Definition Of Frailty Research Articles

Malnutrition, Frailty, and Sarcopenia in Patients With Cirrhosis: 2021 Practice Guidance by the American Association for the Study of Liver Diseases.

Malnutrition, Frailty, and Sarcopenia in Patients With Cirrhosis: 2021 Practice Guidance by the American Association for the Study of Liver Diseases.

Frailty Assessment in Heart Failure and Ventricular Assist Device Populations: A Review from the United States

ImportancePost-operative risk is increased with frail individuals undergoing cardiac surgery. Yet, there is no consensus for frailty assessment prior to durable left ventricular assist device (dLVAD) evaluation. ObjectiveThe objectives of this integrative review were to describe frailty measures, examine psychometrics of measures used, and identify variables related to frailty in heart failure with reduced ejection fraction (HFrEF) and dLVAD populations. Design, Setting, ParticipantsPubMed, CINAHL, and Embase databases were searched for terms related to frailty, HFrEF and dLVAD that met inclusion criteria. ResultsFourteen articles met inclusion criteria. Frailty was inconsistently defined. The Fried Phenotype Criteria was the most widely used approach to measurement. Validity was reported in all articles. Variables related to frailty included readmissions, higher mortality and increased adverse events. ConclusionThere was variability in frailty definition and frailty measurement across studies. Further research in HFrEF and dLVAD populations is needed for frailty evaluation.

Frailty in cardiology: definition, assessment and clinical implications for general cardiology. A consensus document of the Council for Cardiology Practice (CCP), Association for Acute Cardio Vascular Care (ACVC), Association of Cardiovascular Nursing and Allied Professions (ACNAP), European Association of Preventive Cardiology (EAPC), European Heart Rhythm Association (EHRA), Council on Valvular Heart Diseases (VHD), Council on Hypertension (CHT), Council of Cardio-Oncology

Frailty is a health condition leading to many adverse clinical outcomes. The relationship between frailty and advanced age, multimorbidity and disability has a significant impact on healthcare systems. Frailty increases cardiovascular (CV) morbidity and mortality both in patients with or without known CV disease. Though the recognition of this additional risk factor has become increasingly clinically relevant in CV diseases, uncertainty remains about operative definitions, screening, assessment, and management of frailty. Since the burdens of frailty components and domains may vary in the various CV diseases and clinical settings, the relevance of specific frailty-related aspects may be different. Understanding these issues may allow general cardiologists a clearer focus on frailty in CV diseases and thereby make more tailored clinical decisions and therapeutic choices in outpatients. Guidance on identification and management of frailty are sparse and an international consensus document on frailty in general cardiology is lacking. Moreover, new options linked with eHealth are going to better define and manage frailty. This consensus document on definition, assessment, clinical implications, and management of frailty provides an input to integrate strategies pre- and post-acute CV events with a comprehensive view including out of hospital, office-based diagnostic and therapeutic choices, and based on a multidisciplinary team approach (general cardiologists, nurses, and general practitioners).

Correlations, agreement and utility of frailty instruments in prevalent haemodialysis patients: baseline cohort data from the FITNESS study.

ABSTRACTBackgroundFrailty is associated with poor outcomes for haemodialysis patients, but its prevalence is uncertain due to heterogeneous definitions. The aim of this study was to compare and contrast prevalence and features of commonly used frailty instruments in a British haemodialysis cohort.MethodsThe FITNESS (Frailty Intervention Trial iN End-Stage patientS on haemodialysis) study recruited adults aged ≥18 years after informed consent, with ≥3 months haemodialysis exposure and no hospital admission within 4 weeks unless for dialysis access. Study participants were clinically phenotyped with frailty instruments including the Frailty Index (FI), Frailty Phenotype (FP), Edmonton Frailty Scale (EFS) and Clinical Frailty Scale (CFS), alongside comprehensive baseline data collection of biochemical, clinical and social characteristics.ResultsBetween 12 January 2018 and 18 April 2019, 485 haemodialysis patients were recruited. Baseline demographics were median age 63 years, male sex 58.6% and non-White ethnicity 42.1%. Prevalence of frailty was high; 41.9% of participants were frail by FP, 63.3% by FI, 50.2% by EFS and 53.8% by CFS. Female gender was associated with increased frailty, with no independent association observed with age or ethnicity. While correlation between frailty instruments was strong, intraclass correlation coefficient for frailty agreement was 0.628 (95% confidence interval 0.585–0.669) and only weak agreement between instrument pairs.ConclusionFrailty is highly prevalent among haemodialysis patients regardless of criteria used. However, our data suggest caution when interpreting heterogenous definitions of frailty for haemodialysis patients as they are not interchangeable. Consensus agreement on the optimal frailty definition for haemodialysis patients must balance ease of use with predictive ability for adverse outcomes before determining clinical application.

Associations between inflammation, cardiovascular biomarkers and incident frailty: the British Regional Heart Study.

Introductioncardiovascular disease (CVD) and chronic inflammation are implicated in the development of frailty. Longitudinal analyses of inflammatory markers, biomarkers of cardiac dysfunction and incidence of frailty are limited.Methodsin the British Regional Heart Study, 1,225 robust or pre-frail men aged 71–92 years underwent a baseline examination, with questionnaire-based frailty assessment after 3 years. Frailty definitions were based on the Fried phenotype. Associations between incident frailty and biomarkers of cardiac dysfunction (high-sensitivity cardiac troponin T (hs-cTnT), N-terminal pro B-type natriuretic peptide (NT-proBNP)) and inflammation (C-reactive protein (CRP) and interleukin-6 (IL-6)) were examined, by tertile, with the lowest as reference.Resultsfollow-up data were available for 981 men. Ninety one became frail. Adjusted for age, pre-frailty, prevalent and incident CVD, comorbidity, polypharmacy and socioeconomic status, IL-6 (third tertile OR 2.36, 95% CI 1.07–5.17) and hs-cTnT (third tertile OR 2.24, 95% CI 1.03–4.90) were associated with increased odds of frailty. CRP (third tertile OR 1.83, 95% CI 0.97–4.08) and NT-proBNP (second tertile OR 0.48, 95% CI 0.23–1.01) showed no significant association with incident frailty. The top tertiles of CRP, IL-6, hscTnT and NT-proBNP were strongly associated with mortality prior to follow-up.ConclusionIL-6 is associated with incident frailty, supporting the prevailing argument that inflammation is involved in the pathogenesis of frailty. Cardiomyocyte injury may be associated with frailty risk. Associations between elevated CRP and frailty cannot be fully discounted; NT-proBNP may have a non-linear relationship with incident frailty. CRP, IL-6, hs-cTnT and NT-proBNP are vulnerable to survivorship bias.

A 10-Item Frailty Index Based on a Comprehensive Geriatric Assessment (FI-CGA-10) in Older Adults with Cancer: Development and Construct Validation.

A frailty index (FI) based on domain-level deficits identified through a comprehensive geriatric assessment (CGA) has been previously developed and validated in general geriatric patients. Our objectives were to construct an FI-CGA and to assess its construct validity in the geriatric oncology setting. Five hundred forty consecutive Japanese patients with cancer who underwent a CGA on a geriatric oncology service were included (median age 80 years, range 66-96 years). We developed a 10-item frailty index based on deficits in 10 domains (FI-CGA-10): cognition, mood, communication, mobility, balance, nutrition, basic and instrumental activities of daily living, social support, and comorbidity. Deficits in each domain were scored as 0 (no problem), 0.5 (minor problem), and 1.0 (major problem). Scores were calculated by dividing the sum of the scores for each domain by 10 and then categorized as fit (<0.2), pre-frail (0.2-0.35), and frail (>0.35). Construct validity was tested by correlating the FI-CGA-10 with other established frailty measures. FI-CGA-10 was well approximated by the gamma distribution. Overall, 20% of patients were fit, 41% were pre-frail, and 39% were frail. FI-CGA-10 was correlated with Canadian Study of Health and Aging (CSHA) Clinical Frailty Scale (r=0.83), CSHA rules-based frailty definition (r=0.67), and CSHA Function Score (r=0.77). Increasing levels of frailty were significantly associated with functional and cognitive impairments, high comorbidity burden, poor self-rated health, and low estimated survival probabilities. The FI-CGA-10 is a user-friendly and construct-validated measure for quantifying frailty from a CGA. This article describes the construction of a user-friendly 10-item frailty index based on a comprehensive geriatric assessment (FI-CGA-10) for older adults with cancer: cognition, mood, communication, mobility, balance, nutrition, basic and instrumental activities of daily living, social support, and comorbidity. The FI-CGA-10 simplifies the original FI-CGA used in the general geriatric setting while maintaining its content validity. The index's construct validity was demonstrated in a cohort of older adults with various cancer types. The advantage of the FI-CGA-10 is that a frailty score can be calculated more readily and interpreted in a more clinically sensible manner than the original FI-CGA.

Frailty in the Context of Older People Living With HIV: A Concept Analysis.

Despite advances in knowledge about older people living with HIV infection (PLWH), frailty remains a challenge to HIV care. Numerous studies have documented its impact; however, the concept remains unclear. Concept exploration of frailty in the context of older PLWH was conducted to provide a comprehensive understanding of the concept based on the Walker and Avant method. After the literature review, a concept analysis and a definition of frailty among older PLWH emerged. Implications for further practice, education, public policy, and research are presented to use the concept consistently, develop interventions to prevent frailty, and improve health outcomes.

Effectiveness of nutrition interventions and combined nutrition and physical activity interventions in older adults with frailty or prefrailty: a systematic review and meta-analysis

Background:Although nutrition interventions may reverse frailty, it is unclear which interventions are optimal. We conducted a systematic review and meta-analysis to identify effective nutrition interventions that improve outcomes related to frailty.Methods:We searched MEDLINE, Embase, the Cochrane Central Register of Controlled Trials and CINAHL (inception to July 2019) for English-language trials of nutrition and combined-approach (nutrition and exercise) interventions (with a control group) involving prefrail or frail adults aged 65 years or more. Outcomes of interest were frailty, mobility, health (body weight, body mass index), physical function (e.g., activities of daily living, muscle strength, appendicular lean mass), use of health care services (e.g., hospital admissions), quality of life, diet quality, mortality, and caregiver and social support. After data extraction, we assessed the risk of bias using the Cochrane Collaboration risk of bias tool for randomized controlled trials, rated the certainty of evidence with the Grading of Recommendation, Assessment, Development and Evaluations (GRADE) approach, and assessed statistical and methodologic heterogeneity. In addition, we conducted subgroup analyses of studies based on the primary intervention of protein supplementation.Results:We identified 15 studies involving 1825 prefrail or frail older participants: 7 were nutrition trials, 7 were combined-approach trials, and 1 trial had both a nutrition arm and a combined-approach arm. Seven studies had low risk of bias, 2 studies had high risk of bias, and for 6 studies the risk of bias was unclear. Nutrition interventions had small but significant effects on measures of physical function (standardized mean difference [SMD] 0.16, 95% confidence interval [CI] 0.02 to 0.29), mobility (SMD 0.15, 95% CI 0.00 to 0.30) and frailty (SMD −0.22, 95% CI −0.44 to −0.01) outcomes. Nutrition interventions combined with physical activity also had small but significant effects on physical function (SMD 0.19, 95% CI 0.06 to 0.32), mobility (SMD 0.25, 95% CI 0.02 to 0.48) and frailty (SMD −0.41, 95% CI −0.68 to −0.14; risk ratio 0.72, 95% CI 0.52 to 1.00) measures. Protein supplementation (5 studies) had small but significant effects on physical function measures (SMD 0.16, 95% CI 0.01 to 0.31) and mobility measures (SMD 0.20, 95% CI 0.02 to 0.39), with moderate certainty of evidence.Interpretation:There is moderate evidence that nutrition (including protein supplementation) and combined interventions are beneficial for prefrail or frail older adults. Trials with clear definitions of frailty and outcomes that reflect frailty identification and diagnosis are needed. PROSPERO registration:CRD42020144819

Association between frailty and ischemic heart disease: a systematic review and meta-analysis

BackgroundFrailty is increasingly reported among older adults with cardiovascular diseases and it has been demonstrated to increase negative health outcomes and mortality. To date, no systematic review of the evidence is available regarding the association between frailty and ischemic heart disease (IHD). We performed a systematic review of literature and a meta-analysis to assess the association between frailty and IHD.MethodsWe selected all the studies that provided information on the association between frailty and IHD, regardless of the study setting, study design, or definition of IHD and frailty. PubMed, Web of Science and Embase were searched for relevant papers. Studies that adopted the Fried definition for frailty were included in the meta-analyses. For each measure of interest (proportions and estimates of associations), a meta-analysis was performed if at least three studies used the same definition of frailty. Pooled estimates were obtained through random effect models and Mantel-Haenszel weighting.ResultsThirty-seven studies were included. Of these, 22 adopted the Fried criteria to define frailty and provided estimates of prevalence and therefore they were included in meta-analyses. The pooled prevalence of IHD in frail individuals was 17% (95% Confidence Interval [95%CI] 11–23%) and the pooled prevalence of frailty in individuals with IHD was 19% (95% CI 15–24%). The prevalence of frailty among IHD patients ranged from 4 to 61%. Insufficient data were found to assess longitudinal association between frailty and IHD.ConclusionsFrailty is quite common in older persons with IHD. The identification of frailty among older adults with IHD should be considered relevant to provide individualized strategies of cardiovascular prevention and care. Further research should specifically explore the association between frailty and IHD and investigate the potential common biological ground.

Definitions of Frailty in Qualitative Research: A Qualitative Systematic Review.

The purpose of this qualitative systematic review was to examine how frailty was conceptually and operationally defined for participant inclusion in qualitative research focused on the lived experience of frailty in community-living frail older adults. Search of six electronic databases, 1994–2019, yielded 25 studies. Data collection involved extracting the definition of frailty from the study aim, background, literature review, methods, and sampling strategy in each research study. Quality appraisal indicated that 13 studies (52%) demonstrated potential researcher bias based on insufficient information about participant recruitment, sampling, and relationship between the researcher and participant. Content analysis and concept mapping were applied for data synthesis. Although frailty was generally defined as a multidimensional, biopsychosocial construct with loss of resilience and vulnerability to adverse outcomes, most studies defined the study population based on older age and physical impairments derived from subjective assessment by the researcher, a healthcare professional, or a family member. However, 13 studies (52%) used objective or performance-based quantitative measures to classify participant frailty. There was no consistency across studies in standardized measures or objective assessment of frailty. Synthesis of the findings yielded four themes: Time, Vulnerability, Loss, and Relationships. The predominance of older age and physical limitations as defining characteristics of frailty raises questions about whether participants were frail, since many older adults at advanced age and with physical limitations are not frail. Lack of clear criteria to classify frailty and reliance on subjective assessment introduces the risk for bias, threatens the validity and interpretation of findings, and hinders transferability of findings to other contexts. Clear frailty inclusion and exclusion criteria and a standardized approach in the reporting of how frailty is conceptually and operationally defined in study abstracts and the methodology used is necessary to facilitate dissemination and development of metasynthesis studies that aggregate qualitative research findings that can be used to inform future research and applications in clinical practice to improve healthcare.

967-P: Glycemic Control and Frailty in Older Adults with Type 2 Diabetes

Background: Frailty is due to the combined influence of both aging and chronic disease and is increasingly a factor in T2DM clinical practice guidelines. Most definitions of frailty fall into three categories: a clinical phenotype definition (Cardiovascular Health Study Index; CHS index), a measure of accumulated deficits (Rockwood Clinical Frailty Scale, RCFS), and a single performance measure (such as gait speed). We examined the association between glycemic control and different frailty measures in older adults with type 2 diabetes (T2DM). Methods: 72 older adults (age >= 65) with type 2 diabetes were recruited sequentially from a geriatric medicine clinic (26 women, 46 men, mean age 80.5±0.6 years). Each subject had glycosylated hemoglobin (HgAIC), CHS index, RCFS and gait speed measured. Our initial models contained both age and HgAIC as predictor variables, and our outcome variables were the measures of frailty. Results: With age as a covariate, HgAIC showed a strong association with the CHS index (Standardized β=0.254±0.119, p=0.036) but no association with either the RCFS (Standardized β=0.248±0.122, p=0.840) or gait speed (Standardized β=-0.180±0.121, p=0.140). Conclusions: Glycemic control has a strong association with a phenotype-based definition of frailty but no association with other frailty models. In future diabetes guidelines for frail older adults, care must taken as to how frailty is being defined. Disclosure K. M. Madden: None. B. Feldman: None. S. Arishenkoff: None. S. M. Sy: None. G. S. Meneilly: None. Funding Allan M. McGavin Foundation

A 10-item frailty index based on a comprehensive geriatric assessment (FI-CGA-10) in older adults with cancer: Development and construct validation.

e24011 Background: A frailty index based on domain-level deficits in a comprehensive geriatric assessment (FI-CGA) has been previously developed and validated in general geriatric patients (Jones D, Aging Clin Exp Res 2005). Our objectives were to construct an FI-CGA and to assess its construct validity in geriatric oncology setting. Methods: Consecutive older adults with cancer who underwent a CGA on a geriatric oncology service were included. We developed a 10-item frailty index based on deficits in 10 domains (FI-CGA-10): cognition, mood, communication, mobility, balance, nutrition, basic and instrumental activities of daily living, social support and comorbidity. Deficits in each domain were scored as 0 (no problem), 0.5 (minor problem) and 1.0 (major problem). Scores were calculated by dividing the sum of the score of each domain by 10, and categorized as fit ( &lt; 0.2), pre-frail (0.2–0.35), and frail ( &gt; 0.35). Construct validity was tested by comparing the FI-CGA-10 with the following established frailty measures: the Canadian Study of Health and Aging (CSHA) Clinical Frailty Scale (CFS), CSHA rules-based frailty definition and CSHA Function Scale. To evaluate the ability to predict mortality, we tested association between the FI-CGA-10 and validated prognostic indices for mortality: the Lee index and Schonberg index (higher scores reflect a higher risk of mortality). We also examined associations between the FI-CGA-10 and several features commonly seen in frail older adults such as function (Timed Up &amp; Go (TUG) test), cognitive impairment (Mini-Cog), and high comorbidity burden (Charlson Comorbidity Index (CCI)). Results: Of 540 patients (median age 80 years, range 66–96 years), common cancer types were gastrointestinal tract in 37%, hepatobiliary and pancreatic in 22%, and head and neck in 12%. 406 (75%) patients had ECOG PS 0 to 1. The FI-CGA-10 had a right-skewed distribution and was well approximated by the gamma distribution. Overall, 20% of patients were fit, 41% were pre-frail, and 39% were frail. The FI-CGA-10 was highly correlated with CSHA CFS (Pearson's r = 0.83), CSHA rules-based frailty definition (r = 0.67) and CSHA Function Score (r = 0.77). People who were more frail had higher scores on the Lee index (fit: 7.3, prefrail: 8.8, frail: 12.0; p &lt; .0001) and Schonberg index (fit: 10.1, prefrail: 13.1, frail: 15.7; p &lt; .0001), suggesting an increased probability of death. Increasing levels of frailty were significantly associated with a longer TUG (seconds), fit: 11.3, prefrail: 13.0, frail: 26.3; p &lt; .0001, poorer cognitive function (Mini-Cog score, fit: 4.7, prefrail: 4.0, frail: 3.1; p &lt; .0001), and higher comorbidity burden (CCI, fit: 0.8, prefrail: 1.4, frail: 1.9; p &lt; .0001). Conclusions: The FI-CGA-10 is a clinically sensible and construct-validated measure of quantifying frailty from a CGA.

Frailty, a Dimension of Impaired Functional Status in Advanced COPD: Utility and Clinical Applicability.

Background and Objectives: In advanced chronic obstructive pulmonary disease (COPD), functional status is significantly impaired mainly as a result of disease related respiratory symptoms such as dyspnea or as a result of fatigue, which is the extra-respiratory symptom the most prevalent in this setting. “Physical” frailty, considered to be an aging phenotype, has defining traits that can also be considered when studying impaired functional status, but little is known about this relationship in advanced COPD. This review discusses the relevance of this type of frailty in advanced COPD and evaluates it utility and its clinical applicability as a potential outcome measure in palliative care for COPD. Materials and Methods: A conceptual review on the functional status as an outcome measure of mortality and morbidity in COPD, and an update on the definition and traits of frailty. Results: Data on the prognostic role of frailty in COPD are rather limited, but individual data on traits of frailty demonstrating their relationship with mortality and morbidity in advanced COPD are available and supportive. Conclusions: Frailty assessment in COPD patients is becoming a relevant issue not only for its potential prognostic value for increased morbidity or for mortality, but also for its potential role as a measure of functional status in palliative care for advanced COPD.

Performance assessment of the metastatic spinal tumor frailty index using machine learning algorithms: limitations and future directions.

Frailty is recognized as an important consideration in patients with cancer who are undergoing therapies, including spine surgery. The definition of frailty in the context of spinal metastases is unclear, and few have studied such markers and their association with postoperative outcomes and survival. Using national databases, the metastatic spinal tumor frailty index (MSTFI) was developed as a tool to predict outcomes in this specific patient population and has not been tested with external data. The purpose of this study was to test the performance of the MSTFI with institutional data and determine whether machine learning methods could better identify measures of frailty as predictors of outcomes. Electronic health record data from 479 adult patients admitted to the Massachusetts General Hospital for metastatic spinal tumor surgery from 2010 to 2019 formed a validation cohort for the MSTFI to predict major complications, in-hospital mortality, and length of stay (LOS). The 9 parameters of the MSTFI were modeled in 3 machine learning algorithms (lasso regularization logistic regression, random forest, and gradient-boosted decision tree) to assess clinical outcome prediction and determine variable importance. Prediction performance of the models was measured by computing areas under the receiver operating characteristic curve (AUROCs), calibration, and confusion matrix metrics (positive predictive value, sensitivity, and specificity) and was subjected to internal bootstrap validation. Of 479 patients (median age 64 years [IQR 55-71 years]; 58.7% male), 28.4% had complications after spine surgery. The in-hospital mortality rate was 1.9%, and the mean LOS was 7.8 days. The MSTFI demonstrated poor discrimination for predicting complications (AUROC 0.56, 95% CI 0.50-0.62) and in-hospital mortality (AUROC 0.69, 95% CI 0.54-0.85) in the validation cohort. For postoperative complications, machine learning approaches showed a greater advantage over the logistic regression model used to develop the MSTFI (AUROC 0.62, 95% CI 0.56-0.68 for random forest vs AUROC 0.56, 95% CI 0.50-0.62 for logistic regression). The random forest model had the highest positive predictive value (0.53, 95% CI 0.43-0.64) and the highest negative predictive value (0.77, 95% CI 0.72-0.81), with chronic lung disease, coagulopathy, anemia, and malnutrition identified as the most important predictors of postoperative complications. This study highlights the challenges of defining and quantifying frailty in the metastatic spine tumor population. Further study is required to improve the determination of surgical frailty in this specific cohort.

Consideration of frailty versus limited life expectancy when deprescribing

The letter1 by the authors of the LESS CHRON provides an opportunity to highlight an important issue regarding the definition of frailty and how frailty influences deprescribing. As the authors of the LESS CHRON highlight, their tool is not limited to use in people with limited life expectancy. The LESS CHRON tool was mentioned in the review2 of types of tools available to aid deprescribing in clinical practice within the section describing the ‘special population’ of those living with frailty and those with limited life expectancy. This section was informed by a systematic review by Thompson et al.3 on the deprescribing tools available for this population. No specific criteria for frailty or limited life expectancy were used in their review, instead ‘studies had to state explicitly that the tool was designed for this population or include specific considerations relevant to this population’.3 The LESS CHRON tool was included in their review as it was developed for those with multimorbidity. However, the letter1 begs the question, are frailty and limited life expectancy synonymous, and should these two groups be treated the same regarding appropriate and inappropriate medication use and deprescribing? In short, no, but they both should trigger a re-evaluation of medication appropriateness given changes in risks and benefits of medication use, the individual’s condition and goals of care. Frailty is a condition of cumulative reduction in organs, systems and function. It is a state of vulnerability, where individuals are more susceptible to adverse outcomes and less able to recover after an acute event.4, 5 Frail older adults are more susceptible to adverse drug reactions, likely due to both changes in pharmacokinetics and increased vulnerability.5 Limited life expectancy usually applies to individuals with a life expectancy of less than 12 months. However, there are various definitions and tools available to identify both frailty and limited life expectancy. Indeed, the review by Thompson et al.3 reported that the identified tools all had different approaches to identify frailty and limited life expectancy. Overall, not all patients who are frail have limited life expectancy, but frailty (and increasing degrees of frailty) is associated with increased risk of mortality.4 Thompson et al.3 notes that all tools for deprescribing may be useful in those with frailty and limited life expectancy, but the tools they identified (including LESS CHRON) may have greater applicability as they specifically incorporate consideration of time to benefit (of preventative medications) and highlight the likely changing goals of care. However, different tools may be necessary for those with limited life expectancy, as medications that are considered potentially inappropriate in older adults in general may actually be appropriate (or vice versa) in end-of-life care where the goal is comfort and concerns about long-term risks are minimised (e.g. opioids).6 There is considerable complexity when caring for people with frailty and those with limited life expectancy, not only in the identification, but in the implications for ensuring safe and appropriate medication use through deprescribing. The author declares that they have no conflicts of interest.

Impact of frailty in cardiac surgical patients-Assessment, burden, and recommendations.

Elderly patients undergoing cardiac surgery are at an increased risk of adverse postoperative outcomes. Frailty, a state of decreased physiological reserve, is highly prevalent among elderly patients. Despite being associated with adverse surgical outcomes, no universally accepted definition or measurement tool for frailty exists. Moreover, regardless of all the recommendations, a routine perioperative frailty assessment is often ignored. In addition to complications, frailty increases the burden to the healthcare system, which is of particular concern in Southeast Asia due to its socioeconomically disadvantaged and resource limited settings. This narrative review focuses to develop clinical practice plans for perioperative frailty assessment in the context of a cardiac surgical setting.

Frailty and driving status associated with disability: a 24-month follow-up longitudinal study

ObjectivesTo examine the relationship of driving status and frailty with disability in older adults.DesignA prospective study.Setting and participantsThe study included 8533 participants (mean age: 72.0±6.1 years (range: 60–98 years), women:...

29 Predicting Unplanned Readmission and Death After Hospital Discharge: How Do Frailty Tools Compare to Electronic Health Record Frailty Markers?

Abstract Introduction Numerous frailty tools and definitions have been described. Amongst hospitalised patients, the validity of face-to-face instruments may be confounded by acute illness. However, patient assessment after recovery at the point of hospital discharge, or recognition of electronic health record (EHR) frailty markers, may overcome this issuep. Methods In a consented, prospective observational cohort study, we recruited patients ≥70 years old within 24 hours of expected discharge from the cardiology ward of the Royal Infirmary of Edinburgh. Three established frailty instruments were tested: the Fried phenotype, Short Physical Performance Battery and nurse-administered Clinical Frailty Scale (CFS). An unweighted 32-item EHR score was generated using frailty markers (e.g. falls risk, continence, cognition) recorded within mandated admission documentation. Comorbidity was assessed by count of chronic health conditions. Outcomes were a 90-day composite of unplanned readmission or death and 12-month mortality. Adjusted Cox modelling determined the hazard ratio (HR) per standard deviation increase in each frailty score. Results 186 patients (mean age 79 ± 6 years, 64% male) were included, of whom 55 (30%) had a 90-day composite outcome, and 21 (11%) died within 12 months. All four frailty tools were moderately correlated with age and comorbidity (Pearson’s r 0.21 to 0.43, all p &amp;lt; 0.05). The Fried phenotype (HR 1.47, 95% CI 1.18–1.81), CFS (HR 1.24, 95% CI 1.01–1.51) and EHR score (HR 1.26, 95% CI 1.03–1.55) independently predicted 90-day readmission or death, after adjustment for age, sex and comorbidity. All frailty instruments were independent predictors of 12-month mortality, with age, sex and comorbidity losing predictive power (p &amp;gt; 0.05) once frailty was included in modelling. Conclusions At hospital discharge, the Fried phenotype and CFS added to age and comorbidity in risk prediction for future unplanned readmission or death. EHR frailty markers appeared comparable to face-to-face assessment. An automated trigger for high-risk patients using routine EHR data merits prospective evaluation.

The Impact of Frailty on COVID-19 Outcomes: A Systematic Review and Meta-analysis of 16 Cohort Studies.

BackgroundFrail patients are increasingly vulnerable to stress, which is mainly manifested by a reduced physiologic reserve in metabolic and immune systems and neuromuscular system. Several studies found a significant association of frailty with COVID-19 severity to support the evidence for the application of frailty assessment. However, there were contradictory results in other studies. Thus we conducted a systematic review and meta-analysis to synthesize the current studies to investigate impact of frailty on COVID-19 outcomes and provide evidence-based decisions in clinical practice.ObjectiveWe aimed to synthesize the current studies to investigate impact of frailty on COVID-19 outcomes and provide evidence-based decisions in clinical practice.DesignA systematic review and Meta-analysis of 16 cohort studies.ParticipantsPatients with COVID-19.MethodsA systematic retrieving for potential literature was conducted in several public electronic databases, including Medline(OvidSP), EMBASE, Pubmed and Chinese databases(China National Knowledge Infrastructure, Wanfang and Weipu) on August 1, 2020. The literature research was updated on October 26, 2020. Newcastle Ottawa Scale for cohort studies was used for quality assessment. RevMan (Version 5.3) and Stata 14.0 were used to synthesize the pooled effects.ResultsAccording to the predefined inclusion and exclusion criteria, sixteen studies of 4324 patients were included in the final analysis. Frailty was significantly associated with increased risk of all-cause mortality among patients with COVID-19, with pooled adjusted odds ratios of 1.81 (95% confidence intervals:1.48,2.21, I2=87.0%, P<0.001). The result was consistent in stratified analysis to according to age, patient source, definitions of frailty, study quality, and adjustment method. Frailty was significant associated with an increased risk of COVID-19 severity, admission to intensive care unit, application of invasive mechanical ventilation, long-length stay.ConclusionsIn this meta-analysis, we found frailty was significantly associated with an increased risk of clinical adverse events (all- cause mortality, COVID-19 severity, admission to the intensive care unit, application of invasive mechanical ventilation, long-length stay). Given the epidemic of COVID-19 and shortage of medical resources, paying more attention to screening frailty would contribute to disease management and resource allocation among patients with COVID-19.Electronic Supplementary MaterialSupplementary material is available for this article at 10.1007/s12603-021-1611-9 and is accessible for authorized users.

New Horizons in the impact of frailty on pharmacokinetics: latest developments

Frail older people have a high prevalence of drug use and are susceptible to adverse drug reactions. The physiological changes of frailty are likely to affect pharmacokinetics and pharmacodynamics. We reviewed the methods and findings of published studies of pharmacokinetics in frailty. Nine studies describing pharmacokinetics and an additional three of pharmacokinetic pathways in frail older people were identified. Most pharmacokinetic studies investigated a single administration of a medication, dose or formulation, in small populations, often with limited representation of males or females, and applied variable definitions of frailty. Pharmacokinetic sampling designs generally utilised saturated sampling followed by analysis based on the trapezoidal rule for area under the curve, with more recent studies using sparser sampling and more sophisticated modelling to obtain individual and population values of all pharmacokinetic parameters. Overall, the pharmacokinetic studies reported only small changes in some parameters for some drugs with frailty, with the most consistent change reduced hepatic clearance in frail older people. Recommendations for future studies of pharmacokinetics in frailty include (i) standard objective definitions of frailty; (ii) larger studies including people with mild, moderate and severe frailty; (iii) population pharmacokinetic modelling to allow sparser sampling and consideration of multiple influences on pharmacokinetics; (iv) physiologically based modelling as the physiology of frailty emerges and (v) longitudinal pharmacokinetic studies of chronic drug therapy from middle to old age and from robust to pre-frail to frail, including pre-clinical studies. These data, accompanied by pharmacodynamics data in frailty, will inform safe, effective prescribing for frail older people.