A Comparison of Frailty Assessment Instruments in Different Clinical and Social Care Settings: The Frailtools Project

Not All Frailty Assessments Are Created Equal: Comparability of Electronic Health Data-Based Frailty Assessments in Assessing Older People in Residential Care

Objectives: To evaluate the comparability of frailty assessment tools - the electronic frailty index (eFI), retrospective electronic frailty index (reFI), and clinical frailty scale (CFS) - in older residents of care facilities. Methods: Data from 813 individuals aged 65 or older, with frailty and co-morbidities, collected between 2022 and 2023, were analysed using various statistical methods. Results: The results showed significant differences in frailty classification among the tools: 78.3% were identified as moderately to severely frail by eFI, 59.6% by reFI, and 92.1% by CFS. Statistical tests confirmed significant differences (p < .05) in their assessments, indicating variability in measurement methods. Discussion: This study advances the understanding of frailty assessment within aged-care settings, highlighting the differences in the efficacy of these assessment tools. It underscores the challenges in frailty assessments and emphasizes the need for continuous refinement of assessment methods to address the diverse facets of frailty in aged care.

Biomarkers of frailty

Several biomarkers have been proposed to identify frailty, a multisystemic age-related syndrome. However, the complex pathophysiology and the absence of a consensus on a comprehensive and universal definition make it challenging to pinpoint a singular biomarker or set of biomarkers that conclusively characterize frailty. This review delves into the main laboratory biomarkers, placing special emphasis on those associated with various pathways closely tied to the frailty condition, such as inflammation, oxidative stress, mitochondrial dysfunction, metabolic and endocrine alterations and microRNA. Additionally, we provide a summary of different clinical biomarkers encompassing different tools that have been proposed to assess frailty. We further address various imaging biomarkers such as Dual Energy X-ray Absorptiometry, Bioelectrical Impedance analysis, Computed Tomography and Magnetic Resonance Imaging, Ultrasound and D3 Creatine dilution. Intervention to treat frailty, including non-pharmacological ones, especially those involving physical exercise and nutrition, and pharmacological interventions, that include those targeting specific mechanisms such as myostatin inhibitors, insulin sensitizer metformin and with special relevance for hormonal treatments are mentioned. We further address the levels of different biomarkers in monitoring the potential positive effects of some of these interventions. Despite the availability of numerous biomarkers, their performance and usefulness in the clinical arena are far from being satisfactory. Considering the multicausality of frailty, there is an increasing need to assess the role of sets of biomarkers and the combination between laboratory, clinical and image biomarkers, in terms of sensitivity, specificity and predictive values for the diagnosis and prognosis of the different outcomes of frailty to improve detection and monitoring of older people with frailty or at risk of developing it, being this a need in the everyday clinical practice.

Relationship of endogenous plasma concentrations of β-hydroxy β-methyl butyrate (HMB) with frailty in community dwelling older adults with type-2 diabetes mellitus

BACKGROUND

Supplementation with β-hydroxy β-methyl butyrate (HMB) appears to be effective in preserving muscle in older adults. However, the association between endogenously produced HMB with frailty has not been studied in people with chronic disease.

OBJECTIVES

The purpose of this study is to explore whether an association exists between endogenous HMB levels and frailty status in older adults with type-2 diabetes mellitus (T2DM).

METHODS

Data were taken from the Toledo Study of Healthy Ageing, a community-dwelling aged (65 years+) cohort. Frailty was assessed at baseline and at 2.99 median years according to the Frailty Phenotype (FP) standardized to our population and the Frailty Trait Scale 12 (FTS12). The associations between HMB levels and frailty were assessed using three nested multivariate logistic regressions and segmented by sex. Glucose, HMB and glucose interaction, age and body composition were used as covariables.

RESULTS

255 participants (mean age 75.3 years, 52.94% men) were included. HMB levels showed an inverse cross-sectional association with frailty, which was modified when the interaction term HMB*glucose was included, remaining significant only for FTS12 [OR (95% CI): 0.436 (0.253, 0.751), p-value 0.003]. The association between HMB endogenous levels and FTS12 appears to be independent of sex, in which the association was maintained after adjusting for the covariates. However, there appears to be threshold points for glucose levels, above which the protective effect of HMB is lost: 145.4 mg/dl adjusted by gender for the whole sample and 149.6 mg/dl and 138.9 mg/dl for men and women, respectively. Endogenous HMB levels were not found to be associated with incident frailty.

CONCLUSIONS

Cross-sectional analysis revealed that endogenous HMB levels were inversely associated with frailty as assessed by the FTS12 in older people with T2DM. This association was found to be dependent on circulating fasted glucose levels.

Impact of Frailty on Heart Failure Prognosis: Is Sex Relevant?

PURPOSE OF REVIEW

Heart failure (HF) is one of the most frequent causes of hospital admission in elderly patients, especially in women, who present a high prevalence of geriatric syndromes like frailty. Studies have suggested that frailty and its impact may also differ between males and females. Understanding how frailty may differently affect HF patients depending on sex is therefore imperative for providing personalized care. The aim of this review is to summarize the role of sex in the prognostic impact of frailty in HF patients.

RECENT FINDINGS

Numerous studies have identified frailty as a significant predictor of all-cause mortality and hospital readmissions. A recent study of elderly HF out-patients demonstrated that while women had a higher prevalence of frailty, it was an independent predictor of mortality and readmission only in men. Moreover, another study revealed that physical frailty was associated with time to first clinical event among men but not among women. These results raise the question about why frailty affects differently HF prognosis in men and women. Women with HF present a higher prevalence of frailty, especially when it is considered as physical decline. Nevertheless, frailty affects differently HF prognosis in men and women. Women with HF present lower mortality than men and frailty is related with prognosis only in men. The different severity of HF between men and women and other hormonal, psychosocial, and clinical factors might be involved in this fact.

Development of Continuous Assessment of Muscle Quality and Frailty in Older Patients Using Multiparametric Combinations of Ultrasound and Blood Biomarkers: Protocol for the ECOFRAIL Study

BACKGROUND

Frailty resulting from the loss of muscle quality can potentially be delayed through early detection and physical exercise interventions. There is a demand for cost-effective tools for the objective evaluation of muscle quality, in both cross-sectional and longitudinal assessments. Literature suggests that quantitative analysis of ultrasound data captures morphometric, compositional, and microstructural muscle properties, while biological assays derived from blood samples are associated with functional information.

OBJECTIVE

This study aims to assess multiparametric combinations of ultrasound and blood-based biomarkers to offer a cross-sectional evaluation of the patient frailty phenotype and to track changes in muscle quality associated with supervised exercise programs.

METHODS

This prospective observational multicenter study will include patients aged 70 years and older who are capable of providing informed consent. We aim to recruit 100 patients from hospital environments and 100 from primary care facilities. Each patient will undergo at least two examinations (baseline and follow-up), totaling a minimum of 400 examinations. In hospital environments, 50 patients will be measured before/after a 16-week individualized and supervised exercise program, while another 50 patients will be followed up after the same period without intervention. Primary care patients will undergo a 1-year follow-up evaluation. The primary objective is to compare cross-sectional evaluations of physical performance, functional capacity, body composition, and derived scales of sarcopenia and frailty with biomarker combinations obtained from muscle ultrasound and blood-based assays. We will analyze ultrasound raw data obtained with a point-of-care device, along with a set of biomarkers previously associated with frailty, using quantitative real-time polymerase chain reaction and enzyme-linked immunosorbent assay. Additionally, we will examine the sensitivity of these biomarkers to detect short-term muscle quality changes and functional improvement after a supervised exercise intervention compared with usual care.

RESULTS

At the time of manuscript submission, the enrollment of volunteers is ongoing. Recruitment started on March 1, 2022, and ends on June 30, 2024.

CONCLUSIONS

The outlined study protocol will integrate portable technologies, using quantitative muscle ultrasound and blood biomarkers, to facilitate an objective cross-sectional assessment of muscle quality in both hospital and primary care settings. The primary objective is to generate data that can be used to explore associations between biomarker combinations and the cross-sectional clinical assessment of frailty and sarcopenia. Additionally, the study aims to investigate musculoskeletal changes following multicomponent physical exercise programs.

TRIAL REGISTRATION

ClinicalTrials.gov NCT05294757; https://clinicaltrials.gov/ct2/show/NCT05294757.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/50325.

Diabetic Sarcopenia. A proposed muscle screening protocol in people with diabetes : Expert document

OBJECTIVES

To propose the grounds for "diabetic sarcopenia" as a new comorbidity of diabetes, and to establish a muscle screening algorithm proposal to facilitate its diagnosis and staging in clinical practice.

METHOD

A qualitative expert opinion study was carried out using the nominal technique. A literature search was performed with the terms "screening" or "diagnostic criteria" and "muscle loss" or "sarcopenia" and "diabetes" that was sent to a multidisciplinary group of 7 experts who, in a face-to-face meeting, discussed various aspects of the screening algorithm.

RESULTS

The hallmark of diabetic sarcopenia (DS) is muscle mass atrophy characteristic of people with diabetes mellitus (DM) in contrast to the histological and physiological normality of muscle mass. The target population to be screened was defined as patients with DM with a SARC-F questionnaire > 4, glycosylated haemoglobin (HbA1C) ≥ 8.0%, more than 5 years since onset of DM, taking sulfonylureas, glinides and sodium/glucose cotransporter inhibitors (SGLT2), as well as presence of chronic complications of diabetes or clinical suspicion of sarcopenia. Diagnosis was based on the presence of criteria of low muscle strength (probable sarcopenia) and low muscle mass (confirmed sarcopenia) using methods available in any clinical consultation room, such as dynamometry, the chair stand test, and Body Mass Index (BMI)-adjusted calf circumference. DS was classified into 4 stages: Stage I corresponds to sarcopenic patients with no other diabetes complication, and Stage II corresponds to patients with some type of involvement. Within Stage II are three sublevels (a, b and c). Stage IIa refers to individuals with sarcopenic diabetes and some diabetes-specific impairment, IIb to sarcopenia with functional impairment, and IIc to sarcopenia with diabetes complications and changes in function measured using standard tests Conclusion: Diabetic sarcopenia has a significant impact on function and quality of life in people with type 2 diabetes mellitus (T2DM), and it is important to give it the same attention as all other traditionally described complications of T2DM. This document aims to establish the foundation for protocolising the screening and diagnosis of diabetic sarcopenia in a manner that is simple and accessible for all levels of healthcare.

Frailty assessment tools in the emergency department: A geriatric emergency department guidelines 2.0 scoping review

Objective

Given the aging population and growing burden of frailty, we conducted this scoping review to describe the available literature regarding the use and impact of frailty assessment tools in the assessment and care of emergency department (ED) patients older than 60 years.

Methods

A search was made of the available literature using the Covidence system using various search terms. Inclusion criteria comprised peer-reviewed literature focusing on frailty screening tools used for a geriatric population (60+ years of age) presenting to EDs. An additional search of PubMed, EBSCO, and CINAHL for articles published in the last 5 years was conducted toward the end of the review process (January 2023) to search specifically for literature describing interventions for frailty, yielding additional articles for review. Exclusion criteria comprised articles focusing on an age category other than geriatric and care environments outside the emergency care setting.

Results

A total of 135 articles were screened for inclusion and 48 duplicates were removed. Of the 87 remaining articles, 20 were deemed irrelevant, leaving 67 articles for full-text review. Twenty-eight were excluded for not meeting inclusion criteria, leaving 39 full-text studies. Use of frailty screening tools were reported in the triage, care, and discharge decision-making phases of the ED care trajectory, with varying reports of usefulness for clinical decision-making.

Conclusion

The literature reports tools, scales, and instruments for identifying frailty in older patients at ED triage; multiple frailty scores or tools exist with varying levels of utilization. Interventions for frailty directed at the ED environment were scant. Further research is needed to determine the usefulness of frailty identification in the context of emergency care, the effects of care delivery interventions or educational initiatives for front-line medical professionals on patient-oriented outcomes, and to ensure these initiatives are acceptable for patients.

Effectiveness of a randomized intervention by a geriatric team in frail hospital inpatients in non-geriatric settings: FRAILCLINIC project

BACKGROUND

Little research has been undertaken on the benefits of frailty management within different hospital settings. The objective of this study is to provide evidence on the viability and effectiveness of frailty management in non-geriatric hospital settings on mortality and functional decline after discharge.

METHODS

Data from the FRAILCLINIC (NCT02643069) study were used. FRAILCLINIC is a randomized controlled trial developed in non-geriatric hospital inpatient settings (emergency room, cardiology and surgery) from Spain (2), Italy (2) and the United Kingdom (1). Inpatients must met frailty criteria (according to the Frailty Phenotype and/or FRAIL scale), ≥75 years old. The control group (CG) received usual care. The intervention group (IG) received comprehensive geriatric assessment (CGA) and a coordinated intervention consisting in recommendations to the treating physician about polypharmacy, delirium, falls, nutrition and physical exercise plus a discharge plan. The main outcomes included functional decline (worsening ≥5 points in Barthel Index) and mortality at 3 months. We used multivariate logistic regression models adjusted by age, gender and the Charlson index. Intention-to-treat (ITT) and per-protocol (PP) analyses were used.

RESULTS

Eight hundred twenty one participants (IG: 416; mean age 83.00 ± 4.91; 51.44% women; CG: 405; mean age 82.46 ± 6.03; 52.35% women) were included. In the IG, 77.16% of the participants followed the geriatric team's recommendations as implemented by the treating physicians. The intervention showed a benefit on functional decline and mortality [OR: 0.67(0.47-0.96), P-value 0.027 and 0.29(0.14-0.57), P-value < 0.001, respectively) when fully followed by the treating physician. A trend to benefit (close to statistical significance) in functional decline and mortality were also observed when any of the recommendations were not followed [OR (95% CI): 0.72 (0.51-1.01), P-value: 0.055; and 0.64 (0.37-1.10), P-value: 0.105, respectively].

CONCLUSIONS

An individualized intervention in frail in-patients reduces the risk of functional deterioration and mortality at 3 months of follow-up when a care management plan is designed and followed.

Frailty detection in older adults via fractal analysis of acceleration signals from wrist-worn sensors

Purpose

Frailty is a reversible multidimensional syndrome that puts older people at a high risk of adverse health outcomes. It has been proposed to emerge from the dysregulation of the complex system dynamics of physiologic control systems. We propose the analysis of the fractal complexity of hand movements as a new method to detect frailty in older adults.

Methods

FRAIL scale and Fried's phenotype scores were calculated for 1209 subjects-72.4 (5.2) y.o. 569 women-and 1279 subjects-72.6 (5.3) y.o. 604 women-in the pubicly available NHANES 2011-2014 data set, respectively. The fractal complexity of their hand movements was assessed with a detrended fluctuation analysis (DFA) of their accelerometry records and a logistic regression model for frailty detection was fit.

Results

Goodness-of-fit to a power law was excellent (R2 > 0.98 ). The association between complexity loss and frailty level was significant, Kruskal-Wallis test (df = 2, Chisq = 27.545, p-value < 0.001 ). The AUC of the logistic classifier was moderate (AUC with complexity = 0.69 vs. AUC without complexity = 0.67).

Conclusion

Frailty can be characterized in this data set with the Fried phenotype. Non-dominant hand movements in free-living conditions are fractal processes regardless of age or frailty level and its complexity can be quantified with the exponent of a power law. Higher levels of complexity loss are associated with higher levels of frailty. This association is not strong enough to justify the use of complexity loss after adjusting for sex, age, and multimorbidity.

The association between patients' frailty status, multimorbidity, and demographic characteristics and changes in primary care for chronic conditions during the COVID-19 pandemic: a pre-post study

BACKGROUND

The purpose of this study was to assess the impact of SARS-COV-2 (Severe acute respiratory syndrome coronavirus 2) pandemic on primary care management (frequency of monitoring activities, regular prescriptions, and test results) of older adults with common chronic conditions (diabetes, hypertension, and chronic kidney disease) and to examine whether any changes were associated with age, sex, neighbourhood income, multimorbidity, and frailty.

METHODS

A research database from a sub-set of McMaster University Sentinel and Information Collaboration family practices was used to identify patients ≥65 years of age with a frailty assessment and 1 or more of the conditions. Patient demographics, chronic conditions, and chronic disease management information were retrieved. Changes from 14 months pre to 14 months since the pandemic were described and associations between patient characteristics and changes in monitoring, prescriptions, and test results were analysed using regression models.

RESULTS

The mean age of the 658 patients was 75 years. While the frequency of monitoring activities and prescriptions related to chronic conditions decreased overall, there were no clear trends across sub-groups of age, sex, frailty level, neighbourhood income, or number of conditions. The mean values of disease monitoring parameters (e.g. blood pressure) did not considerably change. The only significant regression model demonstrated that when controlling for all other variables, patients with 2 chronic conditions and those with 4 or more conditions were twice as likely to have reduced numbers of eGFR (Estimated glomerular filtration rate) measures compared to those with only 1 condition ((OR (odds ratio) = 2.40, 95% CI [1.19, 4.87]); (OR = 2.19, 95% CI [1.12, 4.25]), respectively).

CONCLUSION

In the first 14 months of the pandemic, the frequency of common elements of chronic condition care did not notably change overall or among higher-risk patients.

Fecal microbiota transplantation for recurrent Clostridioides difficile infection in frail and very old patients

BACKGROUND

Older age is a well-known risk factor for recurrent and severe Clostridioides difficile infection (CDI). Fecal microbiota transplantation (FMT) is widely recognized as an effective and safe therapeutic option for the treatment of recurrent CDI (rCDI). However, the efficacy and safety of FMT for rCDI in very old patients are uncertain. This study evaluated the efficacy and safety of FMT in a group of very old subjects with rCDI, and the reliability of overall comorbidity and frailty assessment for identifying patients at higher risk of worse clinical outcomes.

METHODS

This is a retrospective single-center study including patients ≥85 years undergoing FMT for rCDI between 2014 and 2022. Primary outcomes included efficacy of FMT, defined as cure of CDI at 8 week-follow-up, and safety evaluation. At baseline, comorbidity was measured with the Charlson Comorbidity Index (CCI). Frailty was measured with the Clinical Frailty Scale (CFS).

RESULTS

Overall, 43 patients with a median age of 88 years underwent FMT by colonoscopy in the study period. The rate of first FMT success was 77%. Five of the 10 patients who failed the first FMT infusion were cured after repeat FMT, with an overall efficacy of 88%. In patients with successful treatment, the CFS was significantly lower compared to those who failed the FMT or underwent repeat FMT (p < 0.01 for both). Mild adverse events occurred in 11 patients (25%). One death, not related to FMT or rCDI, occurred within 7 days from the first procedure.

CONCLUSIONS

FMT is effective and safe in very old patients. Frailty and high comorbidity do not limit use of FMT in these patients. Frailty assessment has potential to better identify patients at higher risk of worse outcomes or for repeat treatment with FMT.

Assessment of frailty in the person with type 2 diabetes mellitus: Expert analysis

INTRODUCTION

People with type 2 diabetes mellitus (DM2) have a higher prevalence of frailty compared to those without DM2. However, there is a lack of consensus on the diagnosis and clinical management of frail individuals with DM2.

OBJECTIVES

This study aims to identify limitations and current needs in the use of the frailty concept in PCDM2 (people with DM2), as well as define and evaluate the dimensions that should be included in its routine clinical assessment.

METHODS

A multidisciplinary team of eight health professionals from different hospitals in Spain participated in a process based on the nominal group technique.

RESULTS

The study identified eight limitations in the assessment of frailty in PCDM2, categorized by importance, and 10 unmet needs related to the diagnosis and follow-up of the disease. Additionally, seven dimensions were identified that should be included in the definition of frail individuals with DM2, prioritized by importance and novelty.

CONCLUSIONS

This article aims to increase knowledge and usage of the frailty concept in individuals with DM2 within the medical community. It also suggests the potential for future projects to develop a consensus definition of frailty tailored to this specific group.

Implementation and Core Components of a Multimodal Program including Exercise and Nutrition in Prevention and Treatment of Frailty in Community-Dwelling Older Adults: A Narrative Review

Increasing disability-free life expectancy is a crucial issue to optimize active ageing and to reduce the burden of evitable medical costs. One of the main challenges is to develop pragmatic and personalized prevention strategies in order to prevent frailty, counteract adverse outcomes such as falls and mobility disability, and to improve quality of life. Strong evidence reports the effectiveness of exercise interventions to improve various physical parameters and muscle function that are cornerstones of frailty. Other findings also suggest that the interactions between nutrition and physical exercise with or without health behavior promotion prevent the development of frailty. Multimodal programs, including structured exercise, adequate dietary intervention and health behavior promotion, appear increasingly consensual. However, in order for implementation in real-life settings, some pitfalls need to be addressed. In this perspective, structuring and tailoring feasible, acceptable and sustainable interventions to optimize exercise training responses are essential conditions to warrant short, medium and long-term individual benefits. The different components of exercise programs appear to be fairly consensual and effective. However, specific composition of the programs proposed (frequency, intensity, type, time, volume and progressiveness) have to be tailored to individual characteristics and objectives in order to improve exercise responses. The intervention approaches, behavioral strategies and indications for these programs also need to be refined and framed. The main objective of this work is to guide the actions of healthcare professionals and enable them to widely and effectively implement multimodal programs including exercise, nutrition and behavioral strategies in real-life settings.

Fear of Falling Score Is a Predictor of Falls in Community-Dwelling Pre-Frail and Frail Older People

Identifying frail older people at risk of falling is a priority in order to apply preventive strategies. This cross-sectional study included community-dwelling pre-frail and frail people (Fried's criteria) aged 70 years and older to assess the prevalence of falls and identify screening strategies based on comprehensive geriatric assessments to detect an increased risk of falling and recurrent falling in community-dwelling frail and pre-frail old people. Of the 229 participants, 121 (54.9%) had fallen in the previous 12 months, and 20 of these (16.5%) were recurrent fallers (≥2 falls). A score of 20 points or more on the Falls Efficacy Scale International was predictive of falling (area under the receiver-operating characteristics curve 0.67, 95% confidence interval: 0.61-0.74, p < 0.001) with a sensitivity of 51.7% and a specificity of 73.9%. Polypharmacy, Short Physical Performance Battery score of 8 points or less, and Falls Efficacy Scale International score of 20 points or more show an area under the curve of 0.78 (95% confidence interval: 0.67-0.89, p < 0.001) for recurrent falling.

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.

Translation of the Pictorial Fit-Frail Scale Into the Greek Language and Examination of Its Validity and Reliability

BACKGROUND

For the evaluation of frailty, a great variety of research tools are used internationally; however, only two have been translated and validated in Greek. The aim of the study was to translate the Pictorial Fit-Frail Scale (PFFS) into the Greek language and examine its validity and reliability.

METHODS

Initially, the PFFS scale was translated into the Greek language through a six-step process. Subsequently, in a sample of 157 elderly patients (47.1% women), construct validity was examined with the known-groups method using the one-way ANOVA test and criterion concurrent validity by comparison with the Clinical Frailty Scale (CFS) using Pearson's correlation coefficient. Finally, inter-rater reliability and test-retest reliability were checked using the intraclass correlation coefficient.

RESULTS

A comparison of known groups showed that older patients with greater dependence on activities of daily living, greater impairment of cognitive function, reduced mobility, balance, and swallowing disorders, as well as those who were socially withdrawn, scored higher on the PFFS scale, supporting the construct validity. The positive correlation between PFFS and CFS (r = 0.625, p ≤ 0.001) demonstrated the concurrent criterion validity of the PFFS scale. Intraclass correlation was excellent for both inter-rater reliability (0.951 (95% CI: 0.934-0.964)) and test-retest reliability (0.948 (95% CI: 0.930-0.962)).

CONCLUSION

The translated PFFS scale in Greek is a valid and reliable tool.

Facilitators and Barriers to Nurses Screening for Frailty in Acute Care in a Provincial Health-Care System: a Survey Study Guided by the Theoretical Domains Framework

Background

Older adults living with frailty represent the largest population of hospitalized patients in Canada, but they do not always receive the quality of care needed. Nurses are well-positioned to screen for frailty, but current frailty screening practices are poorly understood.

Methods

A cross-sectional survey study was conducted over a six-week period with nurses from Alberta, Canada working in acute care with older adults. Demographics were descriptively reported. Frailty screening methods were quantified on 5-point frequency scales, reported descriptively and compared by practice area using linear regression. The top-five mean scores from a 43-item, 6-point Likert-type questionnaire based on the Theoretical Domains Framework were compared by practice area.

Results

Frailty screening by clinical impression was "usually" used (median = 4, IQR = 4-5), while tools were "rarely" used (median = 2, IQR = 1-3). Medical and/or surgical nursing had higher general frailty screening tool use (β = 0.81, r = .31, p < .001), but no significant (p > .05) differences for using clinical impression, or preference of screening method. The top facilitator was the disbelief that frailty screening negatively impacts relationships with older adults. The top barrier was belief that conducting frailty screening was routine. Nursing practice area influenced frailty screening beliefs.

Conclusions

There is an opportunity to implement frailty screening tools into the nursing practice of Alberta' nurses working in acute care. Frailty screening tools that become routine have greater likelihood for utilization. Nursing practice areas may have unique situations that require tailored approached to tool implementation.

Differential utility of various frailty diagnostic tools in non-geriatric hospital departments of several countries: A longitudinal study

BACKGROUND

There is limited knowledge on the performance of different frailty scales in clinical settings. We sought to evaluate in non-geriatric hospital departments the feasibility, agreement and predictive ability for adverse events after 1 year follow-up of several frailty assessment tools.

METHODS

Longitudinal study with 667 older adults recruited from five hospitals in three different countries (Spain, Italy and United Kingdom). Participants were older than 75 years attending the emergency room, cardiology and surgery departments. Frailty scales used were Frailty Phenotype (FP), FRAIL scale, Tilburg and Groningen Frailty Indicators, and Clinical Frailty Scale (CFS). Analyses included the prevalence of frailty, degree of agreement between tools, feasibility and prognostic value for hospital readmission, worsening of disability and mortality, by tool and setting.

RESULTS

Emergency Room and cardiology were the settings with the highest frailty prevalence, varying by tool between 40.4% and 67.2%; elective surgery was the one with the lowest prevalence (between 13.2% and 38.2%). The tools showed a fair to moderate agreement. FP showed the lowest feasibility, especially in urgent surgery (35.6%). FRAIL, CFS and FP predicted mortality and readmissions in several settings, but disability worsening only in cardiology.

CONCLUSIONS

Frailty is a highly frequent condition in older people attending non-geriatric hospital departments. We recommend that based upon their current feasibility and predictive ability, the FRAIL scale, CFS and FP should be preferentially used in these settings. The low concordance among the tools and differences in prevalence reported and predictive ability suggest the existence of different subtypes of frailty.

Association between frailty, chronic conditions and socioeconomic status in community-dwelling older adults attending primary care: a cross-sectional study using practice-based research network data

OBJECTIVES

Frailty is a multidimensional syndrome of loss of reserves in energy, physical ability, cognition and general health. Primary care is key in preventing and managing frailty, mindful of the social dimensions that contribute to its risk, prognosis and appropriate patient support. We studied associations between frailty levels and both chronic conditions and socioeconomic status (SES).

DESIGN

Cross-sectional cohort study SETTING: A practice-based research network (PBRN) in Ontario, Canada, providing primary care to 38 000 patients. The PBRN hosts a regularly updated database containing deidentified, longitudinal, primary care practice data.

PARTICIPANTS

Patients aged 65 years or older, with a recent encounter, rostered to family physicians at the PBRN.

INTERVENTION

Physicians assigned a frailty score to patients using the 9-point Clinical Frailty Scale. We linked frailty scores to chronic conditions and neighbourhood-level SES to examine associations between these three domains.

RESULTS

Among 2043 patients assessed, the prevalence of low (scoring 1-3), medium (scoring 4-6) and high (scoring 7-9) frailty was 55.8%, 40.3%, and 3.8%, respectively. The prevalence of five or more chronic diseases was 11% among low-frailty, 26% among medium-frailty and 44% among high-frailty groups (χ²=137.92, df 2, p<0.001). More disabling conditions appeared in the top 50% of conditions in the highest-frailty group compared with the low and medium groups. Increasing frailty was significantly associated with lower neighbourhood income (χ²=61.42, df 8, p<0.001) and higher neighbourhood material deprivation (χ²=55.24, df 8, p<0.001).

CONCLUSION

This study demonstrates the triple disadvantage of frailty, disease burden and socioeconomic disadvantage. Frailty care needs a health equity approach: we demonstrate the utility and feasibility of collecting patient-level data within primary care. Such data can relate social risk factors, frailty and chronic disease towards flagging patients with the greatest need and creating targeted interventions.

Comparison of the association between six different frailty scales and clinical events in patients on hemodialysis

BACKGROUND

Frailty is associated with adverse outcomes in patients undergoing hemodialysis (HD). However, no study has used various frailty assessments in patients on HD to examine their association with clinical events. In this study, we investigated the association between clinical events and six frailty scales.

METHODS

Outpatients who underwent HD between 2018 and 2020 were retrospectively enrolled. Frailty was defined using the Fried Frailty Phenotype, Study of Osteoporotic Fractures (SOF) Index, Short Physical Performance Battery (SPPB), Frail Screening Index, FRAIL scale and Clinical Frailty Scale. Outcomes were clinical events, including a composite of multiple (i.e. recurrent) all-cause hospitalizations, fractures and/or all-cause mortality. The association of clinical events and the frailty scales were investigated using negative binomial regression analysis.

RESULTS

Fried Frailty Phenotype [incident rate ratio (IRR), 1.62; 95% confidence interval (CI), 1.49-1.76], SOF Index (IRR, 1.42; 95% CI, 1.10-1.83), SPPB (IRR, 1.79; 95% CI, 1.11-2.88) and Clinical Frailty Scale (IRR, 1.65; 95% CI, 1.04-2.61) were significantly associated with clinical events. However, Frail Screening Index (IRR, 1.38; 95% CI, 0.60-3.18) and FRAIL scale (IRR, 1.30; 95% CI, 0.88-1.92) showed no significant association with clinical events.

CONCLUSIONS

Objective frailty assessments (SPPB) and medical staff impression-based frailty (Clinical Frailty Scale) may be useful prognostic predictors for patients on HD. Questionnaire-based frailty assessment should be carefully considered when used as a measurement of frailty.

External validation of the hospital frailty risk score among hospitalised home care clients in Canada: a retrospective cohort study

BACKGROUND

The Hospital Frailty Risk Score (HFRS) is scored using ICD-10 diagnostic codes in administrative hospital records. Home care clients in Canada are routinely assessed with Resident Assessment Instrument-Home Care (RAI-HC) which can calculate the Clinical Frailty Scale (CFS) and the Frailty Index (FI).

OBJECTIVE

Measure the correlation between the HFRS, CFS and FI and compare prognostic utility for frailty-related outcomes.

DESIGN

Retrospective cohort study.

SETTING

Alberta, British Columbia and Ontario, Canada.

SUBJECTS

Home care clients aged 65+ admitted to hospital within 180 days (median 65 days) of a RAI-HC assessment (n = 167,316).

METHODS

Correlation between the HFRS, CFS and FI was measured using the Spearman correlation coefficient. Prognostic utility of each measure was assessed by comparing measures of association, discrimination and calibration for mortality (30 days), prolonged hospital stay (10+ days), unplanned hospital readmission (30 days) and long-term care admission (1 year).

RESULTS

The HFRS was weakly correlated with the FI (ρ 0.21) and CFS (ρ 0.28). Unlike the FI and CFS, the HFRS was unable to discriminate for 30-day mortality (area under the receiver operator characteristic curve (AUC) 0.506; confidence interval (CI) 0.502-0.511). It was the only measure that could discriminate for prolonged hospital stay (AUC 0.666; CI 0.661-0.673). The HFRS operated like the FI and CFI when predicting unplanned readmission (AUC 0.530 CI 0.526-0.536) and long-term care admission (AUC 0.600; CI 0.593-0.606).

CONCLUSIONS

The HFRS identifies a different subset of older adult home care clients as frail than the CFS and FI. It has prognostic utility for several frailty-related outcomes in this population, except short-term mortality.

Understanding social care need through primary care big data: a rapid scoping review

BACKGROUND

A more comprehensive understanding and measurement of adult social care need could contribute to efforts to develop more effective, holistic personalised care, particularly for those with multiple long-term conditions (MLTC). Progress in this area faces the challenge of a lack of clarity in the literature relating to how social care need is assessed and coded within variables included in primary care databases.

AIM

To explore how social care need is assessed and coded within variables included in primary care databases.

DESIGN & SETTING

An exploratory rapid scoping review of peer-reviewed articles and grey literature.

METHOD

Articles were screened and extracted onto a charting sheet and findings were summarised descriptively. Articles were included if published in English and related to primary and social care using data from national primary care databases.

RESULTS

The search yielded 4010 articles. Twenty-seven were included. Six articles used the term 'social care need', although related terminology was identified including 'need factors', 'social support', and 'social care support'. Articles mainly focused on specific components of social care need, including levels of social care usage or service utilisation and costs incurred to social care, primary care, and other providers in addressing needs. A limited range of database variables were found measuring social care need.

CONCLUSION

Further research is needed on how social care need has been defined in a UK context and captured in primary care big databases. There is potential scope to broaden the definition of social care need, which captures social service needs and wider social needs.

Clinical Perspectives on Cardiac Rehabilitation After Heart Failure in Elderly Patients with Frailty: A Narrative Review

The purpose of this narrative review is to examine rehabilitation modalities for patients with heart failure and Frailty who require comprehensive intervention. Ischemic heart disease is the leading cause of death worldwide, accounting for 16% of global mortality. Due to population growing and aging, the total number of heart failure patients continues to rise, a condition known as the heart failure pandemic. Furthermore, frailty has been associated with an increased risk for heart failure and increased morbidity and mortality. The 2021 update of the 2017 ACC expert consensus decision pathway for optimization of HF treatment has become more concerning, citing frailty as one of the 10 most important issues associated with heart failure with reduced ejection fraction (HFrEF). Frailty and heart failure share common pathological mechanisms and are associated with poor clinical outcomes. Most studies of frailty in patients with heart failure primarily focus on physical frailty, and associations between psycho-psychological and social factors such as cognitive dysfunction and social isolation have also been reported. These results suggest that a more comprehensive assessment of frailty is important to determine the risk in patients with heart failure. Therefore, mechanisms of the three domains, including not only physical frailty but also cognitive, psychological, spiritual, and social aspects, should be understood. In addition to interventions in these three domains, nutritional and pharmacological interventions are also important and require tailor-made interventions for the widely varied conditions associated with heart failure and frailty. Although several studies have shown a relationship between frailty and prognosis in patients with heart failure, interventions to improve the prognosis have not yet been established. Further information is needed on frailty intervention by a multidisciplinary team to improve the prognosis.

[PAPPS update on older people 2022]

This article examines the latest available evidence on preventive activities in the elderly, including sleep disorders, physical exercise, deprescription, cognitive disorders and dementias, nutrition, social isolation and frailty.

Healthcare cost expenditures associated to frailty and sarcopenia

Objectives

Frailty and sarcopenia have been related with adverse events, including hospitalization. However, its combined effect with hospitalization-related outcomes, including costs, has not been previously investigated. Our purpose was to explore how frailty, sarcopenia and its interaction could impact on healthcare expenditures.

Methods

1358 community-dwelling older adults from the Toledo Study of Healthy Ageing (TSHA) were included. Sarcopenia was measured using the Foundation for the National Institutes of Health criteria fitted to our cohort. Frailty was defined according to Frailty Trait Scale 5 (FTS5) and the Frailty Index fitted to the cut-off points of TSHA population. Hospitalization costs were taken from hospital records and costs were attributed according to Diagnostic-Related Groups, using as the cost base year 2015. Two-part regression models were used to analyze the relationship between frailty and sarcopenia and hospital admission, number of hospitalizations, length of stay and hospitalization costs.

Results

Sarcopenia was associated only with the probability of being admitted to hospital. Frailty was also associated with higher hospital use, regardless of the frailty tool used, but in addition increased hospital admission costs at follow-up by 23.72% per year and by 19.73% in the full model compared with non-frail individuals. The presence of sarcopenia did not increase the costs of frailty but, by opposite, frailty significantly increased the costs in people with sarcopenia, reaching by 46–56%/patient/year at follow-up. Older adults with frailty and sarcopenia had a higher risk of hospitalization, disregarding the tool used to assess frailty, and higher hospitalization costs (FTS5) in the full model, at the cross-sectional and at the follow-up level.

Conclusions

Frailty is associated with increased hospitalization costs and accounts for the potential effects of sarcopenia.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12877-022-03439-z.

Comparison of Multidimensional Frailty Instruments for Estimation of Long-term Patient-Centered Outcomes After Cardiac Surgery

Importance

Little is known about the performance of available frailty instruments in estimating patient-relevant outcomes after cardiac surgery.

Objective

To examine how well the Johns Hopkins Adjusted Clinical Groups (ACG) frailty indicator, the Hospital Frailty Risk Score (HFRS), and the Preoperative Frailty Index (PFI) estimate long-term patient-centered outcomes after cardiac surgery.

Design, Setting, and Participants

This retrospective cohort study was conducted in Ontario, Canada, among residents 18 years and older who underwent coronary artery bypass grafting or aortic, mitral or tricuspid valve, or thoracic aorta surgery between October 2008 and March 2017. Long-term care residents, those with discordant surgical encounters, and those receiving dialysis or dependent on a ventilator within 90 days were excluded. Statistical analysis was conducted from July 2021 to January 2022.

Main Outcomes and Measures

The primary outcome was patient-defined adverse cardiovascular and noncardiovascular events (PACE), defined as the composite of severe stroke, heart failure, long-term care admission, new-onset dialysis, and ventilator dependence. Secondary outcomes included mortality and individual PACE events. The association between frailty and PACE was examined using cause-specific hazard models with death as a competing risk, and the association between frailty and death was examined using Cox models. Areas under the receiver operating characteristic curve (AUROC) were determined over 10 years of follow-up for each frailty instrument.

Results

Of 88 456 patients (22 924 [25.9%] female; mean [SD] age, 66.3 [11.1] years), 14 935 (16.9%) were frail according to ACG criteria, 63 095 (71.3%) according to HFRS, and 76 754 (86.8%) according to PFI. Patients with frailty were more likely to be older, female, and rural residents; to have lower income and multimorbidity; and to undergo urgent surgery. Patients meeting ACG criteria (hazard ratio [HR], 1.66; 95% CI, 1.60-1.71) and those with higher HFRS scores (HR per 1.0-point increment, 1.10; 95% CI, 1.09-1.10) and PFI scores (HR per 0.1-point increment, 1.75; 95% CI, 1.73-1.78) had higher rates of PACE. Similar magnitudes of association were observed for each frailty instrument with death and individual PACE components. The HFRS had the highest AUROC for estimating PACE during the first 2 years and death during the first 4 years, after which the PFI had the highest AUROC.

Conclusions and Relevance

These findings could help to tailor the use of frailty instruments by outcome and follow-up duration, thus optimizing preoperative risk stratification, patient-centered decision-making, candidate selection for prehabilitation, and personalized monitoring and health resource planning in patients undergoing cardiac surgery.

The association between metabolic syndrome and presence of frailty: a systematic review and meta-analysis

BACKGROUND

Frailty represents a progressive deterioration in multi-system of the body and could increase vulnerability to stressors. Recently, several studies found that metabolic syndrome was significantly associated with frailty and emphasized its role in assessing and preventing frailty. However, these conclusions are controversial. We conducted this systematic review and meta-analysis to evaluate the association between metabolic syndrome and frailty.

METHODS

Databases including Pubmed, Embase, Web of Science, CINAHL Complete, China National Knowledge Infrastructure (CNKI) and Wanfang Data Knowledge Service Platform were searched for studies on the association between metabolic syndrome and frailty, from inception to 17th June 2022. Two researchers independently screened the literature, extracted the data and evaluated the quality. Stata/SE 15.0 software was used to perform the statistical analysis.

RESULTS

Eleven studies were included in this review and eight studies were included in the meta-analysis, involving one prospective cohort studies and ten cross-sectional studies with 12,640 participants. The pooled results indicated that metabolic syndrome was significantly associated with frailty (OR = 1.82, 95% CI = 1.46-2.27) with a low heterogeneity (I² = 32.1%), and there were significant associations between MetS and weakness (OR = 1.35, 95% CI = 1.15-1.58, I² = 0.0%), slow gait speed (OR = 1.80, 95% CI = 1.51-2.14, I² = 93.4%), weight loss (OR = 1.77, 95% CI = 1.36-2.29, I² = 0.0%) and decreased physical activity (OR = 1.87, 95% CI = 1.49-2.35, I² = 39.7%).

CONCLUSIONS

The findings of this systematic review and meta-analysis suggested that metabolic syndrome could be significantly associated with the presence of frailly. Future studies need to further consider the effects of measurement tools, age and specific disease status in this association. Furthermore, the casual relationship between them is to be determined.

Machine Learning Approaches for the Frailty Screening: A Narrative Review

Frailty characterizes a state of impairments that increases the risk of adverse health outcomes such as physical limitation, lower quality of life, and premature death. Frailty prevention, early screening, and management of potential existing conditions are essential and impact the elderly population positively and on society. Advanced machine learning (ML) processing methods are one of healthcare’s fastest developing scientific and technical areas. Although research studies are being conducted in a controlled environment, their translation into the real world (clinical setting, which is often dynamic) is challenging. This paper presents a narrative review of the procedures for the frailty screening applied to the innovative tools, focusing on indicators and ML approaches. It results in six selected studies. Support vector machine was the most often used ML method. These methods apparently can identify several risk factors to predict pre-frail or frailty. Even so, there are some limitations (e.g., quality data), but they have enormous potential to detect frailty early.

[Frailty in primary care: Diagnosis and multidisciplinary management]

El envejecimiento poblacional se asocia a un mayor uso de recursos sociales sanitarios, asociados a la mayor morbimortalidad y discapacidad de este grupo etario. La fragilidad es un síndrome geriátrico previo a la aparición de la dependencia funcional, que permite la identificación de individuos de mayor riesgo de dependencia, institucionalización, efectos adversos de fármacos, mortalidad y otros eventos negativos de salud. Este síndrome es potencialmente reversible con una intervención multicomponente. La atención primaria de salud es el lugar preferente para el diagnóstico y seguimiento de la fragilidad, a través de escalas como la FRAIL scale, el fenotipo de Fried o modelos de acumulación de déficits. Para el seguimiento se precisa la intervención multidimensional y coordinada de diferentes profesionales sanitarios y sociales, con la implicación del paciente y su familia. Se debe fomentar la investigación para determinar las intervenciones más eficaces y los cursos clínicos más frecuentes.

The ability of eight frailty instruments to identify adverse outcomes across different settings: the FRAILTOOLS project

BACKGROUND

To compare the performance of eight frailty instruments to identify relevant adverse outcomes for older people across different settings over a 12 month follow-up.

METHODS

Observational longitudinal prospective study of people aged 75 + years enrolled in different settings (acute geriatric wards, geriatric clinic, primary care clinics, and nursing homes) across five European cities. Frailty was assessed using the following: Frailty Phenotype, SHARE-FI, 5-item Frailty Trait Scale (FTS-5), 3-item FTS (FTS-3), FRAIL scale, 35-item Frailty Index (FI-35), Gérontopôle Frailty Screening Tool, and Clinical Frailty Scale. Adverse outcomes ascertained at follow-up were as follows: falls, hospitalization, increase in limitation in basic (BADL) and instrumental activities of daily living (IADL), and mortality. Sensitivity, specificity, and capacity to predict adverse outcomes in logistic regressions by each instrument above age, gender, and multimorbidity were calculated.

RESULTS

A total of 996 individuals were followed (mean age 82.2 SD 5.5 years, 61.3% female). In geriatric wards, the FI-35 (69.1%) and the FTS-5 (67.9%) showed good sensitivity to predict death and good specificity to predict BADL worsening (70.3% and 69.8%, respectively). The FI-35 also showed good sensitivity to predict BADL worsening (74.6%). In nursing homes, the FI-35 and the FTSs predicted mortality and BADL worsening with a sensitivity > 73.9%. In geriatric clinic, the FI-35, the FTS-5, and the FRAIL scale obtained specificities > 85% to predict BADL worsening. No instrument achieved high enough sensitivity nor specificity in primary care. All the instruments predict the risk for all the outcomes in the whole sample after adjusting for age, gender, and multimorbidity. The associations of these instruments that remained significant by setting were for BADL worsening in geriatric wards [FI-35 OR = 5.94 (2.69-13.14), FTS-3 = 3.87 (1.76-8.48)], nursing homes [FI-35 = 4.88 (1.54-15.44), FTS-5 = 3.20 (1.61-6.38), FTS-3 = 2.31 (1.27-4.21), FRAIL scale = 1.91 (1.05-3.48)], and geriatric clinic [FRAIL scale = 4.48 (1.73-11.58), FI-35 = 3.30 (1.55-7.00)]; for IADL worsening in primary care [FTS-5 = 3.99 (1.14-13.89)] and geriatric clinic [FI-35 = 3.42 (1.56-7.49), FRAIL scale = 3.27 (1.21-8.86)]; for hospitalizations in primary care [FI-35 = 3.04 (1.25-7.39)]; and for falls in geriatric clinic [FI-35 = 2.21 (1.01-4.84)].

CONCLUSIONS

No single assessment instrument performs the best for all settings and outcomes. While in inpatients several commonly used frailty instruments showed good sensitivities (mainly for mortality and BADL worsening) but usually poor specificities, the contrary happened in geriatric clinic. None of the instruments showed a good performance in primary care. The FI-35 and the FTS-5 showed the best profile among the instruments assessed.

Frailty as a Predictor of Poor Rehabilitation Outcomes among Older Patients Attending a Geriatric Day Hospital Program: An Observational Study

Background: The Geriatric Day Hospital (GDH) is an important outpatient geriatric service, but there are few data on the role of frailty as a potential predictor of poor outcomes in this setting. Methods: Data were analyzed from 499 patients aged ≥ 60 years attending a 12-week GDH program between 2018 and 2021. Frailty status was defined as non-frail (68, 13.6%), mild/moderate frailty (351, 70.3%), and severe frailty (80, 16.0%) based on the Clinical Frailty Scale (CFS). Outcomes were defined as (1) poor outcome (hospital readmission, death, or medical deterioration) during the program and (2) admission to permanent nursing home care upon completion of the program. Multivariate logistic models were used for predictive analyses. Results: The mean age was 80.3 (standard deviation 7.0); 58.3% were women. Overall, 77 patients (15.4%) had a poor outcome, and 48 (9.6%) were admitted to permanent nursing home care. Poor outcome was experienced by none of the non-frail patients (0%), by 49 (14.0%) patients with mild/moderate frailty, and 22 (27.5%) patients with severe frailty (adjusted OR, 2.0; 95% CI 1.3, 3.2; p < 0.01). Admission to a permanent nursing home care was experienced by none of the non-frail patients (0%), 20 (5.7%) of those with mild/moderate frailty, and 28 (35.0%) with severe frailty (adjusted OR, 2.9; 95% CI 1.3, 6.3; p < 0.01). Conclusions: The CFS is a promising risk predictor of poor outcome and admission to permanent nursing home discharge among older patients attending a GDH program.

Diagnostic accuracy of the frail scale plus functional measures for frailty screening

BACKGROUND

There is little knowledge of the diagnostic accuracy of screening programmes for frailty in primary care settings.

AIM

To assess a two-step strategy consisting of the administration of the FRAIL scale to those who are non-dependent, aged ≥75 years, followed-up by measurement of the Short Physical Performance Battery (SPPB) or gait speed in those who are positive.

DESIGN & SETTING

Cross-sectional and longitudinal cohort study. Analysis of primary care data from the FRAILTOOLS project at five European cities.

METHOD

All patients consecutively attending were enrolled. They received the index tests plus the Fried phenotype and the frailty index to assess their frailty status. Mortality and worsening of dependency in basic (BADL) and instrumental (IADL) activities of daily living over a year were ascertained.

RESULTS

Prevalence of frailty based on frailty phenotype was 14.9% in the 362 participants. A FRAIL scale score ≥1 had a sensitivity of 83.3% (95%CI:73.1-93.6) to detect frailty. A positive result and a SPPB score <11 had a sensitivity of 72.2% (95%CI: 59.9-84.6); when combined with a gait speed <1.1 m/s, the sensitivity was 80% (95%CI: 68.5-91.5). Two thirds of those screened as positive were not frail. In the best scenario, sensitivities of this last combination to detect IADL and BADL worsening were 69.4% (95%CI: 59.4-79.4) and 63.6% (95%CI: 53.4-73.9).

CONCLUSION

Combining the FRAIL scale with other functional measures offers an acceptable screening approach for frailty. Accurate prediction of worsening dependency and death need to be confirmed through the piloting of a frailty screening programme.

Multisystem derangements in frailty and sarcopenia: a source for biomarker discovery

PURPOSE OF REVIEW

Multisystem derangements, encompassing metabolic, musculoskeletal and stress-response systems, occur during aging and are associated with the development of physical frailty and sarcopenia. These modular changes are relevant sources for the identification of biomarkers for the two conditions. Here, we provide an up-to-date overview on existing biomarkers of physical frailty and sarcopenia and discuss emerging approaches for biomarker discovery.

RECENT FINDINGS

Inflammatory, metabolic and hematologic markers are shared between physical frailty and sarcopenia. Gut microbial derivatives and damage-associated molecular patterns transferred via extracellular vesicles have been indicated as possible gut-muscle axis regulators and candidate markers of physical frailty and sarcopenia.

SUMMARY

Mediators of metabolic, musculoskeletal and stress-response system dysregulation are shared by physical frailty and sarcopenia and indicate the existence of common pathophysiological pathways. Multiplatform biomarker analyses have been proposed as an innovating approach for tracking the multifaceted and dynamic nature of physical frailty and sarcopenia. Upon validation, the identified biomarkers may support diagnostic makeup and tracking of the two conditions in both research and clinical settings.

Accuracy, feasibility and predictive ability of different frailty instruments in an acute geriatric setting

Aim

To investigate the feasibility and accuracy of four frailty instruments: FRAIL, Clinical Frailty Scale (CFS), hand grip strength (HGS) and the Spanish Frailty-VIG; and to evaluate their ability to predict adverse outcomes in an acute care setting (ACS).

Findings

The four instruments had high feasibility but provided variable prevalence of frailty. FRAIL and CFS predicted well for three-month mortality, and FRAIL also for length of stay. However, none of the instruments predicted for the other outcomes.

Message

The FRAIL and CFS may be of value in diagnostic and therapeutic decision-making in an acute geriatric setting, given their prognostic ability and feasibility. Further studies are needed to identify the best frailty instrument in an ACS.

Supplementary Information

The online version contains supplementary material available at 10.1007/s41999-022-00645-1.

Purpose

To analyze the feasibility, accuracy and the ability of different frailty instruments to predict adverse outcomes.

Methods

A prospective cohort study was conducted in patients ≥ 70 years admitted to the acute care setting (ACS). Feasibility and prevalence of frailty were assessed by FRAIL, Clinical Frailty Scale (CFS), hand grip strength (HGS) and the Spanish Frailty-VIG. Receiver operator characteristic (ROC) curves and area under the curve (AUC) were performed to identify frailty according to each instrument, setting VIG as the reference. For each instrument, multiple logistic regressions were used to examine the effect of frailty on primary outcome (i.e., three-month mortality) and secondary outcomes (i.e., in-hospital mortality, length of stay, institutionalization, functional decline and 30-day readmission).

Results

A total of 185 patients were included, with a median age of 89 years. The feasibility of the instruments was 100%, except for HGS (67%). The prevalence of frailty varied from 65.2% (FRAIL) to 86.7% (VIG). AUCs against VIG ranged from 0.69 (95% confidence interval [CI] 0.57–0.81: FRAIL) to 0.77 (95% CI 63.5–90.2: CFS). Frail patients defined by FRAIL were 2.7times more likely to have a prolonged length of stay than non-frail patients (95% CI 1.385–5.416). Three-month mortality occurred more among frail patients, either defined by FRAIL (OR 2.5; 95% CI 1.072–5.881) or CFS (OR 3.7; 95% CI 1.255–10.812), than in non-frail patients.

Conclusion

The four instruments had high feasibility providing variable prevalence of frailty. FRAIL and CFS predicted well for three-month mortality, and FRAIL also for length of stay. However, none of the instruments predicted for the other secondary outcomes of the study.

Supplementary Information

The online version contains supplementary material available at 10.1007/s41999-022-00645-1.

An international Delphi consensus process to determine a common data element and core outcome set for frailty: FOCUS (The Frailty Outcomes Consensus Project)

Background

Despite increased recognition of frailty and its importance, high quality evidence to guide decision-making is lacking. There has been variation in reported data elements and outcomes which makes it challenging to interpret results across studies as well as to generalize research findings. The creation of a frailty core set, consisting of a minimum set of data elements and outcomes to be measured in all frailty studies, would allow for findings from research and translational studies to be collectively analyzed to better inform care and decision-making. To achieve this, the Frailty Outcomes Consensus Project was developed to reach consensus from the international frailty community on a set of common data elements and core outcomes for frailty.

Methods

An international steering committee developed the methodology and the consensus process to be followed. The committee formulated the initial list of data elements and outcomes. Participants from across the world were invited to take part in the Delphi consensus process. The Delphi consisted of three rounds. Following review of data after three rounds, a final ranking round of data elements and outcomes was conducted. A required retention rate of 80% between rounds was set a priori.

Results

One hundred and eighty-four panelists from 25 different countries participated in the first round of the Delphi consensus process. This included researchers, clinicians, administrators, older adults, and caregivers. The retention rate between rounds was achieved. Data elements and outcomes forming primary and secondary core sets were identified, within the domains of participant characteristics, physical performance, physical function, physical health, cognition and mental health, socioenvironmental circumstances, frailty measures, and other.

Conclusion

It is anticipated that implementation and uptake of the frailty core set will enable studies to be collectively analyzed to better inform care for persons living with frailty and ultimately improve their outcomes. Future work will focus on identification of measurement tools to be used in the application of the frailty core set.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12877-022-02993-w.

Frailty, Guideline-Directed Medical Therapy, and Outcomes in HFrEF: From the GUIDE-IT Trial

OBJECTIVES

In this study, we sought to evaluate the association of frailty with the use of optimal guideline-directed medical therapy (GDMT) and outcomes in heart failure with reduced ejection fraction (HFrEF).

BACKGROUND

The burden of frailty in HFrEF is high, and the patterns of GDMT use according to frailty status have not been studied previously.

METHODS

A post hoc analysis of patients with HFrEF enrolled in the GUIDE-IT (Guiding Evidence-Based Therapy Using Biomarker Intensified Treatment in Heart Failure) trial was conducted. Frailty was assessed with the use of a frailty index (FI) using a 38-variable deficit model, and participants were categorized into 3 groups: class 1: nonfrail, FI <0.21); class 2: intermediate frailty, FI 0.21-0.31), and class 3: high frailty, FI >0.31). Multivariate-adjusted Cox models were used to study the association of frailty status with clinical outcomes. Use of optimal GDMT over time (beta-blockers, angiotensin-converting enzyme inhibitors/angiotensin receptor blockers, and mineralocorticoid receptor antagonists) across frailty strata was assessed with the use of adjusted linear and logistic mixed-effect models.

RESULTS

The study included 879 participants, of which 56.3% had high frailty burden (class 3 FI). A higher frailty burden was associated with a significantly higher risk of HF hospitalization or death in adjusted Cox models: high frailty vs nonfrail HR: 1.76, 95% CI: 1.20-2.58. On follow-up, participants with high frailty burden also had a significantly lower likelihood of achieving optimal GDMT: high frailty vs non-frail GDMT triple therapy use at study end: 17.7% vs 28.4%; P interaction, frailty class × time <0.001.

CONCLUSIONS

Patients with HFrEF with a high burden of frailty have a significantly higher risk for adverse clinical outcomes and are less likely to be initiated and up-titrated on an optimal GDMT regimen.

Association of Frailty with Perioperative Outcomes Following Hepatic Resection: A National Study

OBJECTIVES

Risk of mortality and major comorbidity remains high following hepatic resection. Given recent advancements in nonsurgical techniques to control hepatic malignancy, accurate assessment of surgical candidates, especially those considered frail, has become imperative. The present study aimed to characterize the impact of frailty on clinical and financial outcomes following hepatic resection in older individuals.

DESIGN

Retrospective cohort study.

SETTING AND PARTICIPANTS

All older adults (≥65 years) undergoing elective hepatic resection were identified from the 2012 to 2019 National Inpatient Sample.

METHODS

Frailty was defined by using the Johns Hopkins Adjusted Clinical Groups frailty-defining diagnosis indicator. Multivariable regression models were developed to assess the independent association of frailty with mortality, perioperative complications, and resource utilization. Marginal effects were tabulated to assess the impact of hospital volume on frailty-associated mortality.

RESULTS

Of an estimated 40,735 patients undergoing major hepatic resection, 9.0% were considered frail. After multivariable adjustment, frailty was associated with increased odds of mortality (adjusted odds ratio [AOR] 2.9; 95% confidence interval [CI] 2.0-4.3; P < .001) and perioperative complication (AOR 2.9; 95% CI 2.4-3.4; P < .001). Furthermore, frail patients incurred longer risk-adjusted length of stay (14.2 vs 6.7 days, P < .001) and greater hospitalization costs ($55,100 vs $29,300, P < .001). In assessing the impact of institutional expertise on perioperative outcomes, the marginal effect of frailty on mortality became less pronounced with increasing operative volume.

CONCLUSIONS AND IMPLICATIONS

As the population of the United States continues to age, surgeons are increasingly likely to encounter candidates for major hepatic resection who are frail. The present study associated frailty with inferior clinical and financial outcomes; however, frailty-associated mortality became less pronounced at centers with high hepatic resection operative volume. Coding-based instruments, such as the Johns Hopkins Adjusted Clinical Groups, may identify patients from electronic medical records who may benefit from further geriatric assessment and targeted treatments.

Factors influencing fear of falling in community-dwelling older adults in Singapore: a cross-sectional study

BACKGROUND

Fear of falling (FoF) has far-reaching implications including activity restriction, functional decline and reduced quality of life. It is a common consequence of falls but may be present even in non-fallers. This study aimed to determine the factors associated with FoF in a segment of Singapore's community-dwelling older adults.

METHODS

This descriptive cross-sectional study recruited a convenience sample of adults aged 65 and above from 4 primary care clinics from September 2020 to March 2021. Data were collected on demographic factors, clinical factors such as multi-morbidity, falls characteristics such as history of falls, injuries, and reasons for falls and frailty as determined by the Clinical Frailty Scale (CFS). FoF was measured using the Short Falls Efficacy Scale-International (Short FES-I), cut-off score of 14 and above indicated high FoF. Logistic regression was used to determine factors associated with high FoF.

RESULTS

Out of 360 older adults, 78.1% were Chinese and 59.7% females. The mean age was 78.3 years and 76 (21.1%) had a history of falls in the past six months. Almost half (43.1%) were mildly to moderately frail and most (80.6%) had multi-morbidity. The mean FoF score was 15.5 (SD 5.97) and 60.8% reported high FoF. There were statistically significant differences in age, gender, ethnicity, marital status, educational level, use of walking aid, multi-morbidity, frailty status, history of falls within six months and reason for falls between patients who had high FoF versus those who had moderate or low FoF. Logistic regression found that Malay ethnicity (OR = 5.81, 95% CI 1.77-19.13), marital status, use of walking aids (OR = 3.67, 95% CI = 1.54-8.77) and frailty were significant factors associated with high FoF. Compared to those who were never married, the odds of high FoF were significantly higher in married older adults (OR = 6.75, 95% CI 1.39 to 32.76), those who were separated or divorced (OR 10.40, 95% CI 1.13 to 95.76) and those who were widowed (OR = 7.41, 95% CI 1.51 to 36.41). Compared to well older adults, the odds of high FoF were significantly higher in pre frail older adults (OR = 6.87, 95% CI = 2.66-17.37), mildly frail older adults (OR = 18.58, 95% CI = 4.88-70.34) and moderately frail older adults (OR = 144.78, 95% CI = 13.86-1512.60).

CONCLUSIONS

The study found that pre frail to moderately frail older adults as determined by CFS have significantly higher risk of high FoF. The demographic factors such as marital status and ethnicity and falls characteristics associated with FoF in this study will be helpful to develop targeted and tailored interventions for FoF.

Outcomes of Frail Patients While Waiting for Kidney Transplantation: Differences between Physical Frailty Phenotype and FRAIL Scale

Frailty is associated with poorer outcomes among patients waiting for kidney transplantation (KT). Several different tools to measure frailty have been used; however, their predictive value is unknown. This is a prospective longitudinal study of 449 KT candidates evaluated for frailty by the Physical Frailty Phenotype (PFP) and the FRAIL scale. During the study period, 296 patients received a KT, while 153 remained listed. Patients who did not get receive a transplant were more frequently frail according to PFP (16.3 vs. 7.4%, p = 0.013). Robust patients had fewer hospital admissions during the 1st year after listing (20.8% if PFP = 0 vs. 43.4% if ≥1, and 27.1% if FRAIL = 0 vs. 48.9% if ≥1) and fewer cardiovascular events (than FRAIL ≥ 1) or major infectious events (than PFP ≥ 1). According to PFP, scoring 1 point had an impact on patient survival and chance of transplantation in the univariate analysis. The multivariable analysis corroborated the result, as candidates with PFP ≥ 3 had less likelihood of transplantation (HR 0.45 [0.26–0.77]). The FRAIL scale did not associate with any of these outcomes. In KT candidates, pre-frailty and frailty according to both the PFP and the FRAIL scale were associated with poorer results while listed. The PFP detected that frail patients were less likely to receive a KT, while the FRAIL scale did not.

Frailty-aware care: giving value to frailty assessment across different healthcare settings

Healthcare systems need to adapt to better serve an aging population with complex presentations. Frailty assessments are a potential means to address this heterogeneity in aging to identify individuals at increased risk for adverse health outcomes. Furthermore, frailty assessments offer an opportunity to optimize patient care in various healthcare settings. While the vast number of frailty assessment tools available can be a source of confusion for clinicians, each tool has features adaptable to the constraints and goals of different healthcare settings. This review discusses and compares barriers, facilitators, and the application of frailty assessments in primary care, the emergency department/intensive care unit and surgical care to cover a breadth of settings with different frailty assessment considerations. The implementation of frailty-aware care across healthcare settings potentiates better healthcare outcomes for older adults.

Frailty in kidney transplant candidates: a comparison between physical frailty phenotype and FRAIL scales

BACKGROUND

Frailty is common among advanced chronic kidney disease (CKD) patients who are kidney transplant (KT) candidates, and predisposes to poor outcomes after transplantation. However, frailty is not routinely measured during pretransplant work-up and it is unknown which metric should be used in this specific population. Our aim was to establish frailty prevalence in KT candidates according to different frailty scales.

METHODS

Prospective longitudinal study of 451 KT candidates evaluated for frailty by both Physical Frailty Phenotype (PFP) and FRAIL scale at the time of inclusion on the KT waiting list. Clinical and functional characteristics including sociodemographics, comorbidities, disability and nutritional status were recorded. Agreement between PFP and FRAIL scales as well as dissonant patients were analyzed.

RESULTS

Mean age was 60.9 years and 31.7% were female. Comorbidity burden among patients was high, with 36.9% and 16.2% presenting with diabetes and ischemic coronary disease, respectively. Disabilities were also frequent. More than 70% of patients presented with ≥ 1 PFP criteria while this percentage for ≥ 1 FRAIL criteria was 45.4%. Agreement between PFP and FRAIL was not good (kappa index 0.317). There were 132 patients who were pre-frail or frail according to PFP but non-frail according to the FRAIL scale and they presented with fewer comorbidities and less disability.

CONCLUSIONS

Frailty is frequent in advanced CKD patients, although its prevalence may vary according to different scales. Agreement between PFP and FRAIL scale is not good, and FRAIL scale might misclassify as robust patients those frail/prefrail patients who are in better health conditions.

Ability of 3 Frailty Measures to Predict Short-Term Outcomes in Older Patients Admitted for Post-Acute Inpatient Rehabilitation

OBJECTIVES

To evaluate the ability of 3 commonly used frailty measures to predict short-term clinical outcomes in older patients admitted for post-acute inpatient rehabilitation.

DESIGN

Observational cohort study.

SETTING AND PARTICIPANTS

Consecutive patients (n = 207) admitted to a geriatric inpatient rehabilitation facility.

METHODS

Frailty on admission was assessed using a frailty index, the physical frailty phenotype, and the Clinical Frailty Scale (CFS). Predictive capacity of the frailty instruments was analyzed for (1) nonhome discharge, (2) readmission to acute care, (3) functional decline, and (4) prolonged length of stay, using multivariate logistic regression models and receiver operating characteristic (ROC) curves.

RESULTS

The number of patients classified as frail was 91 (44.0%) with the frailty index, 134 (64.7%) using the frailty phenotype, and 151 (73.0%) with the CFS. The 3 frailty measures revealed acceptable discriminatory accuracy for nonhome discharge (area under the curve ≥ 0.7) but differed in their predictive ability: the adjusted odds ratio (OR) for nonhome discharge was highest for the CFS [6.2, 95% confidence interval (CI) 1.8-21.1], compared to the frailty index (4.1, 95% CI 2.0-8.4) and the frailty phenotype (OR 2.9, 95% CI 1.2-6.6). For the other outcomes, discriminatory accuracy based on ROC tended to be lower and predictive ability varied according to frailty measure. Readmission to acute care from inpatient rehabilitation was predicted by all instruments, most pronounced by the frailty phenotype (OR 5.4, 95% CI 1.6-18.8) and the frailty index (OR 2.5, 95% CI 1.1-5.6), and less so by the CFS (OR 1.4, 95% CI 0.5-3.8).

CONCLUSIONS AND IMPLICATIONS

Frailty measures may contribute to improved prediction of outcomes in geriatric inpatient rehabilitation. The choice of the instrument may depend on the individual outcome of interest and the corresponding discriminatory ability of the frailty measure.