Frailty indexes

Introduction

In today's healthcare practice, many patients live longer with multiple health issues, often in a frail or terminally ill state. Their quality of life doesn't necessarily improve. These patients require optimal supportive care that respects their dignity. Advanced Care Plans (ACPs) are crucial here, facilitating person-centered discussions about future care preferences while the patients have the mental capacity for meaningful participation. We aim in this study to assess how many patients in General Internal Medicine department would benefit from ACP and compare that to our current practice in implementing ACPs

Method

This cross-sectional retrospective study was done in 2 instances, 1 month apart from 29/03/23 to 01/05/23. The Sample size was 300 patients. The eligibility criteria were life expectancy of 12 months or less, age of 80 years and above, Clinical Frailty Scale (CFS) 8 or more, advanced dementia, and end-stage disease.

Result

33 patients (11%) met the eligibility criteria for ACP. 8 patients (24.2%) were above the age of 85. 25 patients (75.8%) had a Clinical Frailty Scale score higher than 7. 12 patients (36%) had terminal cancer. ACP was done for only 6% of the cases that meet the eligibility criteria. Within three months, 90% of these cases passed away. It is important to mention that in 57.6% of the cases, ACP was discussed with the patient and the next of kin (NOK) but was not formally documented.

Conclusion

Our findings revealed that only 6% of the eligible cases had evidence of ACP. This aligns with the study “advanced care planning in patients referred to the hospital for acute medical care: Results of a National Day of Care survey” which showed 4.8% had an ACP. The absence of ACP in the vast majority of re-admitted patients represents a significant missed opportunity to improve care.

Introduction: According to the latest NELA report(1), frailty doubles the risk of mortality in patients >65 and above, but review by a geriatrician can significantly reduce this risk. To identify patients at risk, the report recommended that a formal frailty assessment for all patients>65 should be performed. The aim of this audit was to check compliance with this recommendation.

Methods: Data were collected retrospectively from a prospectively maintained electronic hospital records. Patients > 65 years admitted acutely under general surgery were identified from handover lists spanning a period of two weeks. The admission documents were reviewed to check for a formal assessment of clinical frailty score (CFS) had been completed. Following initial results, posters were put up in the SAU doctors office and all clerking doctors made aware via e-mails, WhatsApp groups and teaching to complete a CFS for patients >65 years. Results: In the first cycle, 50 patients were identified and compliance rate was 18%. Following intervention, 51 patients were identified in the subsequent cycle with a compliance rate of 47%. After a second intervention, 99 patients were identified with a compliance rate of 61%.

Discussion: The NELA report highlighted only 23% of patients had a CFS documented and this was similar to the results of the initial audit. The main reason was lack of awareness, which was addressed by creating an awareness among the colleagues via poster, group chats and emails. This brought compliance up to 47% Another reason was doctors being unable to locate the CFS on the electronic clerking document. A second round of intervention by poster, group chat, email communication and teaching achieved a 61% completion rate. The recommendation is to continue to improve the documentation of CFS further and utilize this to get input from geriatricians.

Introduction: The Acute Frailty Team (AFT) review all acute admissions referred to Medicine for the Elderly within our organisation. Our team is comprised of a consultant, AHPs and a specialist clinical pharmacist. The Clinical Frailty Scale Score (CFS) was used to quantify frailty within our patient population. Recognising that older patients are at increased risk of medicine related harm, medication reviews are undertaken as part of the comprehensive geriatric assessment. The aim of this project was to determine the number of documented Level 3 medication reviews on discharge including number of medication interventions and determine any correlation with CFS. 

Methods: For a 5 month period, all patients reviewed by AFT (Monday to Friday) had a documented CFS score on admission. A retrospective review was then undertaken with data collected on CFS score, patient demographics and number of Level 3 medication reviews documented on discharge. Data was then collated to indicate medication interventions and the most common medication changes.

Results:  212 patients were reviewed during the study period. Range of CFS score was 2 to 8 and 81.2% were classified as CFS ≥5. 101 patients had a documented Level 3 medication review accounting for 380 medication interventions; 210 medications were stopped and 82 medications were started. 36.6% of the patient group were deceased within 1 year of review.

Conclusion(s):

In order to optimise effective prescribing and minimise harm in older, frail people, this data will be used locally to promote the importance of medication reviews during an acute admission and ensure this is reliably communicated on discharge. Deprescribing accounted for 55.3% of changes. Since 1/3 of patients are deceased within one year, a targeted medication review is essential and should influence our prescribing practice going forward.

Background

Patients living with Parkinson's disease (PD) who are sarcopenic are at significantly higher risk of falling (Cai et al., Frontiers in Neurology,2021,12,598035). Handgrip strength is a useful tool to assess for sarcopenia but is not commonly measured in clinical practice, despite the consequences that sarcopenia poses. This study aims to incorporate handgrip strength into the assessment of outpatients living with PD. Secondary objectives are to increase the understanding of whether exercise is associated with increased handgrip strength and to implement interventions for patients who are identified as sarcopenic; to improve their health outcomes.

Methods

Questionnaires were designed to gather quantitative data about patients' demographics, how frequently they fall, disease severity and their weekly exercise. These were given to patients attending the movement disorders clinic at Crawley hospital, between February and October 2023. Patients without a diagnosis of PD were excluded. Their grip strength was measured using a standardised technique with a calibrated manometer. Data was input to Microsoft Excel and analysed using Spearman's rank and Kruskal-Wallis test.

Results

Handgrip strength was obtained for 125 of 271 patients (46%) attending clinic over this period. Initially healthcare workers took 9.2 minutes to complete the questionnaire but this improved to 4.3 minutes after updating the form. Sixteen patients were excluded, leaving 51 females and 58 males; both with a mean age of 80. Grip strength reduced with PD severity when adjusted for gender; this was significant in males (H=51.9, p=0.00) but not females (H=4.8,p=0.31). Grip strength was weakly correlated with exercise, although not significant (r2=0.15,p=0.15) but did not appear to be related to frequency of falls (r2=0.01,p=0.92).

Conclusions

Handgrip measurement can be successfully implemented into outpatient assessment. Handgrip strength could be used to monitor the effect of lifestyle change in individuals. Limitations include self-reporting bias; which activities each individual classifies as exercise.

Introduction: In operative patients, frailty results in increased rates of postoperative morbidity and mortality. The BGS guidelines for perioperative care stipulate that all patients over the age of 65 should have a clinical frailty score (CFS) documented within 72 hours of admission. One benefit of recognising frailty and increased risk of death is timely establishment of a ceiling of care (CoC) for patients undergoing emergency surgery, in line with the NICE guidelines for advanced care planning. In our orthogeriatric department preliminary data suggested that the CFS was almost never routinely calculated, and that clinicians were not always establishing ceilings of care for patients. Methods: Y/N data was recorded for CFS completion and CoC documentation, which included a pre-existing DNACPR and for full active treatment, pre- and post- intervention. Inclusion criteria were patients aged >65yrs on admission, presenting with a neck of femur fracture undergoing operative management. 2 plan-do-study-act (PDSA) cycles were completed, with the aim of improving completion rate of a CFS and establishment of CoC within 72 hours of admission. Intervention: Alteration of the clerking pro-forma to make CFS and consideration of CoC mandatory pre-op assessments, alongside communication to current and incoming resident doctors on the orthogeriatric ward. Results were shared at a clinical governance meeting, initiating discussion between anaesthetic, surgical, and geriatric departments regarding advanced care planning best practice. Results: Following intervention, completion of CFS for patients within 72hrs increased from 4.5% to 41% and documentation of a CoC within 72hrs increased from 68% to 82%. Conclusions: This QIP improved both completion of CFS and consideration of CoC for elderly patients with hip fractures. In discussion at the clinical governance meeting it was agreed that careful consideration and documentation of CoC is always warranted and is an important component of care for this patient cohort.

Key to managing frailty is to first measure it. Until recently, there was no hospital coding for frailty, which meant that it was not visible to commissioners in routine datasets, despite the wealth of studies highlight poor outcomes for older people living with frailty. AFN has created the Hospital Frailty Risk Score (HFRS), which generates a frailty risk from routine codes included in NHS datasets. This allows commissioners and providers to ‘see’ frailty across their system.

We have designed and implemented easy to use tools that allow any NHS staff to look at frailty risk profiles in any NHS organisation, to support improvement activity. The HFRS tool has been downloaded by 122 health systems in England.

Patient safety is fundamental to AFN and reducing the harm older people are exposed to in hospital is the main aim of the programme and sites participating in the network. To achieve this and spread best practice the AFN delivery team use a specific QI approach, primarily the Model for Improvement, focusing on Plan-Do-Study-Act cycles to build change in local systems.

The team deliver events each year for all participating teams to support teams and enable sharing of experience. Site visits comprise discussion about the local context, plans for change and a discussion about possible barriers, as well as a walk-though the patient pathway with patient safety as the absolute focus. Each participating hospital has an allocated QI Associate to support the team to plan, deliver and measure improvements.

AFN has linked closely with other campaigns that support the safety and improve the care of older people, such as ‘end PJ paralysis’ and ‘no decision about me without me’.

Background:

This cross-sectional study aimed to assess the socio-demographic, anthropometric, and patient characteristics of 94 Yoruba speakers aged 60 years and older, and to validate the Yoruba version of the Clinical Frailty Scale (CFS).

Methods:

This study used a cross-sectional design with a purposive sampling technique and a sample size of 94 participants. This study also made use of the World Health Organization methodologic guidelines on cultural adaptation of clinical scales. Convergent validity was assessed by evaluating the context that the Clinical frailty scale (CFS) relates to the Edmonton frailty scale, using the Spearman rank correlation coefficient. The known group validity was assessed using one-way ANOVA.

Results:

The mean age of participants was 70.81±8.11 years, with a mean BMI of 27.04±5.61. The cohort included 38 males (44.4%) and 56 females (59.6%). Educational attainment varied, with 20.2% having no education and 9.6% holding postgraduate degrees. The validated CFS has excellent content validity (S-CVI/AVE=0.96; S-CVI-UA=0.78). Convergent validity demonstrated a moderate correlation between the CFS and the Edmonton Frail Scale (Spearman's rho=0.61, p<.01). Known-group validity indicated significant associations between frailty, age (p="0.007)." and BMI.

Conclusion:

The Yoruba version of CFS is a valid tool for assessing frailty in elderly Yoruba-speaking populations.

Introduction:

Frailty significantly affects outcomes like length of stay and readmissions in elderly patients. At Queen Alexandra Hospital, inpatients under 85 are under the care of General Internal Medicine (GIM) wards and they lack regular access to frailty services. This baseline audit evaluated frailty assessment, management practices and patient outcomes, implementing staff education, ward posters, and a frailty Multidisciplinary Team (MDT) between cycles.

Methods:

Data were retrospectively collected from three GIM wards over two cycles—January and August 2024. Eligibility criteria: Patients aged 65-85, admitted to GIM were included. The audit measured frailty assessment using the Clinical Frailty Scale (CFS), Comprehensive Geriatric Assessment (CGA) practices, frailty prevalence (CFS ≥ 5), advance care planning (ACP), and readmission rates.

Results:

Frailty assessment compliance rose from 76.6% to 94.4%. Frailty detection (CFS ≥ 5) increased from 36% to 75%. CFS documentation improved to 34.5%, with better CGA documentation. However, ACP rates remained low at 3.03%, and 56.6% of frail patients were readmitted within the year, indicating ongoing challenges. Conclusion: Improvements were seen in frailty assessments and detection, yet ACP remains underutilized, and readmission rates are high. Continued efforts are needed to enhance ACP documentation and frailty management strategies.

Recommendations:

1. Implement robust policies for ACP and implement a straightforward pathway for ACP documentation by all doctors.
2. Educate all doctors to practice comprehensive geriatric assessment and participate in frailty MDT meetings.
3. Further audits to specifically investigate the proportion of patients admitted with frailty syndrome and assess their prognosis.
4. Prioritize triage based on CFS scores/frailty over age to enhance targeted care and resource allocation.

Introduction: It’s estimated that 52% of elective vascular patients are frail, with predictions by 2030, one-fifth of surgical procedures will involve patients over 75. This project aimed to evaluate current practices around frailty recognition and documentation at the South-East Wales Vascular Network's regional surgical centre.

Objectives:

Assess the proportion of patients >65 years with documented frailty assessments using the Clinical Frailty Scale (CFS).

Assess healthcare workers' understanding of frailty and familiarity with the CFS. Identify barriers to recognising and undertaking frailty assessments.

Provide a frailty-focused educational intervention for the multidisciplinary team.

Methods: Data was collected prospectively for 22 patients >65 over two weeks in March 2024. The project team reviewed whether a CFS score was recorded on electronic workstation and independently completed a CFS score. Teaching sessions were organised for the multidisciplinary team on frailty recognition and CFS use. Pre- and post-teaching questionnaires gauged confidence levels in using the CFS.

Results: Out of 22 patients, 10 had recorded CFS scores, with 6 being accurate. For the 12 patients without recorded scores, 8 were classified as frail. The mean age was 76 years. The questionnaire revealed knowledge gaps: none of the nurses knew where to document a frailty score, and only 33% of physiotherapists and 60% of occupational therapists knew where to record a CFS score. Post-teaching, staff confidence in frailty recognition increased significantly.

Conclusions: Identifying frailty enables better perioperative risk assessment and surgical decision-making. Frailty documentation on Ward B2 is inadequate. Data collection highlighted nurses' lower awareness of frailty scoring, necessitating further improvement cycles. 73% of patients were frail, with 36% not previously identified as such. Improving frailty recognition will enhance care planning for frail patients undergoing vascular surgery. Designating a 'Frailty Champion' could improve frailty score documentation and ensure its routine inclusion in assessments on Ward B2 at UHW.

Introduction: Within our hospital, the Surgical Acute Frailty Team (SAFT) delivers perioperative care to the older emergency surgical population. SAFT focuses on early identification of frailty using the Clinical Frailty Scale and subsequent comprehensive geriatric assessment delivery. The most common referral reason to the team is delirium therefore widespread awareness and timely management is essential. Given the challenging clinical environment, SAFT decided to implement a blended teaching programme to support with delivering frailty education to the surgical multidisciplinary team. The aim of the education programme was to improve confidence in frailty identification, delirium assessment and management.

Methods: Teaching sessions targeting all healthcare professionals were delivered by members of SAFT. Education was delivered in two formats: ‘tea trolley teaching’ and small group classroom-based lectures. ‘Tea trolley teaching’ provides focussed ward-based education with a sweet treat provided as an incentive to attend. Feedback was gathered real-time before and after sessions to identify areas of knowledge improvement.

Results: 53 healthcare professionals attended these face to face teaching sessions. Prior to receiving this education, only 26% of participants felt confident in the identification of frailty. This improved to 91% post education. There was also significant improvement in participants’ confidence with delirium assessment from 23% to 74%. A similar improvement was also recorded in confidence with use of the TIME bundle for delirium management from 13% to 60%.

Conclusions: Delivering our education programme using a blended learning approach has improved participants’ confidence with frailty identification, delirium assessment and management. Future plans include the expansion of the teaching curriculum to include other common frailty-related topics, with the goal of improving the perioperative care of older adults within the emergency surgical setting.