Implementation and current status of frailty assessment in Japanese hospitals: Processes, epidemiology, and future directions.

Frail older adults are at increased risk of poor clinical outcomes. Frailty assessment is therefore important in clinical trials to understand the benefits and harms of interventions. However, consensus is lacking on how frailty should be assessed. We developed a prospectively specified index using a battery of formal tests and instruments and a retrospectively generated index using medical comorbidities and patient reported outcomes (PROs) within an adjuvanted recombinant zoster vaccine (RZV) trial (NCT02979639). For both frailty indices (FIs), a total deficit score was calculated as the accumulation of deficits and participants were categorized as non-frail, pre-frail and frail. We assessed (1) the feasibility and validity of both FIs; (2) the impact of RZV vaccine reactogenicity by frailty status on Short Form-36 [SF-36] physical functioning (PF) scores. Of 401 participants, aged ≥50 years, 236 (58.9%) were categorized non-frail, 143 (35.7%), pre-frail, and 22 (5.5%) frail using the prospective FI. Corresponding numbers for the retrospective FI were 192 (47.9%), 169 (42.1%) and 40 (10.0%), respectively. Strong concordance was observed between the frailty status assessments (P < .001). The proportion defined as frail increased from 1.5%, to 10.4% in participants aged 50–59, and ≥70 years, respectively, for the prospective FI. Corresponding numbers for the retrospective FI were 3.7%, and 17.2%, respectively. RZV vaccination was associated with a transient, non-clinically meaningful, decrease on the SF-36 PF score in frail participants. Both frailty indices provided similar results. The retrospectively generated FI offers the advantage of being easier to incorporate into vaccine clinical trials of older adults.

Mortality prediction models are useful to guide clinical decision-making based on prognosis. The frailty index, which allows prognostication and personalized care planning, has not been directly compared with validated prognostic models. To compare the discrimination of mortality, disability, falls, and hospitalization between a frailty index and validated prognostic indices. Secondary Analysis of the National Health and Aging Trends Study. Seven thousand thirty-three Medicare beneficiaries 65years or older. We measured a deficit-accumulation frailty index, Schonberg index, and Lee index at the 2011 baseline assessment. Primary outcome was mortality at 5years. Secondary outcomes were decline in activities of daily living (ADL), decline in instrumental activities of daily living (IADL), fall, and hospitalization at 1year. We used C-statistics to compare discrimination between indices, adjusting for age and sex. The study population included 4146 (44.8%) with age ≥ 75years, with a median frailty index of 0.15 (interquartile range 0.09-0.25). A total of 1385 participants died (14.7%) and 2386 (35.2%) were lost to follow-up. Frailty, Schonberg, and Lee indices predicted mortality similarly: C-statistics (95% confidence interval) were 0.78 (0.77-0.80) for frailty index; 0.79 (0.78-0.81) for Schonberg index; and 0.78 (0.77-0.80) for Lee index. The frailty index had higher C-statistics for decline in ADL function (frailty index, 0.80 [0.78-0.83]; Schonberg, 0.74 [0.72-0.76]; Lee, 0.74 [0.71-0.77]) and falls (frailty index, 0.66 [0.65-0.68]; Schonberg, 0.61 [0.58-0.63]; Lee, 0.61 [0.59-0.63]). C-statistics were similar for decline in IADL function (frailty index, 0.61 [0.59-0.63]; Schonberg, 0.60 [0.59-0.62]; Lee, 0.60 [0.58-0.62]) and hospitalizations (frailty index, 0.68 [0.66-0.70]; Schonberg, 0.68 [0.66-0.69]; Lee, 0.65 [0.63-0.67]). A deficit-accumulation frailty index performs as well as prognostic indices for mortality prediction, and better predicts ADL disability and falls in community-dwelling older adults. Frailty assessment offers a unifying approach to risk stratification for key health outcomes relevant to older adults.

Aim Frailty assessment amongst emergency laparotomy patients is essential. The 8th NELA report highlighted that only 31.8% of patients who were frail and over 65 years received geriatrician input. Within our organisation, patients who undergo emergency laparotomy are included in the Emergency Laparotomy and Laparoscopic Scottish Audit (ELLSA). The consultant geriatrician led Surgical Acute Frailty Team (SAFT) works collaboratively with the emergency general surgery team and ELLSA specialist nurse to review ELLSA patients within our hospital. Our aim was to establish outcomes of ELLSA patients reviewed by SAFT. Methods Data collected routinely via Redcap as part of our organisation’s ELLSA was reviewed. All ELLSA patients aged ≥65 years admitted between November 2022 and November 2023 were included. Data included frailty assessment, discharge destination and 30 day mortality. Results 152 patients aged ≥ 65 years underwent operative intervention as defined by ELLSA. 100% of patients had a documented Clinical Frailty Scale (CFS) score. 72 patients (47.4%) had a pre-operative frailty review. 68.4% of patients had their initial frailty assessment by a consultant geriatrician. 19.7% of patients were reviewed by frailty ANPs or clinical fellow. Only 7.9% of patients required care support on discharge. 30 day mortality was 17.1%. Conclusions Embedding a dedicated frailty team within our general surgery wards has been incredibly successful; frailty assessment is significantly above that of the 8th NELA report. The majority of ELLSA patients aged ≥65 years are discharged home independently. Collaborative working and early identification of frailty in ELLSA patients is essential to improve patient outcomes.

Frailty, characterized by a decreased physiological reserve and an increased vulnerability to stressors, is common among kidney transplant (KT) candidates and recipients. In this review, we present and summarize the key arguments for and against the assessment of frailty as part of KT evaluation. The key arguments for including frailty were: (i) sheer prevalence and far-reaching consequences of frailty on KT, and (ii) the ability to conduct a more holistic and objective evaluation of candidates, removing the inaccuracy associated with 'eye-ball' assessments of transplant fitness. The key argument against were: (i) lack of agreement on the definition of frailty and which tools should be used in renal populations, (ii) a lack of clarity on how, by whom and how often frailty assessments should be performed, and (iii) a poor understanding of how acute stressors affect frailty. However, it is the overwhelming opinion that the time has come for frailty assessments to be incorporated into KT listing. Although ongoing areas of uncertainty exist and further evidence development is needed, the well-established impact of frailty on clinical and experiential outcomes, the invaluable information obtained from frailty assessments, and the potential for intervention outweigh these limitations. Proactive and early identification of frailty allows for individualized and improved risk assessment, communication and optimization of candidates.

Changes in Frailty Categorization Over One Year among Real-World Patients With Multiple Myeloma: A Prospective Cohort Study (MFRAIL).

The population of Japan has become multi-cultural, and there is more demand for culturally competent nursing care. The purpose of this study was to explore cultural characteristics of nursing practice in Japan focusing on behaviour. We interviewed 25 professionals with experience in or knowledge of nursing practice both in Japan and either the United States, the United Kingdom, Sweden, Thailand or South Korea. Qualitative content analysis has yielded three themes for cultural characteristics of nursing practice in Japan: practice expectations, communication and relationships with patients. Practice expectations for nurses in Japan involved various aspects; nurses conducted a wide range of basic nursing tasks, including bed baths and toileting. They often relied on non-verbal communication to deliver thoughtfulness and perceptiveness. They typically show deference to doctors and colleagues, emphasizing building and maintaining harmony with them. This emphasis on a multifaceted, non-verbal, and harmonious approach seemed characteristic of practice among Japanese nurses.

An introduction: From an international point of view, Japan government have promoted integrated care system in the community-based way. Incentives through the long-term care and medical fee system already promoted collaboration between healthcare facilities and community-based long-term care services, and the new reform of the system in 2012 will reinforce this integration of care.On the other hand, in large cities, long-term care benefit cost are increasing with the increasing elderly population ratio. In Japan, long-term care providers are increasing rapidly in which provide services for elderly people whose care levels are low. It is because they can run the business at a relatively small scale and their income is firm. As a result of this situation, among others, there is a problem of extremely increasing number of the providers in cities. We need the control of the number of these providers through the assessment of the quality of the services they provide.In this research, we try to development of quality indicator for adult day Services towards the community-based integrated care system in O-city. These indicators should be associated with transitions of scores such as ADL and QOL and third parties can use it easily.Short description of practice change implemented: We conducted pilot project at O-city. There have already been 278 providers in O-city and 11,439 people have used their services, but even from the point of the city's scale, these numbers are remarkable in Japan. 178 providers (64.0%) participated in this pilot project. In order to create a draft version of the indicators, we made the committee composed of the city workers, the representatives of long-term care providers, and academic experts. The index is composed of categories, staff support, care techniques, awareness of providers, and awareness of community residents, and 25 items. We asked all the providers participated in this project to submit the data concerning ADL/QOL of all their services users in these indicators and at the two points in 2015 (August and February).Key findings: Through the analysis of the collected data, we choose the 5 indicators (1.the rate of the staffs who participate in training courses in the providers, 2.the rate of staffs who participate in training courses outside the providers, 3.the rate of staffs who is qualified to be a certified care worker, 3.the rate of staffs who is qualified to be a rehabilitation specialist, and 5.the rate of demented people in the users) out of 25 items. From the relationship between this index and the evaluation index scores of shift in 6 months and quality of the daily living functional evaluation of 1,517 users in the participating providers, we found that 3 indicators (2,4,5) were related to an improvement of users.Highlights: The O-city continued the project concerning the evaluation of the qualities and announced the result to the citizens. And the O-city prepares making financial incentive to use the quality evaluation by indicators. Besides the city considers including the strength of cooperation between medical services and long-term care in the indicators from the point of constructing a community-based integrated care system.Conclusion: Japan promotes constructions of community-based integrated care system and its means depends on autonomous local governments. The O-city starts to control the long-term care providers through the evaluation of the quality of the day-service providers and verifies whether the control have an effect on a hold-down on medical and care expenses as one of its outcome. This efforts is seems to be advanced practice in Japan, but we need to make it more common in the future.

Frailty indices as a predictor of postoperative outcomes: a systematic review protocol

BackgroundFrailty is a common problem among older people and it is associated with an increased risk of death and long-term institutional care. Early identification of frailty is necessary to prevent a further decline in the health status of home care clients. The aims of the present study were to determine the prevalence of frailty and associated factors among 75-year-old or older home care clients.MethodsThe study participants were 75-year-old or older home care clients living in three cities in Eastern and Central Finland. Home care clients who had completed the abbreviated Comprehensive Geriatric Assessment (aCGA) for frailty (n = 257) were included in the present study. Baseline data were obtained on functional status, cognitive status, depressive symptoms, self-rated health, ability to walk 400 m, nutritional status, drug use and comorbidities.ResultsMost of the home care clients (90%) were screened for frailty using the aCGA. Multivariate analysis showed that the risk of malnutrition or malnutrition (OR = 4.27, 95% CI = 1.56, 11.68) and a low level of education (OR = 1.14, 95% CI = 1.07, 1.23) were associated with frailty.ConclusionFrailty is a prevalent problem among home care clients. The risk of malnutrition or malnourishment and a lower level of education increase the risk of frailty. Screening for frailty should be done to detect the most vulnerable older people for further intervention to prevent adverse health problems.Trial registrationClinicalTrials.gov: NCT02214758.

Measuring frailty in the older surgical patient: the case for evidence synthesis

Deficit-accumulation Frailty Indices (FIs) have rapidly been integrated into health systems worldwide to quantify the state of reduced physiologic reserve to recover from a health insult in the aging population. Common data models (CDMs) have further enabled international, interinstitutional applications of FIs. However, the validity of such applications is unknown. We conducted an international network study comparing estimates of frailty from two electronic health record (EHR)-based FIs: United States (US)-based Veterans Affairs FI (VAFI) and United Kingdom (UK)-based electronic FI (eFI) across 5 research and clinical databases. US: All of Us (n=159,721), IQVIA Pharmetrics+ (n=5,099,557); UK: IMRD-THIN (n=3,036,003), IMRD-EMIS (n=832,455), and BioBank (n=207,202). In US databases, VAFI identified higher proportions of frailty ([VAFI; eFI] All of US: 10.3%; 2.5%, Pharmetrics+: 9.6%; 2%) while in UK databases, the eFI identified higher proportions (IMRD-THIN: <0.003%; 0.08%, IQVIA-EMIS: 0.09%; 0.4%, UK BioBank: 0.03%; 0.1%). Additional manipulations (alternative lookback periods, FI variations) were examined. FIs are likely dependent on their development context, such as local coding behaviors and incentives, limiting their external validity despite CDM harmonization. We suggest caution in the application of FIs outside of their development context and recommend further instrument development before more widespread use.

A systematic review on frailty indices utilized in oncologic surgery and radiotherapy for metastatic spine disease: A critical appraisal of components and performance

Introduction. The coexistence of cardiovascular diseases and frailty has been demonstrated, with the prevalence of frailty ranging from 19% to 76%. The presence of frailty significantly influences decision-making regarding the type and timing of diagnostic strategies. Objectives. To assess the features of frailty syndrome in patients with heart failure. Material and methods. A comprehensive search was conducted in PubMed, Google Search, and ResearchGate databases using the keywords “frailty”, “heart failure”, following the STROBE criteria and PRISMA recommendations. Outcomes. The first publication on frailty syndrome in patients with heart failure dates back to 2007, with research in this area peaking in 2021. The prevalence of frailty in heart failure varies due to differences in age groups, assessment methods, and study designs. Frailty affects approximately 70% of heart failure patients over 80 years of age, challenging the stereotype that frailty is solely associated with elderly individuals. Recently issued data by the World Health Organization (WHO) stated that although frailty and heart failure are common in older adults, the prevalence of frailty in this category of patients is independent of age. It is worth noting that frailty is more common in women, yet women tend to have a better prognosis. Diagnosing frailty in heart failure patients is challenging due to the overlap of clinical symptoms. The interaction between heart failure and frailty increases the risk of decompensation, dependency, and negative outcomes. Conclusions. Previous studies have primarily focused on frailty in elderly patients with heart failure. However, chronological age cannot represent an independent parameter in the assessment of frailty, and patients with heart failure should be assessed for the presence of frailty sovereignly of age for prudent risk stratification. Recognizing and early identification of frailty across all age groups will improve prognosis by reducing hospitalizations and enhancing quality of life.

Background:Frailty represents a state of risk in which a relatively small stressor results in a disproportionate decline in health status. This study aims to determine the prevalence of frailty among patients with COPD in the Indian population and its associated risk factors.Methods:A descriptive cross-sectional study was conducted in 150 COPD patients. Frailty was assessed using the frailty phenotype method.Results:The mean age (SD) of the study population was 60.59 (5.9) years with 88.67% males and 53.33% ex-smokers. The prevalence of frailty was 51.33% (n = 77). Most of the frail patients belonged to GOLD group D (66.23%) (P < 0.0001). Post-bronchodilator FEV1(%) was lowest in the frail group (40 [36–47]%) (P < 0.0001). Risk of frailty significantly correlated with smoking pack years (1.036; 1.001–1.074), history of 1 exacerbation in last year (6.810; 2.036–22.779), post-bronchodilator FVC(%) (0.955; 0.926–0.985), post-bronchodilator FEV1(%) (0.940; 0.913–0.968), distance covered in 6-minute walk test [0.975; 0.965–0.986] and dyspnoea severity [1.044; 1.024–1.063]. In multivariate regression, 6-minute walk distance and GOLD group B were the independent predictors of frailty in COPD.Conclusion:The prevalence of frailty in Indian patients with COPD was 51.33%. Six-minute walk distance is an important predictor of frailty. Early identification of frailty will lead to prompt intervention and rehabilitation.

Deficit-accumulation Frailty indices (FIs) are a key tool in population-level translational geroscience approaches to understanding function, health, and aging. International applications of Fis have been enabled by the uptake of common data models (CDMs) but the validity of such applications is not guaranteed. We compared frailty prevalence using two validated electronic health record based FIs - the United States (US)-based Veterans Affairs FI (VAFI) and United Kingdom (UK)-based electronic FI (eFI) across 5 Observational Medical Outcomes Partnership CDM databases. Frailty was calculated by age for patient-records 40+ years old with 1+ years of data in the 1) US All of Us database (n=211,568), 2) US IQVIA Pharmetrics+ (n=5,292,854), 3) UK IMRD-THIN (n=3,080,557), 4) UK IMRD-EMIS (n=843,928), 5) UK BioBank (n=209,566). Code and results are available in an open-source R package and interactive website. The VAFI identified higher prevalence of frailty in US databases (All of US: VAFI 10.3% v eFI 2.5%, Pharmetrics+: 9.6% v 2%) while the eFI identified higher prevalence in UK databases (IMRD-THIN: &amp;lt; 0.003% v 0.08%, IMRD-EMIS: 0.09% v 0.4%, UK BioBank: 0.03% v 0.1%). eFI prevalence was lower than previously reported (2.2% v 15-20%, &amp;gt;65 years old; Clegg et al., 2016). FIs appear to be dependent on their development context, limiting external validity for international network studies. FIs must be vetted for consistency and validity when used across CDM sources if they are to contribute to the study of health and aging at scale. Future work will extend this comparison to additional international data sources.