The Clinical Frailty Scale (CFS) as an Independent Prognostic Factor for Patients ≥80 Years with Small Bowel Obstruction (SBO)

BACKGROUND

SBO is a potentially life-threatening condition that often affects older patients. Frailty, more than age, is expected to play a crucial role in predicting SBO prognosis in this population. This study aims to define the influence of Clinical Frailty Scale (CFS) on mortality and major complications in patients ≥80 years with diagnosis of SBO at the emergency department (ED).

METHODS

All patients aged ≥80 years admitted to our ED for SBO from January 2015 to September 2020 were enrolled. Frailty was assessed through the CFS, and then analyzed both as a continuous and a dichotomous variable. The endpoints were in-hospital mortality and major complications.

RESULTS

A total of 424 patients were enrolled. Higher mortality (20.8% vs 8.6%, p<0.001), longer hospital stay (9 [range 5-14] days vs 7 [range 4-12] days, p=0.014), and higher rate of major complications (29.9% vs 17.9%, p=0.004) were associated with CFS ≥7. CFS score and bloodstream infection were the only independent prognostic factors for mortality (OR 1.72 [CI: 1.29-2.29], p<0.001; OR 4.69 [CI: 1.74-12.6], p=0.002, respectively). Furthermore, CFS score, male sex and surgery were predictive factors for major complications (OR 1.41 [CI: 1.13-1.75], p=0.002; OR 1.67 [CI: 1.03-2.71], p=0.038); OR 1.91 [CI: 1.17-3.12], p=0.01; respectively). At multivariate analysis, for every 1-point increase in CFS score, the odds of mortality and the odds of major complications increased 1.72-fold and 1.41-fold, respectively.

CONCLUSION

The increase in CFS is directly associated with an increased risk of mortality and major complications. The presence of severe frailty could effectively predict an increased risk of in-hospital death regardless of the treatment administered. The employment of CFS in elderly patients could help the identification of the need for closer monitoring and proper goals of care.

Predicting ICU admission and death in the Emergency Department: A comparison of six early warning scores

AIM

To compare the ability of the most used Early Warning Scores (EWS) to identify adult patients at risk of poor outcomes in the emergency department (ED).

METHODS

Single-center, retrospective observational study. We evaluated the digital records of consecutive ED admissions in patients ≥ 18 years from 2010 to 2019 and calculated NEWS, NEWS2, MEWS, RAPS, REMS, and SEWS based on parameters measured on ED arrival. We assessed the discrimination and calibration performance of each EWS in predicting death/ICU admission within 24 hours using ROC analysis and visual calibration. We also measured the relative weight of clinical and physiological derangements that identified patients missed by EWS risk stratification using neural network analysis.

RESULTS

Among 225,369 patients assessed in the ED during the study period, 1941 (0.9%) were admitted to ICU or died within 24 hours. NEWS was the most accurate predictor (area under the receiver operating characteristic [AUROC] curve 0.904 [95% CI 0.805-0.913]), followed by NEWS2 (AUROC 0.901). NEWS was also well calibrated. In patients judged at low risk (NEWS < 2), 359 events occurred (18.5% of the total). Neural network analysis revealed that age, systolic BP, and temperature had the highest relative weight for these NEWS-unpredicted events.

CONCLUSIONS

NEWS is the most accurate EWS for predicting the risk of death/ICU admission within 24 h from ED arrival. The score also had a fair calibration with few events occurring in patients classified at low risk. Neural network analysis suggests the need for further improvements by focusing on the prompt diagnosis of sepsis and the development of practical tools for the measurement of the respiratory rate.

Frailty in Elderly Patients with Covid-19: A Narrative Review

Introduction

The SARS CoV-2 pandemic still generates a very high number of affected patients and a significant mortality rate. It is essential to establish objective criteria to stratify COVID-19 death risk. Frailty has been identified as a potential determinant of increased vulnerability in older adults affected by COVID-19, because it may suggest alterations of physical performance and functional autonomy.

Methods

We have conducted a narrative review of the literature on the evidences regarding COVID-19 and the frailty condition. Thirteen observational studies were included.

Conclusion

Data emerging from the studies indicate that older COVID-19 patients with a frailty condition have an increased risk of mortality compared with non-frail patients, and this association is independent of other clinical and demographic factors. A frailty evaluation is required to help clinicians to better stratify the overall risk of death for older patients with COVID-19.

Frailty Assessment in the Emergency Department for Risk Stratification of COVID-19 Patients Aged ≥80 Years

OBJECTIVES

To evaluate, in a cohort of adults aged ≥80 years, the overlapping effect of clinical severity, comorbidities, cognitive impairment, and frailty, for the in-hospital death risk stratification of COVID-19 older patients since emergency department (ED) admission.

DESIGN

Single-center prospective observational cohort study.

SETTING AND PARTICIPANTS

The study was conducted in the ED of a teaching hospital that is a referral center for COVID-19 in central Italy. We enrolled all patients with aged ≥80 years old consecutively admitted to the ED between April 2020 and March 2021.

METHODS

Clinical variables assessed in the ED were evaluated for the association with all-cause in-hospital death. Evaluated parameters were severity of disease, frailty, comorbidities, cognitive impairment, delirium, and dependency in daily life activities. Cox regression analysis was used to identify independent risk factors for poor outcomes.

RESULTS

A total of 729 patients aged ≥80 years were enrolled [median age 85 years (interquartile range 82-89); 346 were males (47.3%)]. According to the Clinical Frailty Scale, 61 (8.4%) were classified as fit, 417 (57.2%) as vulnerable, and 251 (34.4%) as frail. Severe disease [hazard ratio (HR) 1.87, 95% confidence interval (CI) 1.31-2.59], ≥3 comorbidities (HR 1.54, 95% CI 1.11-2.13), male sex (HR 1.46, 95% CI 1.14-1.87), and frailty (HR 6.93, 95% CI 1.69-28.27) for vulnerable and an overall HR of 12.55 (95% CI 2.96-53.21) for frail were independent risk factors for in-hospital death.

CONCLUSIONS AND IMPLICATIONS

The ED approach to older patients with COVID-19 should take into account the functional and clinical characteristics of patients being admitted. A sole evaluation based on the clinical severity and the presence of comorbidities does not reflect the complexity of this population. A comprehensive evaluation based on clinical severity, multimorbidity, and frailty could effectively predict the clinical risk of in-hospital death for patients with COVID-19 aged ≥80 years at the time of ED presentation.