The impact of interventions on management of frailty in hospitalized frail older adults: a systematic review and meta-analysis

Systematic review of interventions for pre-frail and frail older adults: Evidence from clinical trials on frailty levels

INTRODUCTION

The increasing global longevity underscores the necessity of effective interventions for older adults. Pre-frailty and frailty affect 54.1 % and 26.3 % of the elderly population, respectively, leading to adverse physical and cognitive outcomes. This study systematically reviewed the effectiveness of interventions targeting robust, pre-frail, and frail older adults in randomized controlled trials, analyzing frailty levels both collectively and individually.

METHODS

Following the Joanna Briggs Institute (JBI) methodology and PRISMA guidelines, seven databases were searched for studies published between 2018 and 2023. Randomized controlled trials involving individuals aged ≥65 years were included. Methodological quality was assessed using the PEDro scale, with scores ranging from 7 to 10, indicating moderate to high quality.

RESULTS

A total of 3416 records were identified, and 40 studies were included, encompassing 17,822 participants (82.3 % women, mean age: 68-79 years). Physical exercise interventions accounted for 42.5 % of the studies, while multicomponent programs constituted 27.5 %. Improvements in frailty levels were reported in 32.5 % of the studies, with significant gains in quality of life (+15.2 %), gait speed (+0.22 m/s), and muscle strength (+18.7 %). Pre-frail individuals exhibited the greatest responsiveness to interventions, reflecting their remaining adaptability and potential for improvement.

DISCUSSION

Multifaceted interventions were found to be particularly effective for pre-frail individuals, emphasizing the need for standardized criteria for frailty assessment. Geographic variability and inconsistencies in assessment methods were noted. Physical activity emerged as a key component in improving outcomes, with most interventions led by physiotherapists and physical education professionals.

CONCLUSION

Integrated interventions significantly enhance health and functionality, particularly for pre-frail older adults, underscoring the importance of early and tailored approaches. This study highlights the need for standardized guidelines and multidisciplinary strategies to address the heterogeneity of the aging population effectively.

Association between frailty and physical function recovery of people who received physiotherapy early rehabilitation during acute hospitalisation: An observational cohort study

OBJECTIVES

Examine the effect of frailty on physical function recovery in people admitted to hospital who received a physiotherapy Early Rehabilitation program.

METHODS

Observational cohort (1 January 2021 to 31 December 2021). Patients admitted to the acute site at Austin Health, Australia who received an Early Rehabilitation program (targeted physical rehabilitation to address goals aligned to physiotherapy intervention in parallel with acute medical treatment) were eligible. Frailty was measured with the Clinical Frailty Scale (CFS). The primary outcome was, across the CFS, magnitude of change from admission to discharge in physical function assessed with the modified Iowa Level of Assistance Scale (mILOA). Secondary outcomes were length of stay and discharge destination. Generalised additive models were used.

RESULTS

There were 674 patients included in the study. Irrespective of frailty status, mean improvement in physical function from admission to discharge exceeded the minimal datable change of 5.8 points for the mILOA. Larger average improvements in mILOA were observed in patients with lower degrees of frailty (p < 0.001 overall effect), where a portion of patients with severe frailty did not make clinically meaningful gains in physical function following Early Rehabilitation. Mean improvement in physical function and predicted probabilities for discharge home were similar; where greater frailty severity was associated with a lesser chance of going home at acute hospital discharge (p = 0.002 overall effect).

CONCLUSIONS

Validating the link between predictions for change in physical function and discharge home in people receiving early rehabilitation during acute hospitalisation would be of great clinical utility.

Effectiveness of comprehensive geriatric assessment in frail older inpatients

BACKGROUND

Evidence regarding the effects of comprehensive geriatric assessment (CGA) on frail older inpatients is inconclusive. Moreover, various prior studies lacked proper patient selection using frailty assessment tools. Our review aimed to assess whether objectively identifying frail patients in clinical settings using a frailty tool and intervening with CGA provides clinical benefits in frail older inpatients.

METHODS

A systematic review and meta-analysis were conducted by searching PubMed, Embase, and Web of Science (January 1998-October 2022). Keywords included frailty, hospitalization, and CGA. Eligible studies were randomized controlled trials involving patients aged ≥65 years, with frailty defined by specific tools. The primary outcome was mortality; secondary outcomes included activities of daily living, quality of life, pain, patient satisfaction, polypharmacy, antidepressant use, post-discharge disposition, rehospitalization, and cost-effectiveness.

RESULTS

Of 2587 articles, 18 met inclusion criteria (2724 participants). Meta-analysis of five studies showed no significant differences in overall mortality for frail inpatients receiving CGA. However, CGA reduced mortality during follow-ups of ≤6 months. CGA also improved health-related quality of life, patient satisfaction, and activities of daily living, while reducing polypharmacy and modifying antidepressant use.

CONCLUSIONS

CGA did not significantly reduce overall mortality in frail older inpatients compared to usual care but lowered mortality rates at the 6-month follow-up. CGA also improved quality of life, daily functioning, and medication management, underscoring its value for managing frail older inpatients.

The impact of age and frailty on hospitalization and survival in older liver transplant recipients: a longitudinal cohort study

Purpose

Frailty is a well-established risk factor for adverse outcomes, particularly in liver transplant candidates. This study investigates the impact of age and frailty on key clinical outcomes-hospitalizations, waitlist survival, and post-transplant mortality-in cirrhotic patients evaluated for liver transplantation.

Methods

This study included older adults with chronic liver disease under consideration for transplantation. Data collected encompassed medical history, Model for End-Stage Liver Disease (MELD) and Child-Turcotte-Pugh (CTP) scores, Mini-Mental State Examination (MMSE), Mini Nutritional Assessment (MNA), and frailty status, assessed using both the Liver Frailty Index (LFI) and the Survey of Health, Ageing, and Retirement in Europe Frailty Index (SHARE-FI). Clinical outcomes, including mortality and hospitalizations, were tracked over a 24-month period.

Results

Among 100 patients (67% male), those under 70 exhibited higher MNA, MMSE, and SHARE-FI scores. Based on frailty classification, 25 patients were frail, 28 pre-frail, and 47 robust. Younger patients experienced more hospitalizations during follow-up (p = 0.03) and had a higher probability of hospitalization within 24 months (p = 0.002). Although transplant-free survival did not differ significantly across groups, frail patients had a significantly higher mortality rate (p = 0.04). Overall, 24 patients underwent transplantation, while 26 died, including six post-transplant deaths. MELD and CTP scores were strong predictors of mortality, while among frailty measures, only SHARE-FI demonstrated significant predictive value. In multivariate Cox models, MELD [HR = 1.17, p = 0.001; HR = 1.11, p = 0.002], CTP [HR = 1.43, p = 0.003; HR = 1.41, p = 0.006], and LFI (HR = 1.69, p = 0.04) were significantly associated with mortality.

Conclusion

Frailty, rather than age, emerges as a key predictor of mortality in liver transplant candidates. Further research is needed to validate these findings and enhance frailty assessment, ultimately improving candidate selection for transplantation.

Exercise interventions for older patients with frailty and heart failure: A scoping review

BACKGROUND

To provide a structured analysis of exercise interventions and outcome measures in older patients with frailty and heart failure (HF).

METHODS

8 databases were searched up to May 22, 2024 to identify relevant studies. Two independent reviewers assessed and collected data according to the TIDieR checklist, CONTENT scale and COMET outcome taxonomy.

RESULTS

We screened 1,253 articles, resulting in 8 articles being included in the scoping review. Aerobic exercise and resistance training were fundamental elements of exercise rehabilitation, with balance training also being essential. Most exercise interventions are individualized, with the type and intensity of exercise being set and adjusted according to the patient's actual condition. However, the tailoring process of resistance training, including exercise load, sets, and repetitions, needs to be more detailed in most studies. The exercise interventions were provided by qualified therapists in most studies, and various methods were taken to ensure fidelity. None of the studies mentioned their theoretical basis. Only two exercise interventions were considered therapeutically valid. The two most commonly reported outcomes were physical function and quality of life.

CONCLUSIONS

It is necessary to focus on addressing research heterogeneity and report transparency to better implement exercise interventions in older frail adults with HF.

Knowledge, attitude, and practice of frailty management among clinical nurses: a cross-sectional study

BACKGROUND

Frailty is a leading risk factor of falls, incapacitation, functional decline, and even death in aging populations globally. Clinical nurses play pivotal roles in screening, prevention, and intervention to reverse or slow the progression of frailty. The present study aimed to (1) understand the extent and influencing factors of knowledge, attitudes, and practices of clinical nurses for managing frailty, (2) elucidate the relationships of the knowledge, attitudes, and practices of clinical nurses for frailty management.

METHODS

This cross-sectional study was conducted from March to April 2024 on 524 clinical nurses in a tertiary hospital in Zhejiang Province, China. The survey instruments included a questionnaire inquiring about the knowledge, attitudes, and practices of nurses in terms of frailty management, a demographic data form, and a self-designed frailty educational information questionnaire. Data were analyzed by descriptive statistics, univariate analysis, multiple linear regression, and structural equation modeling.

RESULTS

Of 524 nurses, Only 37.2% were rated as good in terms of knowledge, attitude, and practice of frailty management, while 55.7% were rated as moderate. Among them, the proportion of nurses with good knowledge (10.3%) and practical skills (13.4%) is much lower than their attitude (65.3%). Structural equation modeling found that knowledge and attitudes were related to frailty management practices, with significant associations between knowledge and practices(β = 0.499, p < 0.001). Of the total effect size of knowledge influencing practice (total effect = 0.624, 95% CI: 0.455,0.791), approximately 20.0% was mediated by attitudes (indirect effect = 0.125, 95% CI: 0.076,0.187). Multiple linear regression analysis showed that age, organizational support, familiarity with relevant guidelines, familiar with the term frailty, and department all had a significant effect on the total score(adjusted R2 = 0.264, p < 0.001).

CONCLUSIONS

Despite inadequate knowledge and limited experience in frailty management, clinical nurses' attitudes towards frailty management were positive, indicating potential for improvement. The model was useful to explain practices in frailty management, thereby providing a theoretical basis for development of targeted training programs.

CLINICAL TRIAL NUMBER

Not applicable.

Social frailty in older adults: A concept analysis

BACKGROUND

Social frailty has been increasingly prevalent due to the aging populations. This concept is a relatively new topic in the gerontology. Older adults experiencing social isolation because of social frailty remain in a state of loneliness or depression. Many misconceptions exist regarding the association between social frailty and high levels of loneliness and depression in older adults, which may exacerbate their condition.

OBJECTIVE

To analyze the concept of social frailty on the basis of method introduced by Rodgers and Knafl.

DESIGN

Rodgers and Knafl' evolutionary concept analysis INFORMATION SOURCES: PubMed, Cochrane Library, Cumulated Index to Nursing and Allied Health Literature (CINAHL), Embase were searched for the terms "Social frailty" and "Elderly" OR "Older adults" OR "Aged."

RESULTS

A total of 65 articles on social frailty were selected from 4 databases and subjected to concept analysis based on Rodgers and Knafl' evolutionary concept. Data extraction and analysis adhered to the Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines. The analysis yielded 4 domains (11 subdomains) of antecedents, 3 attributes, and 2 domains (28 subdomains) of consequences.

CONCLUSION

The study findings contribute to a comprehensive and structured understanding of social frailty for health-care workers and the general public. Emphasizing the concept of social frailty can increase the levels of awareness and vigilance among health-care workers regarding the risks associated with social frailty in older adults.

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

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

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

BACKGROUND

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

OBJECTIVES

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

METHODS

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

RESULTS

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

CONCLUSION

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

Frailty as an independent predictor for midterm adverse outcomes in the elderly undergoing primary percutaneous coronary intervention: A longitudinal cohort study

BACKGROUND

Frailty is associated with poor health outcomes in elderly population. However, its effect on midterm outcomes in elderly patients undergoing primary percutaneous coronary intervention (PCI) for ST-elevation myocardial infarction (STEMI) remains unknown.

AIMS

This study aimed to evaluate the association between frailty, as classified by the Clinical Frailty Scale (CFS), and midterm adverse outcomes in elderly STEMI patients after primary PCI.

METHODS

In this prospective, observational, multicenter cohort study, frailty status of 426 STEMI patients aged ≥60 years undergoing primary PCI was determined using the nine-point CFS 2 weeks before the occurrence of STEMI. Patients scoring at least four points on the CFS were considered frail. The primary outcome was a composite of cardiovascular death or readmission. Secondary outcomes included cardiovascular death, cardiovascular readmission, heart failure-related death or readmission, and myocardial reinfarction. Follow-up data were collected through medical record reviews and/or telephone interviews.

RESULTS

Of 426 elderly patients, 116 were frail. The median follow-up period was 15 months (interquartile range 5-19 months). Primary outcome events occurred in 87 (75.0%) frail and 75 (24.2%) nonfrail patients. The adjusted hazard ratio was 3.278 after model selection using the Bayesian Model Averaging approach (95% confidence interval 2.372-4.531). Multivariate Cox proportional hazard survival analysis showed that frailty was significantly associated with a higher prevalence of all secondary outcome events after adjusting for TIMI, PAMI, and CADILLAC risk scores.

CONCLUSIONS

Frailty, as defined by the CFS, was independently associated with midterm adverse outcomes in elderly patients undergoing primary PCI for STEMI.

Understanding how older people with mild frailty engage with behaviour change to support their independence: a qualitative study

OBJECTIVES

To explore barriers and facilitators to behaviour change in older people with mild frailty.

DESIGN

Qualitative study.

SETTING

Community-dwelling older people living with mild frailty.

PARTICIPANTS

64 older people with mild frailty, workers delivering the service and stakeholders.

METHODS

Semistructured interviews were conducted between July 2022 and May 2023 with participants in a randomised controlled trial ('HomeHealth') of a 6-month, home-based, personalised goal setting intervention, based around the Capability-Opportunity-Motivation-Behaviour model. We purposively sampled older participants receiving the service (n=49), workers delivering it (n=7) and stakeholders supporting its delivery (n=8). Interviews explored participation experiences, including engagement, perceived progress and impact. Transcripts were analysed using thematic analysis.

RESULTS

Key themes included frailty symptoms and adapting/compensating for these, self-efficacy and beliefs about capacity or need for change, familiarity with goal-setting processes and health-related knowledge, accessibility of services and outdoor environments, and enabling social support. Participants were empowered to change behaviours with support, where personalised meaningful goals were set. These were maintained where they led to a tangible outcome and had increased self-efficacy; however, new health challenges and lack of intrinsic motivation could be barriers.

CONCLUSIONS

Regular and continued empathic person-centred support helps empower mildly frail people who are motivated to change their behaviour. Identifying those willing and able to identify their need for change may be key to maximise service use impact.

TRIAL REGISTRATION NUMBER

ISRCTN54268283.

Evaluation of the effects of thyroid functions on frailty in geriatric patients using the Edmonton, SOF and FRAIL Scales

BACKGROUND AND RATIONALE: Thyroid dysfunction in older adults often mimics the signs of aging, impacting metabolism and overall physiological balance. While age-related chronic conditions have been extensively studied, the relationship between thyroid function and frailty remains underexplored.

OBJECTIVE

This study aimed to evaluate the effects of thyroid dysfunction on frailty among individuals aged 65 years and older. Thyroid-stimulating hormone (TSH), free triiodothyronine (fT3), free thyroxine (fT4), and thyroid peroxidase antibody (anti-TPO) levels were analyzed. The study further examined the correlation between thyroid dysfunction, chronic diseases, sociodemographic factors, and optimal TSH levels in relation to frailty, using the Study of Osteoporotic Fractures (SOF), Edmonton Frail Scale (EFS), and FRAIL scales.

METHODS

This cross-sectional study included 220 older adults with either treated or untreated thyroid dysfunction. Comprehensive geriatric assessments were conducted, including detailed medical histories, sociodemographic data collection, and thyroid function tests. Frailty was assessed using the SOF, EFS, and FRAIL scales. Multivariate logistic regression analyses were performed to identify significant associations between thyroid parameters and frailty.

RESULTS

The median age of participants was 73 years, and 68.2% (n = 150) were women. Frailty prevalence was significantly higher in individuals with abnormal TSH levels (outside the 0.5-6 mIU/L range). Lower fT3 levels and the fT3/fT4 ratio were significantly associated with frailty, particularly as assessed by the SOF and EFS scales. In contrast, the FRAIL scale revealed a significant association between increased frailty and lower fT3 levels only. Subgroup analysis indicated that in individuals aged ≥ 80 years, a lower fT3/fT4 ratio was consistently associated with frailty across all frailty scales, whereas in those aged < 80 years, lower TSH levels showed a strong association with frailty as assessed by the FRAIL scale. These findings underscore age-specific variations in the relationship between thyroid function and frailty.

CONCLUSION

This study highlights the significant impact of thyroid dysfunction on frailty in older adults. Lower fT3 levels and the fT3/fT4 ratio emerged as key indicators of increased frailty, particularly on the SOF and EFS scales. Subgroup analysis further emphasized the importance of age-specific assessments, with a lower fT3/fT4 ratio being a critical indicator of frailty in individuals aged ≥ 80 years, while lower TSH levels were significant in those aged < 80 years. Abnormal TSH levels were strongly associated with frailty on the SOF scale, suggesting the need to consider thyroid dysfunction as a modifiable risk factor. Additionally, factors such as age, sex, education, thyroid medication use, and comorbidities influenced frailty status. Incorporating thyroid function tests into frailty assessments could enhance early identification and targeted interventions for at-risk older adults, particularly when age-specific thresholds are applied.

A frailty census of older adults in the emergency department and acute inpatient settings of a model 4 hospital in the Mid-West of Ireland

BACKGROUND

Frailty is a risk factor for presentation to the ED, in-hospital mortality, prolonged hospital stays and functional decline at discharge. Profiling the prevalence and level of frailty within the acute hospital setting is vital to ensure evidence-based practice and service development within the construct of frailty. The aim of this cross-sectional study was to establish the prevalence of frailty and co-morbidities among older adults in an acute hospital setting.

METHODS

Data collection was undertaken by clinical research nurses and advanced nurse practitioners experienced in assessing older adults. All patients aged ≥ 65 years and admitted to a medical or surgical inpatient setting between 08:00 and 20:00 and who attended the ED over a 24-h period were screened using validated frailty and co-morbidity scales. Age and gender demographics, Clinical Frailty Scale (CFS), Charlson Co-morbidity Index (CCI) and admitting specialty (medical/surgical) were collected. Descriptive statistics were used to profile the cohort, and p values were calculated to ascertain the significance of results.

RESULTS

Within a sample of 413 inpatients, 291 (70%) were ≥ 65 years and therefore were included in the study. 202 of these 291 older adults (70%) were ≥ 75 years. Frailty was investigated using validated clinical cut-offs on the CFS (not frail < 5; frail ≥ 5). Comorbidities were investigated using the Charlson Comorbidity Index (mild 1-2; moderate 3-4; severe ≥ 5). The median CFS was 6 indicating moderate frailty levels, and the median CCI score was 3 denoting moderate co-morbidity. In the inpatient cohort, 245 (84%) screened positive for frailty, while 223 (75%) had moderate-severe co-morbidity (CCI Mod 3-4, severe ≥ 5). No significant differences were observed across genders for CFS and CCI. In the ED, 81 patients who attended the ED were ≥ 65 years. The median CFS was 6 (moderate frailty), and the median CCI was 5 (severe co-morbidity level). Seventy-four percent (60) of participants screened positively for frailty (CFS ≥ 5), and 31% (25) had a CFS of 7 or greater (severely frail). Ninety-six percent (78) of patients had a moderate-severe level of comorbidity. No significant associations were found between the CFS and CCI and ED participants age, gender, and medical/surgical speciality usage.

CONCLUSION

There is a high prevalence of frailty and co-morbidity among older adults who present to the ED and require inpatient care. This may contribute to increased waiting times, lengths of stay, and the need for specialist intervention. With an increased focus on the integration of care for older adults across care transitions, there is a clear need for expansion of frailty-based services, staff training in frailty care and multidisciplinary team resources across the hospital and community setting.

Artificial Intelligence (AI)-Driven Frailty Prediction Using Electronic Health Records in Hospitalized Patients With Cardiovascular Disease

Background

This study aimed to create a deep learning model for predicting phenotypic physical frailty from electronic medical record information in patients with cardiovascular disease.

Methods and Results

This single-center retrospective study enrolled patients who could be assessed for physical frailty according to cardiovascular health study criteria (25.5% [691/2,705] of the patients were frail). Patients were randomly separated for training (Train set: 80%) and validation (Test set: 20%) of the deep learning model. Multiple models were created using LightGBM, random forest, and logistic regression for deep learning, and their predictive abilities were compared. The LightGBM model had the highest accuracy (in a Test set: F1 score 0.561; accuracy 0.726; area under the curve of the receiver operating characteristics [AUC] 0.804). These results using only commonly used blood biochemistry test indices (in a Test set: F1 score 0.551; accuracy 0.721; AUC 0.793) were similar. The created models were consistently and strongly associated with physical functions at hospital discharge, all-cause death, and heart failure-related readmission.

Conclusions

Deep learning models derived from large sample sizes of phenotypic physical frailty have shown good accuracy and consistent associations with prognosis and physical functions.

Frailty screening with comprehensive geriatrician-led multidisciplinary assessment for older adults during emergency hospital attendance in Ireland (SOLAR): a randomised controlled trial

BACKGROUND

Multidisciplinary comprehensive geriatric assessment (CGA) improves outcomes in hospitalised older adults but there is limited evidence on its effectiveness in the emergency department. We aimed to assess the benefits of CGA in the emergency department for older adults living with frailty.

METHODS

In this randomised controlled trial, we enrolled older adults (≥75 years) who presented to the emergency department with medical complaints at University Hospital Limerick (Limerick, Ireland). Participants screened positive for frailty on the Identification of Seniors at Risk screening tool (score ≥2). Patients requiring resuscitation as well as those with COVID-19, psychiatric, surgical, or trauma complaints were excluded. Participants were randomly allocated 1:1 to geriatrician-led multidisciplinary CGA and management or usual care. Outcome assessors were masked to treatment allocation. The primary efficacy outcome was time spent in the emergency department, defined as the time from registration on the computer database until time of discharge or admission to an inpatient ward in the intention-to-treat population. This study is registered with ClinicalTrials.gov, NCT04629690.

FINDINGS

Between Nov 9, 2020, and May 13, 2021, we recruited 228 patients. 113 participants were included in the intervention group (mean age 82·4 years [SD 4·9]; 63 [56%] women; 113 [100%] White Irish) and 115 in the control group (83·1 [5·6]; 61 [53%]; 112 [97%]). Median time in the emergency department was 11·5 h (IQR 5-27) in the intervention group and 20 h (7-29) in the control group (median difference [Hodges-Lehmann estimator] 3·1 h [95% CI 0·6-7·5]; p=0·013). There were no adverse events related to the intervention.

INTERPRETATION

Geriatrician-led multidisciplinary assessment of older adults living with frailty was associated with reduced time spent in the emergency department setting at index visit and lower rates of nursing home admission, greater increases in quality of life, and lower decreases in function at both 30 days and 180 days. Multicentre trials are needed to confirm the external validity of the findings. This study provides an evidence base for similar teams in an emergency department setting.

FUNDING

Health Research Board (ILP-HSR-2017-014).

Using Existing Clinical Data to Measure Older Adult Inpatients' Frailty at Admission and Discharge: Hospital Patient Register Study

BACKGROUND

Frailty is a widespread geriatric syndrome among older adults, including hospitalized older inpatients. Some countries use electronic frailty measurement tools to identify frailty at the primary care level, but this method has rarely been investigated during hospitalization in acute care hospitals. An electronic frailty measurement instrument based on population-based hospital electronic health records could effectively detect frailty, frailty-related problems, and complications as well be a clinical alert. Identifying frailty among older adults using existing patient health data would greatly aid the management and support of frailty identification and could provide a valuable public health instrument without additional costs.

OBJECTIVE

We aim to explore a data-driven frailty measurement instrument for older adult inpatients using data routinely collected at hospital admission and discharge.

METHODS

A retrospective electronic patient register study included inpatients aged ≥65 years admitted to and discharged from a public hospital between 2015 and 2017. A dataset of 53,690 hospitalizations was used to customize this data-driven frailty measurement instrument inspired by the Edmonton Frailty Scale developed by Rolfson et al. A 2-step hierarchical cluster procedure was applied to compute e-Frail-CH (Switzerland) scores at hospital admission and discharge. Prevalence, central tendency, comparative, and validation statistics were computed.

RESULTS

Mean patient age at admission was 78.4 (SD 7.9) years, with more women admitted (28,018/53,690, 52.18%) than men (25,672/53,690, 47.81%). Our 2-step hierarchical clustering approach computed 46,743 inputs of hospital admissions and 47,361 for discharges. Clustering solutions scored from 0.5 to 0.8 on a scale from 0 to 1. Patients considered frail comprised 42.02% (n=19,643) of admissions and 48.23% (n=22,845) of discharges. Within e-Frail-CH's 0-12 range, a score ≥6 indicated frailty. We found a statistically significant mean e-Frail-CH score change between hospital admission (5.3, SD 2.6) and discharge (5.75, SD 2.7; P<.001). Sensitivity and specificity cut point values were 0.82 and 0.88, respectively. The area under the receiver operating characteristic curve was 0.85. Comparing the e-Frail-CH instrument to the existing Functional Independence Measure (FIM) instrument, FIM scores indicating severe dependence equated to e-Frail-CH scores of ≥9, with a sensitivity and specificity of 0.97 and 0.88, respectively. The area under the receiver operating characteristic curve was 0.92. There was a strong negative association between e-Frail-CH scores at hospital discharge and FIM scores (rs=-0.844; P<.001).

CONCLUSIONS

An electronic frailty measurement instrument was constructed and validated using patient data routinely collected during hospitalization, especially at admission and discharge. The mean e-Frail-CH score was higher at discharge than at admission. The routine calculation of e-Frail-CH scores during hospitalization could provide very useful clinical alerts on the health trajectories of older adults and help select interventions for preventing or mitigating frailty.

Physiotherapy in acute geriatrics wards: What (de)motivates patients? A qualitative study based on self-determination theory

BACKGROUND

While the benefits of physiotherapy for hospitalized older patients (HOPs) are well established, these patients are often considered demotivated by healthcare team members (HTMs), which is perceived as a hindrance to their rehabilitation. The quantitative data currently available on the lack of involvement of HOPs are mainly measures of mobility. Motivation as such has, to our knowledge, never been measured. Therefore, this study aims to quantify for the first time the motivation levels of HOPs in their participation in activities of daily living (ADLs) and physiotherapy, and to explore the motivating factors behind their participation in physiotherapy.

METHODS

The motivation of 60 older patients hospitalized in an acute geriatrics ward was quantified using the Scale of Demotivation Assessment (SDA). Out of these participants, 14 were interrogated through individual semi-structured face-to-face interviews. After transcription, data were analyzed according to Self-Determination Theory, which has been proven effective in the understanding of motivational mechanisms.

RESULTS

The prevalence of demotivation was 47% (95% CI: [0.34;0.6]) for ADLs and 35% (95% CI: [0.23;0.48]) for physiotherapy. The main demotivating factors were the feeling of external control (lack of autonomy) and dependance experienced by HOPs, as well as the limited availability of staff during hospitalization. Conversely, feelings of competence, security, respect for limits, and commitment from the HTMs were important motivating factors.

CONCLUSION

A large number of relational factors have an impact on the motivation of HOPs regarding their participation in ADLs and in physiotherapy sessions. Appropriate time and space organizing and the provision of suitable equipment, combined with a genuine caring and respectful attitude from the HTMs, could considerably encourage the expression of intrinsic motivation and thus the involvement of HOPs in their own care program.

Impact of frailty on pneumonia outcomes in older patients: a systematic review and meta-analysis

PURPOSE

The ideal method for identifying frailty remains unclear, but the condition is associated with poor prognoses in many illnesses. Despite the availability of studies, the prognostic implications of frailty on older patients with pneumonia remains unexplored. To determine the burden and effect of frailty on selected clinical outcomes among older patients with pneumonia.

METHODS

We searched Medline, Google Scholar, and Science Direct databases for articles published in English following the PRISMA framework to guide our review. We included studies conducted on patients (> 60 years) with frailty and pneumonia, and reporting the effect of frailty on mortality, hospital stay, length readmission, and ICU admission. We performed a meta-analysis using STATA 14.2, calculating pooled odds ratios and 95% confidence intervals.

RESULTS

We analysed data from 16 studies and calculated a pooled frailty prevalence of 49% (95% CI 37-60%) in older patients with pneumonia. Unadjusted analyses revealed an odds ratio (OR) of 2.50 (95% CI 1.88-3.32) for the intermediate risk group, and an OR of 3.51 (95% CI 3.05-4.05) for the high risk group regarding mortality. The high risk frailty group also exhibited significant elevations in the risk of readmissions and extended hospital stay lengths. Substantial heterogeneity was observed in both adjusted and unadjusted analyses.

CONCLUSIONS

Our systematic review and meta-analysis results show that one in every two older individuals with pneumonia present frailty, a condition that significantly influences their rates of mortality and readmission, and their hospital stay length.

Association between modified frailty index and postoperative delirium in patients after cardiac surgery: A cohort study of 2080 older adults

AIM

To evaluate the association between frailty and postoperative delirium (POD) in elderly cardiac surgery patients.

METHODS

A retrospective study was conducted of older patients admitted to the intensive care unit after cardiac surgery at a tertiary academic medical center in Boston from 2008 to 2019. Frailty was measured using the Modified Frailty Index (MFI), which categorized patients into frail (MFI ≥3) and non-frail (MFI = 0-2) groups. Delirium was identified using the confusion assessment method for the intensive care unit and nursing notes. Logistic regression models were used to examine the association between frailty and POD, and odds ratios (OR) with 95% confidence intervals (CI) were calculated.

RESULTS

Of the 2080 patients included (median age approximately 74 years, 30.9% female), 614 were frail and 1466 were non-frail. The incidence of delirium was significantly higher in the frail group (29.2% vs. 16.4%, p < 0.05). After adjustment for age, sex, race, marital status, Acute Physiology Score III (APSIII), sequential organ failure assessment (SOFA), albumin, creatinine, hemoglobin, white blood cell count, type of surgery, alcohol use, smoking, cerebrovascular disease, use of benzodiazepines, and mechanical ventilation, multivariate logistic regression indicated a significantly increased risk of delirium in frail patients (adjusted OR: 1.61, 95% CI: 1.23-2.10, p < 0.001, E-value: 1.85).

CONCLUSIONS

Frailty is an independent risk factor for POD in older patients after cardiac surgery. Further research should focus on frailty assessment and tailored interventions to improve outcomes.

Higher blood biochemistry-based biological age developed by advanced deep learning techniques is associated with frailty in geriatric rehabilitation inpatients: RESORT

BACKGROUND

Accelerated biological ageing is a major underlying mechanism of frailty development. This study aimed to investigate if the biological age measured by a blood biochemistry-based ageing clock is associated with frailty in geriatric rehabilitation inpatients.

METHODS

Within the REStORing health of acutely unwell adulTs (RESORT) cohort, patients' biological age was measured by an ageing clock based on completed data of 30 routine blood test variables measured at rehabilitation admission. The delta of biological age minus chronological age (years) was calculated. Ordinal logistic regression and multinomial logistic regression were performed to evaluate the association of the delta of ages with frailty assessed by the Clinical Frailty Scale. Effect modification of Cumulative Illness Rating Scale (CIRS) score was tested.

RESULTS

A total of 1187 geriatric rehabilitation patients were included (median age: 83.4 years, IQR: 77.7-88.5; 57.4 % female). The biochemistry-based biological age was strongly correlated with chronological age (Spearman r = 0.883). After adjustment for age, sex and primary reasons for acute admission, higher biological age (per 1 year higher in delta of ages) was associated with more severe frailty at admission (OR: 1.053, 95 % CI:1.012-1.096) in patients who had a CIRS score of <12 not in patients with a CIRS score >12. The delta of ages was not associated with frailty change from admission to discharge. The specific frailty manifestations as cardiac, hematological, respiratory, renal, and endocrine conditions were associated with higher biological age.

CONCLUSION

Higher biological age was associated with severe frailty in geriatric rehabilitation inpatients with less comorbidity burden.

Frailty in Older Adults with Dengue Fever

Background and objectives: Dengue is one of the most common epidemic infections around the world. Dengue infections in older adults are related to an atypical presentation and a high mortality. Frailty is associated with poor recovery from hospitalization due to infection. However, few studies describe frailty and functional decline after dengue infection. The current case series study aims to investigate the baseline frailty status, functional decline, and time to recovery in older adults after dengue infection. Method: We studied seven patients with post-dengue frailty who had been admitted to the geriatric ward in one tertiary medical center in Taiwan during the 2023 dengue fever outbreak. Result: The mean age was 82 years old. The clinical frailty scale worsened from a mean of 4.7 at baseline to 6.3 at dengue diagnosis. The mean Katz Index of independence in activities of daily living decreased from 10.6 at baseline to 4.7 with dengue, and it recovered to 6.7 one month after discharge. Conclusions: Our preliminary data suggest that there is indeed an increase in frailty in older adults due to dengue. Post-dengue frailty and functional decline might be profound and persistent. Acute geriatric care intervention rehabilitation for frailty after dengue may benefit this population.

The Association between Functional Health Patterns and Frailty in Hospitalized Geriatric Patients

This study investigates the association between the Functional Health Pattern Assessment Screening Tool (FHPAST) and frailty in hospitalized geriatric patients. One hundred and forty patients (mean age 78.2 years, age range 65-90) were screened for frailty using the Frail Scale during hospitalization in the geriatric unit. Among them, 57 patients were identified as prefrail (40.7%), and 83 were identified as frail (59.3%). A comparative analysis between groups in terms of the FHPAST components covering health risk, general well-being, and health promotion was performed. Correlations between FHAPST components, socio-demographic data, frailty criteria, as well as logistic regression to identify variables that better predict frailty were also sought. Frailty was mainly associated with difficulty urinating, limitations in performing activities of daily living and walking, physical discomfort, less positive feelings in controlling one's own life, lower compliance with recommendations from the healthcare provider, and engagement in seeking healthcare services. Patients with difficulty urinating and walking had a probability of 4.38 times (OR = 4.38, CI 95% [1.20-15.94]), p = 0.025) and 65.7 times (OR = 65.7, CI 95% [19.37-223.17], p < 0.001) higher of being frail rather than prefrail. The relationship between frailty and prefrailty in hospitalized geriatric patients and components of nursing Functional Health Patterns (FHP) has yet to be explored. This study provides evidence of the most prevalent needs of frail geriatric patients in hospital settings.

Head Protection Device for Individuals at Risk for Head Injury due to Ground-Level Falls: Single Trauma Center User Experience Investigation

BACKGROUND

Falls represent a large percentage of hospitalized patients with trauma as they may result in head injuries. Brain injury from ground-level falls (GLFs) in patients is common and has substantial mortality. As fall prevention initiatives have been inconclusive, we changed our strategy to injury prevention. We identified a head protection device (HPD) with impact-resistant technology, which meets head impact criteria sustained in a GLF. HPDs such as helmets are ubiquitous in preventing head injuries in sports and industrial activities; yet, they have not been studied for daily activities.

OBJECTIVE

We investigated the usability of a novel HPD on patients with head injury in acute care and home contexts to predict future compliance.

METHODS

A total of 26 individuals who sustained head injuries, wore an HPD in the hospital, while ambulatory and were evaluated at baseline and 2 months post discharge. Clinical and demographic data were collected; a usability survey captured HPD domains. This user experience design revealed patient perceptions, satisfaction, and compliance. Nonparametric tests were used for intragroup comparisons (Wilcoxon signed rank test). Differences between categorical variables including sex, race, and age (age group 1: 55-77 years; age group 2: 78+ years) and compliance were tested using the chi-square test.

RESULTS

Of the 26 patients enrolled, 12 (46%) were female, 18 (69%) were on anticoagulants, and 25 (96%) were admitted with a head injury due to a GLF. The median age was 77 (IQR 55-92) years. After 2 months, 22 (85%) wore the device with 0 falls and no GLF hospital readmissions. Usability assessment with 26 patients revealed positive scores for the HPD post discharge regarding satisfaction (mean 4.8, SD 0.89), usability (mean 4.23, SD 0.86), effectiveness (mean 4.69, SD 0.54), and relevance (mean 4.12, SD 1.10). Nonparametric tests showed positive results with no significant differences between 2 observations. One issue emerged in the domain of aesthetics; post discharge, 8 (30%) patients had a concern about device weight. Analysis showed differences in patient compliance regarding age (χ12=4.27; P=.04) but not sex (χ12=1.58; P=.23) or race (χ12=0.75; P=.60). Age group 1 was more likely to wear the device for normal daily activities. Patients most often wore the device ambulating, and protection was identified as the primary benefit.

CONCLUSIONS

The HPD intervention is likely to have reasonably high compliance in a population at risk for GLFs as it was considered usable, protective, and relevant. The feasibility and wearability of the device in patients who are at risk for GLFs will inform future directions, which includes a multicenter study to evaluate device compliance and effectiveness. Our work will guide other institutions in pursuing technologies and interventions that are effective in mitigating injury in the event of a fall in this high-risk population.

Summary of best evidence for prevention and management of frailty

BACKGROUND

Frailty in older people can seriously affect their quality of life and increase the demand for long-term care and health care expenses. Aims of this study are to provide an evidence-based basis for clinical practice of frailty in older people by systematically searching for the best current evidence on interventions for the prevention and management of frailty.

METHODS

According to the '6S' evidence resource model, evidence retrieval is searched from the top-down and collected relevant guidelines, best practices, evidence summaries, systematic reviews and expert consensus. The retrieval time limit was from the database establishment to 20 March 2023. Two reviewers independently screened and evaluated the literature, and then extracted and summarised the evidence according to the JBI grading of evidence and recommendation system.

RESULTS

A total of 44 publications were finally included, including 12 guidelines, 5 best practices, 4 expert consensus, 5 evidence summaries and 18 systematic reviews. Through the induction and integration of the evidence, the evidence was finally summarised from eight aspects: frailty screening, frailty assessment, exercise intervention, nutrition intervention, multi-domain intervention, drug administration, social support and health education, and 43 best evidences were formed.

CONCLUSIONS

This study summarised the best evidence for the prevention and management of frailty from eight aspects, which can provide guidance for clinical or community medical staff to develop and apply frailty intervention and practice programmes for older people and improved the clinical outcome and quality of life of older people.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Frailty is associated with worse executive function and higher cerebral blood velocity in cognitively healthy older adults: a cross-sectional study

Frailty is characterized by an increased vulnerability to adverse health events. Executive function impairment is an early sign of progression towards cognitive impairments. Whether frailty is associated with executive function and the associated mechanisms are unclear. We test the hypothesis that higher frailty is associated with worse executive function (Trail Making Test) and if aerobic fitness, prefrontal cortex oxygenation (ΔO2Hb), or middle-cerebral artery velocity (MCAv) impact this association. Forty-one (38 females) cognitively health older adults (70.1 ± 6.3 years) completed a Trail task and 6-min walk test. Prefrontal cortex oxygenation was measured during the Trail task (via functional near-infrared spectroscopy) and MCAv in a sub-sample (n=26, via transcranial Doppler). A 35-item frailty index was used. Frailty was independently, non-linearly related to trail B performance (Frailty2: β=1927 [95% CI: 321-3533], p = 0.02), with the model explaining 22% of the variance of trail B time (p = 0.02). Aerobic fitness was an independent predictor of trail B (β=-0.05 [95% CI: -0.10-0.004], p = 0.04), but age and ΔO2Hb were not (both, p > 0.78). Frailty was positively associated with the difference between trails B and A (β=105 [95% CI: 24-186], p = 0.01). Frailty was also associated with a higher peak MCAv (ρ = 0.40, p = 0.04), but lower ΔO2Hb-peakMCAv ratio (ρ = -0.44, p = 0.02). Higher frailty levels are associated to worse Trail times after controlling for age, aerobic fitness, and prefrontal oxygenation. High frailty level may disproportionately predispose older adults to challenges performing executive function tasks that may manifest early as a compensatory higher MCAv despite worse executive function, and indicate a greater risk of progressing to cognitive impairment.

To Be Frail or Not to Be Frail: This Is the Question-A Critical Narrative Review of Frailty

Many factors have contributed to rendering frailty an emerging, relevant, and very popular concept. First, many pandemics that have affected humanity in history, including COVID-19, most recently, have had more severe effects on frail people compared to non-frail ones. Second, the increase in human life expectancy observed in many developed countries, including Italy has led to a rise in the percentage of the older population that is more likely to be frail, which is why frailty is much a more common concern among geriatricians compared to other the various health-care professionals. Third, the stratification of people according to the occurrence and the degree of frailty allows healthcare decision makers to adequately plan for the allocation of available human professional and economic resources. Since frailty is considered to be fully preventable, there are relevant consequences in terms of potential benefits both in terms of the clinical outcome and healthcare costs. Frailty is becoming a popular, pervasive, and almost omnipresent concept in many different contexts, including clinical medicine, physical health, lifestyle behavior, mental health, health policy, and socio-economic planning sciences. The emergence of the new "science of frailty" has been recently acknowledged. However, there is still debate on the exact definition of frailty, the pathogenic mechanisms involved, the most appropriate method to assess frailty, and consequently, who should be considered frail. This narrative review aims to analyze frailty from many different aspects and points of view, with a special focus on the proposed pathogenic mechanisms, the various factors that have been considered in the assessment of frailty, and the emerging role of biomarkers in the early recognition of frailty, particularly on the role of mitochondria. According to the extensive literature on this topic, it is clear that frailty is a very complex syndrome, involving many different domains and affecting multiple physiological systems. Therefore, its management should be directed towards a comprehensive and multifaceted holistic approach and a personalized intervention strategy to slow down its progression or even to completely reverse the course of this condition.

Effectiveness of a multicomponent activity and horticultural intervention for the hospitalized older adults: A randomized controlled trial: Effectiveness of Intervention for the Hospitalized Older Adults

This study evaluated the effectiveness of different intervention programs in improving function among hospitalized older individuals using the Comprehensive Geriatric Assessment (CGA). A randomized controlled trial consisted of three groups: routine care, horticulture, and multicomponent activities (n = 32 each). Horticultural and multicomponent activity interventions showed beneficial effects on the CGA in hospitalized older individuals, particularly regarding cognitive function and quality-of-life. Additionally, horticultural activities significantly contributed to the perception of older adults' health status. We recommend to select older patients in geriatric wards with long-term hospitalization and adjust the frequency of activities or choose a single intervention program to provide long-term and effective intervention effects.

Practical Utility of a Clinical Pathway for Older Patients with Aspiration Pneumonia: A Single-Center Retrospective Observational Study

Introduction: Clinical pathways (CPWs) are patient management tools based on a standardized treatment plan aimed at improving quality of care. This study aimed to investigate whether CPW-guided treatment has a favorable impact on the outcomes of hospitalized older patients with aspiration pneumonia. Method: This retrospective study included patients with aspiration pneumonia, aged ≥ 65 years, and hospitalized at a community hospital in Japan. CPW implementation was arbitrarily determined by the attending physician upon admission. Outcomes were compared according to with or without the CPW (CPW-group and non-CPW groups). Propensity score (PS)-based analyses were used to control for confounding factors. Logistic regression analyses were conducted to evaluate the impact of CPW on the clinical course and outcomes. Results: Of 596 included patients, 167 (28%) received the CPW-guided treatment. The mortality rate was 16.4%. In multivariable model, CPW implementation did not increase the risk for total and 30-day mortality, and resulted in shorter antibiotic therapy duration (≤9 days) (PS matching (PSM): odds ratio (OR) 0.50, p = 0.001; inverse provability of treatment weighting (IPTW): OR 0.48, p < 0.001) and length of hospital stay (≤21 days) (PSM: OR 0.67, p = 0.05; IPTW: OR 0.66, p = 0.03). Conclusions: This study support CPW utility in this population.

Network analysis of frailty indicators in hospitalized elderly patients: unveiling the role of depression and hemoglobin as core factors

BACKGROUND

Frailty is a significant concern among hospitalized older adults, influenced by multiple factors. Understanding the complex interactions between these variables can be facilitated through a network perspective.

AIM

This study aimed to identify the core factor and physiological indicator of frailty in hospitalized elderly patients and visualize their interactions within the network structure.

METHODS

Frailty was assessed using the Tilburg Frailty Indicators, with a score of 5 or higher indicating frailty. Additional variables related to sociodemographic, physical and clinical, psychological and cognitive aspects, as well as physiological indicators, were extracted from electronic health records. A partial correlation network analysis was conducted using an adaptive LASSO algorithm, based on univariate correlation and logistic regression, to examine the network structure and identify influential nodes.

RESULTS

The average age of participants was 70.74 ± 7.52 years, with 24.27% classified as frail. Frailty was associated with 38 of 145 initially included variables (P < 0.05). The network analysis revealed depression as the most central node, followed by drugs used, sleep disorders, loneliness, masticatory obstacles, drinking, and number of teeth missing. Hemoglobin emerged as the most central biochemical indicator in the network, based on network center index analysis (Strength = 4.858, Betweenness = 223, Closeness = 0.034).

CONCLUSIONS

Frailty in hospitalized older adults is influenced by various social, physical, and psychological factors, with depression as the core factor of utmost importance. Changes in hemoglobin levels could serve as an essential indicator. This innovative network approach provides insights into the multidimensional structure and relationships in real-world settings.

Inclusion of functional measures and frailty in the development and evaluation of medicines for older adults

The International Council for Harmonisation of Technical Requirements for Pharmaceuticals for Human Use (ICH) E7, the guidance for the conduct of clinical trials in people older than age 65 years, dates from 1994. Since then, the inclusion of older people in clinical trials has hardly improved, particularly for the oldest old age group (individuals older than age 75 years), which is the fastest growing demographic bracket in the EU. Even though most medications are taken by this group, relevant endpoints and safety outcomes for this cohort are rarely included and reported, both in clinical trials and regulatory approval documents. To improve the critical appraisal and the regulatory review of medicines taken by frail older adults, eight recommendations are presented and discussed in this Health Policy. These recommendations are brought together from different perspectives and experience of the treatment of older patients. On one side, the perspective of medical practitioners from various clinical disciplines, with their direct experience of clinical decision making; on the other, the perspective of regulators assessing the data submitted in medicine registration dossiers, their relevance to the risk-benefit balance for older patients, and the communication of the findings in the product information. Efforts to improve the participation of older people in clinical trials have been in place for more than a decade, with little success. The recommendations presented here are relevant for stakeholders, authorities, pharmaceutical companies, and researchers alike, as the implementation of these measures is not under the capacity of a single entity. Improving the inclusion of frail older adults requires awareness, focus, and action on the part of those who can effect a much needed change.

Frailty Screening and Detection of Geriatric Syndromes in Acute Inpatient Care: Impact on Hospital Length of Stay and 30-Day Readmissions

BACKGROUND

Frailty is prevalent in acute care and is associated with negative outcomes. While a comprehensive geriatric assessment to identify geriatric syndromes is recommended after identifying frailty, more evidence is needed to support this approach in the inpatient setting. This study examined the association between frailty and geriatric syndromes and their impact on outcomes in acutely admitted older adults.

METHODS

A total of 733 individuals aged ≥65 years admitted to the General Surgery Service of a tertiary hospital were assessed for frailty using the Clinical Frailty Scale (CFS) and for geriatric syndromes using routine nursing admission assessments, including cognitive impairment, falls, incontinence, malnutrition, and poor oral health. Multinomial logistic regression and Cox regression were used to evaluate the associations between frailty and geriatric syndromes and their concomitant impact on hospital length of stay (LOS) and 30-day readmissions.

RESULTS

Greater frailty severity was associated with an increased likelihood of geriatric syndromes. Individuals categorized as CFS 4-6 and CFS 7-8 with concomitant geriatric syndromes had 29% and 35% increased risks of a longer LOS, respectively. CFS 4-6 was significantly associated with functional decline (relative risk ratio =1.46; 95% confidence interval [CI], 1.03-2.07) and 30-day readmission (hazare ratio=1.78; 95% CI, 1.04-3.04), whereas these associations were not significant for CFS 7-8.

CONCLUSION

Geriatric syndromes in frail individuals can be identified from routine nursing assessments and represent a potential approach for targeted interventions following frailty identification. Tailored interventions may be necessary to achieve optimal outcomes at different stages of frailty. Further research is required to evaluate interventions for older adults with frailty in a wider hospital context.

Effectiveness of holistic assessment-based interventions for adults with multiple long-term conditions and frailty: an umbrella review of systematic reviews

Holistic assessment-based interventions (HABIs) are effective in older people admitted to hospital, but it is unclear whether similar interventions are effective in adults with multiple long-term conditions or frailty in the community. We conducted an umbrella review to comprehensively evaluate the literature on HABIs for adults (aged ≥18 years) with multiple long-term conditions, and frailty. We searched eight databases for systematic reviews reporting on experimental or quasi-experimental studies. Of 9803 titles screened, we identified 29 eligible reviews (14 with meta-analysis) reporting on 14 types of HABIs. The evidence for the effectiveness of HABIs was largely inconsistent across different types of interventions, settings, and outcomes. We found evidence of no benefit from hospital HABIs on health-related quality of life (HRQoL) and emergency department re-attendance, and evidence of no benefit from community HABIs on overall health-care utilisation rates, emergency department attendance, nursing home admissions, and mortality. The best evidence of effectiveness was for hospital comprehensive geriatric assessment (CGA) on nursing home admissions, keeping patients alive and in their own homes. There was some evidence of benefit from community CGA on hospital admissions, and from CGA spanning community and hospital settings on HRQoL. Patient-centred medical homes had beneficial effects on HRQoL, mental health, self-management, and hospital admissions.

Predictive Biochemical Model of Frailty and Mortality After Acute Myocardial Infarction

Frailty, characterized by reduced resistance to stressors, is associated with adverse outcomes in patients with myocardial infarction. The Fried score is commonly used to assess frailty but has several limitations. This study aimed to evaluate the relation between frailty and blood biomarkers and their predictive value for long-term mortality using a biochemical model. A total of 2 cohorts of elderly patients (>65 years old) hospitalized for acute coronary syndrome were included. Geriatric assessments and several blood biomarkers were measured. The predictive models for frailty were developed using logistic regression. The survival models were also developed using Cox regression. Among 466 patients, 9 biomarkers were significantly associated with frailty. Between these biomarkers, white blood cells count, hemoglobin, and fibrinogen showed the highest predictive power. Model 1, without growth differentiation factor 15 (GDF-15), showed a better accuracy in predicting the mortality than the Fried score. Model 2, with GDF-15, had a stronger correlation with frailty but had a lower predictive power for survival. Frailty is associated with dysregulation in the physiological systems and several biomarkers were linked to this fact in our study. However, the inclusion of GDF-15 did not significantly improve the model's predictive ability. Frailty assessment using blood biomarkers can provide valuable prognostic information in elderly patients with acute coronary syndrome.

Predictive Strategies to Reduce the Risk of Rehospitalization with a Focus on Frail Older Adults: A Narrative Review

Frailty is a geriatric syndrome that has physical, cognitive, psychological, social, and environmental components and is characterized by a decrease in physiological reserves. Frailty is associated with several adverse health outcomes such as an increase in rehospitalization rates, falls, delirium, incontinence, dependency on daily living activities, morbidity, and mortality. Older adults may become frailer with each hospitalization; thus, it is beneficial to develop and implement preventive strategies. The present review aims to highlight the epidemiological importance of frailty in rehospitalization and to compile predictive strategies and related interventions to prevent hospitalizations. Firstly, it is important to identify pre-frail and frail older adults using an instrument with high validity and reliability, which can be a practically applicable screening tool. Comprehensive geriatric assessment-based care is an important strategy known to reduce morbidity, mortality, and rehospitalization in older adults and aims to meet the needs of frail patients with a multidisciplinary approach and intervention that includes physiological, psychological, and social domains. Moreover, effective multimorbidity management, physical activity, nutritional support, preventing cognitive frailty, avoiding polypharmacy and anticholinergic drug burden, immunization, social support, and reducing the caregiver burden are other recommended predictive strategies to prevent post-discharge rehospitalization in frail older adults.

Interrupting bedtime to reverse frailty levels in acute care: a study protocol for the Breaking Bad Rest randomized controlled trial

BACKGROUND

Hospitalized older patients spend most of the waking hours in bed, even if they can walk independently. Excessive bedrest contributes to the development of frailty and worse hospital outcomes. We describe the study protocol for the Breaking Bad Rest Study, a randomized clinical trial aimed to promoting more movement in acute care using a novel device-based approach that could mitigate the impact of too much bedrest on frailty.

METHODS

Fifty patients in a geriatric unit will be randomized into an intervention or usual care control group. Both groups will be equipped with an activPAL (a measure of posture) and StepWatch (a measure of step counts) to wear throughout their entire hospital stay to capture their physical activity levels and posture. Frailty will be assessed via a multi-item questionnaire assessing health deficits at admission, weekly for the first month, then monthly thereafter, and at 1-month post-discharge. Secondary measures including geriatric assessments, cognitive function, falls, and hospital re-admissions will be assessed. Mixed models for repeated measures will determine whether daily activity differed between groups, changed over the course of their hospital stay, and impacted frailty levels.

DISCUSSION

This randomized clinical trial will add to the evidence base on addressing frailty in older adults in acute care settings through a devices-based movement intervention. The findings of this trial may inform guidelines for limiting time spent sedentary or in bed during a patient's stay in geriatric units, with the intention of scaling up this study model to other acute care sites if successful.

TRIAL REGISTRATION

The protocol has been registered at clinicaltrials.gov (identifier: NCT03682523).

Multidisciplinary inpatient rehabilitation for older adults with COVID-19: a systematic review and meta-analysis of clinical and process outcomes

BACKGROUND

Older adults are at increased risk for disease severity and poorer prognosis following COVID-19 infection. The aim of this systematic review and meta-analysis is to explore the impact of multidisciplinary rehabilitation in the acute or post-acute hospital setting for older adults with COVID-19.

METHODS

The Cochrane library, EMBASE, Cinahl and Medline (via EBSCO), PubMed, and Web of Science were systematically searched in June 2022 and a repeat search was completed in March 2023. Screening, data extraction and quality appraisal were conducted independently by two reviewers. Studies reporting outcomes for older adults following multidisciplinary rehabilitation (provided by two or more Health and Social Care Professionals) were included. Both observational and experimental study designs were included. The primary outcome was functional ability. Secondary outcomes included discharge disposition, acute hospital and rehabilitation unit length of stay, mortality, primary and secondary healthcare utilisation, and long-term effects of COVID-19.

RESULTS

Twelve studies met the inclusion criteria, comprising a total of 570 older adults. Where reported, older adults stayed in the acute hospital for a mean of 18 days (95%CI, 13.35- 23.13 days) and in rehabilitation units for 19 days (95%CI, 15.88-21.79 days). There was a significant improvement in functional ability among older adults with COVID-19 who received multidisciplinary rehabilitation (REM, SMD = 1.46, 95% CI 0.94 to 1.98). The proportion of older adults who were discharged directly home following rehabilitation ranged from 62 to 97%. Two studies reported a 2% inpatient mortality rate of older persons during rehabilitative care. No study followed up patients after the point of discharge and no study reported on long term effects of COVID-19.

CONCLUSIONS

Multidisciplinary rehabilitation may result in improved functional outcomes on discharge from rehabilitation units/centres for older adults with COVID-19. Findings also highlight the need for further research into the long-term effect of rehabilitation for older adults following COVID-19. Future research should comprehensively describe multidisciplinary rehabilitation in terms of disciplines involved and the intervention provided.

Factors Affecting the Effectiveness of Discharge Planning Implementation: A Case-Control Cohort Study

BACKGROUND

In many hospitals, a discharge planning team works with the medical team to provide case management to ensure high-quality patient care and improve continuity of care from the hospital to the community. However, a large-scale database analysis of the effectiveness of overall discharge planning efforts is lacking.

PURPOSE

This study was designed to investigate the clinical factors that impact the efficacy of discharge planning in terms of hospital length of stay, readmission rate, and survival status.

METHODS

A retrospective study was conducted based on patient medical records and the discharge plans applied to patients hospitalized in a regional medical center between 2017 and 2018. The medical information system database and the care service management information system maintained by the Ministry of Health and Welfare were used to collect data and explore patients' medical care and follow-up status.

RESULTS

Clinical factors such as activities of daily living ≤ 60, having indwelling catheters, having poor control of chronic diseases, and insufficient caregiver capacity were found to be associated with longer hospitalization stays. In addition, men and those with indwelling catheters were found to have a higher risk of readmission within 30 days of discharge. Moreover, significantly higher mortality was found after discharge in men, those ≥ 75 years old, those with activities of daily living ≤ 60, those with indwelling catheters, those with pressure ulcers or unclean wounds, those with financial problems, those with caregivers with insufficient capacity, and those readmitted 14-30 days after discharge.

CONCLUSIONS

The findings of this study indicate that implementing case management for discharge planning does not substantially reduce the length of hospital stay nor does it affect patients' readmission status or prognosis after discharge. However, age, underlying comorbidities, and specific disease factors decrease the efficacy of discharge planning. Therefore, active discharge planning interventions should be provided to ensure transitional care for high-risk patients.

Mortality Risks after Two Years in Frail and Pre-Frail Older Adults Admitted to Hospital

BACKGROUND

Frailty is characterized by a progressive decline in the physiological functions of multiple body systems that lead to a more vulnerable condition, which is prone to the development of various adverse events, such as falls, hospitalization, and mortality. This study aims to determine whether frailty increases mortality compared to pre-frailty and to identify variables associated with a higher risk of mortality.

MATERIALS

Two cohorts, frail and pre-frail subjects, are evaluated according to the Fried phenotype. A complete examination of frailty, cognitive status, comorbidities and pharmacology was carried out at hospital admission and was extracted through electronic health record (EHR). Mortality was evaluated from the EHR.

METHODS

Kaplan-Meier estimates of survival probability functions were calculated at two years censoring time for frail and pre-frail cohorts. The log-rank test assessed significant differences between survival probability functions. Significant variables for frailty (p < 0-05) were extracted by independent sample t-test. Further selection was based on variable significance found in multivariate logistic regression discrimination between frail and pre-frail subjects. Cox regression over univariate t-test-selected variables was calculated to identify variables associated with higher proportional hazard risks (HR) at two years.

RESULTS

Frailty is associated with greater mortality at two years censoring time than pre-frailty (log-rank test, p < 0.0001). Variables with significant (p < 0.05) association with mortality identified in both cohorts (HR 95% (CI in the frail cohort) are male sex (0.44 (0.29-0.66)), age (1.05 (1.01-1.09)), weight (0.98 (0.96-1.00)), and use of proton-pump inhibitors (PPIs) (0.60 (0.41-0.87)). Specific high-risk factors in the frail cohort are readmission at 30 days (0.50 (0.33-0.74)), SPPB sit and stand (0.62 (0.45-0.85)), heart failure (0.67 (0.46-0.98)), use of antiplatelets (1.80 (1.19-2.71)), and quetiapine (0.31 (0.12-0.81)). Specific high-risk factors in the pre-frail cohort are Barthel's score (120 (7.7-1700)), Pfeiffer test (8.4; (2.3-31)), Mini Nutritional Assessment (MNA) (1200 (18-88,000)), constipation (0.025 (0.0027-0.24)), falls (18,000 (150-2,200,000)), deep venous thrombosis (8400 (19-3,700,000)), cerebrovascular disease (0.01 (0.00064-0.16)), diabetes (360 (3.4-39,000)), thyroid disease (0.00099 (0.000012-0.085)), and the use of PPIs (0.062 (0.0072-0.54)), Zolpidem (0.000014 (0.0000000021-0.092)), antidiabetics (0.00015 (0.00000042-0.051)), diuretics (0.0003 (0.000004-0.022)), and opiates (0.000069 (0.00000035-0.013)).

CONCLUSIONS

Frailty is associated with higher mortality at two years than pre-frailty. Frailty is recognized as a systemic syndrome with many links to older-age comorbidities, which are also found in our study. Polypharmacy is strongly associated with frailty, and several commonly prescribed drugs are strongly associated with increased mortality. It must be considered that frail patients need coordinated attention where the diverse specialist taking care of them jointly examines the interactions between the diversity of treatments prescribed.

Frail2Fit study protocol: a feasibility and acceptability study of a virtual multimodal intervention delivered by volunteers to improve functional outcomes in older adults with frailty after discharge from hospital

INTRODUCTION

Physical activity (PA) and replete nutritional status are key to maintaining independence and improving frailty status among frail older adults. In response to the COVID-19 pandemic, healthcare has increasingly turned to virtual modes of delivery and there is interest in the use of trained volunteers to deliver PA and nutrition interventions. We aim to evaluate the feasibility and acceptability of training hospital volunteers to deliver an online intervention, comprising exercise, behaviour change and nutrition support, to older people with frailty after discharge from hospital.

METHODS

We will use a quasi-experimental mixed methods approach. Hospital volunteers (n=6) will be trained to deliver an online, 3-month, multimodal intervention to frail (Clinical Frailty Scale ≥5) adults ≥65 years (n=30) after discharge from hospital. Feasibility will be assessed by determining the number of volunteers recruited, trained and retained at the end of the study; the proportion of intervention sessions delivered; participant recruitment, retention and adherence to the intervention. To determine the acceptability of the intervention, interviews will be conducted among a purposive sample of older adults, and volunteers. Secondary outcomes will include physical function, appetite, well-being, quality of life, anxiety and depression, self-efficacy for managing chronic disease and PA. Outcomes will be measured at baseline, 3 months and 6 months.

ANALYSIS

Descriptive statistics will be used to describe feasibility and adherence to the intervention. Secondary outcomes at baseline will be compared at 3 and 6 months. Interviews will be transcribed verbatim and analysed using thematic analysis.

ETHICS AND DISSEMINATION

Health Research Authority ethical approval was obtained on 30 May 2022 (reference: 22/WA/0155). Results will be disseminated through peer-reviewed journal articles, volunteer organisations, National Health Service communication systems and social media platforms. A toolkit will be developed to facilitate roll out of volunteer training.

TRIAL REGISTRATION NUMBER

NCT05384730.

Frailty and pain in an acute private hospital: an observational point prevalence study

Frailty and pain in hospitalised patients are associated with adverse clinical outcomes. However, there is limited data on the associations between frailty and pain in this group of patients. Understanding the prevalence, distribution and interaction of frailty and pain in hospitals will help to determine the magnitude of this association and assist health care professionals to target interventions and develop resources to improve patient outcomes. This study reports the point prevalence concurrence of frailty and pain in adult patients in an acute hospital. A point prevalence, observational study of frailty and pain was conducted. All adult inpatients (excluding high dependency units) at an acute, private, 860-bed metropolitan hospital were eligible to participate. Frailty was assessed using the self-report modified Reported Edmonton Frail Scale. Current pain and worst pain in the last 24 h were self-reported using the standard 0-10 numeric rating scale. Pain scores were categorised by severity (none, mild, moderate, severe). Demographic and clinical information including admitting services (medical, mental health, rehabilitation, surgical) were collected. The STROBE checklist was followed. Data were collected from 251 participants (54.9% of eligible). The prevalence of frailty was 26.7%, prevalence of current pain was 68.1% and prevalence of pain in the last 24 h was 81.3%. After adjusting for age, sex, admitting service and pain severity, admitting services medical (AOR: 13.5 95% CI 5.7-32.8), mental health (AOR: 6.3, 95% CI 1. 9-20.9) and rehabilitation (AOR: 8.1, 95% CI 2.4-37.1) and moderate pain (AOR: 3.9, 95% CI 1. 6-9.8) were associated with increased frailty. The number of older patients identified in this study who were frail has implications for managing this group in a hospital setting. This indicates a need to focus on developing strategies including frailty assessment on admission, and the development of interventions to meet the care needs of these patients. The findings also highlight the need for increased pain assessment, particularly in those who are frail, for more effective pain management.Trial registration: The study was prospectively registered (ACTRN12620000904976; 14th September 2020).

Early physical rehabilitation effectiveness in frail older patients hospitalized for community-acquired pneumonia: analysis of a nationwide database in Japan

BACKGROUND

Frailty is a significant predictor of prognosis in older patients with community-acquired pneumonia (CAP). No effective therapy has been reported in frail patients with CAP, with frailty determined using the Hospital Frailty Risk Score (HFRS).

AIMS

To investigate whether early physical rehabilitation intervention would effectively minimize adverse outcomes in frail older patients (determined using the HFRS) hospitalized for CAP.

METHODS

This retrospective cohort analysis involved patients with CAP aged ≥ 65 years enrolled in the Japanese Diagnostic Procedure Combination Database between 2014 and 2020 and assessed as being frail. We compared 30-day mortality and readmission rates for patients who did and who did not receive physical rehabilitation within three days of admission and evaluated the association between outcomes and receiving early physical rehabilitation using Cox regression models and inverse probability weighting (IPW) for sensitivity analysis.

RESULTS

The analysis involved 31,133 frail older patients hospitalized for CAP (mean age 84.3 ± 6.3 years; females, 49.1%), including 11,515 (37.0%) who received early physical rehabilitation. Cox regression analysis showed that early physical rehabilitation intervention was inversely associated with 30-day mortality and readmission rates. The IPW model also showed similar results.

DISCUSSION

Early physical rehabilitation was associated with reduced risks of 30-day mortality, overall in-hospital mortality, and 30-day readmission rates in frail older patients with CAP.

CONCLUSIONS

Early physical rehabilitation in frail older patients hospitalized for CAP may improve outcomes. This finding highlights the importance of simultaneously introducing the HFRS and early physical rehabilitation intervention into clinical practice for frail older patients with CAP.

Frailty modifies the effect of polypharmacy and multimorbidity on the risk of death among nursing home residents: Results from the SHELTER study

Background

Frailty, disability, and polypharmacy are prevalent in nursing home (NH) residents, often co-occurring with multimorbidity. There may be a complex interplay among them in terms of outcomes such as mortality. Aims of the study were to (i) assess whether nursing home residents with polypharmacy (5-9 medications) or hyperpolypharmacy (≥10 drugs), have an increased risk of death and (ii) whether any association is modified by the co-presence of frailty or disability.

Methods

Cohort study with longitudinal mortality data including 4,023 residents from 50 European and 7 Israeli NH facilities (mean age = 83.6 years, 73.2% female) in The Services and Health for Elderly in Long Term care (SHELTER) cohort study. Participants were evaluated with the interRAI-LongTerm Care assessment tool. Frailty was evaluated with the FRAIL-NH scale. Hazard ratio (HR) of death over 12 months was assessed with stratified Cox proportional hazards models adjusted for demographics, facilities, and cognitive status.

Results

1,042 (25.9%) participants were not on polypharmacy, 49.8% (n = 2,002) were on polypharmacy, and 24.3% (n = 979) on hyperpolypharmacy. Frailty and disability mostly increased risk of death in the study population (frailty: HR = 1.85, 95%CI 1.49-2.28; disability: HR = 2.10, 95%CI 1.86-2.47). Among non-frail participants, multimorbidity (HR = 1.34, 95%CI = 1.01-1.82) and hyperpolypharmacy (HR = 1.61, 95%CI = 1.09-2.40) were associated with higher risk of death. Among frail participants, no other factors were associated with mortality. Polypharmacy and multimorbidity were not associated with mortality after stratification for disability.

Conclusions

Frailty and disability are the strongest predictors of death in NH residents. Multimorbidity and hyperpolypharmacy increase mortality only in people without frailty. These findings may be relevant to identify patients who could benefit from tailored deprescription.

Multicomponent intervention for frail and pre-frail older adults with acute cardiovascular conditions: The TARGET-EFT randomized clinical trial

BACKGROUND

Hospitalization for cardiovascular disease (CVD) may be complicated by hospital-acquired disability (HAD) and subsequently poor health-related quality of life (HRQOL). While frailty has been shown to be a risk factor, it has yet to be studied as a therapeutic target to improve outcomes.

OBJECTIVES

This trial sought to determine the effects of an in-hospital multicomponent intervention targeting physical weakness, cognitive impairment, malnutrition, and anemia on patient-centered outcomes compared to usual care.

METHODS

A single-center parallel-group randomized clinical trial was conducted in older patients with acute CVD and evidence of frailty or pre-frailty as measured by the Essential Frailty Toolset (EFT). Patients were randomized to usual care or a multicomponent intervention. Outcomes were HRQOL (EQ-5D-5L score) and disability (Older Americans Resources and Services score) at 30 days post-discharge and mood disturbances (Hospital Anxiety and Depression Scale) at discharge.

RESULTS

The trial cohort consisted of 142 patients with a mean age of 79.5 years and 55% females. The primary diagnosis was heart failure in 29%, valvular heart disease in 28%, ischemic heart disease in 14%, arrhythmia in 11%, and other CVDs in 18%. The intervention improved HRQOL scores (coefficient 0.08; 95% CI 0.01, 0.15; p = 0.03) and mood scores (coefficient -1.95; 95% CI -3.82, -0.09; p = 0.04) but not disability scores (coefficient 0.18; 95% CI -1.44, 1.81; p = 0.82). There were no intervention-related adverse events.

CONCLUSION

In frail older patients hospitalized for acute CVDs, an in-hospital multicomponent intervention targeted to frailty was safe and led to modest yet clinically meaningful improvements in HRQOL and mental well-being. The downstream impact of these effects on event-free survival and functional status remains to be evaluated in future research, as does the generalizability to other healthcare systems.

CLINICAL REGISTRATION NUMBER

NCT04291690.

The Effectiveness of Frailty Intervention for Older Patients with Frailty during Hospitalization

OBJECTIVES

This study aims to assess the effectiveness of a multidomain intervention program on the change in functional status of hospitalized older adults.

DESIGN

This single-arm, prospective, non-randomized interventional study investigates the efficacy of a multidomain interventional program including cognitive stimulation activity, simple exercises, frailty education, and nutrition counseling.

SETTING AND PARTICIPANTS

At a tertiary hospital in southern Taiwan, 352 eligible patients were sequentially enrolled. Included patients were aged ≥65 years (mean age, 79.6 ± 9.0 years; 62% male), scored 3-7 on the Clinical Frailty Scale (CFS), and were hospitalized in the geriatric acute ward.

INTERVENTION

Those receiving standard care (physical rehabilitation and nutrition counseling) during January-July 2019 composed the historical control group. Those receiving the multidomain intervention during August-December 2019 composed the intervention group.

MEASUREMENTS

The primary outcome was the change in activities of daily life (ADL) and frailty status, as assessed by Katz Index and Clinical Frailty Scale, with using the generalized estimating equation model. The length of hospital stay, medical costs, and re-admission rates were secondary outcomes.

RESULTS

Participants undergoing intervention (n = 101; 27.9%) showed greater improvements in the ADL and CFS during hospitalization (ADL adjusted estimate, 0.61; 95% CI, 0.11-1.11; p = 0.02; CFS adjusted estimate, -1.11; 95% CI, -1.42- -0.80; p < 0.01), shorter length of hospital stay (adjusted estimate, -5.00; 95% CI, -7.99- -2.47; p < 0.01), lower medical costs (adjusted estimate, 0.58; 95% CI, 0.49-0.69; p < 0.01), and lower 30- and 90-day readmission rates (30-day adjusted OR [aOR], 0.12; 95% CI, 0.27-0.50; p < 0.01; 60-day aOR, 0.04; 95% CI, 0.01-0.33; p < 0.01) than did controls.

CONCLUSIONS

Participation in the multidomain intervention program during hospitalization improved the functional status and decreased the hospital stay length, medical costs, and readmission rates of frail older people.

Adherence to Mediterranean Diet and Response to an Exercise Program to Prevent Hospitalization-Associated Disability in Older Adults: A Secondary Analysis from a Randomized Controlled Trial

OBJECTIVES

To investigate the relationship between Mediterranean diet (MedDiet) adherence and response to an exercise and health education program to prevent hospitalization-associated disability (HAD) in acutely hospitalized older adults.

DESIGN

Randomized controlled trial.

SETTING AND PARTICIPANTS

Secondary analysis of a subset of 109 participants from AGECAR-PLUS study with available data on MedDiet adherence (mean age 87, and range 75-98).

INTERVENTION

Participants were randomized into the control group (n = 46, usual care) or the intervention group (n = 63, supervised exercise and health education) at admission.

MEASUREMENTS

MedDiet adherence was measured with MEDAS and through urinary total polyphenols (UTP). Functional status was assessed with the Barthel Index.

RESULTS

At discharge, patients in the intervention group who had low levels of MedDiet or UTP showed an increase in functional status [adjusted mean (95% CI) = 77.8 (70.8-84.8) points, p = 0.005, and adjusted mean (95% CI) = 78.0 (68.3-87.7) points, p = 0.020, respectively].

CONCLUSION

Older individuals over age 75 with low MedDiet adherence were likely to benefit more from a physical exercise and health education intervention.

Association between changes in frailty during hospitalization in older adults and 3-month mortality after discharge

Frailty is a dynamic status that can worsen or improve. However, changes in their frailty status that occur during hospitalization and their significance have not been comprehensively investigated. In this study, we explored the association between such changes and mortality 3 months after discharge in older adults hospitalized for acute care. In total, 257 participants (mean age 84.95 ± 5.88, 41.6% male) completed comprehensive geriatric assessments, including the Clinical Frailty Scale (CFS) at admission and discharge. Mean CFS score was 5.14 ± 1.35 at admission. CFS scores increased, indicating deteriorating frailty, in 29.2% of the participants (75/257) during hospitalization. Multiple logistic regression analysis demonstrated a positive association between increased CFS score during hospitalization and mortality (odds ratio, 2.987) independent of potential co-founding factors. This deterioration in frailty during hospitalization may be modifiable risk factor of poor prognosis in older adults who need acute care hospitalization.

Frailty and muscle weakness in elderly patients with asthma and their association with cumulative lifetime oral corticosteroid exposure

BACKGROUND

Frailty is a geriatric syndrome of age-related physiological decline, which is associated with higher mortality and decreased healthy life expectancy, and muscle weakness is one of the presentations of frailty. We investigated an association between lifetime oral corticosteroid (OCS) exposure with frailty and muscle weakness among elderly patients with asthma.

METHODS

We studied 203 consecutive elderly outpatients with asthma aged ≥60 years old. They were classified into three groups according to their cumulative lifetime OCS dose (lifetime non-users, lower-dose users, and higher-dose users), which was retrospectively estimated from the response to a structured questionnaire. The prevalence of frailty determined by the Kihon Checklist was compared between the three groups. Hand-grip strength, and lean mass index were also measured as markers of muscle strength.

RESULTS

Thirty-seven percent of the patients studied were considered frail. Higher cumulative lifetime OCS exposure was associated with a significantly higher prevalence of frailty (33% in lifetime non-users, 59% in lower-dose users, and 68% in higher-dose users; P for trend <0.005). This was also associated with lower hand-grip strength in both sexes (P for trend; 0.012 in men, and 0.020 in women), and lower lean mass index in men (P for trend 0.002). However, current doses of OCS were not significantly associated with these outcomes.

CONCLUSIONS

Cumulative lifetime OCS exposure was associated with a higher prevalence of frailty and muscle weakness. These findings emphasize the importance of minimizing lifetime OCS exposure for the prolongation of healthy life expectancy in patients with asthma.