The concept of frailty in the end of disease era

The perceptions of European geriatricians on the co-occurrence and links between dementia, delirium and frailty

PURPOSE

This study aimed to explore the perceptions of geriatricians and experienced geriatric trainees in Europe of the complex relationship between dementia, delirium and frailty, including their relative prevalence, overlaps and causality.

METHODS

An online anonymous survey was administered across 30 European countries, via the mailing list of the European Geriatric Medicine Society (EuGMS), national member groups and the authors' professional networks. Questions were framed in the context of recently hospitalised 80-year-old patients.

RESULTS

Within the 440 included surveys, respondents particularly over-estimated frailty prevalence in older hospitalised patients, with two-thirds choosing between 41 and 80% prevalence, when the literature suggests only 23-46%, but paradoxically underestimated the frequency of frailty in people with delirium (more than three quarters of responses across 21-80%; literature suggests 71-93%). Severe dementia and previous delirium were correctly considered the strongest risks for future inpatient delirium. However, many considered pre-frailty a moderate (44%) or even strong (19%) risk for future delirium, while a minority considered severe dementia a low risk. Respondents viewed delirium superimposed on dementia (DSD) as having the strongest influence on in-hospital mortality and discharge to residential care, dementia as having the strongest influence on future residential care admission, and frailty as the condition most strongly influencing future mortality.

CONCLUSION

Geriatricians and experienced geriatric trainees across Europe gave varied responses to questions about delirium, dementia and frailty prevalence, co-occurrence and consequences. This indicates a need for the performance and wide dissemination of robust, prospective research examining all three conditions in older hospital cohorts. We suggest a merging of selective delirium-frailty and dementia-delirium interests to the dementia-delirium-frailty triumvirate.

A scoping review of the measurement and analysis of frailty in randomised controlled trials

BACKGROUND

Frailty is of increasing interest in trials, either as a target of intervention, as an outcome or as a potential treatment modifier. However, frailty measurement is often highly variable. This scoping review assessed how frailty is quantified in randomised controlled trials (RCTs), in what context and for what purposes.

METHODS

We searched five electronic databases for RCTs in which frailty was measured among trial participants. We extracted data on intervention type, the frailty measure used and the purpose for which frailty was assessed. We then compared these data according to reasons for frailty assessment.

RESULTS

We identified 415 RCTs assessing frailty across a range of interventions. Frailty was used to define the target population (166 trials), as an outcome (156 trials), as an effect modifier examining interaction of frailty on treatment effect (61 trials), as a purely descriptive characteristic (42 trials) or as a prognostic marker examining the impact of frailty on future health outcome (78 trials). The trials used 28 different measures of frailty (plus 29 additional trial-specific measures). The frailty phenotype model was the most common overall (164 trials), for defining the target population (90/166 trials) and as an outcome (81/156 trials). The cumulative deficit model frailty index was also frequently used (102 trials) and was most common among trials assessing treatment effect modification (21/61 trials).

CONCLUSION

Frailty measurement in RCTs is highly variable. Understanding the properties of respective frailty measures and how these relate to frailty as encountered in clinical practice is a priority to ensure that trial findings can inform healthcare delivery for people living with frailty.