Using frailty tools as prognostic markers in patients who are acutely ill

Abstract

F railty is a state that arises from a multisystem decline. It compromises the body's ability to respond to stressors. 1 Although frailty has been shown to be a good indicator of poor outcomes across settings, limited evidence supports the use of frailty screening tools in acute care, and few studies have been conducted outside of geriatric medicine. In the linked article, Li and colleagues examined the prognostic value of frailty for death and readmission to hospital in 308 older patients with no severe disability who were undergoing emergency abdominal surgery. 2 Preadmission frailty was measured using the Clinical Frailty Scale (CFS), a tool that is commonly used in clinical settings because it is easy to implement. 3 The authors found that 77% of the patients were either vulnerable or frail (CFS > 2), and these patients were more likely than nonfrail participants either to die or be readmitted to hospital within 30 days and six months after surgery. 2 However, frailty is a dynamic process and interventions to assess and address frailty could affect such outcomes.Comprehensive geriatric assessment, the mainstay of a good geriatric consultation, represents an evidence-based intervention for frail inpatients. A well-done 2011 meta-analysis of data involving 10 315 older adults who were admitted to hospital found that the benefits of an inpatient comprehensive geriatric assessment included a greater chance of survival and living at home at six months (odds ratio [OR] 1.25, 95% confidence interval [CI] 1.11-1.42) and 12 months (OR 1.16, 95% CI 1.05-1.28), and a lower chance of placement in long-term care (OR 0.79, 95% CI 0.69-0.88) and deterioration (OR 0.76, 95% CI 0.64-0.90). 4 A systematic review reported that there were 2.6% to 19.7% fewer admissions to hospital when a comprehensive geriatric assessment was completed for older adults in the emergency department. 5 Li and colleagues recorded a low number of geriatric assessments among patients in the population of the linked study: only 4% of patients in the frailty group received a geriatric consultation. 2 This may have been a lost opportunity to prevent the poor outcomes that this group experienced.There are fewer studies of frailty among specific groups of older inpatients undergoing surgery. However, specific shared ortho-geriatric care appears to improve functional outcomes compared with usual care. 6 A 2014 meta-analysis of models for interventions using geriatric assessment in orthogeriatrics (comparing geriatric ward, consultation or shared care), showed that presurgical geriatric consultation decreased in-hospital mortality (relative risk [RR] 0.60, 95% CI 0.43-0.84) and long-term mortality (RR 0.83, 95% CI 0.74-0.94); however, the meta-analysis could not determine which model was superior. 7 It would be important to know if a comprehensive geriatric assessment would benefit a subpopulation of older adults admitted to hospital for abdominal surgery and if this type of intervention would be cost-effective.Many tools for frailty assessment distinguish o...

Diagnosing Frailty in Primary Care Practice

“…Few available multidimensional tools can be used for both cases finding and component definition (i.e., exploring the components of frailty such as cognitive ability, multimorbidity, functional status and mobility, polypharmacy, social supports, continence, and mood) [7]. However, no specific instruments or biomarkers are adequately proven to be superior to others [4,7].…”

“…The falls of the elderly affect the family, social and economic dynamics because they increase the number of hospitalizations due to fractures, can generate incapacities, and lead to premature death. Few identifiable risk factors for falls in the elderly are impaired vision, pain, gait alteration, lack of physical conditioning, polypharmacy, comorbidities, impaired balance, musculoskeletal impairment, sarcopenia, pre-obesity, obesity, decreased cognitive function, and sedentary lifestyle [1][2][3][4]. Also, with aging, the information processing capacity decreases.…”

“…Prior to a disability, an intermediate state known as frailty is characterized by diminished capacity to respond to stressors due to a reduced functional reserve [2]. Frailty prevalence rises with advancing age, from 16% in people older than 65 to as high as 52% in those older than 85 [4]. Frailty syndrome encompasses physical, cognitive, psychological, and social factors.…”

“…Over half of the frail adults are reported to have fallen in the previous year [6]. Frailty-induced falls are associated with a greater risk of fractures, disability, immobility, hospitalizations, institutionalization, caregiver burden, decreased life quality, and even death [4,7].…”

Examining Frailty and Multimorbidity in Nursing Research of Older Emergency Department Patients

“…Where possible, nursing and emergency researchers focused on geriatric care should aim to collect or analyze data on patient frailty, using one of the many valid instruments available, such as the Clinical Frailty Scale (Rockwood et al, 2005;Theou et al, 2021), Fried's phenotypic model (Fried et al, 2001), or the ED Frailty Index (Brousseau et al, 2018), to name a few. If interested in the unique prognostic value of frailty or multimorbidity, uncontaminated measures are needed to prevent overfit statistical models and poor external validity (Theou & Searle, 2018). In other words, it is essential to ensure that the selected frailty measure does not take into account co-morbid status and vice versa.…”