Frailty transitions and prevalence in an ageing population: longitudinal analysis of primary care data from an open cohort of adults aged 50 and over in England, 2006-2017

Frailty indices based on routinely collected data: a scoping review

A frailty index (FI) is a frailty assessment tool calculated as the proportion of the number of health-related deficits an individual has to the total number of variables in the index. Routinely collected clinical and administrative data can be used as sources of deficits to automatically calculate FIs. This scoping review aimed to evaluate the current research landscape on routine data-based FIs. We searched seven databases to find literature published in 2013-2023. Main inclusion criteria were original research articles on FIs constructed from routine data, with deficits in at least two of the following categories: "symptoms/signs", "laboratory values", "diseases", "disabilities", and "others". From 7526 publications screened, 218 were included. Studies were primarily from North America (47.7 %), conducted in the community (35.3 %), and used routine data-based FIs for risk stratification (51.4 %). FIs were calculated using various routine data sources; however, most were initially developed and validated using hospital records. We noted geographical differences in study settings and routine data sources. We identified 611 unique deficits comprising these FIs. Most were either "diseases" (34.4 %) or "symptoms/signs" (32.1 %). Routine data-based FIs are feasible and valid risk stratification tools, but research is confined to high-income countries, their routine adoption is slow, and deficits comprising these FIs emphasise a reactive and overtly medical approach in addressing frailty. Future directions include exploring the feasibility and applicability of using routine databases for frailty assessment in lower- and middle-income countries, and leveraging non-clinical routine data through data linkages to proactively identify and manage frailty.

Frailty transitions in electronic health records: who first? what first?

BACKGROUND

Frailty is associated with an increased risk of adverse health outcomes and may worsen over time.

OBJECTIVES

This study aims to describe the dynamic trajectory of frailty, identify the characteristics of those who deteriorate first, and determine what deteriorates first.

STUDY DESIGN AND SETTING

A primary care longitudinal population-based cohort with repeated measures at baseline and one year later.

PARTICIPANTS

The cohort included all 119,952 Meuhedet members aged 65 years and over as of January 2023.

PREDICTORS

Demographic factors, health indicators, and the Meuhedet Electronic Frailty Index containing 36 deficits.

OUTCOMES

Worsening frailty is defined as a higher frailty level one year later in 2024 compared to 2023. A new frailty deficit is defined as a deficit appearing in 2024 that was not present in 2023.

STATISTICAL ANALYSIS

The comparison of worsening percentages by demographic and clinical characteristics was tested using the chi-square test at the univariable level and logistic regression at the multivariable level.

RESULTS

Overall, 13.3% of participants worsened after one year of follow-up, with 2.3% dying. Higher risk groups for worsening included females, older individuals, those belonging to the Arab sector, and those with multimorbidity. New deficits mainly included modifiable risk factors related to general health and functionality, despite chronic diseases being more frequent at baseline.

CONCLUSIONS

Emphasizing intervention programs based on these health promotion issues may significantly impact disease control and slow frailty worsening.

Analysis of alterations in the composition of the intestinal microbiota in frail older individuals

BACKGROUND

Frailty is an ageing-associated geriatric syndrome that severely affects the functional status, quality of life and life expectancy of older adults. Immune dysfunction and chronic inflammation play crucial roles in frailty, and this study aimed to explore the correlation between the intestinal microbiota and frailty.

METHODS

A cross-sectional survey was conducted using a comprehensive geriatric assessment of older individuals who underwent medical checkups at the Health Management Center from April 2023 to May 2024. A total of 672 older individuals who met the inclusion criteria were included and divided into a healthy control group and a frail case group. Clinical data, as well as blood and stool samples, were collected. The data from the two groups were analysed with 16S rRNA sequencing in 20 and 30 cases, respectively. SPSS 25.0 was used for statistical analysis.

RESULTS

There were significant differences in income, smoking, and globulin levels between the two groups, while there were no differences in age or sex. There was no significant difference in the abundance or species evenness of intestinal bacteria between the two groups. However, the abundance of accessory bacteria, bifidobacteria, and Escherichia coli in the frail group was greater than that in the control group. Specifically, Escherichia-Shigella was significantly upregulated and fit well into the prediction model of frailty.

CONCLUSION

The gut microbiota of frail older individuals underwent significant changes in structural composition, and the presence of Escherichia-Shigella may be a diagnostic marker for debilitating diseases. These findings provide an essential clinical reference value for developing methods for preventing or alleviating frailty based on specific microbial communities.

Prevalence and severity of frailty amongst middle-aged and older adults conveyed to hospital by ambulance between 2010 and 2017 in Wales

BACKGROUND

Ambulance services are commonly used by older adults. The scope of services continues to adapt in response to more non-life-threatening calls, often due to the acute consequences of chronic illness. Frailty increases with increasing age, but it is not known how common or severe it is within patients conveyed to hospital by ambulance.

METHODS

Open cohort of people aged ≥50 living in Wales between 2010 and 2017. Routinely collected electronic data on ambulance attendances resulting in conveyance were linked to primary care data within the Secure Anonymised Information Linkage databank, and the electronic Frailty Index was calculated. The prevalence and severity of frailty according to patient and incident characteristics was described.

RESULTS

Of 1 264 094 individuals within the cohort, 23.8% were taken to hospital between 2010 and 2017, of which frailty was present in 84.3% of patients. There was an upward trend in the number of conveyances for patients with moderate and severe frailty across the years in all age groups. The distribution of frailty was similar across call categories, deprivation quintiles and out-of-hours incidents. Patients conveyed from residential homes had a higher level of frailty and comprised 8.7% of the total conveyances.

CONCLUSIONS

The high prevalence of frailty within adults aged ≥50 with emergency conveyances suggests upskilling ambulance crews with frailty training to enhance their assessment and decision making may improve patient outcomes. The high proportion of conveyances from residential homes indicates scope for increasing integration of community services to provide more patient-centred care pathways.

Enhancing readiness for advance care planning among community-dwelling older adults with frailty: A mixed-method systematic review

BACKGROUND

Given uncertain illness trajectories faced by older adults with frailty and risk of decline and poor outcomes, intervention development for readiness to engage with advance care planning may confer benefits. However, evidence in this area remains limited.

AIM

DESIGN: A mixed-methods systematic narrative review, underpinned by the COM-B system behaviour change model and employing thematic data synthesis.

DATA SOURCES

Primary studies were included using experimental or observational designs, qualitative and quantitative. Eligible studies were identified through searches of four electronic databases from inception to January 19, 2025.

RESULTS

26 articles met the inclusion criteria. The data synthesis generated 14 themes across the three COM-B system components. The review identified the components of older adults' readiness, such as their limited physical and cognitive capacity for engaging in ACP (capability), influence and involvement of family (opportunity), and their desire to maintain the present and fear of change (motivation). It emphasised that readiness for advance care planning is a dynamic process influenced by family carers' and professionals' attitudes and behaviours, uncertainties inherent in older adults' conditions, as well as healthcare system, political, and social factors. The review also highlighted the uncertainties and ongoing changes involved in readiness, such as fluctuating physical and cognitive capabilities and changeable social situations. Based on these findings, a logic model was constructed to guide intervention development, outlining the components, intended outcomes, and influential factors.

CONCLUSION

Individual behaviour change models alone are insufficient to demonstrate older adults' readiness for advance care planning, as various external factors can influence their readiness. This emphasised the need for a comprehensive understanding of the contextual factors affecting readiness and the importance of flexibility in adapting interventions accordingly. Continuous assessment and enhancement of an individual's readiness for advance care planning, initiating conversations about what matters to them now, and improving family carers' readiness for advance care planning by assessing family dynamics and relationships are essential in practice. Further research is needed to elucidate the processes and causal pathways between intervention components and intended outcomes. This systematic review was registered on PROSPERO (CRD42023389337).

Clinical-genomic profiling of MDS to inform allo-HCT: recommendations from an international panel on behalf of the EBMT

ABSTRACT

For patients with myelodysplastic neoplasm/syndrome (MDS), allogeneic hematopoietic cell transplantation (allo-HCT) represents the only potentially curative treatment, capable of eradicating disease-related mutant hematopoietic cells and establishing normal donor hematopoiesis. Biologic-assignment clinical trials have indicated that in eligible patients, allo-HCT is associated with superior clinical outcomes compared with nontransplant therapy. However, this therapeutic option is only available to a subset of patients, and the outcome is influenced by multiple factors inherent to the patient, the MDS subtype, and the allo-HCT procedure itself. In 2017, the European Society for Blood and Marrow Transplantation (EBMT) published recommendations for allo-HCT in MDS to guide practical decision making. In the contemporary era, genomic profiling has become routine clinical practice in many centers, and the most recent classification systems include MDS entities that are defined by genetic abnormalities. In particular, the molecular International Prognostic Scoring System offers more precise prognostication across all clinical end points and currently represents the standard tool for estimating patient survival in the absence of disease-modifying treatment. Evidence from multiple sources increasingly indicates that allo-HCT should be considered at the time of diagnosis in all eligible patients with MDS. Therefore, genomic profiling for somatic mutations and testing for germ line predisposition variants are integral to determining a patient's eligibility for transplantation. Although all patients with higher-risk MDS are potential candidates for immediate transplantation, a subset of those with lower-risk MDS may also derive benefit from this procedure at an earlier disease stage. Comprehensive recommendations on behalf of an expert international panel for clinical practice and future clinical studies of relevance are presented.

Ethnicity and frailty: A systematic review of association with prevalence, incidence, trajectories and risks

BACKGROUND

Ethnic variations in frailty are not fully understood. This systematic review examined ethnic differences in the prevalence, incidence and trajectories of frailty; associations between frailty and sociodemographic/lifestyle risk-factors; and health-related outcomes of frailty.

METHODS

We searched four electronic databases from 2000 to July 2023 using terms for ethnicity and frailty.

INCLUSION CRITERIA

observational studies assessing frailty in adults ≥ 18 years from community-based settings, including care homes; ethnicity defined by race, country of birth, language, ancestry, or culture. We supplemented searches with manual citation and reference list searches. Outcomes included prevalence, incidence, and transitions of frailty; factors associated with frailty; and health-related outcomes (e.g., mortality). Two reviewers independently screened all articles.

RESULTS

We included 82 studies, representing data from 13 countries plus two multi-national samples. Across the included countries, frailty prevalence was higher in minority groups compared to majority groups. Ethnic differences appear sensitive to methods used to measure frailty. Two United States-based studies found that ethnic differences were independent of sociodemographic differences such as income or education. Six studies from the United States or United Kingdom showed that Black and South-Asian people, respectively, had higher frailty incidence or more rapid frailty progression. Two studies showed that frailty was associated with mortality across ethnic groups but with some small differences in magnitude between groups.

CONCLUSION

Ethnic disparities in frailty prevalence persist across community-based settings in different countries and are not fully explained by known inequalities. Addressing these disparities will likely require careful frailty measurement and assessment; confronting structural inequalities; and tailoring interventions to the needs of minoritised populations.

A personalised health intervention to maintain independence in older people with mild frailty: a process evaluation within the HomeHealth RCT

Background

Frailty is common in later life and can lead to adverse health outcomes. Services aimed at preventing decline in early stages of frailty may support older people to remain independent for longer. We developed and tested a new service, HomeHealth, in a randomised controlled trial. HomeHealth was a multidomain behaviour change service based in the voluntary sector in England targeting mobility, socialising, nutrition and psychological well-being.

Objective

To describe the population reach, fidelity, acceptability, context and mechanisms of impact of the HomeHealth service.

Design and methods

Mixed-methods process evaluation of a randomised trial.

Setting and participants

HomeHealth trial participants (older people aged 65+ years with mild frailty) and service providers.

Data sources and analysis

Population reach was evaluated through comparison to local census data. Fidelity of audio-recorded appointments was assessed by two independent raters using a structured checklist. Using data from appointments attended, types of goals set and progress towards goals, we described appointment characteristics, goals and signposting, and evaluated three mechanisms of impact: (1) effect of appointment attendance on independence, (2) effect of goal progress on independence and (3) whether selecting a particular goal type led to improvements in the corresponding intermediate outcome. We thematically analysed qualitative interviews with 49 older people, 7 HomeHealth workers and 8 stakeholders to explore acceptability and context.

Results

HomeHealth participants were similar with regards to deprivation, education and housing status to the local older population but with lower rates of minority ethnic groups. HomeHealth was delivered with good fidelity (81.7%) in voluntary sector organisations. Appointments were well attended (mean 5.33 out of the 6 intended), but attendance was not associated with better independence scores at 12 months [mean difference 1.29 (-8.20 to 10.78)]. Participants varied in progress towards goals within appointments (mean progress 1.15/2.00), but greater goal progress was not associated with improved independence scores at 12 months [mean difference -0.40 (-2.38 to 1.58)]. Mobility goals were most frequently selected (49%), but type of goal had no impact on independence and little impact on intermediate outcomes. Forty-one per cent were signposted or referred to other supportive services, with ongoing support where needed throughout this process. Qualitative data indicated that HomeHealth was acceptable, empowering for those who saw a need for change and fitted well within host voluntary sector organisations.

Limitations

Census data were only available for all adults aged over 65 in local areas rather than a mildly frail population, who are likely to be older, female and less diverse, and therefore population reach calculations may be less accurate. Goal progress was assessed using a simple scale rather than a validated instrument.

Conclusions

HomeHealth represents an acceptable and implementable intervention for older people with mild frailty but may work via different mechanisms than those intended.

Future work

Future work should explore how to best screen older people with mild frailty for readiness to change to maximise benefits from similar services and identify other possible mechanisms of effects.

Funding

This article presents independent research funded by the National Institute for Health and Care Research (NIHR) Health Technology Assessment programme as award number NIHR128334.

Does Allostatic Load in 50-89-Year-Olds Predict the Development of Frailty? Evidence From a National Longitudinal Study Over 12 Years

Frailty is characterised by a loss of function across several domains but is not an inevitable aspect of ageing and can be reversed with intervention. Determining those who are more likely to become frail before physical deficits become manifest will allow earlier intervention. One promising indicator of the potential for frailty is allostatic load, a physiological status associated with prolonged stress that is, characterised by multisystem dysfunction. Previous research has sought to understand the links between allostatic load and frailty, but has not yet explored whether allostatic load may be a predictive factor at younger ages and-if so-at what age it may be predictive. The present study sets out establish whether allostatic load can be used as a predictive indicator of frailty. Using the English Longitudinal Survey on Ageing (ELSA) data with an anticipated sample of 1500 people between 50 and 89 years old, time series analysis will determine if, and at what age, allostatic load may be predictive of pre-frailty and frailty. The findings of these analyses may be supportive of early identification of frailty by establishing an age at which a diagnostic test for allostatic load may prove a critical indicator for future frailty.

Differences in the risk of frailty based on care receipt, unmet care needs and socio-economic inequalities: A longitudinal analysis of the English Longitudinal Study of Ageing

BACKGROUND

The older population is increasingly reliant on social care, especially those who are frail. However, an estimated 1.5 million people over 65 in England have unmet care needs. The relationship between receiving care, or receiving insufficient care, and changes in frailty status remains unclear.

OBJECTIVES

To investigate the associations between care receipt (paid or unpaid), unmet care needs, frailty status, and mortality.

DESIGN

We used multistate models to estimate the risk of increasing or decreasing levels of frailty, using English Longitudinal Study of Ageing (ELSA) data. Covariates included age, gender, wealth, area deprivation, education, and marital status. Care status was assessed through received care and self-reported unmet care needs, while frailty status was determined using a frailty index.

PARTICIPANTS

15,003 individuals aged 50+, using data collected over 18 years (2002-2019).

RESULTS

Individuals who receive care are more susceptible to frailty and are less likely to recover from frailty to a less frail state. The hazard ratio of males receiving care transitioning from prefrailty to frailty was 2.1 [95 % CI: 1.7-2.6] and for females 1.8 [1.5-2.0]. Wealth is an equally influential predictor of changes in frailty status: individuals in the lowest wealth quintile who do not receive care are as likely to become frail as those in the highest wealth quintile who do receive care. As individuals receiving care (including unpaid care) are likely to be in poorer health than those who do not receive care, this highlights stark inequalities in the risk of frailty between the richest and poorest individuals. Unmet care needs were associated with transitioning from prefrailty to frailty for males (hazard ratio: 1.7 [1.2-2.4]) but not for females.

CONCLUSIONS

Individuals starting to receive care (paid or unpaid) and people in the poorest wealth quintile are target groups for interventions aimed at delaying the onset of frailty.

Frailty Focus: Empowering Rural Health With Advanced Nurse Practitioners: A Discussion Paper

BACKGROUND

Frailty is a multidimensional condition with symptoms relating to falls, immobility, incontinence, impaired memory and medication side-effects. With increasing numbers of frailty, particularly in rural areas, healthcare systems are being challenged globally. Moreover, frailty may be more common in rural communities as a consequence of transportation issues, limited access to healthcare services and health promotion activities. Advanced Nurse Practitioners are ideally placed to undertake comprehensive geriatric assessments and identify frailly syndromes.

AIMS

Explore the function of the Advanced Nurse Practitioner in managing people living with frailty in rural areas, drawing on a review of current guidelines, literature, and practice, considering public health agendas and evidence-based practice.

DESIGN

Discussion paper.

KEY LEARNINGS

Frailty is linked to poorer health outcomes, an excessive use of health resources and decreased quality of life. Incorporating Advanced Nurse Practitioners into integrated models of care and health improvement strategies, can improve patient outcomes.

CONCLUSION

Using advanced clinical and decision-making skills, Advanced Nurse practitioners deliver evidence-based care to improve patient safety and health outcomes. Creating partnerships to enhance the provision of healthcare, they are focused on frailty prevention, detection and providing support to develop co-produced management plans to address individual needs. The Advanced Nurse Practitioner has the ability to practice autonomously within an expanded scope of clinical practice, making them the ideal professional to support people living with frailty in rural areas.

IMPACT FOR NURSING

When thinking about future strategies for advanced practice, it is important to acknowledge the lack of regulation, roles in nursing, inadequate title protection, role variability, and different educational requirements. Organisations need to consider the enablers and barriers of Advanced Nurse Practitioners fulfilling their duties. Advanced Nurse practitioners are guided by public health agendas to improve the population health of those in rural areas.

NO PATIENT OR PUBLIC CONTRIBUTION

This is a discussion paper.

Protein supplementation alone or combined with exercise for sarcopenia and physical frailty: A systematic review and meta-analysis of randomized controlled trials

BACKGROUND

Sarcopenia and physical frailty are age-related syndromes characterized by progressive loss of muscle mass and function, significantly impacting mortality and quality of life in older adults. This systematic review evaluated the effectiveness of protein supplementation interventions for these conditions.

METHODS

We systematically searched Medline, CENTRAL, and Ichushi Web from January 2000 to March 2023, with additional manual searching extended to March 2024. Randomized controlled trials investigating protein supplementation, alone or combined with exercise, in adults aged ≥65 years with sarcopenia or physical frailty were included. The primary outcomes were changes in muscle mass, strength, and physical performance.

RESULTS

The systematic literature search identified 1,506 records through database searching (Medline: 357, CENTRAL: 275, Ichushi Web: 639) and 235 additional records through hand searching. Finally, 13 randomized controlled trials (n=1,057) met the inclusion criteria. Combined protein and exercise interventions demonstrated significant improvements in skeletal muscle index (MD = 0.89 kg/m², 95 % CI: 0.45 to 1.33) and handgrip strength (MD: +2.64 kg, 95 % CI: +0.75 to +4.53) compared to exercise alone. Protein supplementation alone showed modest benefits in muscle strength but limited effects on physical performance. No serious adverse events were reported.

CONCLUSIONS

While protein supplementation combined with exercise shows promising effects on muscle mass and strength in older adults with sarcopenia or physical frailty, the evidence quality was consistently rated as very low. Further high-quality trials are needed to establish optimal supplementation strategies.

REGISTRATION

PROSPERO: CRD42023408529.

Deep learning-quantified body composition from positron emission tomography/computed tomography and cardiovascular outcomes: a multicentre study

BACKGROUND AND AIMS

Positron emission tomography (PET)/computed tomography (CT) myocardial perfusion imaging (MPI) is a vital diagnostic tool, especially in patients with cardiometabolic syndrome. Low-dose CT scans are routinely performed with PET for attenuation correction and potentially contain valuable data about body tissue composition. Deep learning and image processing were combined to automatically quantify skeletal muscle (SM), bone and adipose tissue from these scans and then evaluate their associations with death or myocardial infarction (MI).

METHODS

In PET MPI from three sites, deep learning quantified SM, bone, epicardial adipose tissue (EAT), subcutaneous adipose tissue (SAT), visceral adipose tissue (VAT), and intermuscular adipose tissue (IMAT). Sex-specific thresholds for abnormal values were established. Associations with death or MI were evaluated using unadjusted and multivariable models adjusted for clinical and imaging factors.

RESULTS

This study included 10 085 patients, with median age 68 (interquartile range 59-76) and 5767 (57%) male. Body tissue segmentations were completed in 102 ± 4 s. Higher VAT density was associated with an increased risk of death or MI in both unadjusted [hazard ratio (HR) 1.40, 95% confidence interval (CI) 1.37-1.43] and adjusted (HR 1.24, 95% CI 1.19-1.28) analyses, with similar findings for IMAT, SAT, and EAT. Patients with elevated VAT density and reduced myocardial flow reserve had a significantly increased risk of death or MI (adjusted HR 2.49, 95% CI 2.23-2.77).

CONCLUSIONS

Volumetric body tissue composition can be obtained rapidly and automatically from standard cardiac PET/CT. This new information provides a detailed, quantitative assessment of sarcopenia and cardiometabolic health for physicians.

Frailty in robotic pancreaticoduodenectomy: quantifying the impact on perioperative outcomes

BACKGROUND

We sought to determine the significance of age and frailty in predicting peri-operative outcomes of robotic pancreaticoduodenectomy (RPD).

METHODS

Data from our institution's prospectively collected robotic pancreaticoduodenectomy database was analyzed for the years 2018-2023. The 5-factor modified frailty index (mFI-5) was used as a concise stratification tool for frailty. Predictive models for composite adverse event (CAE) variable were created using adjusted logistic regressions.

RESULTS

116 patients underwent RPD. Mean age of this cohort was 70.65 years (±11.44). The mean operative time was 311.47 min (±71.35) and the estimated blood loss was 107.07 mL (±128.49). The most common postoperative complications included in the CAE were pancreatic leak (n = 10, 8.62 %), delayed gastric emptying (n = 10, 8.62 %), bleeding (n = 5, 4.31 %), and atrial fibrillation (n = 2, 1.72 %). The 90-day mortality was 1.72 %. There was a gradual increase in the odds ratio of CAE with increasing mFI-5 score: OR 1.52 (95 % CI 0.25-9.20) for mFI-5 score of 1 and OR 31.92 (95 % CI 1.79-570.09) for mFI-5 score of 4 compared to score of 0.

DISCUSSION

Preoperative mFI-5 score may serve as a risk stratification tool for RPDs.

Towards the automatic detection of activities of daily living using eye-movement and accelerometer data with neural networks

Early diagnosis of neurodegenerative diseases, such as Alzheimer's disease, improves treatment and care outcomes for patients. Early signs of cognitive decline can be detected using functional scales, which are written records completed by a clinician or carer, detailing a patient's capability to perform routine activities of daily living. For example, tasks requiring planning, such as meal preparation, are some of the earliest affected by early mild cognitive impairment. In this article, we describe work towards the development of a system to automatically discriminate and objectively quantify activities of daily living. We train a selection of neural networks to discriminate a novel list of 14 activities, specially selected to overlap with those measured by existing functional scales. Our dataset consists of eight hours of development data captured from four individuals wearing the Continuous Ambulatory Vestibular Assessment (CAVA) device, which was originally developed to aid the diagnosis of vertigo. Using frequency domain recognition features derived from eye-movement and accelerometer data, we compare several classification approaches, including three bespoke neural networks, and two established network architectures commonly applied to time-series classification problems. In 10-fold cross-validation experiments, a peak mean accuracy of 64.1% is obtained. The highest accuracy across all folds is 75.3%, produced by networks comprising Gated Recurrent Units. The addition of eye-movement data is shown to improve discrimination compared to using accelerometer data alone, by close to 9%. Classification accuracy is shown to degrade if the system is trained such that test subjects are excluded from the training data, with the small size of the dataset given as a likely explanation. Our findings demonstrate that the addition of eye-movement data can significantly improve the discrimination of daily activities, and that neural networks are well suited to this task.

Diagnosis of chronic obstructive pulmonary disease (COPD) in older patients : Consensus statement of the Working Group on Pneumology in Older Patients

Chronic obstructive pulmonary disease (COPD) is a frequent disease from which approximately 8% of individuals aged 40 years and above suffer. The prevalence increases up to fivefold as age advances. Following an introduction including the etiology, measurement, characteristic features and classification of COPD, this article presents the consensus recommendations of the German Working Group on Pneumology in Older Patients. These include statements on the screening for frailty, dysphagia, malnutrition and cognitive impairment. The results are summarized with the final conclusion that adequate treatment of COPD can also slow the progression of cognitive decline and could potentially prevent or delay the onset of dementia.

Association of early and late onset of chronic diseases with physical frailty among older Indian adults: study based on a population survey

BACKGROUND

There is a limited understanding of the age at onset of chronic diseases linked to an increased risk of physical frailty among older persons, despite the well-established link between chronic diseases and frailty. This study aimed to examine the prevalence of early- and late-onset chronic diseases and their association with physical frailty and its components in older adults in India.

METHODS

Data from the Longitudinal Aging Study in India (LASI), wave 1 (2017-2018), were used with a sample of 31,386 older adults aged 60 years and above, including 15,043 males and 16,343 females. Physical frailty was assessed by using an adapted version of the frailty phenotype developed by Fried et al.. The main explanatory variable was self-reported age at the onset of chronic diseases, and a cutoff of 50 years was considered to define the early and late onset of chronic disease. Multivariable logistic regression models were used to examine the association between early and late onset of chronic diseases and physical frailty and its components.

RESULTS

Overall, 30.65% of the sample population was physically frail, and frailty was much higher in the 80 years and aboveage group (54.23%). Compared to individuals without any morbidity, those with late onset of single morbidity (AOR: 1.22, CI: 1.09-1.36) and multimorbidity (AOR: 1.49, CI: 1.29-1.71) had higher odds of physical frailty. Similarly, multimorbidity was significantly associated with most components of physical frailty, with the exception of weight loss. Older adults with late-onset hypertension (AOR: 1.22, CI: 1.09-1.36), stroke (AOR: 1.75, CI: 1.35-2.27), and heart disease (AOR: 1.58, CI: 1.21-2.06) had higher odds of physical frailty than those without any morbidity. The odds of being physically frail were higher in those with early onset arthritis (AOR: 1.55, CI: 1.15-2.08) and late-onset of arthritis (AOR: 1.35, CI: 1.13-1.61) than in those without any morbidity. Additionally, the odds of physical frailty were higher among those with late-onset chronic diseases, particularly heart disease (AOR: 3.39, CI: 1.31-8.77) and psychiatric disease (AOR: 3.00, CI: 1.19-7.61), compared to individuals with early onset of these conditions.

CONCLUSIONS

This study found significant positive associations between early and late onset chronic diseases and physical frailty and its components among older Indians. These findings underscore the importance of managing late-onset chronic diseases, especially heart diseases and psychiatric conditions, to mitigate frailty in older adults. These findings also emphasize the critical role of age at onset of specific chronic conditions and multimorbidity in the development of frailty, suggesting that targeted disease-specific interventions could help delay or prevent frailty.

Characteristics of older patients undergoing surgery in the UK: SNAP-3, a snapshot observational study

BACKGROUND

Frailty and multimorbidity are common in older adults, but the prevalence and interaction of these conditions in surgical patients remain unclear. This study describes the clinical characteristics of a heterogeneous cohort of older UK surgical patients.

METHODS

We conducted a prospective observational cohort study during 5 days in March 2022, aiming to recruit all UK patients aged 60 yr and older undergoing surgery, excluding minor procedures (e.g. cataract surgery). Data were collected on patient characteristics, clinical care, frailty, and multimorbidity measures.

RESULTS

A total of 7134 patients from 214 NHS hospitals were recruited, with a mean (sd) age of 72.8 (8.1) yr. Of all operations, 69% (95% confidence interval [CI] 67.9-70.1%) were elective, and 34% (95% CI 32.7-34.8%) were day cases. Of the patients, 19% (95% CI 18.3-20.1%) were living with frailty (Clinical Frailty Score ≥5), and 63.1% (95% CI 62.0-64.3%) were living with multimorbidity (count of ≥2 comorbidities). Those living with frailty, multimorbidity, or both were typically older, were from lower socioeconomic backgrounds, and experienced greater polypharmacy and reduced independence. Patients living with frailty were less likely to undergo elective and day-case surgeries. Four out of five (78.8% [1079/1369]) of those who were living with frailty were also living with multimorbidity; 27.1% (1079/3978) of those who were living with multimorbidity were also living with frailty.

CONCLUSIONS

In the UK, one in five older patients undergoing surgery is living with frailty, and almost two-thirds of older patients are living with multimorbidity. These data highlight the importance of frailty screening. In addition, they can serve to guide resource allocation and provide comparative estimates for future research.

Building Research Infrastructure to Address Psychosocial Frailty and Reach Underserved Aging Populations

Frailty is prevalent in adults aged ≥50 years, particularly among under-served minorities. Frailty is a multidimensional concept including physical, psychological, and social frailty, and any definition of frailty should meet the criterion of practicality that could be measurable, preventable, or modified by interventions and clinically reasonable. Early detection and tailored interventions can delay the progression of frailty and prevent adverse health outcomes. However, there is limited recruitment of underserved minorities and lack of research on early detection of multidimensional frailty and embedded adaptive systems that adequately meet the needs of aging populations. Nursing scientists, public health professionals, and policymakers should be aware of each dimension of frailty while addressing frailty and creating substantial research infrastructure development to prevent frailty that reaches populations in rural, suburban, and urban areas and benefits a larger research community. [Journal of Psychosocial Nursing and Mental health Services, 63(2), 7-10.].

Patient-centred outcome measures for oncological surgery: a narrative review

INTRODUCTION

Peri-operative medicine is becoming increasingly relevant in the context of managing frail patients with cancer. This paper outlines how demographic shifts in populations are affecting cancer incidence and frailty rates, the relevance this holds to the management of cancer care, and the outcome measures that should be used to gauge best clinical practice to ensure patient-centred care.

METHODS

A targeted literature review was conducted using the search terms 'surgical oncology', 'outcomes', 'frailty', 'quality of life' and 'end of life' from 10 to 17 June 2024. Articles were reviewed by all authors and core themes from the literature review were identified. Core themes were then discussed by the authors to construct a narrative review.

RESULTS

The review identified several core themes in relation to patient-centred outcome measures for oncological surgery. The UK population is ageing and consequently, the number of older people being diagnosed with cancer is increasing. There is much evidence to show that older patients have poorer outcomes in terms of mortality and postoperative complications across all types and severities of cancer. Traditional outcome measures such as 30-day mortality, duration of stay and recurrence rates fail to capture the outcomes that are most pertinent to this patient cohort. These include patient quality of life and treatment burden. We discuss the measurement of quality of life through the use of patient-reported outcome measures and their limitations. We also highlight the need for patient-centred, holistic care with the use of tools such as comprehensive geriatric assessment, which have been shown to improve patient outcomes.

DISCUSSION

There is need for a greater emphasis on quality-of-life measures alongside mortality and patient-reported outcome measures. We argue that holistic care approaches should play a greater role in enabling the measurement of outcome states beyond simply dead or alive.

Retrospective observational study of the association between changes in physical activity and frailty in middle-aged and older adults: evidence from the Korean Longitudinal Study of Aging (2006-2022)

OBJECTIVES

This study aimed to investigate the relationship between changes in physical activity and frailty among middle-aged and older adults in Korea, using panel data from the 2006-2022 Korean Longitudinal Study of Aging (KLoSA).

DESIGN

Retrospective observational study.

SETTING

For this longitudinal panel study, data were sourced from the KLoSA dataset.

PARTICIPANTS

We analysed data from 5594 participants (2855 males and 2739 females) extracted from KLoSA data collected between 2006 and 2022.

PRIMARY AND SECONDARY OUTCOME MEASURES

The frailty index was calculated based on 6 clinical domains comprising 34 age-related health deficits. Changes in physical activity were categorised as persistently inactive, decreased, increased or persistently active. Logistic regression analysis using generalised estimating equations was conducted to assess the association between changes in physical activity and frailty.

RESULTS

The persistently active group (OR=0.45, 95% CI: 0.40 to 0.50) showed a lower likelihood of frailty than did the persistently inactive group. In the group that increased their physical activity, the OR was 0.57 (95% CI: 0.52 to 0.63), and higher ORs were observed for current smokers and those residing in rural areas.

CONCLUSIONS

This study demonstrated that persistent and increased physical activity is associated with lower frailty in middle-aged and older adults in Korea. Therefore, participation in physical activity in the older adults is one of the important ways to prevent frailty.

Using nutrition to help recovery from infections

PURPOSE OF REVIEW

Antibiotics are a cornerstone of modern medicine, but antibiotic consumption can have depleting effects on the gut microbiota, potentially leading to gastrointestinal symptoms and other diseases, namely Clostridioides difficile infection. Because nutrition is a major driver of gut microbiota diversity and function, here we explore the current evidence on the potential of diets in alleviate the deleterious effects of antibiotics consumed during infections.

RECENT FINDINGS

Beneficial nutrients can enhance the symbiotic effect of the gut microbiota with the host, supporting anti-inflammatory responses and maintaining tight junction integrity. Short-chain fatty acids have been shown to positively affect the immune response, reducing the severity of C. difficile infection, whereas high-fibre diets have been shown to promote faster recovery of the gut microbiota after antibiotic therapy.

SUMMARY

The role of nutrition during infection is gaining momentum, with key findings exploring the effect of some nutrients in limiting the severity of infections and helping the microbiota recover from antibiotic-induced dysbiosis. Although this field is in its infancy, these findings open the possibility of personalised nutrition as a way of restoring microbiome diversity. But more work is needed to identify the most effective types and combinations of nutrients to achieve this.

Frailty as a trigger for goals-of-care discussions in rapid response calls: A single-centre retrospective cohort study

BACKGROUND

Timely goals-of-care (GOC) discussions are essential for end-of-life planning, particularly during acute hospital admissions, where ambiguity often persists. Frailty, prevalent in the ageing population and linked to adverse outcomes, underscores the need to align treatment strategies with quality of life. Recognising frailty as a trigger for GOC discussions during rapid response calls (RRCs) is critical for efficient resource management and improving patient outcomes.

METHODS

This single-centre retrospective cohort study included all hospitalised patients aged ≥65 years admitted between September 2021 and June 2023 who experienced an RRC. Frailty was assessed using the Clinical Frailty Scale (CFS) during the RRC. The primary outcome was to investigate whether frailty, specifically assessed by the CFS as screened during an RRC, could be a suitable clinical trigger for initiating GOC discussions. We also aimed to identify the proportion of patients with frailty (CFS score: ≥5) and predictors at the time of RRC, resulting in recommendations for GOC discussions.

RESULTS

Among 4954 patients, 1685 (34.0%) were classified as frail (CFS score: ≥5). Recommendations increased with frailty levels (nonfrail [CFS score: 1-4]: 6.6%, mildly frail [CFS score: 5]: 19.3%, moderate-to-severely frail [CFS score: 6-9]: 32.2%; p < 0.001). Frailty independently increased the probability of GOC recommendations during an RRC (area under the receiver operating characteristic curve = 0.71). The CFS cut-off point for GOC recommendations was ≥5. The presence of frailty was associated with higher odds of receiving GOC recommendations for mildly frail (CFS score: 5; odds ratio [OR] = 2.53; 95% confidence interval: 1.96-3.27) and moderate-to-severely frail (CFS score: 6-9; OR = 4.69; 95% confidence interval: 3.81-5.78) compared to nonfrail patients.

CONCLUSION

Frailty, identified during an RRC, served as a robust trigger for GOC recommendations, highlighting the importance of tailored proactive discussions before episodes of deterioration. Higher levels of frailty (CFS score: ≥5) demonstrate practical markers for aiding clinicians with proactive GOC discussions.

Cardiac rehabilitation for old-old patients with heart failure and severe functional impairment

BACKGROUND

The effects of cardiac rehabilitation (CR) in old patients with heart failure (HF) and severe functional impairment (SFI) are not well established.

METHODS

We studied 1397 patients with HF and severe functional impairment, defined as a six-minute walking distance (6MWD) <300 m, admitted to inpatient CR. The patients were divided into three groups: Group A (young, ≤65 years), Group B (old-young, 66 to 75 years), and Group C (old-old, >75 years). The primary outcome was an increase in 6MWD to 300 m or more after CR. We used multivariable Cox modeling to determine the association of the primary outcome with three-year mortality after discharge from CR.

RESULTS

At admission to CR, 38.5 % of the patients in group A, 40.0 % in group B, and 46.3 % in group C (p = .029) were unable to walk unassisted. Of these patients, 29.5 %, 32.6 %, and 30.2 % (p = .835), respectively, regained the ability to walk independently. Overall, 370 (26.5 %) patients achieved the primary outcome, 49.1 % in group A, 32.2 % in group B, and 15.7 % in group C (p < .001). The adjusted HR of 3-year mortality for the patients who achieved the primary outcome was 0.53 (95 %CI 0.34-0.83; p = .005) in group A, 0.49 (95 %CI 0.33-0.74; p = .001) in group B, and 0.68 (95 %CI 0.47-0.98; p = .037) in group C.

CONCLUSIONS

Our findings suggest that old-old patients with HF and severe functional impairment may benefit from CR and that functional improvement may predict improved survival.

Association Between Sugar-Sweetened Beverage Consumption and Frailty Among Older Adults With Hypertension: Evidence From the National Health and Nutrition Examination Survey 1999-2020

Frailty is a condition characterized by increased vulnerability to adverse health outcomes, particularly among older adults. With the significant prevalence of hypertension and the consumption of sugar-sweetened beverages (SSBs) in this demographic, it is essential to explore their potential combined effects on frailty. This cross-sectional study utilized data from the National Health and Nutrition Examination Survey (NHANES) spanning 1999-2020, involving 13,465 hypertensive adults aged 60 and above. Frailty was assessed using a Frailty Index based on 49 deficits, categorizing individuals as frail if their score was ≥ 0.25. SSB consumption was measured through 24-h dietary recalls. Multivariate logistic regression analyses, adjusted for various confounding factors including age, sex, body mass index (BMI), socioeconomic status, and lifestyle choices, indicated that SSB consumption was independently associated with an increased likelihood of frailty (odds ratio = 1.18, 95% confidence interval: 1.02-1.37, p = 0.02). Additionally, restricted cubic spline curve fitting revealed a linear relationship between SSB intake and frailty levels. Our findings suggested that SSB consumption was associated with frailty in older hypertensive adults, emphasizing the need for further research on the underlying mechanisms and potential interventions.

SANTANA Cohort: Study on Frailty in Institutionalised Older Adults and Its Relationship With Gordon's Functional Health Patterns

AIM

This study investigated whether Gordon's Functional Health Patterns (FHPs) can predict frailty in older adults residing in nursing homes over 5 years.

DESIGN

Prospective cohort study with participants from 10 nursing homes across five countries.

METHODS

Researchers assessed 1245 participants at baseline and 903 at follow-up (5 years) using standardised frailty measures and FHP assessments. Statistical analyses explored the relationships between FHPs and frailty.

RESULTS

FHPs, particularly those related to mobility, nutrition and social interaction, significantly predicted lower frailty risk at baseline. Furthermore, FHPs showed an increased ability to predict frailty over time, explaining a substantial portion of frailty variation at both baseline and follow-up. Analyses also revealed differences in how specific FHPs impacted frailty, suggesting the importance of individual functional variations.

CONCLUSION

This study suggests that Gordon's FHPs are a valuable tool for predicting frailty in older adults within institutional settings. Integrating FHPs into clinical practice can promote early frailty detection and intervention. Future research should explore how FHPs change over time and their impact on frailty in broader populations.

REPORTING METHOD

The study followed the CONSORT guideline for cohort studies to enhance the quality and transparency of reporting the results.

PATIENT OR PUBLIC CONTRIBUTION

Not applicable.

Associations of 2 Established Methods of Measuring Gait Speed and Sit-To-Stand Performance with Frailty and Life-Space Mobility in Community-Dwelling Older Adults

OBJECTIVES

The 4-m gait speed (4mGS) and 10-m gait speed (10mGS) tests and the 30-second sit-to-stand (30sSTS) and 5-times sit-to-stand (5xSTS) tests are commonly used and advocated in consensus recommendations. We compared these tests on their predictive and clinical value concerning the risk of prefrailty/frailty and restricted life-space mobility (RLSM).

DESIGN

Cross-sectional study.

SETTING AND PARTICIPANTS

A sample of 1235 community-dwelling adults (mean ± SD, 68 ± 7 years) participated in this prospective cohort study.

METHODS

At baseline assessment, participants completed a survey and functional assessment, from which gait speed, sit-to-stand performance, self-reported mobility limitation, 40-item Frailty Index, and Life Space Assessment were measured. Participants with a 40-item Frailty Index >0.15 and a Life Space Assessment <60 points were classified as having prefrailty/frailty and RLSM, respectively. At 1-year follow-up assessment, prefrailty/frailty and RLSM were evaluated.

RESULTS

Correlations between gait speed and sit-to-stand measures were high (ρ values >0.80). In multivariable ordinal models, these measures added incremental prognostic value beyond a base model comprising demographics and self-reported mobility limitation variables in predicting baseline and 1-year outcomes. Between 10mGS and 4mGS, models with 10mGS had higher concordance indices (differences, 0.005-0.009), and these differences translated to generally greater net benefit in decision curve analyses. Between 30sSTS and 5xSTS measures, no one measure consistently outperformed the other, with small net benefit differences between measures (<0.2%).

CONCLUSIONS AND IMPLICATIONS

In community-dwelling older adults, gait speed and sit-to-stand measures meaningfully predicted prefrailty/frailty and RLSM. 10mGS provided more robust prognostic information than the 4mGS, whereas 5xSTS and 30sSTS measures showed near equivalence of performance. These findings could guide the choice of functional measures in clinical and research settings.

The Australian Frailty Network: Development of a consumer-focussed national response to frailty

Frailty is an important concept in the care of older adults. Over the past two decades, significant advances have been made in measuring frailty. While it is now well-recognised that frailty status is an important determinant of outcomes from medical illnesses or surgical interventions, frailty measurement is not currently routinely integrated into clinical practice. In the community setting, it is uncommon for general practitioners to deliver frailty-optimised care. In hospitals, there is substantial variability in how people living with frailty are managed. This variability is notable between and even within disciplines. Furthermore, gains from understanding frailty mechanisms and risk factors are not yet applied/implemented at scale to delay the progression of frailty in community-dwellers. The Australian Frailty Network (AFN) is a national collaborative group of researchers, clinicians, non-government organisations, consumers and policymakers, in which the engagement and active involvement of consumers has been embedded from the outset. The AFN aims to generate new knowledge to improve health outcomes, to ensure evidence-based management is translated into clinical practice and to build capacity in multidisciplinary and translational frailty research. Here, we describe the development of the AFN, highlighting important milestones: (i) securing funding for the network and flagship elements; (ii) an inaugural summit to establish the strategic vision, values and scope with end-users; (iii) sabbatical visits to learn from international examples; and (iv) developing the governance structure and an actionable plan encompassing consumer engagement, research, education and policy and practice to maximise impact.

Review of frailty in geriatric surgical oncology

Frailty is a common phenomenon in older adult population and associated with an elevated risk of adverse health outcomes. Recent studies have demonstrated that patients with frailty undergoing surgery had a significantly higher morbidity and mortality compared to those without frailty. This is particularly important in patients with cancer because the prevalence of frailty is persistently high across a spectrum of primary cancers. Identifying frailty in oncological patients undergoing surgery may provide an important preoperative intervention opportunity to mitigate operative risks. In this review, we provide an overview of frailty and its association with other geriatric syndromes. We will also review the impact of frailty on postoperative outcomes focusing on the field of surgical oncology. We then describe currently available tools to objectively measure frailty to provide clinicians with various practical tools that may be adopted in their clinical practice. Finally, we will describe potential interventional programs, including the recently introduced Geriatric Surgery Verification program by the American College of Surgeons, that may be institutionally adopted to mitigate postoperative complications and improve meeting patient-centered goals in the frail patient population.

Combining motivational and exercise intervention components to reverse pre-frailty and promote self-efficacy among community-dwelling pre-frail older adults: a randomized controlled trial

BACKGROUND

Exercise is effective in preventing frailty status in older adults, but the effect of an exercise program based on Wellness Motivation Theory (WMT) on the frailty status, self-efficacy for exercise, and quality of life for older adults with pre-frailty remains unclear. Our objective was to examine the efficacy of a multicomponent exercise program based on WMT on frailty status, self-efficacy, and quality of life among pre-frail older adults.

METHODS

This was a randomized controlled trial of pre-frail older adults aged from 60 years to 85 years. Participants in the intervention group performed exercise three times a week for 24 weeks, once at a community health service station instructed by two researchers and two times at home. Participants in the control group were given one-time advice on physical activity. The assessor was the only one blinded. The primary outcome was the reversal rate of pre-frailty. The secondary outcomes included self-efficacy and quality of life.

RESULTS

One hundred and forty-four participants were randomized into two groups (n = 72 in the intervention group and n = 72 in the control group) and analyzed. After 24 weeks, the proportion of pre-frailty was significantly lower in the intervention group than in control (31.8% versus 74.6%, P < 0.001). The absolute risk reduction was 42.8% [95% CI, 25.1-57.1]. In the 8th week and the 24th week, the frailty score of the intervention group was significantly lower than that of the control group. There were significant improvements in self-efficacy at week 2, week 8, and week 24. In weeks 8 and 24, participants in the intervention group reported a higher quality of life than the control group. There were no exercise-related injuries or falls among the participants.

CONCLUSIONS

The exercise intervention based on WMT for pre-frail older adults could reverse pre-frailty, increase self-efficacy for exercise, and improve the quality of life in older Chinese.

STUDY REGISTRATION DETAILS

This study was registered in www.

CLINICALTRIALS

gov on the 25th of July, 2024, with the identifier NCT06519695.

REPORTING METHOD

The Consolidated Standards of Reporting Trials (CONSORT) checklist was used in this study for properly reporting how the randomized trial was conducted.

Development and validation of an electronic frailty index in a national health maintenance organization

BACKGROUND

Frailty constitutes a major factor that puts the elderly at risk of health and functional deterioration.

OBJECTIVES

To develop and validate an Electronic Frailty Index based on electronic data routinely collected in the HMO.

STUDY DESIGN AND SETTING

A retrospective cohort of the HMO members.

PARTICIPANTS

120,986 patients, aged 65 years and over at the beginning of 2023.

PREDICTORS

A cumulative frailty index including 36 medical, functional, and social deficits.

OUTCOMES

One-year all-cause mortality or hospitalization.

STATISTICAL ANALYSIS

One-year hazard ratios were estimated for composite outcome of mortality or hospitalization using multivariable hierarchical Cox regression.

RESULTS

The mean EFI score increased with the Social Security Nursing Benefit. Compared to fit patients, mild, moderate, and severe frailty patients had 2.07, 3.35, and 4.4-fold increased risks of mortality or hospitalization, after controlling for covariates.

CONCLUSIONS

The findings showed that the Electronic Frailty Index version we created is valid in predicting mortality or hospitalization. In addition, the Electronic Frailty Index converged with an independent measurement produced by National Social Security.

Factors that affect the implementation of an integrated care programme for older people with different frailty levels: a qualitative study of commissioners and provider stakeholders

INTRODUCTION

The NHS has made it mandatory for General Practices in England to proactively identify and manage older people with moderate and severe frailty since the GMS contract of 2017/2018. In Luton, stakeholders developed the Luton Framework of Frailty (LFF) to implement this national policy. The aim of this study was to explore the factors that affect the implementation of this national policy at a local level.

METHODS

In-depth interviews were conducted with 18 commissioners and service providers, all of whom were involved in providing services for older people with different frailty levels (OPDFL). Purposive and snowball sampling methods were used, with thematic analysis used for data analysis.

RESULTS

Two main themes with several sub-themes were found. The first theme was the tension within existing national policy initiatives to provide integrated care services for OPDFL, which illuminated their strengths and limitations. Participants felt that new initiatives, such as the development of Primary Care Networks and Enhanced Health in Care Homes, have improved primary care coordination. However, the traditional reactive approach for managing older people who are frail was thought to be counterproductive, when an approach that focused on prevention and early intervention would have been better. The second theme concerned the contextual factors that affect implementation of integrated care. These included having key leaders at a local level, the requirement for more funding, as well as the need for good working relationships among service providers. However, the lack of awareness about the care pathways among GPs was thought to be a reason for the variation in the implementation of the LFF. The COVID-19 pandemic was perceived as a challenge for the implementation of the LFF. Finally, polices were thought to succeed only if more resources are provided, while the term frailty should be used with caution due to the negative connotations of OPDFL towards this term.

CONCLUSION

The implementation of an integrated care programme for OPDFL can be affected by several factors. Having proactive national policies that facilitate coordination and, having key leaders locally, the need for more funding, and good working relationships, are some of the contextual factors that could facilitate a successful implementation. In contrast, the lack of awareness of the care pathways that have been introduced locally, insufficient resources to deliver the programmes efficiently and a lack of careful consideration of how the term frailty is used could hinder this being put into practice.

Impact of frailty in older people on health care demand: simulation modelling of population dynamics to inform service planning

Background

As populations age, frailty and the associated demand for health care increase. Evidence needed to inform planning and commissioning of services for older people living with frailty is scarce. Accurate information on incidence and prevalence of different levels of frailty and the consequences for health outcomes, service use and costs at population level is needed.

Objectives

To explore the incidence, prevalence, progression and impact of frailty within an ageing general practice population and model the dynamics of frailty-related healthcare demand, outcomes and costs, to inform the development of guidelines and tools to facilitate commissioning and service development.

Study design and methods

A retrospective observational study with statistical modelling to inform simulation (system dynamics) modelling using routine data from primary and secondary health care in England and Wales. Modelling was informed by stakeholder engagement events conducted in Hampshire, England. Data sources included the Royal College of General Practitioners Research and Surveillance Centre databank, and the Secure Anonymised Information Linkage Databank. Population prevalence, incidence and progression of frailty within an ageing cohort were estimated using the electronic Frailty Index tool, and associated service use and costs were calculated. Association of frailty with outcomes, service use and costs was explored with multistate and generalised linear models. Results informed development of a prototype system dynamics simulation model, exploring population impact of frailty and future scenarios over a 10-year time frame. Simulation model population projections were externally validated against retrospective data from Secure Anonymised Information Linkage.

Study population

The Royal College of General Practitioners Research and Surveillance Centre sample comprised an open cohort of the primary care population aged 50 + between 2006 and 2017 (approx. 2.1 million people). Data were linked to Hospital Episode Statistics data and Office for National Statistics death data. A comparable validation data set from Secure Anonymised Information Linkage was generated.

Baseline measures

Electronic Frailty Index score calculated annually and stratified into Fit, Mild, Moderate and Severe frailty categories. Other variables included age, sex, Index of Multiple Deprivation score, ethnicity and Urban/rural.

Outcomes

Frailty transitions, mortality, hospitalisations, emergency department attendances, general practitioner visits and costs.

Findings

Frailty is already present in people aged 50-64. Frailty incidence was 47 cases per 1000 person-years. Frailty prevalence increased from 26.5% (2006) to 38.9% (2017). Older age, higher deprivation, female sex, Asian ethnicity and urban location independently predict frailty onset and progression; 4.8% of 'fit' people aged 50-64 years experienced a transition to a higher frailty state in a year, compared to 21.4% aged 75-84. Individual healthcare use rises with frailty severity, but Mild and Moderate frailty groups have higher overall costs due to larger population numbers. Simulation projections indicate frailty will increase by 7.1%, from 41.5% to 48.7% between 2017 and 2027, and associated costs will rise by £5.8 billion (in England) over an 11-year period.

Conclusions

Simulation modelling indicates that frailty prevalence and associated service use and costs will continue to rise in the future. Scenario analysis indicates reduction of incidence and slowing of progression, particularly before the age of 65, has potential to substantially reduce future service use and costs, but reducing unplanned admissions in frail older people has a more modest impact. Study outputs will be collated into a commissioning toolkit, comprising guidance on drivers of frailty-related demand and simulation model outputs.

Study registration

This study is registered as NCT04139278 www.clinicaltrials.gov.

Funding

This award was funded by the National Institute for Health and Care Research (NIHR) Health and Social Care Delivery Research programme (NIHR award ref: 16/116/43) and is published in full in Health and Social Care Delivery Research; Vol. 12, No. 44. See the NIHR Funding and Awards website for further award information.

Sustained frailty remission and dementia risk in older adults: A longitudinal study

INTRODUCTION

Physical frailty is reversible, but little is known about the sustainability of frailty remission and its impact on dementia.

METHODS

Data were derived from the National Health and Aging Trends Study (NHATS) (2011 to 2021). Physical frailty was assessed using the Fried frailty phenotype, and frailty transition patterns across three waves were defined. The relationship of sustained frailty remission with incident dementia was examined using Cox proportional regression, stratified by age and gender.

RESULTS

Among 1931 participants, 348 (18.0%) were capable of sustained frailty remission. During the 8-year follow-up, 279 participants developed dementia. In a fully adjusted model, sustained remission was associated with a lower risk of dementia (hazard ratio = 0.66, 95% confidence interval = 0.47 to 0.93). The association was more pronounced among younger-old and male participants but not observed among their counterparts.

DISCUSSION

Sustained frailty remission was associated with a reduced risk of developing dementia. Physical frailty could be an essential forewarning of dementia and a target for interventions.

HIGHLIGHTS

We provided new insights into the natural progression of frailty and its impact on dementia risk using a nationally representative sample Sustained frailty remission reduced risk of incident dementia. Age and gender played a role in the frailty-dementia link, and thus individualized dementia risk screening is necessary. Physical frailty could be an essential forewarning of cognitive decline and an ideal target for interventions to prevent dementia.

Hospital-initiated palliative care interventions for adults with frailty: findings from a systematic review and narrative synthesis

BACKGROUND

Adults with frailty have palliative care needs [1] but have disproportionately less access to palliative care services [2]. Frailty affects ~4000 patients admitted to hospital per day in the UK [3], making the hospital admission a unique opportunity to assess palliative care needs and deliver interventions.

OBJECTIVES

Synthesise the evidence regarding hospital palliative care (HPC) for patients with frailty. Narratively analyse the evidence regarding methods used to identify palliative care needs; types of palliative care interventions studied; and whether HPC improves outcomes.

METHODS

Systematic literature review and narrative synthesis of experimental, observational and systematic review articles investigating palliative care interventions for hospitalised adults aged ≥65 years with frailty. Electronic search of five databases from database inception to 30 January 2023. Included studies analysed using narrative synthesis according to Popay et al [4].

RESULTS

15 465 titles retrieved, 12 included. Three studies detailed how they identified palliative care needs; all three used prognostication e.g. the 'surprise question'. Most papers (10/12) investigated specialist palliative care interventions. These interventions addressed a wider range of care needs than non-specialist interventions. Evidence suggested an improvement in some symptom burden and healthcare utilisation outcomes following HPC.

CONCLUSION

Prognostication was the main method of identifying palliative care needs, rather than individuals' specific needs. Specialist palliative care interventions were more holistic, indicating that non-specialist palliative care approaches may benefit from specialist team input. Despite suggestions of improvement in some outcomes with palliative care, heterogenous evidence prevented establishment of conclusive effects.

The association between frailty and the risk of mortality in critically ill congestive heart failure patients: findings from the MIMIC-IV database

Background

Frailty is a severe, common co-morbidity associated with congestive heart failure (CHF). This retrospective cohort study assesses the association between frailty and the risk of mortality in critically ill CHF patients.

Methods

Eligible patients with CHF from the Medical Information Base for Intensive Care IV database were retrospectively analyzed. The frailty index based on laboratory tests (FI_Lab) index was calculated using 33 variables to assess frailty status. The primary outcomes were in-hospital mortality and one-year mortality. The secondary outcomes were the incidence of acute kidney injury (AKI) and the administration of renal replacement therapy (RRT) in patients with concurrent AKI. Survival disparities among the FI_Lab subgroups were estimated with Kaplan-Meier survival analysis. The association between the FI_Lab index and mortality was examined with Cox proportional risk modeling.

Results

A total of 3273 adult patients aged 18 years and older were enrolled in the study, with 1820 men and 1453 women included. The incidence rates of in-hospital mortality and one-year mortality rate were 0.96 per 1,000 person-days and 263.8 per 1,000 person-years, respectively. Multivariable regression analysis identified baseline FI_Lab > 0.45 as an independent risk factor predicting in-hospital mortality (odds ratio = 3.221, 95% CI 2.341-4.432, p < 0.001) and one-year mortality (hazard ratio=2.152, 95% CI: 1.730-2.678, p < 0.001). In terms of predicting mortality, adding FI_Lab to the six disease severity scores significantly improved the overall performance of the model (all p < 0.001).

Conclusions

We established a positive correlation between the baseline FI_Lab and the likelihood of adverse outcomes in critical CHF patients. Given its potential as a reliable prognostic tool for such patients, further validation of FI_Lab across multiple centers is recommended for future research.

Functional Outcomes after Abdominal Surgery in Older Adults - How concerned are we about this?

Amidst trends of a rapidly ageing population with better surgical outcomes for geriatric patients, it is imperative to consider outcome measures beyond mortality and morbidity rates. In fact, the preservation of one's postoperative function has been cited as a key priority for older adults and is a crucial determinant of postoperative independence and survival. This review aims to examine the prevalence of perioperative function reporting amongst older surgical patients undergoing elective major abdominal surgery for cancer. We systematically reviewed studies from inception to December 2023 for studies which focused on the outcomes of older surgical patients undergoing elective major abdominal surgery for cancer. Relevant citations were screened (title, abstract and full article review) based on the inclusion and exclusion criteria. 103 studies were included, of which only 31 studies consisting of 20885 participants reported perioperative function. While the nominal number of studies which report perioperative function has been on a steady rise since 2018, the proportion of studies which do so remains low. Postoperative function is three times less likely to be reported than preoperative function, suggesting that functional recovery is not sufficiently assessed. This suggests that there is still a poor uptake of functional recovery as an outcome measure amongst surgeons, and any increase in perioperative function reporting is likely due to the increased administration of frailty assessments. These findings should urge greater efforts in quantifying and enabling functional recovery to improve the clinical outcomes and quality of care for older surgical patients.

A comparison of frailty measures in population-based data for patients with colorectal cancer

BACKGROUND

Numerous studies have revealed age-related inequalities in colorectal cancer care. Increasing levels of frailty in an ageing population may be contributing to this, but quantifying frailty in population-based studies is challenging.

OBJECTIVE

To assess the feasibility, validity and reliability of the Hospital Frailty Risk Score (HFRS), the Secondary Care Administrative Records Frailty (SCARF) index and the frailty syndromes (FS) measures in a national colorectal cancer cohort.

DESIGN

Retrospective population-based study using 136,008 patients with colorectal cancer treated within the English National Health Service.

METHODS

Each measure was generated in the dataset to assess their feasibility. The diagnostic codes used in each measure were compared with those in the Charlson Comorbidity Index (CCI). Validity was assessed using the prevalence of frailty and relationship with 1-year survival. The Brier score and the c-statistic were used to assess performance and discriminative ability of models with included each measure.

RESULTS

All measures demonstrated feasibility, validity and reliability. Diagnostic codes used in SCARF and CCI have considerable overlap. Prevalence of frailty determined by each differed; SCARF allocating 55.4% of the population to the lowest risk group compared with 85.1% (HFRS) and 81.2% (FS). HFRS and FS demonstrated the greatest difference in 1-year overall survival between those with the lowest and highest measured levels of frailty. Differences in model performance were marginal.

CONCLUSIONS

HFRS, SCARF and FS all have value in quantifying frailty in routine administrative health care datasets. The most suitable measure will depend on the context and requirements of each individual epidemiological study.

Cost-effectiveness of surgery for degenerative cervical myelopathy in the United Kingdom

PURPOSE

Degenerative cervical myelopathy (DCM) is the commonest cause of adult spinal cord dysfunction worldwide, for which surgery is the mainstay of treatment. At present, there is limited literature on the costs associated with the surgical management of DCM, and none from the United Kingdom (UK). This study aimed to evaluate the cost-effectiveness of DCM surgery within the National Health Service, UK.

MATERIALS AND METHODS

Incidence of DCM was identified from the Hospital Episode Statistics (HES) database for a single year using five ICD-10 diagnostic codes to represent DCM. Health Resource Group (HRG) data was used to estimate the mean incremental surgery (treatment) costs compared to non-surgical care, and the incremental effect (quality adjusted life year (QALY) gain) was based on data from a previous study. A cost per QALY value of <£30,000/QALY (GBP) was considered acceptable and cost-effective, as per the National Institute for Health and Clinical Excellence (NICE) guidance. A sensitivity analysis was undertaken (±5%, ±10% and ±20%) to account for variance in both the cost of admission and QALY gain.

RESULTS

The total number of admissions for DCM in 2018 was 4,218. Mean age was 62 years, with 54% of admissions being of working age (18-65 years). The overall estimated cost of admissions for DCM was £38,871,534 for the year. The mean incremental (per patient) cost of surgical management of DCM was estimated to be £9,216 (ranged £2,358 to £9,304), with a QALY gain of 0.64, giving an estimated cost per QALY value of £14,399/QALY. Varying the QALY gain by ±20%, resulted in cost/QALY figures between £12,000 (+20%) and £17,999 (-20%).

CONCLUSIONS

Surgery is estimated to be a cost-effective treatment of DCM amongst the UK population.

Characterisation of the octogenarians presenting to the diagnostic heart failure clinic: SHEAF registry

INTRODUCTION

Heart failure (HF) incidence is increasing in older adults with high hospitalisation and mortality rates. Treatment is complicated by side effects and comorbidities. We investigated the clinical characteristics of octogenarians presenting to the HF clinic.

METHODS

Data were collected on octogenarians (80-89 years) referred to the HF clinic in two periods. The data included demographics, HF phenotype, comorbidities, symptoms and treatment. We investigate the temporal changes in clinical characteristics using χ2 test. We aimed to determine the clinical characteristics which were associated with optimisation of HF pharmacological intervention in the clinic, conducting multivariate regression analysis. Statistical significance is determined at p<0.05.

RESULTS

Data were collected in April 2012 to January 2014 and in June 2021 to December 2022. In this cross-sectional study of temporal data, 571 octogenarians were referred to the clinic in the latter period, in whom the prevalence of HF was 68.48% (391 patients). HF with preserved ejection fraction (HFpEF) was the most common phenotype and increased significantly compared with the first period (46.3% and 29.2%, p<0.001). Frailty, chronic kidney disease and ischaemic heart disease increased significantly versus the first period (p<0.001). During the second period, and following the consultation, of the patients with HF with reduced ejection fraction (HFrEF), 86.4% and 82.7% were on a beta blocker and on an ACE inhibitor/angiotensin receptor blocker/angiotensin receptor-neprilysin inhibitor, respectively. Clinical characteristics associated with further optimisations of HF pharmacological therapy in the HF clinic were: New York Heart Association (NYHA) functional class III and the presence of HFrEF phenotype CONCLUSIONS: With a prevalence of HF at 68% among the octogenarians referred to the HF clinic, HFpEF incidence is rising. The decision to optimise HF pharmacological treatment in octogenarians is driven by NYHA functional class III and the presence of HFrEF phenotype.

Frailty and In-Hospital Outcomes for Management of Cardiogenic Shock without Acute Myocardial Infarction

(1) Background: Cardiogenic shock (CS) is associated with high morbidity and mortality. Frailty and cardiovascular diseases are intertwined, commonly sharing risk factors and exhibiting bidirectional relationships. The relationship of frailty and non-acute myocardial infarction with cardiogenic shock (non-AMI-CS) is poorly described. (2) Methods: We retrospectively analyzed the National Inpatient Sample from 2016 to 2020 and identified all hospitalizations for non-AMI-CS. We classified them into frail and non-frail groups according to the hospital frailty risk score cut-off of 5 and compared in-hospital outcomes. (3) Results: A total of 503,780 hospitalizations for non-AMI-CS were identified. Most hospitalizations involved frail adults (80.0%). Those with frailty had higher odds of in-hospital mortality (adjusted odds ratio [aOR] 2.11, 95% confidence interval [CI] 2.03-2.20, p < 0.001), do-not-resuscitate status, and discharge to a skilled nursing facility compared with those without frailty. They also had higher odds of in-hospital adverse events, such as acute kidney injury, delirium, and longer length of stay. Importantly, non-AMI-CS hospitalizations in the frail group had lower use of mechanical circulatory support but not rates of cardiac transplantation. (4) Conclusions: Frailty is highly prevalent among non-AMI-CS hospitalizations. Those accompanied by frailty are often associated with increased rates of morbidity and mortality compared to those without frailty.

Postpandemic Sentinel Surveillance of Respiratory Diseases in the Context of the World Health Organization Mosaic Framework: Protocol for a Development and Evaluation Study Involving the English Primary Care Network 2023-2024

BACKGROUND

Prepandemic sentinel surveillance focused on improved management of winter pressures, with influenza-like illness (ILI) being the key clinical indicator. The World Health Organization (WHO) global standards for influenza surveillance include monitoring acute respiratory infection (ARI) and ILI. The WHO's mosaic framework recommends that the surveillance strategies of countries include the virological monitoring of respiratory viruses with pandemic potential such as influenza. The Oxford-Royal College of General Practitioner Research and Surveillance Centre (RSC) in collaboration with the UK Health Security Agency (UKHSA) has provided sentinel surveillance since 1967, including virology since 1993.

OBJECTIVE

We aim to describe the RSC's plans for sentinel surveillance in the 2023-2024 season and evaluate these plans against the WHO mosaic framework.

METHODS

Our approach, which includes patient and public involvement, contributes to surveillance objectives across all 3 domains of the mosaic framework. We will generate an ARI phenotype to enable reporting of this indicator in addition to ILI. These data will support UKHSA's sentinel surveillance, including vaccine effectiveness and burden of disease studies. The panel of virology tests analyzed in UKHSA's reference laboratory will remain unchanged, with additional plans for point-of-care testing, pneumococcus testing, and asymptomatic screening. Our sampling framework for serological surveillance will provide greater representativeness and more samples from younger people. We will create a biomedical resource that enables linkage between clinical data held in the RSC and virology data, including sequencing data, held by the UKHSA. We describe the governance framework for the RSC.

RESULTS

We are co-designing our communication about data sharing and sampling, contextualized by the mosaic framework, with national and general practice patient and public involvement groups. We present our ARI digital phenotype and the key data RSC network members are requested to include in computerized medical records. We will share data with the UKHSA to report vaccine effectiveness for COVID-19 and influenza, assess the disease burden of respiratory syncytial virus, and perform syndromic surveillance. Virological surveillance will include COVID-19, influenza, respiratory syncytial virus, and other common respiratory viruses. We plan to pilot point-of-care testing for group A streptococcus, urine tests for pneumococcus, and asymptomatic testing. We will integrate test requests and results with the laboratory-computerized medical record system. A biomedical resource will enable research linking clinical data to virology data. The legal basis for the RSC's pseudonymized data extract is The Health Service (Control of Patient Information) Regulations 2002, and all nonsurveillance uses require research ethics approval.

CONCLUSIONS

The RSC extended its surveillance activities to meet more but not all of the mosaic framework's objectives. We have introduced an ARI indicator. We seek to expand our surveillance scope and could do more around transmissibility and the benefits and risks of nonvaccine therapies.

AZD1222 effectiveness against severe COVID-19 in individuals with comorbidity or frailty: The RAVEN cohort study

OBJECTIVES

Despite being prioritized during initial COVID-19 vaccine rollout, vulnerable individuals at high risk of severe COVID-19 (hospitalization, intensive care unit admission, or death) remain underrepresented in vaccine effectiveness (VE) studies. The RAVEN cohort study (NCT05047822) assessed AZD1222 (ChAdOx1 nCov-19) two-dose primary series VE in vulnerable populations.

METHODS

Using the Oxford-Royal College of General Practitioners Clinical Informatics Digital Hub, linked to secondary care, death registration, and COVID-19 datasets in England, COVID-19 outcomes in 2021 were compared in vaccinated and unvaccinated individuals matched on age, sex, region, and multimorbidity.

RESULTS

Over 4.5 million AZD1222 recipients were matched (mean follow-up ∼5 months); 68% were ≥50 years, 57% had high multimorbidity. Overall, high VE against severe COVID-19 was demonstrated, with lower VE observed in vulnerable populations. VE against hospitalization was higher in the lowest multimorbidity quartile (91.1%; 95% CI: 90.1, 92.0) than the highest quartile (80.4%; 79.7, 81.1), and among individuals ≥65 years, higher in the 'fit' (86.2%; 84.5, 87.6) than the frailest (71.8%; 69.3, 74.2). VE against hospitalization was lowest in immunosuppressed individuals (64.6%; 60.7, 68.1).

CONCLUSIONS

Based on integrated and comprehensive UK health data, overall population-level VE with AZD1222 was high. VEs were notably lower in vulnerable groups, particularly the immunosuppressed.

Association between natriuretic peptides and C-reactive protein with frailty in heart failure: a systematic review and meta-analysis

BACKGROUND

Heart failure (HF) and frailty are accompanied by a bidirectional relationship, sharing common risk factors including elevated levels of natriuretic peptides and inflammation. The aim of this study was to compare biomarkers associated with poor clinical outcomes, that is, plasma brain natriuretic peptide (BNP), N-terminal-pro B-type natriuretic peptide (NT-proBNP), and C-reactive protein (CRP) in patients with HF and frailty vs. patients with HF without frailty.

METHODS

From inception until July 2023, PubMed, Scopus, Web of Science, and Cochrane Library a systematic literature search was conducted. To evaluate whether frailty is linked with greater levels of BNP, NT-proBNP, and CRP, a meta-analysis using a random-effects model was used to calculate the pooled effects (CRD42023446607).

RESULTS

Fifty-three studies were included in this systematic review and meta-analysis. Patients with HF and frailty displayed significantly higher levels of BNP (k = 11; SMD: 0.53, 95%CI 0.30-0.76, I2 = 86%, P < 0.01), NT-proBNP (k = 23; SMD: 0.33, 95%CI 0.25-0.40, I2 = 72%, P < 0.01), and CRP (k = 8; SMD: 0.30, 95%CI 0.12-0.48, I2 = 62%, P < 0.01) vs. patients with HF without frailty. Using meta-regression, body mass index (BMI) and age were deemed potential moderators of these findings.

CONCLUSIONS

Frailty in HF is linked to increased concentrations of BNP, NT-proBNP, and CRP, which have been epidemiologically associated with adverse outcomes. The increased risk of NYHA III/IV classification further emphasizes the clinical impact of frailty in this population.

Virtual wards for people with frailty: what works, for whom, how and why-a rapid realist review

BACKGROUND

Virtual wards (VWs) deliver multidisciplinary care at home to people with frailty who are at high risk of a crisis or in crisis, aiming to mitigate the risk of acute hospital admission. Different VW models exist, and evidence of effectiveness is inconsistent.

AIM

We conducted a rapid realist review to identify different VW models and to develop explanations for how and why VWs could deliver effective frailty management.

METHODS

We searched published and grey literature to identify evidence on multidisciplinary VWs. Information on how and why VWs might 'work' was extracted and synthesised into context-mechanism-outcome configurations with input from clinicians and patient/public contributors.

RESULTS

We included 17 peer-reviewed and 11 grey literature documents. VWs could be short-term and acute (1-21 days), or longer-term and preventative (typically 3-7 months). Effective VW operation requires common standards agreements, information sharing processes, an appropriate multidisciplinary team that plans patient care remotely, and good co-ordination. VWs may enable delivery of frailty interventions through appropriate selection of patients, comprehensive assessment including medication review, integrated case management and proactive care. Important components for patients and caregivers are good communication with the VW, their experience of care at home, and feeling involved, safe and empowered to manage their condition.

CONCLUSIONS

Insights gained from this review could inform implementation or evaluation of VWs for frailty. A combination of acute and longer-term VWs may be needed within a whole system approach. Proactive care is recommended to avoid frailty-related crises.

New horizons in frailty identification via electronic frailty indices: early implementation lessons from experiences in England and the United States

Frailty represents an integrative prognostic marker of risk that associates with a myriad of age-related adverse outcomes in older adults. As a concept, frailty can help to target scarce resources and identify subgroups of vulnerable older adults that may benefit from interventions or changes in medical management, such as pursing less aggressive glycaemic targets for frail older adults with diabetes. In practice, however, there are several operational challenges to implementing frailty screening outside the confines of geriatric medicine. Electronic frailty indices (eFIs) based on the theory of deficit accumulation, derived from routine data housed in the electronic health record, have emerged as a rapid, feasible and valid approach to screen for frailty at scale. The goal of this paper is to describe the early experience of three diverse groups in developing, implementing and adopting eFIs (The English National Health Service, US Department of Veterans Affairs and Atrium Health-Wake Forest Baptist). These groups span different countries and organisational complexity, using eFIs for both research and clinical care, and represent different levels of progress with clinical implementation. Using an implementation science framework, we describe common elements of successful implementation in these settings and set an agenda for future research and expansion of eFI-informed initiatives.

Primary and secondary care service use and costs associated with frailty in an ageing population: longitudinal analysis of an English primary care cohort of adults aged 50 and over, 2006-2017

BACKGROUND

Frailty becomes more prevalent and healthcare needs increase with age. Information on the impact of frailty on population level use of health services and associated costs is needed to plan for ageing populations.

AIM

To describe primary and secondary care service use and associated costs by electronic Frailty Index (eFI) category.

DESIGN AND SETTING

Retrospective cohort using electronic health records. Participants aged ≥50 registered in primary care practices contributing to the Oxford Royal College of General Practitioners Research and Surveillance Centre, 2006-2017.

METHODS

Primary and secondary care use (totals and means) were stratified by eFI category and age group. Standardised 2017 costs were used to calculate primary, secondary and overall costs. Generalised linear models explored associations between frailty, sociodemographic characteristics. Adjusted mean costs and cost ratios were produced.

RESULTS

Individual mean annual use of primary and secondary care services increased with increasing frailty severity. Overall cohort care costs for were highest in mild frailty in all 12 years, followed by moderate and severe, although the proportion of the population with severe frailty can be expected to increase over time. After adjusting for sociodemographic factors, compared to the fit category, individual annual costs doubled in mild frailty, tripled in moderate and quadrupled in severe.

CONCLUSIONS

Increasing levels of frailty are associated with an additional burden of individual service use. However, individuals with mild and moderate frailty contribute to higher overall costs. Earlier intervention may have the most potential to reduce service use and costs at population level.

"Learning a Way of Thinking"-World Café on Clinical Reasoning in Nursing and Midwifery Education and Practice across Five European Union Countries

Clinical reasoning is a key attribute of nursing and midwifery professionals. As a part of the Erasmus plus project, we designed a study with the aim of exploring the understanding of clinical reasoning as a concept, experiences of teaching clinical reasoning and practices related to using clinical reasoning in nursing and midwifery. A qualitative study was carried out using the World Café method, involving 44 participants from five European countries. The participants represented diverse professional backgrounds, including nurses, midwives and lecturers. Our analytical approach was based on a thematic analysis. We categorized the data into three main categories, namely, "Spiral of thinking", "The learning and teaching of a way of thinking" and "Clinical reasoning in real life", all under an overarching theme, "Learning a way of thinking". This study highlighted areas of learning and teaching which can be improved in current nursing and midwifery education. Furthermore, it identified barriers, facilitators and practices from five European countries which can be used in the further development of nursing and midwifery curricula and courses with the aim of enhancing clinical reasoning competence and ultimately improving patient care.