Frailty

Introduction: The Frailty Intervention Team (FIT) is a multidisciplinary team that provides a service to community based frail adults. This particular service is novel in the sense that it is a hospital based out-patient service as opposed to community based service and has access to rapid diagnostic and intervention services. Aims: The aim of this research is to share and describe the model of this relatively new and novel service for the benefit of other service providers. Method: A prospective database review was performed to provide descriptive data on the service between 2021 & 2022. Variables examined included referral source, MDT members involved on initial assessment and follow up, patient’s objective outcome measures and a history of falls. Result: Between the years 2021 and 2022, 350 new patients and 912 review patients were seen by the team with an additional 139 Medical Assessment Unit consultations carried out also. Of these service users 37.38% were male and 62.61% female. The average Clinical Frailty Score was 4.98 (4.91 men, 5.05 women). This indicates the mean service users is ‘Living with Mild Frailty’ - a cohort that may be otherwise missed by other services. Conclusion: This research highlights the demand for access to out-patient frailty interventions in line with the National Clinical Programme for Older Persons which promotes access to ‘the right person, in the right place, at the right time’.

In 2021, Cardiff and Vale University Health Board’s average length of stay (LOS) in Assessment Unit (AU) for over 75-year-olds was 24.2 days, due to long waits for inpatient beds. Once admitted, 23% of patients moved wards three or more times. Patient experience scores indicated poor satisfaction levels, with nearly 50% of patients feeling their needs had not been met. Staff consensus was that the environment was unsuitable for older patients.

The implementation of an enhanced frailty service began in November 2022. This was managed by a geriatrician-led team, with support from junior doctors and Physician Associates. The provision consisted of a 6-day service for the Frailty Zone, an allocated area of 12 beds in AU, an in-reach service, and input from the therapy and nurse led Frailty Intervention Team (who specialise in admission avoidance). Thus, giving the team wider reach, and ensuring frailty input from the beginning of the patients’ journey.

Between December-March 2023, there was a 36% increase in the number of patients discharged directly from AU, in patients aged 75+. This equates to an extra 21 discharges per week. The average LOS in AU reduced by 6.9 hours. Notably, the LOS for patients under 75 remained largely unaffected during this time. The number of ward transfers for this population also reduced to 13%.

The data obtained from the frailty service led to additional service development. In July 2023, the expansion of the Frailty Zone into a 19 bed Older Persons Acute Medical Unit came into effect. Staff feedback remains positive, with boosted morale. However, there is more development needed in way of communicating with all members of staff.Expansion of the Frailty Intervention Team is being developed to provide patients who are likely to need admission access to therapy and frailty nurses.

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

Increased frailty is associated with increased post-operative morbidity and mortality in older patients undergoing emergency laparotomy. NELA recommend documentation of frailty in surgical patients over 65.

Using QI methodology, we introduced a ‘CARE tool’ for surgical doctors aiming to improve their documentation of an older person’s medical history (including CFS and delirium).

Method

A collaborative team representing geriatric medicine, anaesthetics and surgery devised the acronym CARE (Cognition, Assistance at home, Record the CFS, Exercise tolerance).

The tool was tested using QI methodology over 2 PDSA cycles. Cycle one introduced the tool into electronic patient records (EPR) and presented it at the surgical faculty meeting. Cycle two introduced the tool specifically to surgical FY1 doctors during induction.

The EPR surgical clerkings of patients over 65 years old admitted to general surgery were sampled weekly over seven weeks to assess CARE tool completion.

Post-intervention, we surveyed the surgical doctors assessing their understanding of frailty and perceived value of the CARE tool.

Results

At baseline: 12% of confusion, 92% dementia status, 0% CFS, 30% assistance at home, 8% exercise tolerance were documented.

Following PDSA cycle one, use of the CARE tool was 40%. There was an increase in the documentation of confusion (40%) and CFS (40%). Dementia status and assistance at home were documented in similar frequency pre and post-cycle.

During cycle two, CFS documentation increased to 55% but identification of confusion dropped to 25%. The survey demonstrated that frailty, CFS scoring and delirium screening were better understood by junior doctors than Consultants and registrars.

Conclusions

Our project showed mixed success in improving documentation using the CARE tool. The survey demonstrated a good understanding and knowledge of frailty in surgical FY1s. Ongoing frailty teaching is planned for the surgical department.

Abstract Content - Introduction Frailty is an important clinical syndrome of increased vulnerability to stressors. The impact of frailty on stroke is a growing research area. We carried out a systematic review for an up to date picture of the prevalence of frailty and its impact on a wide range of outcomes Methods We searched Medline, Embase and CINAHL for studies referencing frailty and stroke. We assessed quality of studies using National Heart, Lung, and Blood Institute (NHLBI) quality assessment tools. We collated prevalence of frailty and impact on outcomes after stroke or transient ischaemic attack (TIA). Meta-analysis was conducted to determine pooled odds ratios (OR) and 95% confidence intervals (CI). Where possible, we carried out metanalysis on outcome data. Results We included 28 studies (n=111,787). Studies used the Clinical frailty scale (CFS), (n=6, 10,967). a frailty index (n=10, 19134), Hospital Frailty Risk Score (HFRS) (n=4, 18,373), frailty phenotype (n=4, 10,838), or other assessment methods (n=8, 50,568). Pooled prevalence of frailty was 36% (95% CI 29-43%). Including pre-frailty, prevalence was 48% (40-56%). Increased CFS (n=738) was associated with increased in-hospital mortality, OR=2.43 (95% (CI 1.54-3.84).Higher frailty was associated with higher 28 day, 90 day and one year mortality, higher stroke severity, and NIHSS, mRS and dependency on discharge. Conclusion Increased frailty is associated with multiple adverse outcomes following a stroke, including mortality, worsened functional outcome, and increased dependency at discharge. There was heterogeneity in frailty measures used, precluding meta-analysis.

Introduction

Despite the high prevalence of frailty among older people, the clinical definitions and implications of frailty are not well understood by the public. Existing communication material is predominantly technical in nature and aimed at healthcare professionals.  This project integrated expertise in geriatric medicine, data science, user design and patient and public involvement (PPI) to develop an accessible visual communication resource on frailty that linked data stories, clinical perspectives and public views of frailty in later life.

Methods

We recruited three public contributors from the University of Edinburgh Advanced Care Research Centre’s PPI network to contribute to formulating the aims and objectives of the communication resource. We developed user personas and case scenarios to consider the intended audience for the communication resource and how they might interact with it. To ensure that all key messages were data-driven, we analysed quantitative survey data from the English Longitudinal Study of Ageing (ELSA) (n=7289), which included information on sex, age and health deficits used to calculate standardised Frailty Index scores. We developed a storyboard to present each piece of information.

Results

Using an iterative co-design process with our PPI contributors, we tested different ways of communicating frailty information and ELSA data insights. Visual elements were incorporated to enhance engagement and informativeness. Core themes of the final 6-page resource included placing frailty in the context of resilience, healthy ageing and interactions with common health issues such as living with multiple long-term conditions. The prevalence of frailty and differences between mild, moderate and severe levels were communicated using person-examples inspired by ELSA data.

Conclusions

We produced a communication resource, informed by a co-design process, that addresses a key gap in existing frailty resources. Our work shows the value of integrating user experience research methods, public patient involvement and data insights to enhance health communications.

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

Resistance exercise is an effective intervention for older people at risk of, or living with, sarcopenia and frailty. Surveys of current UK practice in exercise prescription for these conditions found that  resistance exercise was offered in only 9% of departments and was often not optimised for sarcopenia and frailty. The Benchmarking Exercise Programmes for Older People (BEPOP) project is a joint British Geriatrics Society and AGILE initiative to promote best practice in the prescription of resistance exercise for older people.

Methods

Using an online data collection tool, 10 services delivering exercise interventions to older people from across the UK submitted anonymized details of baseline assessment (including demographics), exercise prescription and progression, and outcomes, for up to 20 consecutive patients referred to their services with probable sarcopenia, frailty, falls, and reduced mobility. Descriptive data were reviewed and analysed by an expert panel comprising physiotherapists, geriatricians, and exercise specialists.

Results

Data were analysed for 188 patients with a mean age of 80 years (range 60-101). At the time of referral, 154 (83%) patients did not have a diagnosis of sarcopenia. At baseline, 115 (61%) patients received an objective assessment of muscle strength. The most common modality of resistance exercise prescribed was bodyweight exercises (n=173, 92%) followed by resistance bands (n=49, 26%). Progression of exercise programmes was predominantly through increased repetitions (n=163, 87%) rather than increased load. Forty-one (24%) patients did not undergo any review to inform progression of exercise dose. Fifty patients (30%) patients did not have re-assessment of the outcome measures recorded at baseline on completion of the prescribed exercise programme.

Conclusion

Multiple opportunities exist to improve both the diagnosis and assessment of sarcopenia, and the prescription, delivery, and monitoring of resistance exercise. BEPOP will provide individualized benchmarking reports to each site to facilitate quality improvement and local service development.

Introduction

It is well recognized frailty is increasing amongst the population and can impact on outcomes for patients when admitted to hospital.  Frail older adults are more vulnerable to developing complications form continued hospital admissions. National recommendations by GIRFT indicate CFS scores ought to be documented in the Emergency Department (ED) to facilitate early recognition of frailty and stream patient to the appropriate pathway and clinician. The aim of this is to ensure the correct Clinician reviews the frailer adult in the most appropriate setting and thereby reduce risk of deterioration and patient harm.  In October 2022. Bolton NHS Trust created a dedicated frailty unit staffed by Geriatricians for older frail adults.  Therefore, a method of identifying and streaming frailer older adults is crucial to effectiveness of the unit. This was embedded into Electronic Patient Record (EPR) system.

Methods

PDSA cycles were implemented. A retrospective audit was performed prior to the implementation of the CFS documentation.

A robust education programme was introduced to all clinical staff in the Emergency Department. Online modules were also available. A second audit as part of PDSA cycle was then performed to assess the intervention.

Results

Pre-intervention and EPR documentation tool only 11% of patients had CFS score. Following the intervention, 88% of medical staff included the CFS score in their assessment prior to a Frailty team referral and review. The frailty team have observed an increase in referrals.

Conclusions

Early recognition and documentation has enabled improved streaming and review of the correct patients to the frailty unit.  This has enabled Gold Standard of Comprehensive Geriatric Assessment for frailer adults to be completed.  Further PDSA cycles to the effectiveness of the unit are ongoing. Initial data indicates with correct identification and recognition of frailty; the average length of stay has reduced.

Aim: We proposed that the Hospital Frailty Risk Score (HFRS) could identify patients attending the Emergency Department (ED) who would benefit from our Older Persons Assessment Service (OPAS). Identifying older people at risk of adverse outcomes in hospital can allow a system to provide frailty-specific interventions throughout their stay Methods: OPAS (ED-based) accepts patients with frailty syndromes aged >70 years. All patients receive a contemporaneous Clinical Frailty Score (CFS) following multidisciplinary assessment. A retrospective analysis of the OPAS databank was conducted using HFRS to divide patients in High/Intermediate and Low Frailty Risk. We considered Age, CFS, Postcode with Welsh index of multiple deprivation, length of stay (LOS) and 12-month mortality. Results: 700 consecutive admissions: 400 High/Intermediate and 300 Low HFRS. High/Intermediate HFRS vs Low HFRS had similar deaths (p=0.2) but significant difference in CFS (p05 hfrs was able to detect frailty in those 75 years old (p0.01) but not at ≥76 (p="0.08)." there no association between postcode with or death. sensitivity: 0.44, specificity: 0.83, positive predictive value: 0.66, negative 0.34, area under curve: 0.39. conclusion: the identified 57% of retrospective opas cohort, addition>80yrs of age, the modified score identifies >85% of service users. Of those admitted, High/Intermediate Frail had median LOS of 28.11 days vs 21.26 days for not frail, with 30 day mortality 10.12% vs 8.90%; potentially suggesting the HFRS can identify a subpopulation of high-risk frail patients. We found socio-economic status, quality of discharge summaries and coding had no relationship to the screening efficacy of HFRS. We have developed an electronic, automated Frailty Flag that operates in real-time to signpost appropriate patients who would benefit from comprehensive geriatric assessment which we have tested in clinical practice. HFRS can be used to measure frailty-specific intervention system efficiency.