334 GEMS: Geriatric Emergency Service - Rockwood’s Clinical Frailty Scale and Outcomes

Abstract Background Rockwood’s Clinical Frailty Scale (CFS), which uses clinical descriptors and pictographs, was developed to provide clinicians with an easily applicable tool to stratify older adults according to level of vulnerability. The CFS was validated in a sample of 2305 older participants from the Canadian Study of Health and Aging and was shown to be a strong predictor of institutionalisation and mortality (Rockwood K, 2005). Methods The aim of GEMS is to improve care, outcomes and the patient experience for older people living with Frailty. All people aged 75 years and older who attend as an emergency are screened on triage using the Variable Indicative of Placement Tool (VIP). The GEMS Acute Floor Team respond early to those who screen positive by starting a CGA. At the end of CGA all patients have a score 1 to 9 assigned from the Clinical Frailty Scale (CFS). Results 10,037 patients were triaged in the first two years of the service. 43% screened positive for Frailty. 66% had a CGA. 10% were vulnerable CFS 4, 32% mildly frail CFS 5, 32% moderately frail CFS 6 and 31% severely frail CFS 7. Increasing score on the CFS correlated with increased length of stay, death and institutionalisation. Conclusion The CFS correlates with Length of stay (LOS), mortality and institutionalisation in people aged 75 years and older who attend as an emegency and screen positive for Frailty.

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The Ability of Frailty to Predict Outcomes in Older People Attending an Acute Medical Unit

Acute Medicine Journal ◽

10.52964/amja.0290 ◽

2013 ◽

Vol 12 (2) ◽

pp. 74-76

Author(s):

Simon Conroy ◽

◽

Teresa Dowsing ◽

Keyword(s):

Length Of Stay ◽

Older People ◽

Odds Ratio ◽

Canadian Study ◽

Clinical Frailty Scale ◽

Medical Unit ◽

Acute Medical Unit ◽

Frailty Assessment

Background: This study assessed the role of frailty assessment in the AMU. Methods: Patients were assessed for frailty and their outcomes ascertained at 90 days. Results: The Canadian Study on Health and Aging Clinical Frailty Scale categorised 29% of patients as moderately-severely frail. Frailty did not differentially identify those likely to be discharged within one day, nor with long stays. Mortality at 90 days was 32%; frailty was associated with the risk of dying, odds ratio 1.4. 21% of patients were readmitted at 30 days, and 33% at 90 days, but frailty was not predictive. Discussion: Moderate-severe frailty in people aged 70+ was common and was predictive of higher mortality, but did not appear to predict admission, length of stay or readmission.

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332 GEMS: Geriatric Emergency Service - Outputs and Outcomes from the Acute Floor Team

Age and Ageing ◽

10.1093/ageing/afz103.215 ◽

2019 ◽

Vol 48 (Supplement_3) ◽

pp. iii17-iii65

Author(s):

Lorna Cornally ◽

Megan Hayes Brennan ◽

Danielle Reddy ◽

Grainne Gallagher ◽

Maureen O'Callaghan ◽

...

Keyword(s):

At Risk ◽

Older People ◽

Median Time ◽

Emergency Service ◽

Scientific Evidence ◽

Adverse Outcomes ◽

Older Person ◽

Home Team ◽

Care Approach ◽

Care Outcomes

Abstract Background Frailty is now a key concept in healthcare planning and delivery and is driving vertical and horizontal integration. The positive narrative of Frailty is further emphasised by the growing scientific evidence in the prevention, reversal and modification of Frailty. Early identification of Frailty and early intervention with Comprehensive Geriatric Assessment (CGA) is fundamental. Older people with Frailty admitted to hospital who receive a CGA early are more likely to return home. Benefits are seen early and are sustained (Ellis et al 2011). Methods The aim of GEMS is to improve care, outcomes and the patient experience for older people living with Frailty. All people aged 75 years and older who attend as an emergency are screened on triage using the Variable Indicative of Placement Tool (VIP). Screening is automatic and mandatory. The GEMS Acute Floor Team respond early to those who screen positive by starting a CGA. The GEMS Home Team case manage those who are admitted. Results Over 2 years 10,037 patients were triaged. The median time from arrival to VIP was 15 minutes. 43% screened positive for Frailty. 66% received a CGA. The median time from VIP to CGA was 1.7 hours. 84% identified at risk of polypharmacy, 27% at risk of malnutrition, 29% with delirium. 74% were admitted from home. 78% returned to pre-admission residence. 4% new admissions to NH care. Median length of stay was 7 days. The readmission rate within 30 days was 16%. 7% in hospital mortality. Conclusion The GEMS Team have developed and delivered a pioneering integrated care approach to the management of older person at high risk of adverse outcomes attending the acute floor.

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Rationing care by frailty during the COVID-19 pandemic

Age and Ageing ◽

10.1093/ageing/afaa171 ◽

2020 ◽

Cited By ~ 3

Author(s):

Emma Grace Lewis ◽

Matthew Breckons ◽

Richard P Lee ◽

Catherine Dotchin ◽

Richard Walker

Keyword(s):

Critical Care ◽

Older People ◽

Adverse Outcome ◽

Older Individuals ◽

Short Term ◽

Clinical Frailty Scale ◽

Widespread Implementation ◽

Care Outcomes ◽

Resource Allocation Strategy ◽

The Impact

Abstract The coronavirus disease 2019 (COVID-19) pandemic is disproportionately affecting older people and those with underlying comorbidities. Guidelines are needed to help clinicians make decisions regarding appropriate use of limited NHS critical care resources. In response to the pandemic, the National Institute for Health and Care Excellence published guidance that employs the Clinical Frailty Scale (CFS) in a decision-making flowchart to assist clinicians in assessing older individuals’ suitability for critical care. This commentary raises some important limitations to this use of the CFS and cautions against the potential for unintended impacts. The COVID-19 pandemic has allowed the widespread implementation of the CFS with limited training or expert oversight. The CFS is primarily being used to assess older individuals’ risk of adverse outcome in critical care, and to ration access to care on this basis. While some form of resource allocation strategy is necessary for emergencies, the implementation of this guideline in the absence of significant pressure on resources may reduce the likelihood of older people with frailty, who wish to be considered for critical care, being appropriately considered, and has the potential to reinforce the socio-economic gradient in health. Our incomplete understanding of this novel disease means that there is a need for research investigating the short-term predictive abilities of the CFS on critical care outcomes in COVID-19. Additionally, a review of the impact of stratifying older people by CFS score as a rationing strategy is necessary in order to assess its acceptability to older people as well as its potential for disparate impacts.

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Estimating survival time in older adults receiving chemotherapy for advanced cancer.

Journal of Clinical Oncology ◽

10.1200/jco.2019.37.15_suppl.e23017 ◽

2019 ◽

Vol 37 (15_suppl) ◽

pp. e23017-e23017 ◽

Cited By ~ 1

Author(s):

Erin Moth ◽

Prunella Blinman ◽

Natalie Stefanic ◽

Vasi Naganathan ◽

Andrew James Martin ◽

...

Keyword(s):

Older Adults ◽

Survival Time ◽

Advanced Cancer ◽

Cox Regression ◽

Strong Predictor ◽

Performance Status ◽

Prognostic Significance ◽

Clinical Frailty Scale ◽

Worst Case

e23017 Background: Best-case, worst-case, and typical scenarios for survival time, based on an oncologist’s estimate of expected survival time (EST), have proven accurate in a range of advanced cancers. We sought the accuracy and prognostic significance of such estimates, and of a simple, pragmatic rating of frailty, in older adults starting chemotherapy. Methods: Participants (pts) were aged 65 or older and starting a new line of chemotherapy for advanced cancer. For each pt at baseline, their treating oncologist recorded an individualised estimate of EST (median survival in a group of similar patients), ECOG performance status (PS), and rating of frailty with the single-item, Clinical Frailty Scale from the Canadian Study of Health and Aging. We hypothesised that estimates of EST would be unbiased (approximately 50% of pts would live longer than their EST); imprecise ( < 33% would live for 0.67 to 1.33 times their EST); and, that simple multiples of the EST would provide accurate individualised scenarios for survival time, i.e. approximately 10% of pts would die within ¼ of their EST, 10% would live longer than 3 times their EST, and 50% would live from half to double their EST. We identified independent predictors of observed survival time (OST) with multivariable Cox regression. Results: Baseline characteristics of the 102 pts were: median age 74 (range 65-86), 1st line chemotherapy in 67%, colorectal cancer in 33%, PS 0 or 1 in 80%, and frailty rating of vulnerable to frail in 35%. The median EST was 15 months (range 4-60), median follow-up time was 19 months (range 0-27), and median OST was 15 months (range 0.5-27+). As hypothesized, 54% of pts lived longer than their EST, 30% lived within 0.67 to 1.33 times their EST, 56% lived half to double their EST, and 9% lived ≤1/4 of their EST. Follow-up was too short to observe those who will live ≥3 times their EST. Independent predictors of OST were frailty (HR 2.8, 95%CI 1.6-4.9, p = 0.0004) and EST (HR 0.96, 95%CI 0.93-0.99, p = 0.03). Conclusions: Oncologists’ estimates of EST were unbiased, imprecise, and accurate for formulating scenarios for survival time. A simple, pragmatic rating of frailty by the treating oncologist was a strong predictor of OST even after accounting for their estimate of EST.

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Delirium is prevalent in older hospital inpatients and associated with adverse outcomes: results of a prospective multi-centre study on World Delirium Awareness Day

BMC Medicine ◽

10.1186/s12916-019-1458-7 ◽

2019 ◽

Vol 17 (1) ◽

Cited By ~ 12

Author(s):

Keyword(s):

Older Adults ◽

Length Of Stay ◽

Adverse Outcomes ◽

Point Prevalence ◽

Clinical Frailty Scale ◽

Multi Centre Study ◽

National Programme ◽

Diagnostic And Statistical Manual ◽

Multivariable Analyses ◽

The Uk

Abstract Background Delirium is a common severe neuropsychiatric condition secondary to physical illness, which predominantly affects older adults in hospital. Prior to this study, the UK point prevalence of delirium was unknown. We set out to ascertain the point prevalence of delirium across UK hospitals and how this relates to adverse outcomes. Methods We conducted a prospective observational study across 45 UK acute care hospitals. Older adults aged 65 years and older were screened and assessed for evidence of delirium on World Delirium Awareness Day (14th March 2018). We included patients admitted within the previous 48 h, excluding critical care admissions. Results The point prevalence of Diagnostic and Statistical Manual on Mental Disorders, Fifth Edition (DSM-5) delirium diagnosis was 14.7% (222/1507). Delirium presence was associated with higher Clinical Frailty Scale (CFS): CFS 4–6 (frail) (OR 4.80, CI 2.63–8.74), 7–9 (very frail) (OR 9.33, CI 4.79–18.17), compared to 1–3 (fit). However, higher CFS was associated with reduced delirium recognition (7–9 compared to 1–3; OR 0.16, CI 0.04–0.77). In multivariable analyses, delirium was associated with increased length of stay (+ 3.45 days, CI 1.75–5.07) and increased mortality (OR 2.43, CI 1.44–4.09) at 1 month. Screening for delirium was associated with an increased chance of recognition (OR 5.47, CI 2.67–11.21). Conclusions Delirium is prevalent in older adults in UK hospitals but remains under-recognised. Frailty is strongly associated with the development of delirium, but delirium is less likely to be recognised in frail patients. The presence of delirium is associated with increased mortality and length of stay at one month. A national programme to increase screening has the potential to improve recognition.

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Using an electronic frailty index to predict adverse outcomes in geriatric COVID-19 patients: data from the Stockholm GeroCovid study

10.1101/2021.12.03.21267254 ◽

2021 ◽

Author(s):

Jonathan K. L. Mak ◽

Maria Eriksdotter ◽

Martin Annetorp ◽

Ralf Kuja-Halkola ◽

Laura Kananen ◽

...

Keyword(s):

Length Of Stay ◽

Hospital Mortality ◽

Cox Regression ◽

Predictive Accuracy ◽

Strong Predictor ◽

Characteristic Curve ◽

Frailty Index ◽

Predictive Ability ◽

Adverse Outcomes ◽

Clinical Frailty Scale

ABSTRACTBackgroundThe Clinical Frailty Scale (CFS) is a strong predictor for worse outcomes in geriatric COVID-19 patients, but it is less clear whether an electronic frailty index (eFI) constructed from routinely collected electronic health records (EHRs) provides similar predictive value. This study aimed to investigate the predictive ability of an eFI in comparison to other frailty and comorbidity measures, using mortality, readmission, and the length of stay as outcomes in geriatric COVID-19 patients.MethodsWe conducted a retrospective cohort study using EHRs from nine geriatric clinics in Stockholm, Sweden, comprising 3,405 COVID-19 patients (mean age 81.9 years) between 1/3/2020 and 31/10/2021. Frailty was assessed using a 48-item eFI developed for Swedish geriatric patients, the CFS, and Hospital Frailty Risk Score (HFRS). Comorbidity was measured using the Charlson Comorbidity Index (CCI). We analyzed in-hospital mortality and 30-day readmission using logistic regression and area under receiver operating characteristic curve (AUC). 30-day and 6-month mortality were modelled by Cox regression, and the length of stay by linear regression.ResultsControlling for age and sex, a 10% increase in the eFI was associated with higher risks of in-hospital mortality (odds ratio [OR]=2.84; 95% confidence interval=2.31-3.51), 30-day mortality (hazard ratio [HR]=2.30; 1.99-2.65), 6-month mortality (HR=2.33; 2.07-2.62), 30-day readmission (OR=1.34; 1.06-1.68), and longer length of stay (β=2.28; 1.90-2.66).The CFS, HFRS and CCI similarly predicted these outcomes, but the eFI had the best predictive accuracy for in-hospital mortality (AUC=0.775).ConclusionsAn eFI based on routinely collected EHRs can be applied in identifying high-risk geriatric COVID-19 patients.

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Impact of COVID-19 on Care-Home Mortality and Life Expectancy in Scotland

10.1101/2021.01.15.21249871 ◽

2021 ◽

Author(s):

Jennifer K Burton ◽

Martin Reid ◽

Ciara Gribben ◽

David Caldwell ◽

David N Clark ◽

...

Keyword(s):

Older Adults ◽

Length Of Stay ◽

Life Expectancy ◽

Older People ◽

Care Home ◽

Care Homes ◽

Years Of Life Lost ◽

Home Life ◽

Scottish Population ◽

The Impact

AbstractIntroductionCOVID-19 deaths are commoner among care-home residents, but the mortality burden has not been quantified.MethodsCare-home residency was identified via a national primary care registration database linked to national mortality data. Life expectancy was estimated using Makeham-Gompertz models, to (i) describe yearly life expectancy from Nov 2015 to Oct 2020 (ii) compare life expectancy (during 2016-2018) between care-home residents and the wider Scottish population and (iii) apply care-home life expectancy estimates to COVID-19 death counts to estimate years of life lost (YLL).ResultsAmong care-home residents, life expectancy in 2015/16 to 2019/20 ranged from 2.7 to 2.3 years for women and 2.3 to 1.8 years for men. Life expectancy was lowest in 2019/20. Age-sex specific life expectancy in 2016-2018 in care-home residents was lower than in the Scottish population (10 and 2.5 years in those aged 70 and 90 respectively). Rather than using national life tables, applying care-home specific life expectancies to COVID-19 deaths yields, mean YLLs for care-home residents were 2.6 and 2.2 for women and men respectively, with total care-home resident YLLs of 3,560 years in women and 2,046 years in men. In people aged over-70, approximately half of deaths and a quarter of YLL attributed to COVID-19 were accounted for by the 5% of over-70s who were care-home residents.ConclusionPrioritising care-home residents for vaccination is justified not only in terms of total deaths, but also in terms of years of life lost.Research in contextEvidence before this studyWe searched PubMed to 1st December 2020, with the terms (“nursing home” OR “care-home” OR “long-term care” OR “residential care”) AND (“mortality” OR “life expectancy” OR “length of stay”). We also searched for studies specific to the impact of the COVID-19 pandemic on those living in care-homes. We restricted our search to publications in English. Usual care-home life expectancy, in a UK context, has not previously been defined. One systematic review of length of stay was identified, which found significant heterogeneity in factors and associations. The impact of COVID-19 on excess mortality among care-home residents was noted, but the impact on life expectancy was not reported. Studies evaluating life expectancy among older people in the COVID-19 pandemic have not taken account of residency in their estimates.Added value of this studyUsing Scottish national representative linked data we describe the usual life expectancy of older adults (aged ≥70 years) living in care-homes, compared to older people living elsewhere. Deaths among care-home residents account for a considerable proportion of all mortality in older adults, around 19% for men and 30% for women. Life expectancy in care-home residents during the pandemic fell by almost 6 months, from 2.7 to 2.3 years in men and 2.1 to 1.8 years in women. In total, over 5,600 Years of Life were Lost (YLL) by care-home residents in Scotland who died with COVID-19. Around half of COVID-19 deaths and a quarter of YLL in those aged 70 years and over occurred among care-home residents. During the COVID-19 pandemic a smaller proportion of deaths among care-home residents occurred in hospitals.Implications of all the available evidencePrioritising the 5% of older adults who are care-home residents for vaccination against COVID-19 is justified both in terms of total deaths and total years of life lost. Individual and societal planning for care needs in older age relies on understanding usual care-home life expectancy and patterns of mortality. Understanding life expectancy may help clinicians, residents and their families make decisions about their health care, facilitating more informed discussions around their priorities and wishes. Population-wide estimates of YLL and burden of disease should take account of residency status, given the significant differences between life expectancy of those living in care-homes from their peers in other settings.

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137 Does the Clinical Frailty Scale Predict Rehabilitation Potential in Older Patients?

Age and Ageing ◽

10.1093/ageing/afz103.82 ◽

2019 ◽

Vol 48 (Supplement_3) ◽

pp. iii17-iii65

Author(s):

Maeve D'Alton ◽

Joanne Larkin ◽

Avril McKeag ◽

Grace Coakley ◽

Emma Nolan ◽

...

Keyword(s):

Older Adults ◽

Length Of Stay ◽

Outcome Measure ◽

Discharge Planning ◽

Functional Independence ◽

Discharge Destination ◽

Clinical Frailty Scale ◽

Common Diagnosis ◽

Rehabilitation Potential ◽

Surgical Admission

Abstract Background The Clinical Frailty Scale (CFS) is widely used to assess frailty in older adults and reflects functional independence. We examined its use as an outcome measure in an offsite rehabilitation unit for patients over 65 transferred from an acute hospital following medical/surgical admission. Methods Patients were given a CFS score by consensus opinion from the multidisciplinary team on admission and on completion of rehabilitation. We included data on diagnosis, length of stay and discharge destination Results Thirty patients, with a mean age of 80, completed rehabilitation over a four-month period. The most common diagnosis was fracture of hip or pelvis (53%). Median CFS was 6 on admission and 5 on discharge (range 3-8). Twenty-one (70%) patients saw an improvement in CFS of an average of one point on the scale irrespective of admission score. Of those that improved, 81% were discharged directly home with no need for increased support services, compared with 11% of those who did not improve. Mean length of stay was significantly less in those with mild/moderate frailty (CFS 5-6) at admission versus severe frailty (31 vs 53.8 days, p<0.01). Conclusion Frailty score improved in the majority of patients undergoing rehabilitation, regardless of admission score; CFS alone did not predict rehabilitation potential, emphasising the importance of offering rehabilitation to frail older adults – better judged by experienced clinical assessment. CFS is a broad 9-point tool that can miss small improvements in physical function based on other objective scores e.g. FIM+FAM. Severe frailty was associated with longer length of stay in rehabilitation, possibly reflecting more complex discharge planning as well as rehabilitation progress in this group.

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INTERNET USE AND LONELINESS OF OLDER ADULTS OVER TIME: THE MEDIATION EFFECT OF SOCIAL CONTACT

Innovation in Aging ◽

10.1093/geroni/igz038.697 ◽

2019 ◽

Vol 3 (Supplement_1) ◽

pp. S194-S194

Author(s):

Kexin Yu ◽

Shinyi Wu ◽

Iris Chi

Keyword(s):

Older Adults ◽

Older People ◽

Internet Use ◽

Social Contact ◽

Total Effect ◽

Mediation Effect ◽

Health And Retirement Study ◽

Longitudinal Association ◽

Retirement Study ◽

Over Time

Abstract Internet is increasingly popular among older adults and have changed interpersonal interactions. However, it remains controversial whether older people are more or less lonely with internet use. This paper tests the longitudinal association of internet use and loneliness among older people. One pathway that explains the association, the mediation effect of social contact, was examined. Data from the 2006, 2010 and 2014 waves of Health and Retirement Study was used. Hierarchical liner modeling results showed internet use was related to decreased loneliness over 12-year period of time (b=-0.044, p<.001). Internet use was associated with more social contact with family and friends overtime (b=0.261, p<.001), social contact was related to less perceived loneliness longitudinally (b=0.097, p<.001). The total effect of internet use on loneliness is -0.054 and the mediated effect is -0.025. The findings imply that online activities can be effective for reducing loneliness for older people through increased social contact.

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Older adults with SARS‐CoV2 infection: Utility of the Clinical Frailty Scale to predict mortality

Journal of Medical Virology ◽

10.1002/jmv.26766 ◽

2020 ◽

Author(s):

Marine Gilis ◽

Ninon Chagrot ◽

Severine Koeberle ◽

Thomas Tannou ◽

Anne‐Sophie Brunel ◽

...

Keyword(s):

Older Adults ◽

Clinical Frailty Scale

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