Frailty assessment in emergency medicine using the Clinical Frailty Scale: a scoping review

Improving comprehensive geriatric assessments with the clinical frailty scale: a focus group study

BACKGROUND

The purpose of this study is to exploratively evaluate the geriatric team's views on the implementation of the Comprehensive Geriatric Assessment (CGA) and Clinical Frailty Scale (CFS) on frail older people with acute orthopaedic disorders who are cared for in two geriatric care wards in the southwest of Sweden.

METHODS

A qualitative design with focus groups was applied, based on a social constructivist research tradition. This approach differs from other qualitative methods, such as interviews, in that it encourages interaction between research participants and contributes to shedding light on a collective understanding of the world. This means that the analysis is based on the group's collective input, not individual statements. The study group consisted of 21 professionals participating in four focus groups, with five to six participants per group. The participants in each group represented different professions within the geriatric team, including nurses, nursing assistants, physicians, occupational therapists, and physiotherapists.

RESULTS

The results underscore the importance of the CFS as the basis for CGA, emphasizing the effectiveness of the scale as a shared instrument promoting collaboration in healthcare. Our study uniquely points out the lack of research exploring the team-based use of tools for conducting a frailty assessment using the CFS. The study also highlights the importance of effective teamwork and a person-centred approach. The balance between person-centred care and what is feasible within the organization is crucial to providing the best possible care for patients.

CONCLUSIONS

In Sweden, as in other places, how healthcare staff experience their work is key to the quality of care. The study concludes that positive staff experiences with new approaches drive healthcare improvement, benefiting patients and society. This highlights the potential for further improvements in healthcare delivery through continued innovation and collaboration.

TRIAL REGISTRATION

Clinical trial number: not applicable.

What can we learn from 68 000 clinical frailty scale scores? Evaluating the utility of frailty assessment in emergency departments

BACKGROUND

Emergency departments (EDs) in England are under significant strain, with increasing attendances and extended wait times, affecting frail older adults. The clinical frailty scale (CFS) has been implemented as a tool to assess frailty in ED settings, but its reliability and predictive accuracy as a screening tool remain debated.

OBJECTIVE

To evaluate the use and variability of the CFS in EDs and its association with patient outcomes, including discharge rates, length of stay, readmission and mortality.

METHODS

A retrospective cohort study of ED attendances at two London (UK) hospitals from 2017 to 2021. Data included CFS scores, demographics, clinical observations and outcomes. Comparative statistics, logistic regression, Cox proportional hazards models and competing risk regression were applied to examine CFS predictive validity.

RESULTS

In a sample of 123 324 ED visits, CFS scores strongly correlated with adverse outcomes: e.g. for long-term mortality (n = 33 475, events = 8871), each CFS single-point increase was associated with a 25% increase in mortality risk (95% CI 1.23-1.26). CFS scores varied significantly between raters and across visits, median difference two levels (interquartile range 1-3). Intraclass correlation coefficient analysis showed that 33.1% of CFS score differences was attributable to between-patient differences, 15.4% to inter-rater differences, with 51.5% residual variance from non-frailty factors, such as acute illness severity.

CONCLUSION

The CFS is associated with crucial patient outcomes in the ED. Inter-rater variability and potentially confounding factors can limit its consistency. Automation to enhance CFS score reliability should be explored as a means to support proactive management.

Assessing the utility of frailty scores in triage: a comparative study of validated scales

Currently, there is conflicting evidence regarding the efficacy of frailty scales and their ability to enhance or support triage operations. This study aimed to assess the utility of three common frailty scales (CFS, PRISMA-7, ISAR) and determine their utility in the triage setting. This prospective observational monocentric study was conducted at Merano Hospital's Emergency Department (ED) from June 1st to December 31st, 2023. All patients attending this ED during the 80-day study period were included, and frailty scores were correlated with three outcomes: hospitalization, 30-day mortality, and severity of condition as assessed by ED physicians. Patients were categorized by age, and analyses were performed for the entire study population, patients aged 18-64, and those aged 65 or older. Univariate analysis was followed by multivariable analysis to evaluate whether frailty scores were independently associated with the outcomes. In multivariable analysis, none of the frailty scores were found to be associated with the study outcomes, except for the CFS, which was associated with an increased risk of 30-day mortality, with an odds ratio of 1.752 (95% CI 1.148-2.674; p = 0.009) in the general population and 1.708 (95% CI 1.044-2.793; p = 0.033) in the population aged ≥ 65. Presently, available frailty scores do not appear to be useful in the triage context. Future research should consider developing new systems for accurate frailty assessment to support risk prediction in the triage assessment.

Comparison of frailty screening tools in predicting length of stay and disability in older patients on internal medicine inpatient wards transferred from the emergency department: A retrospective observational study

The aim of this study is to compare frailty screening tools in predicting length of stay (LOS) in older patients on internal medicine inpatient wards transferred from the emergency department (ED). This cross-sectional retrospective study involving 186 subjects aged 65 years or older was conducted at tertiary hospital internal medicine inpatient wards transferred from the ED from September to November 2023. Frailty was defined by the Clinical Frailty Scale (CFS), the identification of Seniors At Risk Tool and the Triage Risk-Screening Tool (TRST). Dependency was defined by Katz Index of Independence in activities of daily living (ADL) and the Lawton instrumental ADL. The presence of frailty according to the CSF and TRST was associated with a long LOS (coefficient of regression β = 0.2 with P < .05). But, in binary logistic regression analysis, there was no association between long LOS and frailty scales. All frailty tools were statistically significant predictors for disability (P < .001). Our findings suggest that, among the tools evaluated, the CFS may be the most robust predictor of both LOS and functional dependency, although its predictive power for actual disability remains limited. Future studies should focus on refining these tools for greater accuracy in predicting functional outcomes and should examine how factors such as polypharmacy and comorbidities impact frailty and hospital outcomes. Additionally, longitudinal studies are needed to establish causative relationships between frailty, LOS, and functional decline.

Pre-injury frailty and clinical care trajectory of older adults with trauma injuries: A retrospective cohort analysis of A large level I US trauma center

BACKGROUND

Pre-injury frailty among older adults with trauma injuries is a predictor of increased morbidity and mortality.

OBJECTIVES

We sought to determine the relationship between frailty status and the care trajectories of older adult patients who underwent frailty screening in the emergency department (ED).

METHODS

Using a retrospective cohort design, we pooled trauma data from a single institutional trauma database from August 2020 to June 2023. We limited the data to adults 65 years and older, who had trauma injuries and frailty screening at ED presentation (N = 2,862). The predictor variable was frailty status, measured as either robust (score 0), pre-frail (score 1-2), or frail (score 3-5) using the FRAIL index. The outcome variables were measures of clinical care trajectory: trauma team activation, inpatient admission, ED discharge, length of hospital stay, in-hospital death, home discharge, and discharge to rehabilitation. We controlled for age, sex, race/ethnicity, health insurance type, body mass index, Charlson Comorbidity Index, injury type and severity, and Glasgow Coma Scale score. We performed multivariable logistic and quantile regressions to measure the influence of frailty on post-trauma care trajectories.

RESULTS

The mean (SD) age of the study population was 80 (8.9) years, and the population was predominantly female (64%) and non-Hispanic White (60%). Compared to those classified as robust, those categorized as frail had 2.5 (95% CI: 1.86-3.23), 3.1 (95% CI: 2.28-4.12), and 0.3 (95% CI: 0.23-0.42) times the adjusted odds of trauma team activation, inpatient admission, and ED discharge, respectively. Also, those classified as frail had significantly longer lengths of hospital stay as well as 3.7 (1.07-12.62), 0.4 (0.28-0.47), and 2.2 (95% CI: 1.71-2.91) times the odds of in-hospital death, home discharge, and discharge to rehabilitation, respectively.

CONCLUSION

Pre-injury frailty is a predictor of clinical care trajectories for older adults with trauma injuries.

Concordance with routine Clinical Frailty Scale screening in the frailty in European emergency departments (FEED) study

BACKGROUND

Frailty screening determines who receive geriatric emergency medicine interventions that are of high importance for patient outcomes. However, post-implementation evaluations show around 50% older Emergency Department (ED) attenders to receive screening. Why and who are omitted from screening remains largely unstudied. This study gave opportunity to compare normal screening status to data from a targeted screening study.

METHODS

The parent Frailty in European Emergency Departments (FEED) study administered the Clinical Frailty Scale (CFS) to consecutive ED attenders on 04 July 2023. This present study considered a subset of sites which provided retrievable CFS data from a "normal day" two weeks prior. Symmetry and dependency of missing CFS entries with observed variables were assessed. The frailty distribution was then compared with the parent FEED study data.

RESULTS

A minority of sites (5/62) recorded CFS in retrievable format. 55 % "normal day" CFS entries were missing compared with 14 % consecutive attenders during the parent FEED study. While no pattern was evident in the FEED cohort, "normal day" CFS entries were more frequently missing with non-white ethnic group (76 %, vs 52 % with white group), self-presentation (68 %), and discharge home from ED (59 %). CFS distributions differed between the routine and research day datasets (p = 0.009).

CONCLUSION

Our findings suggest systematic, non-random omission of CFS in normal screening practice, disproportionately affecting people with non-white ethnic group and self-presentation. This raises concern for limitations when routine CFS data are analysed and prompts study and improvement of concordance with screening.

Comparative Analysis of Frailty Scales in Emergency Department: Highlighting the Strengths of the Triage Frailty and Comorbidity Tool

INTRODUCTION

Currently, there is uncertainty about which frailty scale is most appropriate and valid for use in the emergency department. The objective of this study was to compare the most commonly used frailty scales in triage and evaluate their performance.

METHODS

This prospective, single-center observational study was conducted from June to December 2023. Data collection spanned 80 days, during which the triage nurse recorded frailty scales using the Clinical Frailty Scale, Identification of Seniors at Risk, Program of Research to Integrate the Service for the Maintenance of Autonomy 7 (PRISMA-7), and the Triage Frailty and Comorbidity tool. The Clinical Frailty Scale, Identification of Seniors at Risk, and PRISMA-7 were used for patients aged >65 years, whereas the Triage Frailty and Comorbidity tool was applied to all patients presenting to the emergency department. The scales were compared using the area under the receiver operating characteristic curve for 90-day mortality, 30-day mortality, and hospitalization.

RESULTS

A total of 1270 patients were enrolled during the study period. In comparing the receiver operating characteristic curves, the Triage Frailty and Comorbidity tool demonstrated a receiver operating characteristic curve of 0.894 (95% CI: 0.858-0.929), whereas the Clinical Frailty Scale had 0.826 (95% CI: 0.762-0.890), PRISMA-7 had 0.814 (95% CI: 0.751-0.876), and Identification of Seniors at Risk had 0.821 (95% CI: 0.759-0.882), with a comparison P value of 0.03. The Triage Frailty and Comorbidity tool also significantly outperformed the other scales for 90-day mortality, 30-day mortality, and hospitalization across the overall population. Considering only the population aged >65 years, it identifies frail patients equally well as the other tools.

DISCUSSION

The findings of this study suggest that the Triage Frailty and Comorbidity tool is a valid instrument for assessing frailty in the emergency department. Moreover, among the scales used, it is the only 1 that considers the entire adult population, not just those aged >65 years, making it more inclusive for a setting such as the emergency department.

Scale-based screening and assessment of age-related frailty

As the population ages, the prevalence of age-related frailty increases sharply, which increases the risk of poor health status of older adults, such as disability, falls, hospitalization, and death. Across the globe, frailty is moving toward the forefront of health and medical research. Currently, frailty is believed to be preventable and reversible, so the early identification of frailty is critical. However, there are neither precise biomarkers of frailty nor definitive laboratory tests and corresponding clinical testing techniques and equipment in clinical practice. As a result, the clinical identification of frailty is mainly achieved through the widely used frailty scale, which is an objective, simple, time-saving, effective, economical, and feasible measurement tool. In this narrative review, we summarized and analyzed the various existing frailty scales from different perspectives of screening and evaluation, aiming to provide a reference for clinical researchers and practitioners to judge and manage frail older people accurately.

"What Matters" in the Emergency Department: A Prospective Analysis of Older Adults' Concerns and Desired Outcomes

OBJECTIVE

To describe "What Matters" to older adults seeking emergency department (ED) care and to identify patient characteristics associated with meeting desired outcomes.

BACKGROUND

As part of the 4Ms framework, identifying "What Matters" has been captured across healthcare settings, yet limited attention has been directed to older adults in the ED.

METHODS

We performed a secondary analysis of a multicenter prospective observational study. The study enrolled 1013 patients aged 65 and older during an ED encounter and performed 90-day follow-up interviews. The primary outcome was the quantification of "What Matters" (concerns and desired outcomes) to older adults during emergency care. As secondary outcomes, we assessed concerns at day 90, if desired outcomes were met at follow-up, and patient characteristics associated with outcome achievement by estimating multivariable logistic regression models.

RESULTS

Older adults reported specific concerns at the time of the ED visit including: (1) symptom identification and/or persistence (31.4%), (2) ability to take care of oneself (19.4%), and (3) end-of-life (17.8%). Desired outcomes expressed by participants included: (1) getting well and symptom resolution (72.0%), (2) obtaining a diagnosis (25.7%), and (3) functional independence (19.5%). At day 90 follow-up, concerns remained similar to the initial ED visit, and the majority of participants (66.2%) achieved their desired outcome. Frailty (adjusted odds ratio = 0.56, 95% CI: 0.38-0.83, P < 0.01) was associated with older adults not meeting their desired outcomes.

CONCLUSIONS

Older adults identified a variety of concerns during emergency care, and two-thirds reported that desired outcomes were met at longitudinal day 90 follow-up.

Perspectives on Frailty Among Emergency Physicians: A Qualitative Descriptive Study

Background The proportion of older people in the general population is rising. Accompanying this rise is an increased prevalence of frailty. Frailty is a syndrome of increased vulnerability to stressors due to decreased physiological reserve and is linked to increased health services use. Frailty assessment provides a comprehensive insight into an older person's health status but is not regularly performed in emergency departments (EDs) worldwide. Understanding emergency physicians' (EPs) perspectives on frailty could assist in facilitating the implementation of frailty assessments in the ED. However, little is known about EP perceptions of frailty. Objectives The aim of this study was to explore perspectives on frailty among EPs. Design An exploratory qualitative descriptive study was conducted. EPs' perspectives on frailty were explored in semi-structured interviews, including questions on the meaning of frailty, its detection, management, and potential to improve the care of frail ED patients. Interviews were recorded and transcribed. Setting Central Adelaide Local Health Network, which has two EDs in Adelaide, South Australia. Participants Sixteen EPs were interviewed. Eleven (69%) were male EPs and 10 (63%) were practicing as EPs for 4 years or less. Measurements We analyzed interview transcripts by inductive thematic analysis. We generated, iteratively revised, and applied a coding framework, enabling progression to the formulation of themes. Results We developed three themes. Theme 1: EPs did not perceive frailty as a priority of care due to their focus on acuity, and lack of knowledge, time, and resources. Theme 2: EPs referred to detecting and managing frailty indirectly rather than formally. Theme 3: EPs saw a beneficial role in frailty recognition and management in the future. Conclusions EPs did not perceive frailty as a priority of care. However, they had a positive view on progressing with increased frailty awareness and holistic management in EM, for patient and health system benefits.

Integrating frailty management into cardiac intensive care unit nursing practice: A qualitative study

BACKGROUND

Frailty is prevalent among older patients in intensive care units (ICUs) and poses significant challenges to recovery. Despite its importance, there is limited research on effective nurse-led frailty management strategies in this context.

OBJECTIVE

The purpose of this qualitative study was to explore nurses' perceptions of frailty management in cardiac ICUs through the lens of the Wuli-Shili-Renli (WSR) system approach.

METHODS

Sixteen nurses from two tertiary hospitals in Shandong province, China, participated in semi-structured interviews. Participants were selected based on their involvement in frailty training, educational background, and cardiac ICU work experience. Thematic analysis was conducted to identify key themes and sub-themes.

RESULTS

Analysis in three categories revealed the need for foundational support, including the need for appropriate screening tools, updated evidence-based practices, and institutional support. Closed-loop management involved frailty screening, personalized program implementation, information management, and follow-up assessment. Personnel training and coordination emphasized enhancing nurses' professionalism, multidisciplinary teamwork, and cooperation from patients and their caregivers.

CONCLUSION

The insights gained can inform evidence-based practices and improve the quality of care provided to frail patients in cardiac ICUs. There is a need for future research to empirically investigate these strategies.

Development and validation of a nomogram for assessing comorbidity and frailty in triage: a multicentre observational study

Assessing patient frailty in the Emergency Department (ED) is crucial; however, triage frailty and comorbidity assessment scores developed in recent years are unsatisfactory. The underlying causes of this phenomenon could reside in the nature of the tools used, which were not designed specifically for the emergency context and, thus, are difficult to adapt to the emergency environment. The objective of this study was to create and internally validate a nomogram for identifying different levels of patient frailty during triage. Multicenter, prospective, observational exploratory study conducted in two ED. The study was conducted from April 1 to October 31, 2022. Following the triage assessment, the nurse collected variables related to the patient's comorbidities and chronic conditions using a predefined form. The primary outcome was the 90-day mortality rate. A total of 1345 patients were enrolled in this study; 6% died within 90 days. In the multivariate analysis, the Charlson Comorbidity Index, an altered motor condition, an altered cognitive condition, an autonomous chronic condition, arrival in an ambulance, and a previous hospitalization within 90 days were independently associated with death. The internal validation of the nomogram reported an area under the receiver operating characteristic of 0.91 (95% CI 0.884-0.937). A nomogram was created for assessing comorbidity and frailty during triage and was demonstrated to be capable of determining comorbidity and frailty in the ED setting. Integrating a tool capable of identifying frail patients at the first triage assessment could improve patient stratification.

Comparative Clinical Characteristics of Frail Older Adults in the Emergency Department: Long-Term Care Hospital versus Community Residence

BACKGROUND/OBJECTIVE

Older patients from long-term care hospitals (LTCHs) presenting to emergency departments (EDs) exhibit a higher prevalence of frailty than those from the community. However, no study has examined frailty in patients from LTCHs in the ED. This study compared frailty in older patients from LTCHs and the community.

METHODS

We retrospectively analyzed data from the EDs of three university hospitals between 1 August and 31 October 2023, involving 5908 patients (515 from LTCHs and 5393 from the community). The Korean version of the Clinical Frailty Scale (CFS-K) was used to assess individuals aged 65 and older. We compared clinical characteristics, frailty, length of stay (LOS), and diagnosis between patients from LTCHs (LTCH group) and the community (community group).

RESULTS

Among ED patients, 55.0% and 35.2% in the LTCH and the community groups, respectively, were frail (p < 0.001). Of these, 71.7% in the LTCH group were hospitalized compared with 53.1% in the community group (p = 0.001). The odds ratio for in-hospital mortality was 4.910 (95% CI 1.458-16.534, p = 0.010) for frail LTCH patients and 3.748 (95% CI 2.599-5.405, p < 0.001) for frail community patients, compared to non-frail patients.

CONCLUSIONS

Patients from LTCHs with frailty had higher hospital admission rates and increased in-hospital mortality compared to those in the community at the same frailty level. This study offers essential insights into the characteristics of older patients in LTCHs for healthcare administrators and medical staff worldwide.

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

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

Diabetes, frailty and burden of comorbidities among older Malaysians with stroke

Background

Stroke is a global health challenge. The increasing prevalence of diabetes and the ageing population further add to the complexities of stroke care.

Objective

This study aims to (1) describe the prevalence of diabetes in older patients with stroke and (2) compare the burden of comorbidities among patients with diabetes and frailty compared to those without these conditions.

Methods

This was a cross-sectional study in older patients aged ≥ 65 years with stroke. Comorbidities were assessed using the Charlson Comorbidity Index (CCI). Frailty assessments were done using the Clinical Frailty Scale. Participants were classified into four groups: Group 1, frail and diabetic; Group 2, non-frail and diabetic; Group 3, frail and non-diabetic; and Group 4, non-frail and non-diabetic.

Results

There were 384 participants (mean age 81.11 ± 6.37). Diabetes was present in 45.1%. The mean CCI was highest for the frail and diabetic group (6.97 ± 1.97), followed by non-frail and diabetic (6.00 ± 2.02), frail and non-diabetic (5.49 ± 1.79) and non-frail and non-diabetic (4.74 ± 1.68), p < 0.001. The non-frail and diabetic group had a significantly higher prevalence of hypertension (96.9%) and ischaemic heart disease (34.4%) compared to the other three groups.

Conclusions

There was a high prevalence of diabetes among older patients with stroke. While the frail and diabetic group had the highest overall burden of comorbidities, the non-frail and diabetic group had the most significant cardiovascular disease burden. These findings highlight the urgent need for integrated and personalized management approaches to enhance the overall well-being and quality of life for older stroke survivors with diabetes.

Frailty is associated with 30-day mortality: a multicentre study of Swedish emergency departments

BACKGROUND

Older patients living with frailty have an increased risk for adverse events. The Clinical Frailty Scale (CFS) is a 9-point frailty assessment instrument that has shown promise to identify frail emergency department (ED) patients at increased risk of adverse outcomes. The aim of this study was to investigate the association between CFS scores and 30-day mortality in an ED setting when assessments are made by regular ED staff.

METHOD

This was a prospective multicentre observational study carried out between May and November 2021 at three EDs in Sweden, where frailty via CFS is routinely assessed by ED staff. All patients ≥65 years of age were eligible for inclusion. Mortality at 7, 30 and 90 days, admission rate, ED and hospital length of stay (LOS) were compared between patients living with frailty (CFS≥5) and robust patients. Logistic regression was used to adjust for confounders.

RESULTS

A total of 1840 ED visits of patients aged ≥65 years with CFS assessments done during the study period were analysed, of which 606 (32.9%) were patients living with frailty. Mortality after the index visit was higher in patients living with frailty at 7 days (2.6% vs 0.2%), 30 days (7.9% vs 0.9%) and 90 days (15.5% vs 2.4%). Adjusted ORs for mortality for those with frailty compared with more robust patients were 9.9 (95% CI 2.1 to 46.5) for 7-day, 6.0 (95% CI 3.0 to 12.2) for 30-day and 5.7 (95% CI 3.6 to 9.1) 90-day mortality. Patients living with frailty had higher admission rates, 58% versus 36%, a difference of 22% (95% CI 17% to 26%), longer ED LOS, 5 hours:08 min versus 4 hours:36 min, a difference of 31 min (95% CI 14 to 50), and longer in-hospital LOS, 4.8 days versus 2.7 days, a difference of 2.2 days (95% CI 1.2 to 3.0).

CONCLUSION

Patients living with frailty, had significantly higher mortality and admission rates as well as longer ED and in-hospital LOS compared with robust patients. The results confirm the capability of the CFS to risk stratify short-term mortality in older ED patients.

TRIAL REGISTRATION NUMBER

NCT04877028.

Service provision for Frailty in European Emergency Departments (FEED): a survey of operational characteristics

BACKGROUND

The observational Frailty in European Emergency Departments (FEED) study found 40% of older people attending for care to be living with frailty. Older people with frailty have poorer outcomes from emergency care. Current best practice calls for early identification of frailty and holistic multidisciplinary assessment. This survey of FEED sites explores variations in frailty-attuned service definitions and provision.

METHODS

This cross-sectional survey included study sites across Europe identified through snowball recruitment. Site co-ordinators (healthcare professionals in emergency and geriatric care) were surveyed online using Microsoft Forms. Items covered department and hospital capacity, frailty and delirium identification methods, staffing, and frailty-focused healthcare services in the ED. Descriptive statistics were reported.

RESULTS

A total of 68 sites from 17 countries participated. Emergency departments had median 30 (IQR 21-53) trolley spaces. Most defined "older people" by age 65+ (64%) or 75+ (25%). Frailty screening was used at 69% of sites and mandated at 38%. Night-time staffing was lower compared to day-time for nursing (10 [IQR 8-14] vs. 14 [IQR 10-18]) and physicians (5 [IQR 3-8] vs. 10 [IQR 7-15]). Most sites had provision for ED frailty specialist services by day, but these services were rarely available at night. Sites mostly had accessible facilities; however, hot meals were rarely available at night (18%).

CONCLUSION

This survey demonstrated variability in case definitions, screening practices, and frailty-attuned service provision. There is no unanimous definition for older age, and while the Clinical Frailty Scale was commonly used, this was rarely mandated or captured in electronic records. Frailty services were often unavailable overnight. Appreciation of the variation in frailty service models could inform operational configuration and workforce development.

The Association Between Frailty Evaluated by Clinical Frailty Scale and Mortality of Older Patients in the Emergency Department: A Prospective Cohort Study

Background

Frailty epitomizes the most complex consequence of an aging population. This study aimed to evaluate the impact of frailty, measured using the Clinical Frailty Scale (CFS), on outcomes of older people in an emergency department (ED).

Methods

We conducted a prospective observational study enrolling patients aged 65 years and older in a medical center of Taiwan between March 8, 2021, and November 30, 2021. The primary outcome was 90-day mortality rate. Individuals were categorized into three groups based on the CFS scores. Logistic regression was employed to examine the influence of frailty on clinical outcomes following covariate adjustment. Survival analysis was conducted using Kaplan-Meier curves and Log rank tests.

Results

A total of 473 individuals were included in the study, with a mean age of 82.1 years, and 60.5% of them were males. The 90-day mortality rate was 10.6%. Among these groups, the CFS score 7-9 group had the highest 90-day mortality rate (15.9%), followed by the CFS score 4-6 group (8.0%) and the CFS score 1-3 group (7.1%). The multiple logistic regression analyses demonstrated a significant impact of CFS score on prognosis, with adjusted odd ratios of 1.24 (95% CI 1.06-1.47) for 90-day mortality, 1.18 (95% CI 1.06-1.31) for hospitalization, and 1.30 (95% CI 1.12-1.52) for 180-day mortality. The Kaplan-Meier curves revealed a significantly higher 90-day mortality rate for patients with high CFS scores (Log rank tests, p = 0.019).

Conclusion

In the older ED population, the severity of frailty assessed by the CFS emerged as a significant and important prognostic factor for hospitalization, 90-day mortality, and 180-day mortality.

Atrial fibrillation accelerates functional decline in older adults: a 15-year follow-up population-based study

AIMS

Atrial fibrillation (AF) has been associated with functional impairment. However, the role exerted by AF on the long-term trajectories of functional mobility remains to be elucidated. This study aimed to evaluate the impact of AF on functional mobility by tracing walking speed (WS) trajectories over 15 years of follow-up in a population-based cohort of individuals aged 60+ years.

METHODS AND RESULTS

This population-based cohort study included 3141 community-dwelling participants (mean age 73.7 years; 63.6% women) from the Swedish National Study on Aging and Care in Kungsholmen, who were regularly examined from 2001-2004 to 2016-2019. Functional mobility was assessed by measuring WS in a standardized way. The association between AF and WS trajectories was assessed by multivariable joint models accounting for the longitudinal dropouts due to death. Stratified analyses by demographic and clinical factors were performed. The effect-modifying role of oral anticoagulant therapy (OAC), incident heart failure (HF), and incident stroke was finally investigated. At baseline, 285 (9.1%) participants were ascertained to have AF. A faster annual WS decline was observed in persons with AF than in non-AF peers (adjusted β coefficient per year = -0.011, 95% confidence interval: -0.016 to -0.005). Incident HF and stroke were associated with greater WS decline in participants with AF. OAC use was not associated with a slower functional decline.

CONCLUSION

Atrial fibrillation is associated with a faster physical function decline in older individuals. Incident HF and stroke possibly accelerate WS decline over time in AF participants.

The Burden of Cardiovascular Disease and Geriatric Syndromes in Older Patients Undergoing Chronic Hemodialysis

BACKGROUND

There is limited evidence on the complexity of cardiovascular disease (CVD) and geriatric syndromes in older patients with end-stage renal disease. Our aims were to (1) examine the prevalence of CVD in older patients on chronic hemodialysis, (2) compare the burden of geriatric syndromes in patients with and without CVD, and (3) examine the impact of CVD on hospitalization.

METHODS

This prospective, observational, multi-center study was conducted at two dialysis units of two major hospitals in Vietnam. Consecutive older adults receiving chronic hemodialysis were recruited from November 2020 to June 2021. CVD was defined as having one of these conditions: heart failure, ischemic heart disease, or stroke. Participants were assessed for geriatric conditions including frailty, malnutrition, impairment in instrumental activities/activities of daily living, depression, falls, and polypharmacy. Multivariable logistic regression analysis was applied to examine the impact of CVD on 6-month hospitalization, adjusting for age, sex, duration of dialysis, Charlson Comorbidity Index, and geriatric conditions. Results were presented as odds ratios (ORs) and 95% confidence intervals (CIs).

RESULTS

There were 175 participants (mean age 72.4 ± 8.5 and 58.9% female). CVD was present in 80% of the participants (ischemic heart disease: 49.7%, heart failure: 60.0%, and stroke: 25.7%). Participants with CVD had a higher burden of geriatric syndromes compared to those without CVD. During the 6-month follow-up, 48.6% of the participants were hospitalized (56.4% of those with CVD vs. 17.1% of those without CVD), p < 0.001). CVD independently increased the risk of hospitalization (adjusted OR 3.32, 95% CI 1.12-9.80).

CONCLUSIONS

In this study, there was a very high prevalence of CVD in older patients undergoing chronic dialysis. Participants with CVD had a higher burden of geriatric syndromes and their risk of 6-month hospitalization increased by three times. There is a need for a multidisciplinary and patient-centered approach to treatment planning for these patients.

Prolonged delirium during hospitalization is associated with worse long-term and short-term outcomes in patients with acute heart failure

BACKGROUND

The association between prolonged delirium during hospitalization and long-term prognosis in patients with acute heart failure (AHF) admitted to the cardiac intensive care unit (CICU) has not been fully elucidated.

METHODS

We conducted a prospective registry study of patients with AHF admitted to the CICU at 2 hospitals from 2013 to 2021. We divided study patients into 3 groups according to the presence or absence of delirium and prolonged delirium as follows: no delirium, resolved delirium, or prolonged delirium. Main outcomes were in-hospital mortality and 3-year mortality after discharge.

RESULTS

A total of 1555 patients with AHF (median age, 80 years) were included in the analysis. Of these, 406 patients (26.1%) developed delirium. We divided patients with delirium into 2 groups: the resolved delirium group (n = 201) or the prolonged delirium group (n = 205). Multivariate Cox proportional hazards models for long-term prognosis demonstrated that the prolonged delirium group had a higher incidence of all-cause death (hazard ratio [HR], 1.52; 95% CI, 1.08 to 2.14) and non-cardiovascular death (HR, 1.84; 95% CI, 1.21 to 2.78) than the resolved delirium group. Regarding in-hospital outcomes, multivariate logistic regression modeling showed that prolonged delirium is associated with all-cause death (odds ratio [OR], 9.55; 95% confidential interval [CI], 2.99 to 30.53) and cardiovascular death (OR, 13.02; 95% CI, 2.86 to 59.27) compared with resolved delirium.

CONCLUSIONS

Prolonged delirium is associated with worse long-term and short-term outcomes than resolved delirium in patients with AHF.

A novel scale for triage assessment of frailty in the emergency department (ED-FraS): a prospective videotaped study

BACKGROUND

Rapid recognition of frailty in older patients in the ED is an important first step toward better geriatric care in the ED. We aimed to develop and validate a novel frailty assessment scale at ED triage, the Emergency Department Frailty Scale (ED-FraS).

METHODS

We conducted a prospective cohort study enrolling adult patients aged 65 years or older who visited the ED at an academic medical center. The entire triage process was recorded, and triage data were collected, including the Taiwan Triage and Acuity Scale (TTAS). Five physician raters provided ED-FraS levels after reviewing videos. A modified TTAS (mTTAS) incorporating ED-FraS was also created. The primary outcome was hospital admission following the ED visit, and secondary outcomes included the ED length of stay (EDLOS) and total ED visit charges.

RESULTS

A total of 256 patients were included. Twenty-seven percent of the patients were frail according to the ED-FraS. The majority of ED-FraS was level 2 (57%), while the majority of TTAS was level 3 (81%). There was a weak agreement between the ED-FraS and TTAS (kappa coefficient of 0.02). The hospital admission rate and charge were highest at ED-FraS level 5 (severely frail), whereas the EDLOS was longest at level 4 (moderately frail). The area under the Receiver Operating Characteristic curve (AUROC) in predicting hospital admission for the TTAS, ED-FraS, and mTTAS were 0.57, 0.62, and 0.63, respectively. The ED-FraS explained more variation in EDLOS (R2 = 0.096) compared with the other two methods.

CONCLUSIONS

The ED-Fras tool is a simple and valid screening tool for identifying frail older adults in the ED. It also can complement and enhance ED triage systems. Further research is needed to test its real-time use at ED triage internationally.

Clinical Frailty Scale at presentation to the emergency department: interrater reliability and use of algorithm-assisted assessment

PURPOSE

The Clinical Frailty Scale (CFS) allows health care providers to quickly stratify older patients, to support clinical decision-making. However, few studies have evaluated the CFS interrater reliability (IRR) in Emergency Departments (EDs), and the freely available smartphone application for CFS assessment was never tested for reliability. This study aimed to evaluate the interrater reliability of the Clinical Frailty Scale (CFS) ratings between experienced and unexperienced staff (ED clinicians and a study team (ST) of medical students supported by a smartphone application to assess the CFS), and to determine the feasibility of CFS assignment in patients aged 65 or older at triage.

METHODS

Cross-sectional study using consecutive sampling of ED patients aged 65 or older. We compared assessments by ED clinicians (Triage Clinicians (TC) and geriatric ED trained nurses (geriED-TN)) and a study team (ST) of medical students using a smartphone application for CFS scoring. The study is registered on Clinicaltrials.gov (NCT05400707).

RESULTS

We included 1349 patients aged 65 and older. Quadratic-weighted kappa values for ordinal CFS levels showed a good IRR between TC and ST (ϰ = 0.73, 95% CI 0.69-0.76), similarly to that between TC and geriED-TN (ϰ = 0.75, 95% CI 0.66-0.82) and between the ST and geriED-TN (ϰ = 0.74, 95% CI 0.63-0.81). A CFS rating was assigned to 972 (70.2%) patients at triage.

CONCLUSION

We found good IRR in the assessment of frailty with the CFS in different ED providers and a team using a smartphone application to support rating. A CFS assessment occurred in more than two-thirds (70.2%) of patients at triage.

Frailty Knowledge, Use of Screening Tools, and Educational Challenges in Emergency Departments in Ireland: A Multisite Survey

BACKGROUND

Recognizing frailty and providing evidenced-based management in busy emergency departments is challenging. Understanding the knowledge and educational needs of ED staff is important to design training that might improve patient outcomes.

OBJECTIVE

This study aimed to explore frailty knowledge of ED staff, use of frailty screening instruments in Irish emergency departments, and educational challenges in the emergency department.

METHODS

A multisite survey of ED staff (different specialties) was conducted between April and September 2021. An anonymous online survey was distributed via email. Free-text sections were analyzed using content analysis.

RESULTS

In total, 168 staff (nursing, medical and allied health) participated, representing 9 of 26 Irish emergency departments (35%). Most respondents were nurses (n = 78, 46%). Less than half of respondents had received frailty identification training (n = 81, 48%). One-fifth of emergency doctors and nurses (20%) were unsure how to define frailty. Major barriers to ED frailty screening were resource deficits, insufficient diagnostic pathways from the emergency departments, and lack of education on suitable instruments.

CONCLUSIONS

Most of the ED staff surveyed relied on clinical judgment rather than formal training in frailty identification. A high proportion reported poor knowledge and low confidence in recognizing frailty. Dedicated staff with frailty management expertise, bespoke education initiatives, and clearly defined frailty screening pathways may help address the issues identified.

Prevalence of frailty and associated factors in older adults seeking care at Swedish emergency departments

BACKGROUND

Internationally, prolonged length of stay for older adults in the emergency department (ED) is associated with increased risk of in-hospital adverse events. In Sweden patients 65 years and older account for 35% of emergency visits, and according to consensus from an international expert group, all persons over 70 should be screened for frailty. This is not routinely done in Swedish EDs, and therefore, knowledge about prevalence, characteristics and clinical outcomes associated with frailty is limited.

AIM

To describe the prevalence of frailty and associated factors in older adults seeking care at Swedish EDs.

METHODS

The study has a cross-sectional design. Data was collected at three hospital-based EDs, varying in level and size of setting, for one month. Patients age 70 and older presenting at the EDs and agreed to participate were screened for frailty using the FRail Elderly Support researcH group (FRESH) instrument. Data were analysed using descriptive statistics to assess the distribution of patient characteristics and clinical outcomes. Multivariate logistic regression was used to model the association between frailty and demographic characteristics, and Cox regression was used to model the association between frailty and clinical outcomes.

RESULTS

A total of 3101 patients were eligible for inclusion; of these, 984 (32%) were included and screened for frailty. Of the final sample, 57.3% were assessed as frail. Characteristics significantly associated with frailty were living in a residential care facility, age (> 80 years), being a woman and arriving with emergency medical service (EMS). There was a significant association between frailty and admittance to in-hospital care.

CONCLUSION

Our study shows a high prevalence of frailty in older people. Factors associated with frailty were living in a residential care facility, age ≥ 80 years, being a woman and arriving with EMS to the ED and being admitted to in-hospital care. Frailty screening should be incorporated in the triage system to identify frail patients who need tailored interventions. More studies using the FRESH instrument are needed to further confirm our findings and to develop the methods for screening for frailty in the ED.

Frailty and mortality: Utility of Frail-VIG index in ED short-stay units for older adults

BACKGROUND

Frailty assessment allows the identification of patients at risk of death. The aim here was to study the ability of Frail-VIG Index (FI-VIG) in order to discriminate frailty groups of older adults and garner its correlation with mortality in an Emergency-Department Short-Stay Unit (ED-SSU).

METHODS

Our observational, single-center, prospective study consecutively included patients over 65-years-old admitted between March 1, 2021, and April 30, 2021.

RESULTS

302 patients were included (56 % women), mean age 83 ± 8 years, and 39.1 % of them had a functional disability whilst 16.5 % of them had dementia. A total of 174 patients (58 %) met the frailty criteria (FI-VIG ≥ 0.2): 111 (63.8 %) had mild frailty (FI-VIG 0.2-0.36), 52 (29.9 %) had moderate frailty (FI-VIG 0.36-0.55), and 11 (6.3 %) had advanced frailty (FI-VIG > 0.55). Mortality at 30 days, 6 months, and 1 year was analyzed: no frailty was 6.3 %, 10.8 %, and 12.5 %, respectively; mild frailty was 10.8 %, 22.5 %, and 22.5 %, respectively; moderate frailty was 25 %, 34.6 %, and 42.3 %, respectively; advanced frailty was 36.4 %, 54.5 %, and 3.6 %, respectively. This shows the significant differences between the groups (1-year mortality p < 0.001). Mild frailty vs. non-frail HR was 2.47 (95 %CI 1.12-5.46), moderate frailty vs. non-frail HR was 6.93 (95 %CI 3.16-15.23), and advanced frailty vs. non-frail HR was 11.29 (95 %CI 3.54-36.03). The mean test time was 7 min.

CONCLUSIONS

There was a strong correlation between frailty degree and mortality at 1, 6, and 12 months. FI-VIG is fast and easy-to-use in this setting. It is routine implementation in ED-SSUs could enable early risk stratification.

Reliability and validity of a frailty assessment tool in specialized burn care, a retrospective multicentre cohort study

BACKGROUND

Frailty is a predictor of adverse outcomes in elderly patients. The Canadian Study of Health and Aging Clinical Frailty Scale (CFS) is an often-used frailty assessment instrument. However, the CFS's reliability and validity in patients with burn injuries are unknown. This study aimed to assess the CFS's inter-rater reliability and validity (predictive validity, known group validity and convergent validity) in patients with burn injuries treated to specialized burn care.

METHODS

A retrospective multicentre cohort study was conducted in all three Dutch burn centres. Patients aged ≥ 50 years with burn injuries, with a primary admission in 2015-2018, were included. Based on information in the electronic patient files, a research team member scored the CFS retrospectively. Inter-rater reliability was calculated using Krippendorff's α. Validity was assessed using logistic regression analysis. Patients with a CFS ≥ 5 were considered frail.

RESULTS

In total, 540 patients were included, with a mean age of 65.8 years (SD 11.5) and a Total Body Surface Area (TBSA) burned of 8.5%. The CFS was used to assess frailty in 540 patients and the reliability of the CFS was scored for 212 patients. Mean CFS was 3.4(SD 2.0). Inter-rater reliability was adequate, Krippendorff's α 0.69 (95%CI 0.62-0.74). A positive frailty screening was predictive of a non-home discharge location (OR 3.57, 95%CI 2.16-5.93), a higher in-hospital mortality rate (OR 1.06-8.77), and a higher mortality rate within 12 months after discharge (OR 4.61, 95%CI 1.99-10.65) after adjustment for age, TBSA, and inhalation injury. Frail patients were more likely to be older (for<70 vs. ≥70 years odds ratio 2.88, 95%CI 1.95-4.25) and their comorbidities were more severe (ASA ≥3 vs 1-2 OR 6.43, 95%CI 4.26-9.70) (known group validity). The CFS was significantly related (rSpearman=0.55) to the Dutch Safety Management System (DSMS) frailty screening, reflecting a fair-good correlation between the CFS and DSMS frailty screening outcomes.

CONCLUSION

The Clinical Frailty scale is reliable and has shown its validity, including its association with adverse outcomes in patients with burn injury admitted to specialized burn care. Early frailty assessment with the CFS must be considered, to optimize early recognition and treatment of frailty.

Is the clinical frailty scale feasible to use in an emergency department setting? A mixed methods study

BACKGROUND

The Clinical Frailty Scale (CFS) is a frailty assessment tool used to identify frailty in older patients visiting the emergency department (ED). However, the current understanding of how it is used and accepted in ED clinical practice is limited. This study aimed to assess the feasibility of CFS in an ED setting.

METHODS

This was a prospective, mixed methods study conducted in three Swedish EDs where CFS had recently been introduced. We examined the completion rate of CFS assessments in relation to patient- and organisational factors. A survey on staff experience of using CFS was also conducted. All quantitative data were analysed descriptively, while free text comments underwent a qualitative content analysis.

RESULTS

A total of 4235 visits were analysed, and CFS assessments were performed in 47%. The completion rate exceeded 50% for patients over the age of 80. Patients with low triage priority were assessed to a low degree (24%). There was a diurnal variation with the highest completion rates seen for arrivals between 6 and 12 a.m. (58%). The survey response rate was 48%. The respondents rated the perceived relevance and the ease of use of the CFS with a median of 5 (IQR 2) on a scale with 7 being the highest. High workload, forgetfulness and critical illness were ranked as the top three barriers to assessment. The qualitative analysis showed that CFS assessments benefit from a clear routine and a sense of apparent relevance to emergency care.

CONCLUSION

Most emergency staff perceived CFS as relevant and easy to use, yet far from all older ED patients were assessed. The most common barrier to assessment was high workload. Measures to facilitate use may include clarifying the purpose of the assessment with explicit follow-up actions, as well as formulating a clear routine for the assessment.

REGISTRATION

The study was registered on ClinicalTrials.gov 2021-06-18 (identifier: NCT04931472).

Assessment of frailty by paramedics using the clinical frailty scale - an inter-rater reliability and accuracy study

BACKGROUND

Frailty assessment by paramedics in the prehospital setting is understudied. The goals of this study were to assess the inter-rater reliability and accuracy of frailty assessment by paramedics using the Clinical Frailty Scale (CFS).

METHODS

This was a cross-sectional study with paramedics exposed to 30 clinical vignettes created from real-life situations. There was no teaching intervention prior to the study and paramedics were only provided with the French version of the CFS (definitions and pictograms). The primary outcome was the inter-rater reliability of the assessment. The secondary outcome was the accuracy, compared with the expert-based assessment. Reliability was determined by calculating an intraclass correlation coefficient (ICC). Accuracy was assessed through a mixed effects logistic regression model. A sensitivity analysis was carried out by considering that an assessment was still accurate if the score differed from no more than 1 level.

RESULTS

A total of 56 paramedics completed the assessment. The overall assessment was found to have good inter-rater reliability (ICC = 0.87 [95%CI 0.81-0.93]). The overall accuracy was moderate at 60.6% (95%CI 54.9-66.1) when considering the full scale. It was however much higher (94.8% [95%CI 92.0-96.7] when close assessments were considered as accurate. The only factor associated with accurate assessment was field experience.

CONCLUSION

The assessment of frailty by paramedics was reliable in this vignette-based study. However, the accuracy deserved to be improved. Future research should focus on the clinical impact of these results and on the association of prehospital frailty assessment with patient outcomes.

REGISTRATION

This study was registered on the Open Science Framework registries ( https://doi.org/10.17605/OSF.IO/VDUZY ).

Frailty and prognosis of patients with kidney transplantation: a meta-analysis

BACKGROUND

The prevalence of frailty among candidates and recipients of kidney transplantation (KT) is well-established, yet the impact of frailty on clinical outcomes following KT remains uncertain. To address this knowledge gap, we conducted a systematic meta-analysis to comprehensively assess the aforementioned relationship.

METHODS

The present study conducted a comprehensive search of PubMed, Embase, and Cochrane Library databases to identify relevant observational studies that compared mortality risk and other clinical outcomes of KT recipients with and without frailty. Two authors independently conducted data collection, literature searching, and statistical analysis. The results were synthesized using a heterogeneity-incorporating random-effects model.

RESULTS

In this meta-analysis, 6279 patients from 13 cohort studies were included, and 1435 patients (22.9%) were with frailty before KT. There were higher mortality rates among frail patients at admission, compared to those without frailty (risk ratio [RR]: 1.97, 95% confidence interval [CI]: 1.57 to 2.47, p < 0.001; I2 = 19%). Subgroup analysis suggested the association between frailty and high mortality risk after KT was consistent in studies of frailty assessed via Physical Frailty Phenotype or other methods, and in studies of follow-up duration < or ≥ 5 years. In addition, frailty was associated with higher incidence of delayed graft function (RR: 1.78, 95% CI: 1.21 to 2.61, p = 0.003; I2 = 0%), postoperative complications (RR: 1.88, 95% CI: 1.15 to 3.08, p = 0.01; I2 = 0%), and longer hospitalization (RR: 1.55, 95% CI: 1.22 to 1.97, p < 0.001; I2 = 0%).

CONCLUSION

Following KT, frail patients are at higher risks for all-cause mortality, delayed graft function, postoperative complications, and longer hospital stays.

Prognostic Value of a New Tool (the 3D/3D+) for Predicting 30-Day Mortality in Emergency Department Patients Aged 75 Years and Older

The 3D/3D+ multidimensional geriatric assessment tool provides an optimal model of emergency care for patients aged 75 and over who attend the Emergency Department (ED). The baseline, or static, component (3D) stratifies the degree of frailty prior to the acute illness, while the current, or dynamic, component (3D+) assesses the multidimensional impact caused by the acute illness and helps to guide the choice of care facility for patients upon their discharge from the ED. The objective of this study was to evaluate the prognostic value of the 3D/3D+ to predict short- and long-term adverse outcomes in ED patients aged 75 years and older. Multivariable logistic regression models were used to identify the predictors of mortality 30 days after 3D/3D+ assessment. Two hundred and seventy-eight patients (59.7% women) with a median age of 86 years (interquartile range: 83-90) were analyzed. According to the baseline component (3D), 83.1% (95% CI: 78.2-87.3) presented some degree of frailty. The current component (3D+) presented alterations in 60.1% (95% CI: 54.1-65.9). The choice of care facility at ED discharge indicated by the 3D/3D+ was considered appropriate in 96.4% (95% CI: 93.0-98.0). Thirty-day all-cause mortality was 19.4%. Delirium and functional decline were the dimensions on the 3D/3D+ that were independently associated with 30-day mortality. These two dimensions had an area under receiver operating characteristic of 0.80 (95% CI: 0.73-0.86) for predicting 30-day mortality. The 3D/3D+ tool enhances the provision of comprehensive care by ED professionals, guides them in the choice of patients' discharge destination, and has a prognostic validity that serves to establish future therapeutic objectives.

Discordance in Frailty Measures in Old Community Dwelling People with Multimorbidity - A Cross-Sectional Study

Purpose

Assessment of frailty is a key method to identify older people in need of holistic care. However, agreement between different frailty instrument varies. Thus, groups classified as frail by different instruments are not completely overlapping. This study evaluated differences in sociodemographic factors, cognition, functional status, and quality of life between older persons with multimorbidity who were discordantly classified by five different frailty instruments, with focus on the Clinical Frailty Scale (CFS) and Fried's Frailty Phenotype (FP).

Participants and Methods

This was a cross-sectional study in a community-dwelling setting. Inclusion criteria were as follows: ≥75 years old, ≥3 visits to the emergency department the past 18 months, and ≥3 diagnoses according to ICD-10. 450 participants were included. Frailty was assessed by CFS, FP, Short Physical Performance Battery (SPPB), Grip Strength and Walking Speed.

Results

385 participants had data on all frailty instruments. Prevalence of frailty ranged from 34% (CFS) to 75% (SPPB). Nine percent of participants were non-frail by all instruments, 20% were frail by all instruments and 71% had discordant frailty classifications. Those who were frail according to CFS but not by the other instruments had lower cognition and functional status. Those who were frail according to FP but not CFS were, to a larger extent, women, lived alone, had higher cognitive ability and functional status.

Conclusion

The CFS might not identify physically frail women in older community-dwelling people with multimorbidity. They could thus be at risk of not be given the attention their frail condition need.

Diagnostic Accuracy of Frailty Screening Instruments Validated for Use among Older Adults Attending Emergency Departments: A Systematic Review and Meta-Analysis

Early identification of frailty can prevent functional decline. Although multiple frailty screens exist for use in Emergency Departments (EDs), few are validated against diagnostic standards such as comprehensive geriatric assessment. To examine the diagnostic accuracy of ED screens for frailty, scientific databases were searched for prospective diagnostic accuracy test studies from January 2000 to September 2022. Studies were assessed for risk of bias using QUADAS-C. Psychometric properties were extracted and analysed using R. Six studies involving 1,663 participants describing seven frailty screening instruments (PRISMA-7, CFS, VIP, FRESH, BPQ, TRST, and ISAR), representing 13 unique data points, were included. The mean age of participants ranged from 76 to 86 years. The proportion that was female ranged from 45 to 60%. The pooled prevalence rate of frailty was high at 59%. The pooled estimate for sensitivity was 0.85 (95% CI: 0.76-0.91) versus 0.77 (95% CI: 0.62-0.88) for specificity. Pooled accuracy based on area under the ROC curve was 0.89 (95% CI: 0.86-0.90). Although few studies were found, limiting the ability to conduct a meta-analysis of individual instruments, available frailty screens can accurately diagnose frailty in older adults attending the ED. As specificity was comparatively low, additional assessment may be required to identify those requiring inpatient management or onward community referral. Further study is therefore required.