The feasibility and reliability of frailty assessment tools applicable in acute in-hospital trauma patients: A systematic review

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

A systematic review of predictive accuracy via c-statistic of preoperative frailty tests for extended length of stay, post-operative complications, and mortality

Frailty, as an age-related syndrome of reduced physiological reserve, contributes significantly to post-operative outcomes. With the aging population, frailty poses a significant threat to patients and health systems. Since 2012, preoperative frailty assessment has been recommended, yet its implementation has been inhibited by the vast number of frailty tests and lack of consensus. Since the anesthesiologist is the best placed for perioperative care, an anesthesia-tailored preoperative frailty test must be simple, quick, universally applicable to all surgeries, accurate, and ideally available in an app or online form. This systematic review attempted to rank frailty tests by predictive accuracy using the c-statistic in the outcomes of extended length of stay, 3-month post-operative complications, and 3-month mortality, as well as feasibility outcomes including time to completion, equipment and training requirements, cost, and database compatibility. Presenting findings of all frailty tests as a future reference for anesthesiologists, Clinical Frailty Scale was found to have the best combination of accuracy and feasibility for mortality with speed of completion and phone app availability; Edmonton Frailty Scale had the best accuracy for post-operative complications with opportunity for self-reporting. Finally, extended length of stay had too little data for recommendation of a frailty test. This review also demonstrated the need for changing research emphasis from odds ratios to metrics that measure the accuracy of a test itself, such as the c-statistic.

Long-term health-related quality of life and independence among older survivors of serious injury

BACKGROUND

Little is known about the recovery experiences of older trauma intensive care unit (TICU) survivors and the relationship between geriatric trauma care and long-term functional ability and health-related quality of life (HRQOL).

METHODS

We conducted a prospective cohort study of 218 patients (age, ≥65 years) admitted to a Level 1 regional trauma center TICU before versus after implementation of a geriatric care bundle with protocolized geriatrics consultations (Geri-T). Survivors or their proxies were interviewed approximately 1 year after hospitalization. Outcomes included the Katz Index of Independence in Activities of Daily Living (ADLs), Lawton Instrumental Activities of Daily Living (IADLs), and EQ-5D-5L HRQOL survey. Two investigator-developed questions regarding recovery experiences were included. Differences in outcomes among survivors admitted before versus after Geri-T were analyzed using multivariable linear regression. Responses to questions about recovery experiences were qualitatively assessed using content analysis.

RESULTS

We reached 67% (146/218) of hospital survivors or their proxies across both groups; 126 patients were still alive and completed the survey. Mean age was 76 (SD, 8), 36% were female, and 90% were independent with ADLs preinjury. At follow-up, independence with ADLs was 76% and IADLs was 63%. The mean EQ-5D-5L index score was 0.78 (SD, 0.18). Most patients (65%) reported having not returned to preinjury functional status. Neither functional ability or HRQOL differed significantly among patients admitted before versus after Geri-T. Content analysis of open-ended questions revealed themes of activity limitations, persistent pain, and cognitive dysfunction.

CONCLUSION

Nearly one-fifth of TICU survivors experienced loss of ADL function 1 year after injury, and most reported having not returned to preinjury functional status. Nonetheless, patient-reported HRQOL was comparable to age-adjusted norms. Geri-T was not associated with differences in HRQOL or functional ability. Survivors reported persistent difficulty with activities beyond those of daily living, pain, and cognition.

LEVEL OF EVIDENCE

Prognostic and Epidemiologic, Level III.

Geriatric Trauma and Frailty

Geriatric trauma is increasing in the United States. The care of patients with geriatric trauma is complex due to age-related changes and comorbidities. Patients with geriatric trauma have increased risk of poor outcomes compared with younger patients with trauma, and the highest risk groups are those who have frailty. These patients require special care considerations. Multidisciplinary care can improve outcomes in frail patients with geriatric trauma.

The Association Between the Clinical Frailty Scale and Adverse Health Outcomes in Older Adults in Acute Clinical Settings - A Systematic Review of the Literature

Background

Frail older adults experience higher rates of adverse health outcomes. Therefore, assessing pre-hospital frailty early in the course of care is essential to identify the most vulnerable patients and determine their risk of deterioration. The Clinical Frailty Scale (CFS) is a frailty assessment tool that evaluates pre-hospital mobility, energy, physical activity, and function to generate a score that ranges from very fit to terminally ill.

Purpose

To synthesize the evidence of the association between the CFS degree and all-cause mortality, all-cause readmission, length of hospital stay, adverse discharge destination, and functional decline in patients >65 years in acute clinical settings.

Design

Systematic review with narrative synthesis.

Methods

Electronic databases (PubMed, EMBASE, CINAHL, Scopus) were searched for prospective or retrospective studies reporting a relationship between pre-hospital frailty according to the CFS and the outcomes of interest from database inception to April 2020.

Results

Our search yielded 756 articles, of which 29 studies were included in this review (15 were at moderate risk and 14 at low risk of bias). The included studies represented 26 cohorts from 25 countries (N = 44166) published between 2011 and 2020. All included studies showed that pre-hospital frailty according to the CFS is an independent predictor of all adverse health outcomes included in the review.

Conclusion

A primary purpose of the CFS is to grade clinically increased risk (i.e. risk stratification). Our results report the accumulated knowledge on the risk-predictive performance of the CFS and highlight the importance of routinely including frailty assessments, such as the CFS, to estimate biological age, improve risk assessments, and assist clinical decision-making in older adults in acute care. Further research into the potential of the CFS and whether implementing the CFS in routine practice will improve care and patients' quality of life is warranted.