Frailty

Background: Worldwide population ageing is motivating how to measure the health of ageing populations. One approach is to compare dynamics of frailty, assessed by the cumulative-deficit frailty index, across different populations. We aim to compare the frailty distribution, mortality risk, and change in frailty over time between 18 countries.

Methods: Using data from five harmonised international surveys (HRS, SHARE, ELSA, CHARLS and MHAS) we assessed frailty with a 40-item frailty index (baseline, 2-, 4- and 6-year follow-up), along with mortality status. We constructed separate regression models for participants with the fewest baseline health deficits (“zero-state” – assessing ambient health of the population) and the rest of the population (“non zero-state”). Using logistic and negative binomial, respectively, we assessed the odds of mortality and the rate of deficit accumulation (i.e. change in frailty index) between countries, adjusted for baseline frailty, age, and sex.

Results: Highest baseline frailty, mortality risk, and the most rapid increases in frailty were observed in Mexico, followed by China. Differences in mortality risk and deficit accumulation were similar regardless of baseline frailty. Lowest mortality risk and the slowest rates of deficit accumulation were observed in Scandinavian countries and in Switzerland. Differences between Central/Southern European countries, USA and UK varied when comparing zero-state with non zero-state models. For example, mortality rates and deficit accumulation were relatively lower among the healthiest subset of the USA (and to a lesser extent UK) population. However, when modelling those with some degree of baseline frailty, mortality and deficit accumulation in the USA were relatively higher compared to European countries.

Conclusion: Dynamics of the frailty index can provide insights into population-level differences in health across different settings. For some, but not all, countries, findings are sensitive to the degree of frailty present at baseline, which may reflect inequalities in healthcare provision or access.

Introduction:

The Trauma Audit and Research Network report “Major Trauma in Older People” highlighted the need to recognise falls in older patients as a mechanism leading to potentially life-threatening injuries. Reasons behind falls can be equally serious and must be addressed concurrently. A Frail Trauma Pathway was introduced in the Emergency Department (ED) of a Major Trauma Centre (MTC) and subsequent audit revealed it was underutilised. We relaunched the Frail Trauma Pathway incorporating a checklist with the aim of improving patient care.

Method:

Retrospective data was collected over one week, including patients over 65 years with a Clinical Frailty Score ≥5, a low velocity trauma and multiple injuries or isolated head injury. We then updated the Frail Trauma Pathway incorporating a checklist, re-distributed it throughout the ED, sent staff email reminders and held teaching sessions. An educational “Advent Calendar” was circulated daily in December. Following this we repeated data collection.

Results:

20 patients pre and 18 post-intervention fitted inclusion criteria. There was a reduction in admission rates, improvement in ED senior doctor review for primary survey, increase in timely administration of Parkinson’s disease medication and venous thromboembolism assessment. However, there was a decline in other parameters measured. Due to the small patient cohort, it is difficult to assess if changes in results post-intervention are statistically significant.

Conclusion:

Several aspects of the frailty pathway showed improvement, notably admission reduction. This QIP demonstrates the difficulties of instigating change in an MTC, where numerous pathways result in ‘information overload’ and staff numbers are large and constantly changing. By focusing on the frail trauma checklist and incorporating it into our electronic records system we hope to improve compliance with the pathway. Further research on a national level is required to determine how to best care for this expanding cohort of patients.

Introduction:

Incident frailty is common among older adults with diabetes mellitus. We have previously demonstrated that elevated serum levels of the soluble receptor for advanced glycation-end products (sRAGE) predict mortality in frail older adults. However, the evidence that sRAGE is associated with higher mortality in older adults with diabetes mellitus is rather inconsistent. Therefore, the aim of this study was to investigate whether frailty status influences the relationship between sRAGE and mortality in older adults with this diabetes mellitus.

Methods:

Three hundred and ninety-one participants with diabetes mellitus (median age, 76 years) from four European cohorts, who enrolled in the FRAILOMIC project were analysed. Frailty was evaluated at baseline using Fried’s frailty phenotype. Serum sRAGE was quantified by ELISA. Participants were stratified by frailty status (n = 280 non-frail and 111 frail). Multivariate Cox proportional hazards regression and Kaplan-Meier survival analysis were used to assess the relationship between sRAGE and mortality.

Results:

During 6 years of follow-up, 98 participants died (46 non-frail and 52 frail). Non-survivors had significantly higher baseline levels of sRAGE than survivors (median [IQR]: 1,392 [962–2,043] pg/mL vs. 1,212 [963–1,514], P = 0.008). High serum sRAGE (>1,617 pg/mL) was associated with increased mortality even after adjustment for relevant confounders (HR 2.06, 95% CI: 1.36–3.11, p < 0.001), and there was an interaction between sRAGE and frailty (P = 0.006). Furthermore, the association between sRAGE and mortality was stronger in the frail group compared to the non-frail group ((HR 2.52, 95% CI: 1.30–4.90, P = 0.006) vs. (HR 1.71, 95% CI: 0.91–3.23, P = 0.099, respectively)).

Conclusions:

Frailty status influences the relationship between sRAGE and mortality in older adults with diabetes mellitus. This has significant clinical potential in the risk stratification of diabetic patients.

Introduction: In 2021, there were 38,839 adults >65 years living in Brighton and Hove, 13% of the local population, compared to 18% in England. However, 56% of emergency laparotomy procedures in the UK are in the > 65s. At the Royal Sussex County Hospital, a consultant geriatrician was appointed to lead a Frailty Liaison Service to respond to the needs of frail older patients undergoing general surgery (GS). No process was in place for the early identification of these patients, so intervention decisions were being made without GS Frailty Liaison input, potentially leading to unnecessary procedures and adverse outcomes such as deconditioning, which could potentially be reduced by timely clinical frailty scoring (CFS) and comprehensive geriatric assessment. This quality improvement project sought to identify all appropriate frail older patients over 70 within 1 week of admission to be seen by the Frailty Liaison Team on the general surgical ward.

Methods: We used the Model for Improvement and diagnostic tools (fishbone; stakeholder mapping; driver diagrams) and PDSA cycles to test the impact of junior doctor education on CFS scoring and awareness raising primarily through a newsletter; measured by the number of frailty scores given to patients pre-intervention, remeasured at 3 months after the initial data set. We captured feedback following the education sessions to assess usefulness.

Results and conclusion: Results showed 100% of participants felt more confident in identifying frailty in GS patients. The average number of days from admission to identification and first review decreased from 8.29 to 6.36, possibly reducing adverse outcomes. The proportion of appropriate referrals increased, releasing time to care for those who needed it most. Moving forward, we plan to promote the use of a CFS column on the handover list and continue our education sessions, incorporating real patient cases as requested in feedback.

Introduction: Frailty presents significant challenges to healthcare systems, particularly in Thurrock, Essex, where 14% of residents are aged 65 or older. This demographic shift, combined with socioeconomic factors, highlights the need for patient-centred, clinically effective, and tailored healthcare services that prioritise patient safety. 

Aim: To improve frailty management for elderly patients in Thurrock by integrating pharmacist support within a nurse-led service. The initiative focuses on improving medication management, alleviating workload pressures, and providing holistic care to enhance patient outcomes and reduce hospital admissions. 

Method: A 12-week pilot involved patients aged 65+ undergoing joint reviews with a frailty nurse and pharmacist. Participants had a Rockwood Frailty Score of 5-7 and at least one long-term condition. The reviews encompassed an evaluation of physical observations, medication regimen, functional and fall risk assessment, nutritional status, fracture risk, and analysis of pertinent blood test results. The management phase focused on reviewing long-term chronic conditions, deprescribing, medication dose adjustments, and addressing health metrics such as postural hypotension, bradycardia, bone protection, and fall risk. Regular follow-ups ensured coordinated care between the nurse and pharmacist, focusing on patient-centred outcomes and patient safety. 

Results: A total of 37 patients (mean age: 84) participated from April 4^th to June 28^th, 2024. Comprehensive assessments led to 155 interventions (averaging 4.07 per patient). Medication management improved significantly, with 88 drugs deprescribed, including 55 Falls Risk Increasing Drugs (FRIDs), resulting in a 14.39% reduction in FRIDs and a 23.03% reduction in polypharmacy. These interventions led to £6,252.18 in annual drug savings and a 974.09 kg reduction in CO₂ emissions. Key outcomes included 57 health and social interventions and 38 new medications prescribed. Financial analysis suggested savings of £63,450 from preventable hospital admissions, with a return on investment (ROI) of 1655.4%.

Conclusion: The pilot demonstrated the clinical effectiveness of pharmacist-nurse collaboration in improving medication management, chronic condition control, reducing fall risk, and preventing hospital admissions. It underscores the value of skill mixing between professions for enhanced patient-centred care, safety, and clinical outcomes.

Introduction

Frail older patients with hearing impairments face significant communication challenges in acute care settings such as the Emergency Department (ED) and Same Day Emergency Care (SDEC). These challenges often lead to misdiagnoses, increased anxiety, and diminished patient satisfaction. Improving communication for such patients is critical to enhancing their care experience, maintaining dignity, and improving overall satisfaction and outcomes.

Method

A Quality Improvement Project (QIP) was conducted involving ten participants over 75 years who were identified with hearing impairments and admitted to the SDEC frailty unit from the ED. Baseline communication difficulties were assessed using a pre-designed questionnaire. The AudiMed Communicator 2, a lightweight and ergonomic device with a high-quality amplifier and built-in microphone, was introduced to enhance hearing without requiring traditional hearing aids. Participants provided feedback post-intervention via a follow-up questionnaire, evaluating the device's impact on hearing and communication.

Results

All participants initially relied on alternative communication methods and reported frustration due to impaired hearing. Most did not have functioning hearing aids. Following the implementation of AudiMed, participants' hearing ability scores improved dramatically. All reported a score of 5 on a 1-5 scale, indicating high satisfaction. 100% of participants preferred using AudiMed and highlighted its positive impact on their communication and care experience.

Conclusion

The AudiMed Communicator has significantly enhanced communication, hearing ability, and patient satisfaction among frail older patients in acute care settings. By addressing communication barriers, the device has empowered patients, promoted dignity, and streamlined care delivery, ultimately improving outcomes and quality of life. Recommendations include expanding the use of AudiMed in similar settings, providing staff education for seamless integration, and ensuring ongoing feedback for continued evaluation and improvement.

Introduction 

There is a drive for same day emergency care (SDEC) assessments of older frail patients attending hospitals. Multiple documents suggest how frailty SDEC services could work. 

Methods 

A trial of a mobile frailty SDEC, the Frailty Intervention Team (FIT) took place for 4 weeks in October 2020.. Data were collected manually but most of the presented data was indirect, such as length of stay of all older frail patients, rather than directly related to who FIT had seen. As FIT developed it was clear that data collection required automation. This was achieved through use of specific “Clinical Data Capture” (CDC) forms on the Trust’s Electronic Patient Record (EPR). Utilising a combination of emergency care and admitted patient datasets, a bespoke dashboard has been produced which visualises the data using Statistical Process Control methodology. A CDC form was developed that enabled identification of patients assessed by FIT. 

Results 

Initially the success depended on where the patient was when the CDC form was completed with 135 patients identified a month from ED dropping to 73 after the establishment of a SDEC unit (non significanton SPC) and 51 identified a month among inpatients, with 160 after the SDEC unit opened (p<.05 on spc) . through collaborative working, adjustments were made to how the data was extracted and transformed for reporting. there no significan diferenceinthenumbersofin november 2024, 284 patients seen with 260 cdc forms. of these 250 recognized by developed dataset (96%). 

Conclusion 

Collaborative working between analyst & fit clinical lead has led bespoke dashboard allow demonstrate value system trust board. work is ongoing generate reports demonstrating levels compliance girft standards aligned model hospital sets benchmarking.

The Frailty Hotline is a follow-up service designed to provide ongoing care and support to patients discharged from the frailty service. Patients who have previously been under the care of the frailty team are given a dedicated phone number that allows them to escalate non-urgent concerns regarding their health. This service ensures that patients continue to receive appropriate care and guidance while remaining in their home environment, reducing the need for unnecessary hospital visits.

This quality improvement project sought to evaluate the effectiveness of the Frailty Hotline in reducing avoidable ED visits and improving patient care. The PDSA cycle  was conducted over a 15-day period. During this time, the frailty practitioners at the Royal Preston Hospital responded to a total of 47 phone calls. Details of the calls were recorded using a pro forma to ensure accurate information capture.

The majority of identified concerns centered around queries regarding patient management and issues related to patient symptoms and health. When a problem or concern was identified, actions were typically taken to address it. The majority of the actions involved providing advice to patients and seeking clinical advice from senior practitioners. A significant number of patients were also escalated to the Virtual Frailty Ward.

Out of the 47 phone calls received, 16 (34%) addressed patients' symptoms that could have potentially resulted in Emergency Department (ED) presentations. Of these 16 patients, 9 (19%) were escalated to the Virtual Frailty Ward, potentially preventing hospital admissions. One patient called 999 due to extreme pain and may have presented to the ED. There was no geriatrician available at the time to advise.

This highlights the critical role of the Frailty Hotline service in reducing unnecessary ED visits and hospital admissions. The Frailty Hotline service also played a vital role in improving patient outcomes by addressing a range of queries related to medications, symptoms, and pending investigations, which could have otherwise resulted in unnecessary phone calls to GPs and other services. 

Background 

Delirium and acute functional decline are common in hospitalized older people (HOP), yet data remain scarce. A shortage of geriatricians and geriatric-trained doctors in our healthcare system contributes to poor clinical outcomes, including increased readmissions, morbidity, and mortality. This pilot study aims to assess the clinical burden of HOP—including rates of readmission, delirium, and acute functional decline—before implementing frailty care bundles in general medical wards. 

Methodology 

This prospective cross-sectional study recruited HOP (≥65 years) admitted to general medical wards from 1–31 March 2024. Data collected included demographics, prior-year readmissions, ADL and mobility status (1 month pre-admission vs. discharge), presence of delirium (via symptoms or Confusion Assessment Method), and length of stay. Acute functional decline was defined as deterioration in at least one ADL or mobility domain. Patients transferred to other specialties or district hospitals were excluded. 

Results 

Of 107 HOP (33.7% of total admissions), 103 were analyzed. Median age was 73; 80.6% were 65–80 years, and 59.2% were male. At baseline, 76.7% were CFS ≤5, while 23.3% were moderately/severely frail (CFS 6–7). Prior to admission, 48.5% walked unaided, while 51.5% required assistance. Readmission history was noted in 46.6%. Mean length of stay was 6.5 days. Acute mobility decline occurred in 37.9%, functional decline in 35%, and delirium in 17.5%. 

Conclusion 

This study highlights a substantial clinical burden among hospitalized HOP. A standardized frailty care bundle has been developed to aid non-geriatric-trained healthcare personnel in early detection and management of frailty-related issues, aiming to improve patient outcomes.

Introduction: 

Polypharmacy contributes to frailty, financially strains healthcare resources and causes unplanned hospital admissions. We audited how our Frailty Same Day Emergency Care (SDEC) addressed polypharmacy and the yearly financial impact of deprescribing on the NHS. 

Method: 

We analysed two months of patients seen and recorded medication changes in Excel. The BNF was used to provide the minimum NHS indicative price for a medication. Cost was calculated based on a year of prescribing for medications started, stopped or altered. For PRN medications, single pack usage was assumed. The average monthly saving was then multiplied by 12 to estimate the yearly value. 

Results: 

226 patients were reviewed, with 181 having recorded medication changes. From this sample, the estimated yearly saving through deprescribing is around £31,780. Furosemide, amlodipine and atorvastatin were the most frequently stopped. Anticipatory medication and laxatives were most frequently started. Stopping ticagrelor resulted in the greatest savings (£711.44), whilst the most expensive medication started was mesalazine granules (£897.16). 

Limitations: 

The estimated yearly saving is based on assumption and so can be subjected to anomalous results/prescribing. Alterations are assumed to be permanent and continue throughout the year. PRN usage was generalised and not reflective of true usage over a year. The estimated saving does not account for negative financial complications because of deprescribing (e.g. stopping stomach protection and then representing with an Upper GI Bleed). Whilst deprescribing can result in direct financial benefit to the NHS, true benefit has not been measured (reducing future admissions due to polypharmacy). 

Conclusion: 

The NHS can incur significant financial savings from a frailty day unit. The direct cost reduction of deprescribing is only one of the benefits of addressing polypharmacy. The true value is in improving quality of life, reducing the impact of frailty syndromes and avoiding hospital admissions in older people.