Comprehensive geriatric assessment for frail older people in acute hospitals: the HoW-CGA mixed-methods study

Postoperative outcomes in older patients living with frailty and multimorbidity in the UK: SNAP-3, a snapshot observational study

BACKGROUND

Older surgical patients experience longer hospital stays and a higher risk of morbidity and mortality than their younger counterparts. Frailty (19.6% of cohort) and multimorbidity (63.1% of cohort) increase these risks. The 3rd Sprint National Anaesthesia Project (SNAP-3) describes the impact of frailty and multimorbidity on postoperative outcomes.

METHODS

We conducted a prospective observational cohort study over 5 days in 2022 aiming to recruit all UK patients aged ≥60 yr undergoing surgery (excluding minor procedures). Data included patient characteristics, clinical variables, Clinical Frailty Scale (CFS), multimorbidity (two or more comorbidities), length of stay (LOS), postoperative delirium, morbidity, and mortality. Quantile regression and mixed effects logistic regression were used to analyse relationships.

RESULTS

We recruited 7129 patients from 214 hospitals. Increasing frailty was associated with longer LOS, higher odds of delirium, morbidity, and mortality ≥1 yr, with a clear increase noted from CFS of 4 (19.0% of cohort). Amongst those without multimorbidity, individuals with CFS score of 4 had longer admissions than non-frail individuals (median LOS 0.75 days longer, 95% confidence interval [CI] 0.34-1.16), increasing to 2.69 days longer for CFS 5 (95% CI 0.76-4.62). Multimorbidity increased the odds of postoperative morbidity by 46% (adjusted odds ratio 1.46, 95% CI 1.24-1.73), but there was no evidence for multimorbidity impacting LOS, delirium, or mortality.

CONCLUSIONS

SNAP-3 highlights the impact of frailty on postoperative outcomes. Multimorbidity had less impact, with an effect on postoperative morbidity the only one to have strong statistical evidence. The impact of these conditions must be discussed with older patients considering surgical intervention.

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).

Protocol for the Development and Analysis of the Oxford and Reading Cognitive Comorbidity, Frailty and Ageing Research Database-Electronic Patient Records (ORCHARD-EPR)

BACKGROUND

Hospital electronic patient records (EPRs) offer the opportunity to exploit large-scale routinely acquired data at relatively low cost and without selection. EPRs provide considerably richer data, and in real-time, than retrospective administrative data sets in which clinical complexity is often poorly captured. With population ageing, a wide range of hospital specialties now manage older people with multimorbidity, frailty and associated poor outcomes. We, therefore, set-up the Oxford and Reading Cognitive Comorbidity, Frailty and Ageing Research Database-Electronic Patient Records (ORCHARD-EPR) to facilitate clinically meaningful research in older hospital patients, including algorithm development, and to aid medical decision-making, implementation of guidelines, and inform policy.

METHODS AND ANALYSIS

ORCHARD-EPR uses routinely acquired individual patient data on all patients aged ≥65 years with unplanned admission or Same Day Emergency Care unit attendance at four acute general hospitals serving a population of >800 000 (Oxfordshire, UK) with planned extension to the neighbouring Berkshire regional hospitals (>1 000 000). Data fields include diagnosis, comorbidities, nursing risk assessments, frailty, observations, illness acuity, laboratory tests and brain scan images. Importantly, ORCHARD-EPR contains the results from mandatory hospital-wide cognitive screening (≥70 years) comprising the 10-point Abbreviated-Mental-Test and dementia and delirium diagnosis (Confusion Assessment Method-CAM). Outcomes include length of stay, delayed transfers of care, discharge destination, readmissions and death. The rich multimodal data are further enhanced by linkage to secondary care electronic mental health records. Selection of appropriate subgroups or linkage to existing cohorts allows disease-specific studies. Over 200 000 patient episodes are included to date with data collection ongoing of which 129 248 are admissions with a length of stay ≥1 day in 64 641 unique patients.

ETHICS AND DISSEMINATION

ORCHARD-EPR is approved by the South Central Oxford C Research Ethics Committee (ref: 23/SC/0258). Results will be widely disseminated through peer-reviewed publications and presentations at conferences, and regional meetings to improve hospital data quality and clinical services.

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.

Comprehensive geriatric assessment (CGA) in perioperative care: a systematic review of a complex intervention

OBJECTIVES

Comprehensive geriatric assessment (CGA) is a complex intervention applied to older people with evidence of benefit in medical populations. The aim of this systematic review was to describe how CGA is applied to surgical populations in randomised controlled trials. This will provide a basis for design of future studies focused on optimising CGA as a complex intervention.

SETTING

A systematic review of randomised controlled trials.

PARTICIPANTS

A systematic search was performed for studies of CGA in the perioperative period across Ovid MEDLINE, Ovid EMBASE, CINAHL and Cochrane CENTRAL, from inception to March 2021.

INTERVENTIONS

Any randomised controlled trials of perioperative CGA versus 'standard care' were included.

OUTCOME MEASURES

Qualitative description of CGA.

RESULTS

12 121 titles and abstracts were screened, 68 full-text articles were assessed for eligibility and 22 articles included, reporting on 13 trials. 10 trials focused on inpatients with hip fracture, with 7 of these delivering CGA on a geriatric medicine ward, 3 on a surgical ward. The remaining three trials were in elective general surgery all delivering CGA on a surgical ward. CGA components, duration of intervention and personnel delivering the intervention were highly variable across the different studies. Trials favoured postoperative delivery of CGA (11/13). Only four trials reported data on adherence to the CGA intervention.

CONCLUSIONS

CGA as an intervention is variably described and delivered in randomised controlled trials in the perioperative setting. The reporting of both the intervention and standard care is often poor with little focus on adherence. Future research should focus on clearly defining and standardising the intervention as well as measuring adherence within trials.

PROSPERO REGISTRATION NUMBER

CRD42020221797.

The Evolution of Geriatric Oncology and Geriatric Assessment over the Past Decade

Cancer is predominantly a disease of aging, and older adults represent the majority of cancer diagnoses and deaths. Older adults with cancer differ significantly from younger patients, leading to important distinctions in cancer treatment planning and decision-making. As a consequence, the field of geriatric oncology has blossomed and evolved over recent decades, as the need to bring personalized cancer care to older adults has been increasingly recognized and a focus of study. The geriatric assessment (GA) has become the cornerstone of geriatric oncology research, and the past year has yielded promising results regarding the implementation of GA into routine cancer treatment decisions and outcomes for older adults. In this article, we provide an overview of the field of geriatric oncology and highlight recent breakthroughs with the use of GA in cancer care. Further work is needed to continue to provide personalized, evidence-based care for each older adult with cancer.

What matters most in acute care: an interview study with older people living with frailty

Background

Healthcare outcome goals are central to person-centred acute care, however evidence among older people is scarce. Older people who are living with frailty have distinct requirements for healthcare delivery and have distinct risk for adverse outcomes from healthcare. There is insufficient evidence for whether those living with frailty also have distinct healthcare outcome goals. This study explored the nature of acute care outcome goals in people living with frailty.

Methods

Healthcare outcome goals were explored using semi-structured patient interviews. Participants aged over 65 with Clinical Frailty Score 5-8 (mild to very severe frailty) were recruited during their first 72 hours in a UK hospital. Purposive, maximum variation sampling was guided by lay partners from a Patient and Public Involvement Forum specialising in ageing-related research. Qualitative analysis used a blended approach based on framework and constant comparative methodologies for the identification of themes. Findings were validated through triangulation with participant, lay partner, and technical expert review.

Results

The 22 participants were aged 71 to 98 and had mild to very severe frailty. One quarter were living with dementia. Most participants had reflected on their situation and considered their outcome goals. Theme categories (and corresponding sub-categories) were ‘Autonomy’ (information, control, and security) and ‘Functioning’ (physical, psychosocial, and relief). A novel ‘security’ theme was identified, whereby participants sought to feel safe in their usual living place and with their health problems. Those living with milder frailty were concerned to maintain ability to support loved ones, while those living with most severe frailty were concerned about burdening others.

Conclusions

Outcome goals for acute care among older participants living with frailty were influenced by the insecurity of their situation and fear of deterioration. Patients may be supported to feel safe and in control through appropriate information provision and functional support.

Risk factors for manifestations of frailty in hospitalized older adults: A qualitative study

Aims

To explore the experiences of older people and ward staff to identify modifiable factors (risk factors) which have the potential to reduce development or exacerbation of manifestations of frailty during hospitalization. To develop a theoretical framework of modifiable risk factors.

Design

Qualitative descriptive study.

Methods

Qualitative interviews with recently discharged older people (n = 18) and focus groups with ward staff (n = 22) were undertaken between July and October 2019. Data were analysed using directed content analysis.

Results

Themes identified related to attitude to risk, communication and, loss of routine, stimulation and confidence. Using findings from this study and previously identified literature, we developed a theoretical framework including 67 modifiable risk factors. Risk factors are grouped by patient risk factor domains (pain, medication, nutritional/fluid intake, mobility, elimination, infection, additional patient risk factors) and linked care management sub‐domains (including risk factors relating to the ward environment, process of care, ward culture or broader organizational set up). Many of the additional 36 risk factors identified by this study were related to care management sub‐domains.

Conclusion

A co‐ordinated approach is needed to address modifiable risk factors which lead to the development or exacerbation of manifestations of frailty in hospitalized older people. Risk assessment and management practices should not be duplicative and, should recognize and address modifiable risk factors which occur at the ward and organizational level.

Impact

Some older people leave hospital more dependent than when they come in and this is, in part, due to the environment and process of care and not just the severity of their presenting illness. Many of the risk factors identified need to be addressed at an organizational rather than individual level. Findings will inform a programme of research to develop and test a novel system of care aimed at preventing loss of independence in hospitalized older people.

Effectiveness of acute geriatric unit care on functional decline and process outcomes among older adults admitted to hospital with acute medical complaints: a protocol for a systematic review

INTRODUCTION

Older adults are clinically heterogeneous and are at increased risk of adverse outcomes during hospitalisation due to the presence of multiple comorbid conditions and reduced homoeostatic reserves. Acute geriatric units (AGUs) are units designed with their own physical location and structure, which provide care to older adults during the acute phase of illness and are underpinned by an interdisciplinary comprehensive geriatric assessment model of care. This review aims to update and synthesise the totality of evidence related to the effectiveness of AGU care on clinical and process outcomes among older adults admitted to hospital with acute medical complaints.

DESIGN

Updated systematic review and meta-analysis METHODS AND ANALYSIS: MEDLINE, Cumulative Index of Nursing and Allied Health Literature, Controlled Trials in the Cochrane Library and Embase electronic databases will be systematically searched from 2008 to February 2021. Trials with a randomised design that deliver an AGU intervention to older adults admitted to hospital for acute medical complaints will be included. The primary outcome measure will be functional decline at discharge from hospital and at follow-up. Secondary outcomes will include length of stay, cost of index admission, incidence of unscheduled hospital readmission, living at home (the inverse of death or institutionalisation combined; used to describe someone who is in their own home at follow-up), mortality, cognitive function and patient satisfaction with index admission. Title and abstract screening of studies for full-text extraction will be conducted independently by two authors. The Cochrane risk of bias 2 tool will be used to assess the methodological quality of the included trials. The quality of evidence for outcomes reported will be assessed using the Grading of Recommendations Assessment, Development and Evaluations framework. A pooled meta-analysis will be conducted using Review Manager, depending on the uniformity of the data.

ETHICS AND DISSEMINATION

Formal ethical approval is not required as all data collected will be secondary data and will be analysed anonymously. The authors will present the findings of the review to a patient and public involvement stakeholder panel of older adults that has been established at the Ageing Research Centre in the University of Limerick. This will enable the views and opinions of older adults to be integrated into the discussion section of the paper.

PROSPERO REGISTRATION NUMBER

CRD42021237633.

A comparison of two national frailty scoring systems

BACKGROUND

The electronic Frailty Index (eFI) has been developed in primary care settings. The Hospital Frailty Risk Score (HFRS) was derived using secondary care data.

OBJECTIVE

Compare the two different tools for identifying frailty in older people admitted to hospital.

DESIGN AND SETTING

Retrospective cohort study using the Secure Anonymised Information Linkage Databank, comprising 126,600 people aged 65+ who were admitted as an emergency to hospital in Wales from January 2013 up until December 2017.

METHODS

Pearson's correlation coefficient and weighted kappa were used to assess the correlation between the tools. Cox and logistic regression were used to estimate hazard ratios (HRs) and odds ratios (ORs). The Concordance statistic and area under the receiver operating curves (AUROC) were estimated to determine discrimination.

RESULTS

Pearson's correlation coefficient was 0.26 and the weighted kappa was 0.23. Comparing the highest to the least frail categories in the two scores the HRs for 90-day mortality, 90-day emergency readmission and care home admissions within 1-year using the HFRS were 1.41, 1.69 and 4.15 for the eFI 1.16, 1.63 and 1.47. Similarly, the ORs for inpatient death, length of stay greater than 10 days and readmission within 30-days were 1.44, 2.07 and 1.52 for the HFRS, and 1.21, 1.21 and 1.44 for the eFI. AUROC was determined as having no clinically relevant difference between the tools.

CONCLUSIONS

The eFI and HFRS have a low correlation between their scores. The HRs and ORs were higher for the increasing frailty categories for both the HFRS and eFI.