Frailty indexes

Aim: Several scores have been developed to identify SDEC patients from Emergency Department (ED) triage and acute medical intakes. Scores are designed to improve system efficiency, overcrowding and patient experience but none have been developed for older adults. Previous work has shown that existing scores e.g. Glasgow Admission Prediction Score, Sydney Triage to Admission Risk Tool and the Ambulatory Score were not able to predict admission in our population(1). We have developed a novel, frailty-focused score. Methods: The Older Person’s Assessment service (OPAS) is ED based, accepting patients with frailty syndromes aged >70 years to provide a comprehensive geriatric assessment (CGA) and is extended into medical SDEC. The databases were retrospectively analysed and interactions with age, Charlson Co-morbidity index (CCI) and Clinical Frailty Score (CFS) were evaluated alongside NEWS, 4AT, including who with and where the patient resides. Results 1011 attendances, 414 (40.9%) Male, mean age 82.3(±8.4) years, CFS 5.3(±1.2) and CCI 8.0(±1.8), 701(69.3%) discharged same-day and 629(62.2%) fallers. OPAS: 776 attendances, 306 (39.4%) Male, age 82.4(±8.7) years, CFS 5.3(±1.1) and CCI 7.9(±1.9), 540 (69.5%) discharged same-day, 557(71.8%) fallers. SDEC: 234 attendances, 108(46.2%) Male, age 81.8(±8.0) years, CFS 5.2(±1.3) and CCI 8.2(±1.7),162(69.2%) discharged same-day, 72(30.1%) fallers. There was significant difference between groups with NEWS (p<0.02), mortality (P<0.001) and presenting complaint(p<0.001). We used a cut-off Score >6.5 indicating admission(p<0.0001). Each variable’s weighing was determined using T-tests and Chi-squared analysis. Overall score Sensitivity 0.75, Specificity 0.63, Positive Predictive Value 0.65, Negative Predictive value 0.57, Area under Curve 0.65. Conclusion Frailty is an important determinant in identifying whether ambulatory care is appropriate. The efficacy of the score is comparable to the results derived in validation cohorts of existing and recommended scores. We are currently prospectively testing the score but clinical judgement, alongside a MDT providing a CGA is gold standard care.

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:

Between 5-10% of patients attending the emergency department (ED) are elderly patients living with frailty. NHS England now recommends that all patents aged >65 presenting to acute care should have a Clinical Frailty Score documented within 30 minutes of arrival. We audited the CFS documentation from the Electronic Patient Record (EPR) for patients aged >65 presenting to our local E.D.

Methods:

Our baseline audit looked at patients aged >65 presenting to our ED from 01/09/23-07/09/2023 (n=430). We extracted data for rate and timeliness of documentation from EPR. To calculate accuracy, we compared the documented scores from ED triage staff, with that of our therapist led Frailty Intervention Team (FIT). We excluded patients not assessed by the FIT.

We then re-audited the data for 3 separate weeks after delivering a tailored teaching session for band 6 and 7 nurses, and introduction of an educational poster.

Results:

We found exceptional baseline compliance and timeliness of CFS scoring with a 97% documentation rate with a median time of 31 mins from presentation. When assessing accuracy of triage nurse CFS documentation, we found that 42% of patients fell into a lower category of frailty when compared to scores allocated by the FIT. Following teaching sessions and poster education, we observed no improvement in this.

Conclusion:

Our audit identified an overall excellent baseline compliance and timeliness in EPR documentation of CFS scores despite the department’s heavy workload. We noted a significant underrecognition of frailty at ED triage compared to specialist therapist scoring. Despite delivering education sessions and introduction of an educational poster there is still significant room for improvement in accurate identification of frailty with the CFS.

Introduction

The Rockwood Clinical Frailty Scale (CFS) is a tool that assesses global frailty, validated for use in people aged over 65. It assesses an individual’s functional status to assign a number from 1 (very fit) to 9 (terminally ill). Hull University Teaching Hospitals has integrated mandatory CFS assessment on admission for inpatients aged over 65. This project aimed to improve the accuracy of CFS scoring in an oncology and a geriatric ward by empowering ward nurses to better recognise frailty.

Methods

Phase 1.
Baseline data was collected from admission CFS scores from inpatients on one geriatrics ward and one oncology ward. We then individually reviewed admission CFS scores for the same patients. We recorded concordance if the same score was assigned.

Phase 2.
We surveyed nursing teams on both wards, as they assign the initial CFS score during a patient admission. This revealed unanimous recognition of the pivotal role accurate frailty recognition plays in targeting individualised frailty intervention and called for more staff training in frailty/CFS.  Following this, we introduced a pictographic version of the Rockwood CFS scale to nursing stations where admission documentation takes place and re-assessed CFS score concordance.

Results

A substantial improvement in CFS score concordance was demonstrated within the geriatric ward, from 41% at baseline to 56%. However, only minimal change was observed within the oncology ward remaining static at 11.1% from baseline 8.3%.

Conclusions

We have worked with the two wards to disseminate knowledge and use of the NHS CFS app. Through collaboration with the trust’s frailty leads, the CFS app is now being incorporated into the electronic recording system, encouraging routine use of the app when calculating CFS scores. Once this change is implemented, we will recollect data again.

Background Clinicians are increasingly aware of the association of frailty syndrome and adverse outcomes. The British Geriatric Society recommends that clinical frailty scores (CFS) are assessed for all patients on admission to surgery, to optimise peri-operative care.

Method For in-patients over one month (June 2023), the concordance with guidelines was recorded and any ‘missing’ scores retrospectively completed (Rockwood CFS). Clinical metrics included length of stay.

Results 110 patients were admitted under vascular surgery. The median age was 67 (IQ 61-79). 73 (66%) were aged >65-years and 42 (58%) of these patients were frail or at risk of frailty (CFS 4-9); 37% of all admissions. 10 (14%) patients >65-years had their CSF documented, only 3 (4%) had this documented in an easy-to-access “AdHoc” form. 3 frail patients had formal assessment by a geriatrician during admission. Higher frailty score directly correlated with longer hospital admission (p=0.002), the average stay was 4 days longer in the frail cohort.

Conclusion Despite the high prevalence of frailty among vascular admissions, the overwhelming majority did not have CFS scores recorded in line with BGS Guidance, perhaps increasing risks for these patients. Ongoing quality improvement has focussed on educating foundation staff responsible for clerking surgical patients on the importance of assessing and documenting CFS.

Introduction. Concerns about falling are common among older adults. Many older adults with concerns about falling will restrict their activities. This can trigger a vicious cycle of physical deconditioning, falls, social isolation, reduced confidence, and a loss of one’s sense of self. However, not every older adult with concerns about falling will restrict their activities. In this prospective cohort study we therefore investigated the factors that predict the development of activity restriction due to concerns about falling in older people aged ≥75 years.

Methods. Data were collected as part of the Community Ageing Research 75+ (CARE75+) study. For the baseline (T1) timepoint, we extracted data for 543 older adults who did not report activity restriction due to concerns about falling completed a set of physical and psycho-social assessments. We then assessed which baseline variables predicted the onset of activity restriction at T2 (12-months later).

Results. Of the total sample, 55 older adults reported to have started to restrict activity due to concerns about falling at T2 (10.1% of overall sample), while 488 people reported to (still) not restrict their activities (89.9%). Three key predictors significantly predicted activity restriction status at 12-months follow-up: greater frailty (Fried Frailty Index; OR=1.58, 95%CI: 1.09-2.30), faller status (experiencing a fall between T1 and T2; OR=2.22, 95% CI: 1.13-4.38) and poorer functional mobility/balance (Timed up and Go; OR=1.08, 95%CI: 1.01-1.15).

Conclusions. These findings show that frailty, experiencing a fall and poorer functional mobility/balance may result in the development of activity restriction due to concerns about falling. Clinicians working in balance and falls-prevention services should regularly screen for frailty, and patients referred to frailty services should likewise receive tailored treatment to help prevent the development of such activity restriction.

Aim: Several patient selection scores have been developed to identify patients suitable for ambulatory care from triage in the Emergency Department (ED) and from the acute medical intake. These scores are designed to improve system efficiency, overcrowding and patient experience. Studies have been conducted that compare the ability of several scoring systems; none specifically in frail older adults (1-4). This study compared the Glasgow Admission Prediction Score (GAPS), Sydney Triage to Admission Risk Tool (START) and the Ambulatory Score (Ambs). Methods: The Older Person’s Assessment service is ED based, accepting patients on the basis of the presence of frailty syndromes in patients aged >70 years. The service achieves same day discharge for >75% of patients. The service databank was retrospectively analysed for people assessed between January-December 2021. Interactions between clinical outcomes with age, Charlson Co-morbidity index (CCI) and Clinical Frailty Score (CFS) were evaluated alongside a comparison of each ambulatory score. Emergency department documentation was used to gain triage data. Results: 502 attendances were analysed of which 112 (22.3%) were admissions, 374 (74.5%) presented with falls. 185 (37.2%) were male, mean age 82.8 years, CFS 5.1 and CCI 6.6. There was a significant link between those admitted and those discharged when comparing CFS (p<.001). ambs: sensitivity 0.42, specificity 0.75, positive predictive value (ppv) 0.80, negative (npv) 0.23, area under curve (auc) 0.70. gaps: 0.15, 0.87, ppv npv auc 0.62. start: 0.09, 0.97, 0.92, 0.64. conclusion: frailty is an important determinant in identifying whether ambulatory care appropriate. however, was low for all scores and none could be reliably used as a screen suitable patients same day emergency services although the ambs score most accurate our population.

Introduction The pathway for referral to elective perioperative clinic involves frailty screening patients at the point of referral1. This is adequate If waiting times are short. At Swansea Bay 6,458 patients>65 years are awaiting surgery with up to 5 year waits for cholecystectomies. Opportunity to medically optimise patients prior to surgery are lost using a traditional approach. We aimed to develop a screening tool to identify frailty in patients awaiting surgery. Method The cholecystectomy list (750 patients) of which 258 were> 65years. Older people were sent a postal questionnaire gaining 96 responses. 58.3% felt their health deteriorated since being referred for surgery. 50% stating they had unmet healthcare needs and 17.5% stating unmet social care needs. Frailty was identified using this questionnaire, telephone interview or electronically by the Hospital Frailty Risk Score (HFRS). 193 patients were successfully contacted utilising an expanded CRANE questionnaire. All patients triggering on HFRS, CFS>4 or any concern on the CRANE questionnaire were offered a clinic appointment. Each interaction was then classified into change or no change in medical management of patients. 92 patients had no interventions, 35 had an intervention following the initial CRANE telephone questionnaire that did not require further input, 31 had an intervention following clinic. CFS>4 identifies 56% of the patients that under go any form of intervention. HFRS identifies 34% and the CRANE questionnaire identifies 42%. In patients who need a clinic review HFRS identifies 19%, CFS>4 identifies 59% and CRANE identifies 87%. Conclusion The CRANE questionnaire is a useful screen for patients on a waiting list who will benefit from an elective perioperative clinic. References 1 Guidelines of perioperative care CPOC.

Introduction

Frailty is a syndrome associated with increasing numbers of elderly hospital admissions and prolonged inpatient stays (Archibald et al, Geriatrics, 2020, 20, 17). In 2015, an estimated 14% of inpatients in the UK were considered to have a degree of frailty, representing an approximate annual cost to the NHS of £5.8 billion (Soong et al, BMJ Open, 2015, 5, e008456; Han et al, Age and Aging, 2019, 48, 665-671). Frailty is poorly defined; there are discrepancies in existing literature on how to best quantify frailty. It is recognised there is a higher risk of adverse outcomes in this vulnerable population due to lack of physiological reserve (Clegg et al, The Lancet, 2013, 381, 752-762). The Hospital Frailty Risk Score (HFRS) is a recent development to measure frailty and identify patients at risk (Gilbert et al, The Lancet, 2018, 391, 1775-1782). This study sought to establish whether the HFRS could be used in patients with degenerative spinal disease, undergoing decompression surgery, to predict post-operative outcomes. 

Methods

A retrospective service evaluation of eligible patients in Leeds Teaching Hospitals Trust between March 2018 - March 2020. The exposure was the patients’ HFRS; the outcome was the length of stay (LOS) until physiotherapy discharge. Data was sourced from electronic records.

Results

214 patients were identified with an available HFRS value. Patients were categorised as low, intermediate or high frailty. Kruskal-Wallis test for LOS and categorical HFRS: X² =8.673, p<0.05. The median HFRS value was 1.25 (interquartile range 0.00 to 3.35). Mann-Whitney U test for LOS and numerical HFRS: W=29297, p<0.05. 

Conclusions

The results of this study complement pre-existing studies of similar natures, evaluating frailty scoring and post-operative outcomes. Thus supporting the potential for standardised use of HFRS alongside holistic patient examination to streamline pre-assessment, improve outcomes and reduce the NHS frailty burden.