Frailty

Introduction: Comprehensive Geriatric Assessment (CGA) improves outcomes for frail older adults in acute hospitals. Patients aged 75 and over admitted into the Emergency Department (ED) at the QEUH will automatically generate a “frailty icon” on their electronic record. The number of frail people accessing emergency care is increasing. This Healthcare Improvement Scotland (HIS) frailty tool prompts staff to assess for frailty and refer to the local Frailty Pathway if appropriate. We designed a multidisciplinary quality improvement project (QIP) to increase completion of the frailty icon and the number of referrals to the frailty service from the ED.

Methods: Both medical and nursing staff in the ED were targeted for intervention. Weekly data was collected on the percentage of patients aged 75 and above who were discharged from the ED with a “frailty icon” completed over a 3-month period. Our main intervention was to hold a frailty awareness month. This involved multiple sub-interventions such as; announcements at handovers, e-mails, word-of-mouth, and posters.

Results: The weekly percentage of completed “frailty icons” increased from 28% 2 weeks pre-intervention (n = 283) to 48% in 1 month (n = 258). A peak of 57% (n = 293) completed icons was achieved immediately after our intervention. These increases were then sustained for a further 6 weeks with a weekly average baseline of 45.2% completion (average n = 281). Increased “frailty icon” completion in the ED led to a 100% increase in referrals to the frailty pathway.

Conclusion: Increasing awareness of frailty amongst ED staff results in increased front door assessment for frailty, and subsequent referral to the frailty team. This allows for more patients to receive a CGA. Multidisciplinary QIPs utilise the skills of diverse staff groups to best achieve sustainable change.

Introduction

Older patients admitted to the emergency department (ED) do not have a pharmacist-led medication review within the comprehensive geriatric assessment (CGA), yet the presenting complaint can be attributed to overprescribing and problematic polypharmacy. Taking ten or more medications increases the risk of hospital admission by 300% due to adverse drug reactions (ADRs)1, therefore a medication review can reduce this outcome by optimising current therapy2. Responsibility of safely transferring this medication information between care settings is a healthcare professional's duty, as the rate of error is 30 - 70%3.

Method

Patients were identified by the ED Frailty Team according to local frailty criteria, including patients > 65 years presenting with delirium, a fall and/or multi-morbidities. Medicines reconciliation was carried out by the frailty pharmacist, and medications optimised to reduce future harm with investigations prompted where needed. Interventions were categorised. A summary plan was written to the General Practitioner (GP) and each patient was followed up after 4 weeks to assess if received and actioned appropriately.

Results

73 medication reviews were conducted for patients (mean age 84.4 years) from June to September 2022, majority presenting with fall (69%). High-risk medication review was most common intervention (90%), followed by counselling (50%). 92% patients required a pharmaceutical intervention (n=208). GP plans were actioned for 65% patients in Primary Care.

Conclusion

ED frailty pharmacist's input reduced inappropriate polypharmacy and optimised medication for this patient cohort, with majority of care plans carried out appropriately following discharge. A future study could examine re-admission rates of patients in comparison to those without a frailty pharmacist's input.

References

1. Payne RA et al. British Journal of Clinical Pharmacology 2014; 77: 1073 – 1082.

2. Department of Health and Social Care, 2021. Available at https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/1019475/good-for-you-good-for-us-good-for-everybody.pdf. Accessed 19/1/23.

3. Department of Health, 2011/2012. Available at: www.wp.dh.gov.uk/healthandcare/files/ 2011/01/outcomesglance.pdf. Accessed 19/1/23.

Introduction

Frailty is a condition with increasing prevalence in the UK and significantly impacts the lives of those affected and their families. Frailty is a condition best managed by teams of skilled multi-disciplinary health and social care professionals (HSCPs). It is therefore essential that all HSCPs working with older people living with frailty are equipped with the appropriate knowledge and attitudes to look after affected persons.

Methods

The British Geriatric Society (BGS) and NHS England (NHSE) collaborated to produce an online e-learning module to support HSCPs to provide frailty care in complex situations and lead frailty services. This module was developed in line with the NHS Skills for Health Frailty framework of core capabilities at the tier 3 level. The e-learning module was launched in October 2023 and contained 4 modules: Understanding and Communicating Frailty, Identifying Frailty, Supporting People Living with Frailty and Building Systems Fit for Frailty. This module was made available for free to BGS members.

Results

Between October 2023 and January 2023, over 4000 HSCPs registered for the online module. A wide ranges of HSCPs signed up for the module with nursing staff, advanced clinical practitioners, consultant geriatricians and physiotherapists the most commonly represented groups. 92% of those who completed the module agreed or strongly agreed that the course helped develop knowledge, understanding and confidence in frailty. 91% of those who completed the module said completion of the course would help them to further improve patient care and clinical practice. Areas identified to enhance the module further included addition of further case studies and making the resource more adaptable to all UK regions.

Conclusions

e-Learning can be an effective facilitator of frailty education for a wide range of HSCPs.

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:

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.

Background: In 2022, the QEUH opened an acute short stay frailty unit. Previous QI projects had shown that the 7-day readmission rate was above the national average. Implementing future care plans was thought to be a way of reducing unnecessary readmissions to hospital.

Aim: To ensure that all patients on the acute short stay frailty unit, over a 12 month period, have a Future Care Plan (FCP) discussed and documented on Clinical Portal

Methods: Using the PDSA cycle, baseline data was collected from 92 patients admitted to Ward 2A between October and March to determine if change was needed. Change interventions were then implemented and run charts were made by collecting data from 8 randomly selected patients per week.

Results: Baseline data showed that only 11% (10/92) patients had a documented Future Care Plan. An information session was held and for the first five weeks after this 22.5% (8/40) patients had documented FCPs. A column was then added to the multidisciplinary team (MDT) board and for the 5 weeks following this 17.5% (7/40) patients had a documented FCP.

Discussion: Although the completion of FCP documentation has improved there is still huge scope for improvement. Time pressures and lack of education are two of the main barriers preventing FCP discussion and documentation. The next step for this project is to improve education around FCP discussions and documentation and empowering members of the MDT, such as frailty practitioners and elderly care assessment nurses, to have FCP discussions.

Objectives: Older adults hospitalized with a hip fracture are at risk for adverse health outcomes depending on their level of frailty. This study examined how frailty levels prior to admission impacted length of stay (LOS), requirement for alternative level of care (ALC), returning home post-discharge, and mortality.

Methods: A random sample was generated from all hip fracture patients aged 65 and older admitted to a Level One Trauma Centre in New Brunswick, Canada from 2015-2019. This sample had their frailty level determined retrospectively using the Pictorial Fit-Frail Scale and the patients’ hospital electronic health record.

Results: Our study included 189 patients (mean age: 83.2 ± 8.2, 73.0% female), representing 91 not frail to mildly frail (48.2%; NF-MF), 32 moderately frail (16.9%; ModF), and 66 severely frail (34.9%; SF) patients. The ModF patients had a longer LOS (median: 20.0 days, IQR=22.5) compared to NF-MF patients (median: 11.0 days, IQR=10.0, p=0.039, Kruskal-Wallis test) and SF patients (median: 8 days, IQR=5.5, p<0.0001, Kruskal-Wallis test). More ModF patients (56.3%) required an ALC stay in acute care compared to NF-MF (30.8%) and SF (28.8%) patients (p=0.016, Chi-square test). More SF patients (28.8%) died in hospital or within six months post-discharge compared to NF-MF (8.8%) patients (p=0.005, Chi-square test). Logistic regression revealed that both NF-MF (OR=8.11, 95% CI: [3.12-21.06], p<0.001) and ModF (OR=5.18, 95% CI: [0.85-0.95], p=0.007) patients had greater odds of returning home compared to SF patients when accounting for sex, age, and time to surgery.

Conclusions: A patient’s level of frailty prior to hospital admission impacts various health outcomes following a hip fracture and may provide helpful information for guiding treatment as well as discussions about health care.  

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.

Background:

Frailty has both health + health economic consequences. There are however few data concerning occurrence of frailty in different ethnic groups in the United Kingdom (UK). The aim of this analysis was to determine frailty prevalence across an ethnically diverse city and to explore the influence of age/social-disadvantage/ethnicity on occurrence. We looked also at frailty related risk of severe illness in relation to COVID-19 infection.

Methods:

Using data from the Greater Manchester Health Record(GMCR), we defined frailty index based on the presence/absence of up to 36 deficits scaled 0-1. We defined frailty based on those with 9 or more deficits (out of total=36) and electronic frailty index (eFi) as the total number of deficits present, divided by 36 (range 0-1).

Results:

There were 534567 people aged 60+years on 1January2020 in Greater Manchester. There was noticeable variation in frailty prevalence across general practices. The majority were white (84%) with 4.7% self-describing as Asian/Asian British, and 1.3% Black/Black British. The prevalence of moderate to severe frailty (eFI>0.24) was 22.1%. Prevalence was higher in women than men (25.3% vs 18.5%) and increased with age. Compared to the prevalence of frailty in Whites (22.5%) prevalence was higher in Asian/Asian British ethnicity people (28.1%) and lower in those of Black/Black British descent (18.7%). Prevalence increased with increasing social disadvantage (p=0.002 for trend across disadvantage quintiles). Among those with a positive COVID-19 test those with frailty were more likely to require hospital admission within 28-days, with increased risk for Asian/Asian British descent (OR=1.47; 95% CI 1.34-1.61) and Black/Black British descent (OR 1.86; 95% CI 1.56-2.20) people vs Whites.

Conclusion:

There is marked variation in occurrence of frailty across Greater Manchester. Frailty is more common in Asian/Asian British people than Whites and less common among Black/Black British with a gradient that relates to social disadvantage.

Introduction

Physical activity (PA) and replete nutritional status are key to maintaining independence and improving frailty status among frail older adults. We aimed to evaluate the feasibility and acceptability of training volunteers to deliver a remote intervention, comprising exercise, behaviour change, and nutrition support, to older people with frailty after a hospital stay.

Methods

Volunteers were trained to deliver a 3-month, multimodal intervention to frail (Clinical Frailty Status ≥5) adults ≥65 years after hospital discharge, using telephone, or online support. Feasibility was assessed by determining the number of volunteers recruited, trained, and retained; participant recruitment; and intervention adherence. Interviews were conducted with 16 older adults, 1 carer, and 5 volunteers to explore intervention acceptability. Secondary outcomes included physical function, appetite, well-being, quality of life, anxiety and depression, self-efficacy, and PA. Outcomes were measured and compared at baseline, post-intervention, and follow-up (3-months). Interviews were transcribed verbatim and analysed using thematic analysis.

Results

Five volunteers (mean age 16, 3 female) completed training, and 3 (60%) were retained at the end of the study. Twenty-seven older adults (mean age 80 years, 15 female) signed up to the intervention (10 online;13 telephone). Seventeen completed the intervention. Participants attended 75% (IQR 38-92) online sessions, and 80% (IQR 68.5-94.5) telephone support. Self-reported total PA (p = .006), quality of life (p = .04), and appetite (p = .03) improved significantly post-intervention, with a non-significant decrease at follow-up. The intervention was safe and acceptable to volunteers, and older adults with frailty. Key barriers were lack of social support, and exercise discomfort. The online group was a positive vicarious experience, and telephone calls provided reassurance and monitoring to socially isolated older adults.

Conclusion

Volunteers can safely deliver a remote multimodal intervention for frail older adults discharged from hospital with training and support from a health practitioner.