The Association of Frailty With Adverse Outcomes After Multisystem Trauma

Does frailty scoring help to predict outcomes in older patients with major trauma? A retrospective study at a major trauma centre

OBJECTIVE

The objective of the present study was to evaluate the impact of frailty on outcomes for older patients presenting with major trauma to a tertiary ED in Aotearoa New Zealand.

METHODS

A retrospective observational study of patients 65 years and older who presented to Christchurch ED, New Zealand, with major trauma between 1 January and 31 December 2022. The primary outcome was a composite of in-hospital mortality or increased care requirements on discharge from hospital. Demographic details, in-hospital management, and outcomes were retrieved. Clinical Frailty Scale scoring had prospectively been recorded at the time of admission. Univariable analysis of discrete dependent variables was carried out. Mediation analysis was undertaken, wherein frailty was the mediator between age and the primary outcome variable.

RESULTS

After exclusion criteria were applied, 134 patients were included for analysis. Even after controlling for age, for every additional point on the Clinical Frailty Scale, the odds of in-hospital mortality or increased care requirements on discharge increased by 36.4% (95% confidence interval: 9.4-85). Only 33% of these major trauma patients were appropriately identified at presentation and so received a trauma team activation, with worsened activation rates with increasing frailty.

CONCLUSIONS

The presence of significant injuries in older trauma patients is under-recognised. Frailty scoring could be used in the ED for early identification of those patients at high risk of poor outcomes, so that active management strategies can be put in place to optimise their care.

Frailty across the adult age spectrum and its effects on outcomes: Experience from a level 1 trauma centre

BACKGROUND

Recent evidence suggests that frailty may be a more reliable measure than age to predict outcomes following trauma. Frailty leads to prolonged hospitalisation and increased burden on the hospital system in older patients. The aim of this study is to review the prevalence of frailty in our trauma patients and the association of frailty with hospital-based and twelve-month outcomes.

METHODS

Patient demographics, discharge destination, hospital length of stay (LOS), and functional status at 12 months were reviewed. Frailty was assessed using the Clinical Frailty Scale (score <4 non frail, 4 vulnerable, >4 frail). Factors associated with frailty and outcomes including discharge destination (home or inpatient care) and LOS (p value <0.2) were included in multivariate models.

RESULTS

There were 1230 patients admitted to the trauma ward between November 2020-August 2021 who had linked registry data. Of these, 217 (17.6 %) were deemed frail with 131 (10.7 %) being vulnerable. In the group over 65 years, 38.6 % were frail and 16.1 % were vulnerable. Accounting for confounding factors (including age), being frail was associated with discharge to further inpatient care (AOR 4.82 (3.02 - 7.68), p value <0.001). At 12 months post injury, the mortality rate of patients with frailty was 28 %, compared to 2 % for the rest of the population and patients reported significantly more problems with undertaking daily tasks such as mobility and self-care.

CONCLUSION

After adjusting for confounding factors, frailty is associated with nearly five times the increase in odds of a discharge to further inpatient care. Long term outcomes are also significantly poorer for patients with frailty. Identifying frailty on admission may help outcomes by targeting this patient group and optimising healthcare resource usage.

Age-related mortality risk in cycling trauma: analysis of the National Trauma Databank 2017-2023

BACKGROUND

Cycling promotes health but carries significant injury risks, especially for older adults. In the U.S., cycling fatalities have increased since 1990, with adults over 50 now at the highest risk. As the population ages, the burden of cycling-related trauma is expected to grow, yet age-specific factors associated with mortality risk remain unclear. This study identifies age-specific mortality risk thresholds to inform targeted public health strategies.

METHODS

We conducted a cross-sectional analysis of the National Trauma Data Bank (NTDB) data (2017-2023) on non-motorized cycling injuries. A total of 185,960 records were analyzed using logistic regression with splines to evaluate the relationship between age and mortality risk. The dataset was split into training (80%) and testing (20%) sets. Age thresholds where mortality risk changed were identified, and models were adjusted for injury severity, comorbidities, and helmet use.

RESULTS

The median patient age was 43 years (IQR 20-58). Four key age thresholds (12, 17, 31, and 69) were identified, with the largest mortality increase after age 69. Our model achieved an AUC of 0.93, surpassing traditional age cutoff models, with 84.6% sensitivity and 88.0% specificity.

CONCLUSIONS

Age is a significant predictor of mortality in cycling trauma, with marked increases in risk during adolescence and for adults over 69. These findings underscore the need for age-targeted interventions, such as improved cycling infrastructure for teens and enhanced safety measures for older adults. Public health initiatives should prioritize these vulnerable age groups to reduce cycling-related mortality.

Accelerated epigenetic ageing after burn injury

Individuals who suffer a major burn injury are at higher risk of developing a range of age-associated diseases prematurely leading to an increase in mortality in adult and juvenile burn injury survivors. One possible explanation is that injury is accelerating the biological ageing process. To test this hypothesis, we analysed DNA methylation in peripheral blood mononuclear cells from adult burn-injured patients (> 5%TBSA) upon admission to hospital and 6 months later, to calculate an epigenetic clock value which can be used to determine biological age. Fifty-three burn-injured participants (mean age 45.43 years, 49 male, mean TBSA 37.65%) were recruited at admission and 34 again 6 months post injury (mean age 40.4 years, 34 male, mean TBSA 30.91%). Twenty-nine healthy controls (mean age 43.69 years, 24 male) were also recruited. Epigenetic age acceleration at admission by PhenoAge was + 7.2 years (P = 8.31e-5) but by month 6 was not significantly different from healthy controls. PCGrimAge acceleration was + 9.23 years at admission (P = 5.79e-11) and remained 4.18 years higher than in controls by month 6 (P = 2.64e-6). At admission, the burn-injured participants had a Dunedin PACE of ageing score 31.65% higher than the control group (P = 2.14e-12), the equivalent of + 115 days per year of biological ageing. Six months post injury the Dunedin PACE of ageing remained significantly higher (+ 11.36%, 41 days/year) than in the control group (P = 3.99e-5). No differences were seen using the Horvath and Hannum clocks. Enrichment analysis revealed that key pathways enriched with burn injury related to immune function, activation, and inflammation. The results reveal that epigenetic age, specifically the PACE of ageing and PCGrimAge, was accelerated in burn-injured adults at admission, with some return towards control values by 6 months. That these two clocks are built upon morbidity outcomes suggests that the injury is invoking a biological response that increases the risk of disease. Burn injury in adults induces epigenetic changes suggestive of an acceleration of the ageing process, which may contribute to the increased morbidity and mortality in these patients.

The impact of frailty on long-term functional outcomes in severely injured geriatric patients

BACKGROUND

The incidence of severe injury in the geriatric population is increasing. However, the impact of frailty on long-term outcomes after injury in this population remains understudied. Therefore, we aimed to understand the impact of frailty on long-term functional outcomes of severely injured geriatric patients.

METHODS

We conducted a retrospective cohort study, including patients ≥65 years old with an Injury Severity Score ≥15, who were admitted between December 2015 and April 2022 at one of 3 level 1 trauma centers in our region. Patients were contacted between 6 and 12 months postinjury and administered a trauma quality of life survey, which assessed for the presence of new functional limitations in their activities of daily living. We defined frailty using the mFI-5 validated frailty tool: patients with a score ≥2 out of 5 were considered frail. The impact of frailty on long-term functional outcomes was assessed using 1:1 propensity matching adjusting for patient characteristics, injury characteristics, and hospital site.

RESULTS

We included 580 patients, of whom 146 (25.2%) were frail. In a propensity-matched sample of 125 pairs, frail patients reported significantly higher functional limitations than nonfrail patients (69.6% vs 47.2%; P < .001). This difference was most prominent in the following activities: climbing stairs, walking on flat surfaces, going to the bathroom, bathing, and cooking meals. In a subgroup analysis, frail patients with traumatic brain injuries experienced significantly higher long-term functional limitations.

CONCLUSION

Frail geriatric patients with severe injury are more likely to have new long-term functional outcomes and may benefit from screening and postdischarge monitoring and rehabilitation services.

Surgical stabilization of rib fractures in the geriatric trauma population is associated with equivalent outcomes to a younger cohort: A propensity matched analysis

BACKGROUND

Surgical stabilization of rib fractures (SSRF) improves outcomes in chest wall trauma. Geriatric patients are particularly vulnerable to poor outcomes; yet, this population is often excluded from SSRF studies. Further delineating patient outcomes by age is necessary to optimize care for the aging trauma population.

METHODS

A retrospective cohort study was conducted examining outcomes among patients aged 40+ for whom an SSRF consult was placed between 2017 and 2022 at a level 1 trauma center. Patients were categorized into geriatric (65+) and adult (40-64), as well as 80 years and older (80+) and 79 and younger (40-79). Patient outcomes were assessed comparing non-operative and operative management of chest wall trauma. Propensity matched analysis was performed to evaluate mortality differences between adult and geriatric patients who did and did not undergo SSRF.

RESULTS

A total of 543 patients had an SSRF consult. Of these, 227 were 65+, and 73 were 80+. A total of 129 patients underwent SSRF (24 %). The percentage of patients undergoing SSRF did not vary between 40 and 64 and 65+ (23.7 % and 23.6 %, respectively, p = 0.97) or 40-79 and 80+ (24.0 vs 21.9, p = 0.69). Patients undergoing SSRF had higher chest injury burden and were more likely to require mechanical ventilation and ICU level care on admission. Overall, in-hospital mortality rate was 4.6 %. Among patients who underwent SSRF, mortality rate did not significantly differ between 65+ and 40-64 (7.8% vs 2.7 %, p = 0.18) or 80+ and 40-79 (6.3% vs 4.6 %, p = 0.77). This remained true in propensity matched analysis.

CONCLUSION

Geriatric and octogenarian patients with rib fractures underwent SSRF at similar rates and achieved equivalent outcomes to their younger counterparts. SSRF did not differentially affect mortality outcomes based on age group in propensity matched analysis. SSRF is safe for geriatric patients including octogenarians.

The intersection of frailty and metabolism

On average, aging is associated with unfavorable changes in cellular metabolism, which are the processes involved in the storage and expenditure of energy. However, metabolic dysregulation may not occur to the same extent in all older individuals as people age at different rates. Those who are aging rapidly are at increased risk of adverse health outcomes and are said to be "frail." Here, we explore the links between frailty and metabolism, including metabolic contributors and consequences of frailty. We examine how metabolic diseases may modify the degree of frailty in old age and suggest that frailty may predispose toward metabolic disease. Metabolic interventions that can mitigate the degree of frailty in people are reviewed. New treatment strategies developed in animal models that are poised for translation to humans are also considered. We suggest that maintaining a youthful metabolism into older age may be protective against frailty.

Outcomes of Geriatric Burn Patients Presenting to the Trauma Service: How Does Frailty Factor in?

INTRODUCTION

Frailty has been known to negatively affect the outcomes of geriatric trauma patients. However, there is a lack of data on the effect of frailty on the outcomes of geriatric trauma patients with concomitant burn injuries. The aim of our study was to compare the outcomes of frail versus nonfrail geriatric trauma patients with concomitant burn injuries.

METHODS

We performed a retrospective analysis of American College of Surgeons Trauma Quality Improvement Program (2018). We included geriatric (≥65 y) trauma patients who sustained a concomitant burn injury with ≥10% Total Body Surface Area affected. Patients with body region-specific AIS ≥4 were excluded. Patients were stratified into Frail and Nonfrail, using 5-factor modified Frailty Index. Primary outcomes measured were mortality. Secondary outcomes measured were complications, and hospital and intensive care unit (ICU) length of stay (LOS). Multivariable logistic regression was performed to identify independent predictors of mortality.

RESULTS

A total of 574 patients were identified, of which 172(30%) were Frail. Mean age was 74 ± 7 y and median [interquartile range] ISS was 3[1-10]. Overall, the rate of mortality was 23% and median hospital LOS was 14[3-31]. After controlling for potential confounding factors, frailty was not identified as an independent predictor of mortality (adjusted odds ratio:1.059, P = 0.93) and complications (adjusted odds ratio:1.10, P = 0.73). However, frail patients had longer hospital (β: 5.01, P = 0.002) and ICU LOS (β: 2.12, P < 0.001).

CONCLUSIONS

Among geriatric trauma patients with concomitant burn injuries, frailty is associated with longer hospital and ICU LOS, and higher rates of thrombotic complications, but not higher mortality or overall complications. Future research should investigate the impact of early assessment of frailty as well as tailored interventions on outcomes in this population.

[Relationship Between Frailty and Poor Prognosis in Older Trauma Patients in the Emergency Department: A Prospective Cohort Study]

Objective

To explore the relationship between frailty and adverse outcomes in older trauma patients in the emergency department.

Methods

A prospective cohort study was conducted. Older trauma patients admitted to the emergency department of three tertiary-care hospitals in Chengdu between January 2021 and August 2021 were enrolled. The patients were divided into a frailty group and a non-frailty group according to their assessment results for Trauma-Specific Frailty Index (TSFI). The end points, including falls, readmission, and deaths, were documented during the 6-month follow-up. Cox risk regression model was used to analyze the relationship between frailty and adverse outcomes in older trauma patients in the emergency department.

Results

A total of 375 older trauma patients in the emergency department were enrolled, including 131 in the frailty group and 244 in the non-frailty group. After 6 months of follow-up, the incidences of falls, readmission and deaths in older trauma patients in the emergency department were 18.93%, 14.40%, and 7.73%, respectively. The incidences of falls (28.24% vs. 13.93%, P=0.001), readmission (25.95% vs. 8.20%, P=0.000), and deaths (12.98% vs. 4.92%, P=0.005) in older trauma patients in the emergency department in the frailty group were higher than those in the non-frailty group. After adjusting for multiple confounding factors using the Cox regression model, the risks of falls (hazard ratio [ HR]=1.859, 95% confidence interval [ CI]: 1.070-3.230, P=0.028] and readmission ( HR=2.920, 95% CI: 1.537-5.547, P=0.001) were higher in the frailty group than those in the non-frailty group, but there was no significant difference in the risk of deaths between the frailty group and the non-frailty group.

Conclusion

Frailty is a risk factor for falls and readmissions in older trauma patients in the emergency department and the association between frailty and the risk of deaths in older trauma patients in the emergency department needs to be validated by further studies.

Geriatric Trauma and Frailty

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

Geriatric Assessment Is Associated With Reduced Mortality at 1 Year for Older Adults Admitted to a Major Trauma Center: A Prospective Observational Study

OBJECTIVE

To evaluate the effect of geriatrician review on 1-year mortality in older adults admitted with trauma.

BACKGROUND

Comprehensive geriatric assessment (CGA) has been associated with improved outcomes in older adults with hip fracture, but has not been evaluated in a broader trauma population.

METHODS

Trauma patients aged ≥ 65years admitted to an English Major Trauma Centre between November 2018 and September 2019 were included. Patients were divided into 3 cohorts: no geriatric assessment, reactive geriatric assessment, and proactive CGA. The primary outcome was time to mortality, secondary outcomes were time to discharge and frequency of complications. Analyses were adjusted for factors known to be associated with outcomes including age, frailty, injury severity, and complications.

RESULTS

Five hundred eighty-five patients were included (no geriatric assessment = 125; reactive geriatric assessment = 134; proactive CGA = 326): median age was 81 years (IQR 74-88); 326 (55.7%) were women; 297 (50.8%) were living with frailty (Clinical Frailty Scale ≥5). Median Injury Severity Score was 13 (IQR9-25). At 1-year follow-up, 147 (25.1%) patients had died. In multivariate analysis, both types of geriatric assessment were associated with reduced mortality [reactive aHR = 0.31, 95% CI 0.18-0.53; proactive adjusted hazard ratio (aHR) = 0.41, 95% CI 0.26-0.64]. There was no association between either type of geriatric assessment and length of stay (reactive aHR = 0.84, 95% CI 0.62-1.15; proactive aHR = 0.80, 95% CI 0.63-1.02).

CONCLUSIONS

Geriatrician assessment is associated with reduced mortality in older adults admitted following trauma. Further research should focus on defining optimal models of geriatrician intervention.

A national study of 23 major trauma centres to investigate the effect of frailty on clinical outcomes in older people admitted with serious injury in England (FiTR 1): a multicentre observational study

BACKGROUND

Older people are the largest group admitted to hospital with serious injuries. Many older people are living with frailty, a risk factor for poor recovery. We aimed to examine the effect of preinjury frailty on outcomes.

METHODS

In this multicentre observational study (FiTR 1), we extracted prospectively collected data from all 23 adult major trauma centres in England on older people (aged ≥65 years) admitted with serious injuries over a 2·5 year period from the Trauma Audit and Research Network (TARN) database. Geriatricians assessed the preinjury Clinical Frailty Scale (CFS), a 9-point scale of fitness and frailty, with a score of 1 indicating a patient is very fit and a score of 9 indicating they are terminally ill. The primary outcome was inpatient mortality, with patients censored at hospital discharge. We used a multi-level Cox regression model fitted with adjusted hazards ratios (aHRs) to assess the association between CFS and mortality, with CFS scores being grouped as follows: a score of 1-2 indicated patients were fit; a score of 3 indicated patients were managing well; and a score of 4-8 indicated patients were living with frailty (4 being very mild, 5 being mild, 6 being moderate, and 7-8 being severe).

FINDINGS

Between March 31, 2019, and Oct 31, 2021, 193 156 patients had records were held by TARN, of whom 16 504 had eligible records. Median age was 81·9 years (IQR 74·7-88·0), 9200 (55·7%) were women, and 7304 (44·3%) were men. Of 16 438 patients with a CFS score of 1-8, 11 114 (67·6%) were living with frailty (CFS of 4-8). 1660 (10·1%) patients died during their hospital stay, with a median time from admission to death of 9 days (IQR 4-18). Compared in patients with a CFS score of 1-2, risk of inpatient death was increased in those managing well (CFS score of 3; aHR 1·82 [95% CI 1·39-2·40]), living with very mild frailty (CFS score of 4: 1·99 [1·51-2·62]), living with mild frailty (CFS score of 5: 2·61 [1·99-3·43]), living with moderate frailty (CFS score of 6: 2·97 [2·26-3·90]), and living with severe frailty (CFS score of 7-8: 4·03 [3·04-5·34]).

INTERPRETATION

Our findings support inclusion of the CFS in trauma pathways to aid patient management. Additionally, people who exercise regularly (CFS of 1-2) have better outcomes than those with lower activity levels (CFS of ≥3), supporting exercise as an intervention to improve trauma outcomes.

FUNDING

None.

Multiple Organ Dysfunction in Older Major Trauma Critical Care Patients: A Multicenter Prospective Observational Study

The objective was to explore the characteristics and outcomes of multiple organ dysfunction syndrome (MODS) in older trauma patients.

Background

Severely injured older people present an increasing challenge for trauma systems. Recovery for those who require critical care may be complicated by MODS. In older trauma patients, MODS may not be predictable based on chronological age alone and factors associated with its development and resolution are unclear.

Methods

Consecutive adult patients (aged ≥16 years) admitted to 4 level 1 major trauma center critical care units were enrolled and reviewed daily until discharge or death. MODS was defined by a daily total sequential organ failure assessment score of >5.

Results

One thousand three hundred sixteen patients were enrolled over 18 months and one-third (434) were aged ≥65 years. Incidence of MODS was high for both age groups (<65 years: 64%, ≥65 years: 70%). There were few differences in severity, patterns, and duration of MODS between cohorts, except for older traumatic brain injury (TBI) patients who experienced a prolonged course of MODS recovery (TBI: 9 days vs no TBI: 5 days, P < 0.01). Frailty rather than chronological age had a strong association with MODS development (odds ratio [OR], 6.9; 95% confidence intervals [CI], 3.0-12.4; P < 0.001) and MODS mortality (OR, 2.1; 95% CI, 1.31-3.38; P = 0.02). Critical care resource utilization was not increased in older patients, but MODS had a substantial impact on mortality (<65 years: 17%; ≥65 years: 28%). The majority of older patients who did not develop MODS survived and had favorable discharge outcomes (home discharge ≥65 years NoMODS: 50% vs MODS: 15%; P < 0.01).

Conclusions

Frailty rather than chronological age appears to drive MODS development, recovery, and outcome in older cohorts. Early identification of frailty after trauma may help to predict MODS and plan care in older trauma.

Development and Validation of a Nomogram for Adverse Outcomes of Geriatric Trauma Patients Based on Frailty Syndrome

Purpose

Currently, assessing trauma severity alone in geriatric trauma patients (GTPs) cannot accurately predict the risk of serious adverse outcomes during hospitalization. As an emerging concept in recent years, frailty syndrome is closely related to the poor prognosis of many diseases in elderly patients, including trauma. A logistic model for predicting adverse outcomes in elderly trauma patients during hospitalization was constructed in elderly patients, and the predictive efficacy of the model was verified.

Patients and Methods

Trauma patients aged ≥65 years between June 2020 and September 2021 were selected and randomly divided into a training set and validation set at a ratio of 3:1. Mid arm muscle circumference (MAMC) was measured to determine the degree of frailty. LASSO regression was used to screen appropriate variables for the construction of a prognostic model. The logistic regression model was established and presented in the form of a nomogram. Calibration curves and ROC curves were used to verify the performance of the model.

Results

A total of 209 patients were enrolled, including 143 (68.4%) males and 66 (31.6%) females, with an average age of 70.8 ± 4.8 years. Ageless Charlson comorbidity index, BT unit, ISS, GCS, MAMC, prealbumin and lactic acid levels were screened by LASSO regression to construct a prognostic model. The AUC of the ROC analysis prediction model was 0.89 (95% CI 0.80–0.97) in the validation set. The results of the Hosmer–Lemeshow test for the validation set were χ2 = 11.23, P = 0.189.

Conclusion

The prognostic model of adverse outcomes in GTPs has good accuracy and differentiation, which can improve the prediction results of risk stratification of GTPs during hospitalization by medical staff and provide a new idea for prognostic prediction.

Visualizing Frailty: Exploring Radiographical Measures of Frailty in Trauma Patients

Purpose: This study assessed the relationship of core muscle sarcopenia, myosteatosis, and L1 attenuation to the 5-factor modified frailty index (mFI-5), discharge disposition, and post-admission complications in orthopedic and general trauma patients. It was hypothesized that reduced sarcopenia, L1 attenuation, and increased myosteatosis is associated with higher mFI-5 scores (≥ 0.3), discharge into care, and increased post-admission complications.Methods: This prospective cohort study was performed at a Level 1 trauma center. Patients were surveyed and metrics of the mFI-5 were used. Frail was categorized as a mFI-5 score ≥ 0.3. Recent abdominal computed tomography (CT) scans were used to extract radiographical information of total psoas cross-sectional area, psoas myosteatosis, and L1 vertebrae attenuation.Results: There were 140 patients who consented to the study, of which 83 had available abdomen and pelvis CT scans. The mean age was 43.19 (± 17.36), and 65% were male (<i>n</i> = 52). When comparing the frail (16%, <i>n</i> = 13) and not frail (84%, <i>n</i> = 70) patients, there was a significant difference in mean psoas myosteatosis (<i>p</i> < 0.0001) and the attenuation of the L1 vertebrae (<i>p</i> < 0.001). On multivariate analysis when accounting for age, myosteatosis of the psoas muscles was predictive of an mFI-5 score ≥ 0.3.Conclusion: The findings suggest that myosteatosis and L1 attenuation are associated with frailty indices (mFI-5) after traumatic injury. Future studies are needed to prospectively assess the validity of both radiographical and index-based markers of frailty in predicting post-traumatic complications, mortality, and hospital utilization.

Predicting 1 year mortality after traumatic injury using the Clinical Frailty Scale

BACKGROUND

Frailty is known to affect how people admitted with traumatic injuries recover during their inpatient stay and shortly after discharge. However, few studies have examined the effect of frailty on long-term mortality when adjusted for significant factors including age. We aimed to determine the effect of frailty on 1-year morality in older adults admitted with traumatic injuries.

METHODS

We undertook an observational study at the Severn Major Trauma Network's major trauma centre based in South West England. Patients ≥65 years old admitted between November 2018 and September 2019 with traumatic injuries were included. Isolated hip fractures and inpatient injuries were excluded. A geriatrician assessed all patients for frailty using the Clinical Frailty Scale. Follow-up occurred at 1 year. A multivariable Cox proportional baseline hazards model assessed the effect of frailty on time-to-mortality. The adjusted model included age, sex, multimorbidity, surgery, most injured site, injury severity, postinjury complications, and geriatrician review.

RESULTS

Five hundred and eighty-five patients were included. Median age was 81 years old (IQR 74-88), and median injury severity score was 13 (IQR 9-25). At 1 year 147 (25.1%) patients had died. Living with frailty was associated with mortality. The risk of dying increased with frailty severity. Compared to CFS 1-3: CFS 4 aHR = 1.73 (95% CI 0.89-3.36, p = 0.11); CFS 5 aHR = 3.82 (95% CI 2.11-6.93, p < 0.001); CFS 6 aHR = 4·05 (95% CI 2.21-7.45, p < 0.001); CFS 7-8 aHR = 6.57 (95% CI 3.43-12.59, p < 0.001).

CONCLUSION

This study is the first to demonstrate a consistent effect of frailty, at all levels of severity and independent of age, on older peoples' survival 1 year after traumatic injury. These data support performing an admission frailty assessment to aid long-term management decisions and provide opportunity to modify frailty to improve outcomes.

The Clinical Frailty Scale predicts adverse outcome in older people admitted to a UK major trauma centre

BACKGROUND

Frailty assessment using the Clinical Frailty Scale (CFS) has been mandated for older people admitted to English major trauma centres (MTC) since April 2019. Little evidence is available as to CFS-associated outcomes in the trauma population.

OBJECTIVE

To investigate post-injury outcomes stratified by the CFS.

METHODS

A single centre prospective observational cohort study was undertaken. CFS was prospectively assigned to patients ≥ 65 years old admitted to the MTC over a 5-month period. Primary outcome was 30-day post-injury mortality. Secondary outcomes were length of hospital stay, complications and discharge level of care.

RESULTS

In 300 patients median age was 82; 146 (47%) were frail (CFS 5-9) and 28 (9.3%) severely frail (CFS 7-9). Frail patients had lower injury severity scores (median 9 vs 16) but greater 30-day mortality (CFS 5-6 odds ratio (OR) 5.68; P < 0.01; CFS 7-9 OR 10.38; P < 0.01). Frailty was associated with delirium (29.5% vs 17.5%; P = 0.02), but not complication rate (50.7% vs 41.6%; P = 0.20) or length of hospital stay (13 vs 11 days; P = 0.35). Mild to moderate frailty was associated with increased care level at discharge (OR 2.31; P < 0.01).

CONCLUSIONS

Frailty is an independent predictor of 30-day mortality, inpatient delirium and increased care level at discharge in older people experiencing trauma. CFS can therefore be used to identify those at risk of poor outcome who may benefit from comprehensive geriatric review, validating its inclusion in the 2019 best practice tariff for major trauma.

Feasibility and accuracy of ED frailty identification in older trauma patients: a prospective multi-centre study

BACKGROUND

The burden of frailty on older people is identifiable by its adverse effect on mortality, morbidity and long term functional and health outcomes. In patients suffering from a traumatic injury there is increasing evidence that it is frailty rather than age that impacts greatest on these outcomes and that early identification can guide frailty specific care. The aim of this study was to evaluate the feasibility of nurse-led assessment of frailty in older trauma patients in the ED in patients admitted to major trauma centres.

METHODS

Patients age 65 years and over attending the Emergency Departments (ED) of five Major Trauma Centres following traumatic injury were enrolled between June 2019 and March 2020. Patients were assessed for frailty whilst in the ED using three different screening tools (Clinical Frailty Scale [CFS], Program of Research to Integrate Services for the Maintenance of Autonomy 7 [PRIMSA7], and the Trauma Specific Frailty Index [TSFI]) to compare feasibility and accuracy. Accuracy was determined by agreement with geriatrician assessment of frailty. The primary outcome was identification of frailty in the ED using three different assessment tools.

RESULTS

We included 372 patients whose median age was 80, 53.8% of whom were female. The most common mechanism of injury was fall from less than 2 m followed by falls greater than 2 m. Completion rates for the tools were variable, 31.9% for TSFI, compared to 93% with PRISMA7 and 98.9% with the CFS. There was substantial agreement when using CFS between nurse defined frailty and geriatrician defined frailty. Agreement was moderate using PRISMA7 and slight using TSFI.

CONCLUSIONS

This prospective study has demonstrated that screening for frailty in older major trauma patients within the Emergency Department is feasible and accurate using CFS.

TRIAL REGISTRATION

ISRCTN, ISRCTN10671514 . Registered 22 October 2019.