Abstract
BackgroundPneumonia is a major cause of morbidity and mortality in older adults. The role of frailty assessment in older adults with pneumonia is not well defined. Our purpose of the study was to investigate 30-day clinical course and functional outcomes of pneumonia in older adults with different levels of frailty.MethodsA prospective cohort was conducted at a university hospital in Seoul, Korea with 176 patients who were 65 years or older and hospitalized with pneumonia. A 50-item deficit-accumulation frailty index (FI) (range: 0–1; robust < 0.15, pre-frail 0.15–0.24, mild-to-moderately frail 0.25–0.44, and severely frail ≥ 0.45) and the pneumonia severity CURB-65 score (range: 0–5) were measured. Primary outcome was death or functional decline, defined as worsening dependencies in 21 daily activities and physical tasks in 30 days. Secondary outcomes were intensive care unit admission, psychoactive drug use, nasogastric tube feeding, prolonged hospitalization (length of stay > 15 days), and discharge to a long-term care institution.ResultsThe population had a median age 79 (interquartile range, 75–84) years, 68 (38.6 %) female, and 45 (25.5 %) robust, 36 (47.4 %) pre-frail, 37 (21.0 %) mild-to-moderately frail, and 58 (33.0 %) severely frail patients. After adjusting for age, sex, and CURB-65, the risk of primary outcome for increasing frailty categories was 46.7 %, 61.1 %, 83.8 %, and 86.2 %, respectively (p = 0.014). The risk was higher in patients with frailty (FI ≥ 0.25) than without (FI < 0.25) among those with CURB-65 0–2 points (75 % vs. 52 %; p = 0.022) and among those with CURB-65 3–5 points (93 % vs. 65 %; p = 0.007). In addition, patients with greater frailty were more likely to require nasogastric tube feeding (robust vs. severe frailty: 13.9 % vs. 60.3 %) and prolonged hospitalization (18.2 % vs. 50.9 %) and discharge to a long-term care institution (4.4 % vs. 59.3 %) (p < 0.05 for all). Rates of intensive care unit admission and psychoactive drug use were similar.ConclusionsOlder adults with frailty experience high rates of death or functional decline in 30 days of pneumonia hospitalization, regardless of the pneumonia severity. These results underscore the importance of frailty assessment in the acute care setting.
Highlights
Pneumonia is a major cause of morbidity and mortality in older adults
The risk of primary outcome increased with the frailty level on admission, which remained statistically significant after adjusting for age, sex, and CURB-65 (Table 2): 46.7 % for robust group, 61.1 % for pre-frail group, 83.8 % for mild-to-moderate frailty group (3.95 [1.31–11.89]) and 86.2 % for severe frailty group (5.34 [1.54–18.49])
When we examined the risk of death or functional decline at 30 days by frailty level and pneumonia severity determined using CURB-65 on admission (Fig. 3), we found that frail patients had higher risk than non-frail patients among those with low CURB-65 scores (75 % vs. 52 %; p = 0.022) and among those with high CURB65 scores (93 % vs. 65 %; p = 0.007)
Summary
Pneumonia is a major cause of morbidity and mortality in older adults. The role of frailty assessment in older adults with pneumonia is not well defined. In Korea, it ranked fourth leading cause of death with a mortality rate of 11.6 % [5, 6] and the annual medical costs of $400 million [6, 7]. Clinical risk stratification tools, such as CURB-65 [11] or Pneumonia Severity Index [9], predict mortality based on demographic information, comorbidities, or physiological parameters. These tools do not consider frailty—a clinical state of reduced physiologic reserve and increased vulnerability to poor health outcomes [12]—that is germane to clinical management of older adults. Assessing frailty on admission may provide information about patients’ vulnerability and prognosis that is not captured by the pneumonia severity and is useful to deliver patient-centered care to improve recovery
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