive aging, a clear overview of the outcomes in these patients sustaining a proximal femoral fracture is lacking. This study assessed the prognosis of frail community-dwelling patients who sustained a proximal femoral fracture.

METHODS

A multicenter retrospective cohort study was performed on frail community-dwelling patients with a proximal femoral fracture who aged over 70 years. Patients were considered frail if they were classified as American Society of Anesthesiologists score ≥ 4 and/or a BMI < 18.5 kg/m² and/or Functional Ambulation Category ≤ 2 pre-trauma. The primary outcome was 6-month mortality. Secondary outcomes were adverse events, health care consumption, rate of institutionalization, and functional recovery.

RESULTS

A total of 140 out of 2045 patients matched the inclusion criteria with a median age of 85 (P₂₅-P₇₅ 80-89) years. The 6-month mortality was 58 out of 140 patients (41%). A total of 102 (73%) patients experienced adverse events. At 6 months post-trauma, 29 out of 120 (24%) were readmitted to the hospital. Out of the 82 surviving patients after 6 months, 41 (50%) were unable the return to their home, and only 32 (39%) were able to achieve outdoor ambulation.

CONCLUSION

Frail community-dwelling older patients with a proximal femoral fracture have a high risk of death, adverse events, and institutionalization and often do not reobtain their pre-trauma level of independence. Foremost, the results can be used for realistic expectation management.

The Impact of Frailty on Adverse Outcomes in Geriatric Hip Fracture Patients: A Systematic Review and Meta-Analysis

Objective

With an aging population and advances in medicine, more research focuses on health and longevity in geriatric adults. Recently, frailty has gradually emerged to assess physical conditions. Frailty can be generally described as a multi-dimensional situation of increased vulnerabilities to both endogenous and exogenous stressors. The objective of the review was to evaluate the predictive value of frailty on adverse outcomes in geriatric hip fracture patients.

Materials and Methods

We searched PubMed, Embase, Web of Science, and the Cochrane library for relevant literature about the connection between frailty and poor outcomes in hip fracture elders.

Results

Eleven studies involving a total of 45,979 participants were selected in our study. Our results indicated that frailty could significantly predict postoperative and in-patient complications (OR, 1.46; 95% CI, 1.13–1.90; I2 = 77.4%). Frail elders had higher risk of inpatient mortality (OR, 1.68; 95% CI, 1.26–2.25; I2 = 0.0%), 6-month mortality (OR, 1.46; 95% CI, 1.25–1.72; I2 = 0.0%) and ≥1-year mortality (OR, 2.24; 95% CI, 1.66–3.04; I2 = 91.3%). Furthermore, the risk of prolonged hospital stays was 1.15 times more likely in frail patients (95% CI, 1.03–1.28; I2 = 14.8%).

Conclusion

Frailty can predict adverse outcomes effectively in geriatric hip fracture patients.

Systematic Review Registration

https://www.crd.york.ac.uk/PROSPERO/#recordDetails.

Isolated greater trochanter fracture may impose a comparable risk on older patients' survival as a conventional hip fracture: a population-wide cohort study

Background

Isolated greater trochanter fracture (IGT) and conventional hip fracture (HF) affect the same anatomical area but are usually researched separately. HF is associated with high mortality, and its management is well established. In contrast, IGT’s effect on mortality is unknown, and its best management strategies are unclear. This study aims to compare these patient populations, their acute- and post-acute care, physical and occupational therapy use, and up to three-year mortality.

Methods

This retrospective cohort study is based on population-wide data of Estonia, where routine IGT management is non-operative and includes immediate weight-bearing as tolerated. The study included patients aged ≥ 50 years with a validated index HF or IGT diagnosis between 2009–2017. The fracture populations’ acute- and post-acute care, one-year physical and occupational therapy use and three-year mortality were compared.

Results

A total of 0.4% (50/11,541) of included patients had an IGT. The baseline characteristics of the fracture cohorts showed a close resemblance, but the IGT patients received substantially less care. Adjusted analyses showed that the IGT patients’ acute care was 4.5 days [3.4; 5.3] shorter they had 39.2 percentage points [25.5; 52.8] lower probability for receiving post-acute care, and they had 50 percentage points [5.5: 36]] lower probability for receiving physical and occupational therapy. The IGT and HF patients’ mortality rates were comparable, being 4% and 9% for one month, 28% and 31% for one year, and 46% and 49% for three years, respectively. Crude and adjusted analyses could not find significant differences in their three-year mortality, showing a p-value of 0.6 and a hazard ratio of 0.9 [0.6; 1.3] for the IGT patients, retrospectively.

Conclusions

Despite IGT being a relatively minor injury, the evidence from this study suggests that it may impose a comparable risk on older patients’ survival, as does HF due to the close resemblance of the two fracture populations. Therefore, IGT in older patients may signify an underlying need for broad-based medical attention, ensuring need-based, ongoing, coordinated care.

Trial registration

Retrospectively registered.

Patient-specific risk factors for adverse outcomes following geriatric proximal femur fractures

BACKGROUND

Proximal femur fractures (PFFs) occur frequently among geriatric patients due to diverse risk factors, such as a lower bone mineral density and the increased risk of falls.

METHODS

In this review, we focus on recent literature of patient-specific risk factors and their impact on common complications and outcome parameters in patients with PFF.

RESULTS

Patient- and treatment related factors have a significant impact on outcome and are associated with an increased risk of mortality, impairments in functional rehabilitation and complicative courses.

CONCLUSION

Geriatric patients at high risk for complications are nursing home inhabitants suffering from severe osteoporosis, dementia and sarcopenia. The early and ongoing assessment for these individual risk factors is crucial. Strategies including interdisciplinary approaches, addressing comorbidities and facilitating an optimal risk factor evaluation result in a beneficial outcome. The ongoing ambulant assessment and therapy of complicating factors (e.g., malnutrition, sarcopenia, frailty or osteoporosis) have to be improved.

Effects of Frailty on Outcomes Following Surgery Among Patients With Hip Fractures: A Systematic Review and Meta-Analysis

Background

Frailty is a syndrome of multisystem dysfunction in the elderly. The association between preoperative frailty and postoperative outcomes in patients with hip fractures is unclear. To address this issue, we performed a meta-analysis to determine the association of frailty with postoperative mortality, complications, and readmission in patients with hip fractures.

Methods

We searched PubMed, Web of Science, Embase, and The Cochrane Library for cohort studies of frailty associated with postoperative adverse events in patients with hip fractures from inception to November 6, 2021. The Newcastle-Ottawa Scale was used to evaluate the quality of the included literature. Statistical analysis of meta-analysis was performed using Review Manager 5.3.

Results

Twelve retrospective cohort studies and seven prospective cohort studies involving a total of 62,132 patients met the inclusion criteria for this meta-analysis. Compared with non-frail patients, the pooled results showed that frailty was associated with patient in-hospital mortality (relative risk [RR] = 2.93; 95% confidence intervals [CI]: 2.56–3.34), 30-day mortality (RR = 2.85, 95%CI: 1.67–4.85) and total complications (RR = 1.79, 95%CI: 1.50–2.15). Subgroup analysis showed that the type of study design and frailty assessment tool had no significant effect on the results. Sensitivity analysis showed that the polled results of frailty predicted one-year mortality and 30-day readmission was unstable.

Conclusions

In this meta-analysis, we found that preoperative frailty may be associated with postoperative adverse events in patients with hip fractures, including in-hospital mortality, 30-day mortality, and postoperative complications.

Systematic Review Registration: PROSPERO, identifier: CRD42021287739.

The feasibility and reliability of frailty assessment tools applicable in acute in-hospital trauma patients: A systematic review

BACKGROUND

Assessing frailty in patients with an acute trauma can be challenging. To provide trustworthy results, tools should be feasible and reliable. This systematic review evaluated existing evidence on the feasibility and reliability of frailty assessment tools applied in acute in-hospital trauma patients.

METHODS

A systematic search was conducted in relevant databases until February 2020. Studies evaluating the feasibility and/or reliability of a multidimensional frailty assessment tool used to identify frail trauma patients were identified. The feasibility and reliability results and the risk of bias of included studies were assessed. This study was conducted and reported in line with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement and registered in Prospective Register of Systematic Reviews (ID: CRD42020175003).

RESULTS

Nineteen studies evaluating 12 frailty assessment tools were included. The risk of bias of the included studies was fair to good. The most frequently evaluated tool was the Clinical Frailty Scale (CFS) (n = 5). All studies evaluated feasibility in terms of the percentage of patients for whom frailty could be assessed; feasibility was high (median, 97%; range, 49-100%). Other feasibility aspects, including time needed for completion, tool availability and costs, availability of instructions, and necessity of training for users, were hardly reported. Reliability was only assessed in three studies, all evaluating the CFS. The interrater reliability varied between 42% and >90% agreement, with a Krippendorff α of 0.27 to 0.41.

CONCLUSION

Feasibility of most instruments was generally high. Other aspects were hardly reported. Reliability was only evaluated for the CFS with results varying from poor to good. The reliability of frailty assessment tools for acute trauma patients needs further critical evaluation to conclude whether assessment leads to trustworthy results that are useful in clinical practice.

LEVEL OF EVIDENCE

Systematic review, Level II.

Is Frailty Associated with Adverse Outcomes After Orthopaedic Surgery?: A Systematic Review and Assessment of Definitions

BACKGROUND

There is increasing evidence supporting the association between frailty and adverse outcomes after surgery. There is, however, no consensus on how frailty should be assessed and used to inform treatment. In this review, we aimed to synthesize the current literature on the use of frailty as a predictor of adverse outcomes following orthopaedic surgery by (1) identifying the frailty instruments used and (2) evaluating the strength of the association between frailty and adverse outcomes after orthopaedic surgery.

METHODS

A systematic review was performed using PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. PubMed, Scopus, and the Cochrane Central Register of Controlled Trials were searched to identify articles that reported on outcomes after orthopaedic surgery within frail populations. Only studies that defined frail patients using a frailty instrument were included. The methodological quality of studies was assessed using the Newcastle-Ottawa Scale (NOS). Study demographic information, frailty instrument information (e.g., number of items, domains included), and clinical outcome measures (including mortality, readmissions, and length of stay) were collected and reported.

RESULTS

The initial search yielded 630 articles. Of these, 177 articles underwent full-text review; 82 articles were ultimately included and analyzed. The modified frailty index (mFI) was the most commonly used frailty instrument (38% of the studies used the mFI-11 [11-item mFI], and 24% of the studies used the mFI-5 [5-item mFI]), although a large variety of instruments were used (24 different instruments identified). Total joint arthroplasty (22%), hip fracture management (17%), and adult spinal deformity management (15%) were the most frequently studied procedures. Complications (71%) and mortality (51%) were the most frequently reported outcomes; 17% of studies reported on a functional outcome.

CONCLUSIONS

There is no consensus on the best approach to defining frailty among orthopaedic surgery patients, although instruments based on the accumulation-of-deficits model (such as the mFI) were the most common. Frailty was highly associated with adverse outcomes, but the majority of the studies were retrospective and did not identify frailty prospectively in a prediction model. Although many outcomes were described (complications and mortality being the most common), there was a considerable amount of heterogeneity in measurement strategy and subsequent strength of association. Future investigations evaluating the association between frailty and orthopaedic surgical outcomes should focus on prospective study designs, long-term outcomes, and assessments of patient-reported outcomes and/or functional recovery scores.

CLINICAL RELEVANCE

Preoperatively identifying high-risk orthopaedic surgery patients through frailty instruments has the potential to improve patient outcomes. Frailty screenings can create opportunities for targeted intervention efforts and guide patient-provider decision-making.

Frailty measurements in hospitalised orthopaedic populations age 65 and older: A scoping review

Aims and Objectives

To identify and compare frailty instruments used with hospitalised orthopaedic patients aged over 65.

Background

Frailty predicts clinical events in orthopaedic patients aged over 65. However, the strengths and limitations of different approaches to measuring frailty in this population are rarely discussed. As such, a comprehensive review to address the gap is needed.

Design

Scoping review using Arksey and O’Malley framework.

Methods

PubMed, CINAHL, PsycINFO, Scopus and EMBASE databases were searched to identify studies published from 2006 to 2020 regarding frailty instruments in older orthopaedic patients. The Preferred Reporting Items for Systematic Reviews and Meta‐analyses were followed.

Results

The initial search resulted in 1,471 articles. After review against inclusion and exclusion criteria, a final set of 31 articles containing 15 unique frailty instruments were evaluated. Most of the articles were from Western countries. Fried's phenotype and Frailty Index were commonly used. The frailty index was mostly modified to measure frailty. In hip fracture, physical function items were frequently modified in the measurement of frailty. Trained physicians and nurses administered most frailty instruments. Frailty screening was commonly conducted at hospital admission and used to prognosticate both postoperative complications and hospital outcomes. Most instruments could be completed within 10 min. Reported psychometrics had acceptable reliability and validity.

Conclusion

Many reliable frailty measures have been used in the inpatient orthopaedic settings; however, evidence is still lacking for a gold standard frailty instrument. More research is needed to identify the best‐performing measure. Frailty evaluation in patients with physical limitations is challenging with existing instruments. Clinical context, resources required and instrument quality are essential factors in selecting a frailty instrument.

Relevance to clinical practice

Musculoskeletal symptoms in older patients may bias frailty assessment. Proactive frailty screening with valid and practical instruments is vital to strengthen preoperative risk stratification and improve post‐surgical outcomes.

Risk assessment for postoperative outcomes in a mixed hospitalized gynecological population by the Dutch safety management system (Veiligheidsmanagementsysteem, VMS) screening tool 'frail elderly'

Purpose

Frailty is associated with a higher risk for negative postoperative outcomes. This study aimed to determine the association between the screening tool of the Dutch safety management system, Veiligheidsmanagementsysteem (VMS) ‘frail elderly’ and postoperative complications in a gynecological population.

Methods

This cohort study included women aged 70 years or older, who were scheduled for any kind of gynecological surgery. VMS screening data (including risk for delirium, falling, malnutrition, and functional impairment) were extracted from the electronic patient records. VMS score could range between 0 and 4 patients with a VMS score of one or more were considered frail. Data on possible confounding factors and complications within 30 days after surgery, classified with the Clavien–Dindo classification, were collected. Regression analysis was performed.

Results

157 women were included with a median age of 74 years (inter quartile range 71–79). Most patients underwent prolapse surgery (52%) or hysterectomy (31%). Forty-one patients (26%) experienced any postoperative complication. Sixty-two patients (39%) were considered frail preoperatively by the VMS screening tool. Frailty measured with the VMS screening tool was not independently associated with postoperative complications in multivariable analysis (Odds ratio 1.18; 95% CI 0.49–2.82). However, a recent fall in the last 6 months (n = 208) was associated with postoperative complications (Odds ratio 3.90; 95% CI 1.57–9.66).

Conclusion

An independent association between frailty, determined by the VMS screening tool ‘Frail elderly’, and postoperative complications in gynecological surgery patients could not be confirmed. A recent fall in the last 6 months seems associated with postoperative complications.

Orthogeriatric Management: Improvements in Outcomes during Hospital Admission Due to Hip Fracture

Hip fractures are an important socio-economic problem in western countries. Over the past 60 years orthogeriatric care has improved the management of older patients admitted to hospital after suffering hip fractures. Quality of care in orthogeriatric co-management units has increased, reducing adverse events during acute admission, length of stay, both in-hospital and mid-term mortality, as well as healthcare and social costs. Nevertheless, a large number of areas of controversy regarding the clinical management of older adults admitted due to hip fracture remain to be clarified. This narrative review, centered in the last 5 years, combined the search terms "hip fracture", "geriatric assessment", "second hip fracture", "surgery", "perioperative management" and "orthogeriatric care", in order to summarise the state of the art of some questions such as the optimum analgesic protocol, the best approach for treating anemia, the surgical options recommendable for each type of fracture and the efficiency of orthogeriatric co-management and functional recovery.

Impact of place of residence, frailty and other factors on rehabilitation outcomes post hip fracture

BACKGROUND

Following hip fracture surgery, patients from residential care are frequently excluded from inpatient rehabilitation. We aimed to assess the impact of place of residence and other factors such as frailty on rehabilitation outcomes after hip fracture surgery.

METHODS

Retrospective cohort study. Outcome measures included Functional Independence Measure efficiency, discharge destination and recovery of pre-fracture mobility. Univariable and multivariable linear or logistic regression analyses were performed.

SETTING

One general rehabilitation and two geriatric evaluation and management wards in a large public tertiary teaching hospital.

PARTICIPANTS

A total of 844 patients who underwent inpatient rehabilitation after hip fracture surgery from 2010 to 2018.

RESULTS

There were 139 (16%) patients from residential care. Being from residential care was not an independent predictor of poor outcomes. Premorbid frailty (Clinical Frailty Scale) was the strongest independent predictor of poorer Functional Independence Measure efficiency, inability to recover pre-fracture mobility and return to community dwelling. Dementia and delirium were also independently predictive of poor outcomes across all measures. Age > 90 years was independently predictive of inability to recover pre-fracture mobility and return to community dwelling.

CONCLUSION

Being from residential care is not independently associated with poor outcomes following inpatient rehabilitation after hip fracture surgery and should not be the basis for excluding these patients from rehabilitation. Major predictors of poorer outcomes include premorbid frailty, dementia, delirium and age > 90 years. If able and motivated, those with potentially reversible functional limitations should be given the opportunity to participate in inpatient rehabilitation as even small gains can have a significant impact on quality of life.

Undernutrition, Sarcopenia, and Frailty in Fragility Hip Fracture: Advanced Strategies for Improving Clinical Outcomes

Geriatric patients with hip fractures often experience overlap in problems related to nutrition, including undernutrition, sarcopenia, and frailty. Such problems are powerful predictors of adverse responses, although few healthcare professionals are aware of them and therefore do not implement effective interventions. This review aimed to summarize the impact of undernutrition, sarcopenia, and frailty on clinical outcomes in elderly individuals with hip fractures and identify successful strategies that integrate nutrition and rehabilitation. We searched PubMed (MEDLINE) and Cochrane Central Register of Controlled Trials (CENTRAL) for relevant literature published over the last 10 years and found that advanced interventions targeting the aforementioned conditions helped to significantly improve postoperative outcomes among these patients. Going forward, protocols from advanced interventions for detecting, diagnosing, and treating nutrition problems in geriatric patients with hip fractures should become standard practice in healthcare settings.

Development and Internal Validation of a Prediction Model for In-Hospital Mortality in Geriatric Patients With a Hip Fracture

OBJECTIVE

To develop and validate a prediction model for in-hospital mortality in patients with hip fracture 85 years of age or older undergoing surgery.

DESIGN

A multicenter prospective cohort study.

SETTING

Six Dutch trauma centers, level 2 and 3.

PARTICIPANTS

Patients with hip fracture 85 years of age or older undergoing surgery.

INTERVENTION

Hip fracture surgery.

MAIN OUTCOME MEASUREMENTS

In-hospital mortality.

RESULTS

The development cohort consisted of 1014 patients. In-hospital mortality was 4%. Age, male sex, American Society of Anesthesiologists classification, and hemoglobin levels at presentation were independent predictors of in-hospital mortality. The bootstrap adjusted performance showed good discrimination with a c-statistic of 0.77.

CONCLUSION

Age, male sex, higher American Society of Anesthesiologists classification, and lower hemoglobin levels at presentation are robust independent predictors of in-hospital mortality in patients with geriatric hip fracture and were incorporated in a simple prediction model with good accuracy and no lack of fit.

LEVEL OF EVIDENCE

Prognostic Level II. See Instructions for Authors for a complete description of levels of evidence.

Prognostic value of screening instrument based on the Dutch national VMS guidelines for older patients in the emergency department

PURPOSE

It is important to identify which older patients attending the emergency department are at risk of adverse outcomes to introduce preventive interventions. This study aimed to assess the prognostic value of a shortened screening instrument based on the Dutch national Safety Management System [Veiligheidsmanagementsysteem (VMS)] guidelines for adverse outcomes in older emergency department patients.

METHODS

A cohort study was performed including patients aged 70 years or older who visited the emergency department. Adverse outcomes included hospital admission, return emergency department visits within 30 days, and 90-day mortality. The prognostic value of the VMS-score was assessed for these adverse events and, in addition, a prediction model was developed for 90-day mortality.

RESULTS

A high VMS-score was independently associated with an increased risk of hospital admission [OR 2.26 (95% CI 1.32-3.86)] and 90-day mortality [HR 2.48 (95% CI 1.31-4.71)]. The individual VMS-questions regarding history of delirium and help in activities of daily living were associated with these outcomes as well. A prediction model for 90-day mortality was developed and showed satisfactory calibration and good discrimination [AUC 0.80 (95% CI 0.72-0.87)]. A cut-off point that selected 30% of patients at the highest risk yielded a sensitivity of 67.4%, a specificity of 75.3%, a positive predictive value of 28.5%, and a negative predictive value of 94.1%.

CONCLUSION

The shortened VMS-based screening instrument showed to be of good prognostic value for hospitalization and 90-day mortality. The prediction model for mortality showed promising results and will be further validated and optimized.

The impact of frailty on posttraumatic outcomes in older trauma patients: A systematic review and meta-analysis

BACKGROUND

Frailty is a risk factor for mortality among the elderly. However, evidence from longitudinal studies linking trauma and frailty is fragmented, and a comprehensive analysis of the relationship between frailty and adverse outcomes is lacking. Therefore, we conducted a systematic review and meta-analysis to examine whether frailty is predictive of posttraumatic results including mortality, adverse discharge, complications, and readmission in trauma patients.

METHODS

This systematic review was registered with the PROSPERO international prospective register of systematic reviews. Articles in PubMed, Embase, and Web of Science databases from January 1, 1990, to October 31, 2019, were systematically searched. Articles in McDonald et al.'s study (J Trauma Acute Care Surg. 2016;80(5):824-834) and Cubitt et al.'s study (Injury 2019;50(11):1795-1808) were included for studies evaluating the association between frailty and outcomes in trauma patients. Cohort studies, both retrospective and prospective, were included. Study population was patients suffering trauma injuries with an average age of 50 years and older. Multivariate adjusted odds ratios (ORs) were calculated through a random-effects model, and the Newcastle-Ottawa Quality Assessment Scale was used to assess studies.

RESULTS

We retrieved 11,313 entries. Thirteen studies including seven prospective and six retrospective cohort studies involving 50,348 patients were included in the meta-analysis. Frailty was a significant predictor of greater than 30-day mortality (OR, 2.41; 95% confidence interval [CI], 1.17-4.95; I = 88.1%), in-hospital and 30-day mortality (OR, 4.05; 95% CI, 2.02-8.11; I = 0%), postoperative complications (OR, 2.23; 95% CI, 1.34-3.73; I = 78.2%), Clavien-Dindo IV complications (OR, 4.16; 95% CI, 1.70-10.17; I = 0%), adverse discharge (OR, 1.80; 95% CI, 1.15-2.84; I = 78.6%), and readmission (OR, 2.16; 95% CI, 1.19-3.91; I = 21.5%) in elderly trauma patients. Subgroup analysis showed that prospective studies (OR, 3.06; 95% CI, 1.43-6.56) demonstrated a greater correlation between frailty and postoperative complications.

CONCLUSION

Frailty has significant adverse impacts on the occurrence of posttraumatic outcomes. Further studies should focus on interventions for patients with frailty. Given the number of vulnerable elderly trauma patients grows, further studies are needed to determine the accuracy of these measures in terms of trauma outcomes.

LEVEL OF EVIDENCE

Systematic review and meta-analysis, level IV.

The effect of frailty on outcomes of surgically treated hip fractures in older people

BACKGROUND

Hip fractures are associated with mortality, disability, and loss of independence in older adults. While several risk factors associated with poor outcomes following a hip fracture have been identified, the effect of frailty status prior to hip fracture is not well established.

AIM

To examine the associations of frailty with mortality, change in activities of daily living (ADL) limitations, and transition to permanent residential aged care in older people following a hip fracture.

METHODS

A retrospective cohort study was conducted on people aged 65 years and older with a surgically treated hip fracture between 2003 and 2015. Frailty was estimated using a cumulative deficit-based frailty index and categorized into quartiles. Cox multivariable regression, logistic regression, and Fine-Gray multivariable regression models estimated associations of frailty with mortality, ADL limitations, and entry into permanent residential aged care, respectively. Hazard ratios (HR), odds ratios (OR), subdistribution hazard ratios (SHR), and 95% confidence intervals (95%CI) are reported.

RESULTS

Out of 4771 individuals with hip fractures, 75.6% were female and the median age was 86 (interquartile range 82-90) years old. The two-year survival of patients following hip fracture was 43.7% (95%CI 40.9-46.7%) in those in the highest quartile of frailty, compared to 54.4% (95%CI 51.8-57.2%) for those in the lowest quartile (HR = 1.25, 95%CI 1.11-1.41, p < 0.001). No associations between pre-fracture frailty and post-fracture ADL limitations were observed. Additionally, no association of frailty with transition to permanent residential aged care for patients living in the community (n = 1361) was observed (SHR = 0.98, 95%CI 0.81-1.18, p = 1.000).

CONCLUSIONS

Older patients with the highest level of frailty had an increased risk of mortality after hip fracture. Consideration for appropriate clinical interventions, including fall and frailty prevention measures, may be appropriate for this identified group of vulnerable individuals.

Preoperative Evaluation of the Frail Patient

Perioperative management of older adults is a complex field that is heavily influenced by the clinical heterogeneity of older adults. Frailty-a geriatric syndrome in which a patient is more vulnerable to stressors due to decreases in physical function and reserve-has been indicative of adverse postoperative outcomes. Many tools have been developed to measure frailty that incorporate a variety of factors including physical and cognitive function, comorbidities, self-reported measures of health, and clinical judgment. Most of these frailty assessment tools are able to identify a subset of patients at risk of adverse outcomes including postoperative complications, longer hospital length of stay, discharge to a higher level of care, and mortality. Frailty assessment before surgical interventions can also guide discussions among patients, their families, anesthesiologists, and surgeons to tailor operative plans for patients to mitigate this increased risk. Studies are ongoing to identify interventions in frail patients that can improve postoperative outcomes, but high-quality data in the form of randomized controlled trials are lacking at this time.

The Nottingham Spinal Health (NoSH) Study: a cohort study of patients hospitalised with vertebral fragility fractures

Patients hospitalised with vertebral fragility fractures were elderly, multimorbid and frail and lead to poor outcomes. Their hospital treatment needs to consider this alongside their acute fracture. A systematic organised model of care, such as an adaptation of orthogeriatric hip fracture care, will offer a more holistic approach potentially improving their outcomes.

PURPOSE

Patients admitted to hospital with vertebral fragility fractures are elderly and have complex care needs who may benefit from specialist multidisciplinary input. To date, their characteristics and outcomes have not been reported sufficiently. This study aims to justify such a service.

METHODS

Patients admitted with an acute vertebral fragility fracture over 12 months were prospectively recruited from a university hospital in England. Data were collected soon after their admission, at discharge from hospital and 6 months after their hospital discharge on their characteristics, pain, physical functioning, and clinical outcomes.

RESULTS

Data from 90 participants were analysed. They were mainly elderly (mean age 79.7 years), multimorbid (69% had ≥ 3 comorbid condition), frail (56% had a Clinical Frailty Scale score ≥ 5), cognitively impaired (54% had a MoCA score of < 23) and at high risk of falls (65% had fallen ≥ 2 in the previous year). Eighteen percent died at 6 months. At 6 months post-hospital discharge, 12% required a new care home admission, 37% still reported their pain to be severe and physical functioning was worse compared with their preadmission state.

CONCLUSION

Patients hospitalised with vertebral fragility fractures were elderly, multimorbid, frail and are susceptible to persistent pain and disability. Their treatment in hospital needs to consider this alongside their acute fracture. A systematic organised model of care, such as an adaptation of orthogeriatric hip fracture care, will offer a more holistic approach potentially improving their outcomes.

Involvement of plasma miRNAs, muscle miRNAs and mitochondrial miRNAs in the pathophysiology of frailty

Frailty is a geriatric syndrome that leads not only to the loss of physical functions, but also to a generalized decline of the organism and a high risk of disability and dependency. Frailty's detection and management represent important goals for current gerontology. The advance in its rapid diagnosis could play a relevant role in taking measures to reduce the negative consequences it exerts on the body and to take preventive measures. microRNAs are the one of multiple epigenetic biomarkers that reflect functional changes in aged subject. In this review we analyze microRNAs as molecules involved in the control of the pathways leading to the development of frailty. miRNAs can be present in different body fluids, including plasma/serum and saliva, can be associated with organelles like the mitochondria, and can be expressed in tissues. Based on the multifactorial physiopathology of frailty, we analyzed here the microRNAs linked to "inflammaging" (inflamma-miRs), to musculoskeletal health (myomiRs), and microRNAs that can directly or indirectly affect the mitochondria (mitomiRs). Subsequently, we analyze those microRNAs that can be modified by physical exercise. In this review we will analyze the latest experimental studies carried out in animals, cell cultures, and human samples, with the aim to identify gaps in the research and in order to try to dazzle the information about the pathways regulated by each miRNA. Multiple studies revised here suggest that several miRs can be considered as possible markers of frailty, including miR-1, miR-21, miR-34a, miR-146a, miR-185, and miR-206, miR-223, among others. Normalization of miRNAs data and standardization of the protocols used for their measurement to avoid confounding variables influencing the results, are important to use miRNAs as disease biomarkers.