Outcomes For Frail Older Adults Research Articles

Improving Surgical Outcomes for Older Adults with Adoption of Technological Advances in Comprehensive Geriatric Assessment

Frailty is a well-recognized predictor of poor surgical outcomes for older adults, yet effective measurements and interventions remain limited. Technological advances offer an opportunity to address this gap and improve surgical care for older adults. This paper reviews the background of frailty and comprehensive geriatric assessments in surgery, and how technological innovations can advance frailty measurement and intervention in surgical settings. We review two broad areas of technological advancement as applied to frailty in surgery: 1) Innovation in the use of electronic health records (EHR) using Artificial Intelligence (AI) and Machine Learning (ML), and 2) Novel uses for wearable sensors and mobile health (mHealth) applications. We explore the integration of AI and ML with EHR systems, which can surpass traditional comorbidity indices by providing comprehensive health assessments and enhancing prediction models. Innovations like the electronic Frailty Index (eFI) show promise in expanding the reach of frailty assessments and facilitating real-time screening. Additionally, wearable devices and mobile health (mHealth) applications offer new ways to monitor and improve physical activity, nutrition, and psychological well-being, supporting perioperative rehabilitation. While these technologies present challenges, such as the need for infrastructure, training, and data interoperability, they offer promising strategies to facilitate the assessment and management of frailty among surgical patients. Continued research and tailored implementation strategies will be essential to fully realize the potential of these advancements in improving surgical outcomes for frail older adults.

Cardiovascular disease history as a predictor for adverse outcomes in frail older adults admitted to acute geriatric settings: 12-month outcomes from an Australian frailty registry

Abstract Introduction Frailty is common in older adults with cardiovascular disease (CVD), with prevalence between 25-62% (1). The incidence of CVD increases with age, yet the outcomes of frail older adults with a history of CVD who present to acute geriatric settings, is not well understood. Purpose To report the association of CVD and rehospitalisation and/or mortality at 12 months in a cohort of frail older adults enrolled in an Australian frailty registry. Methods A convenience sample of participants enrolled in the frailty registry, with 12-month follow-up completed. The frailty registry is a prospective cohort study of adults admitted to the rehabilitation and aged care departments at two Australian hospitals. Frailty was assessed using the Clinical Frailty Scale (CFS), a score of 1-4 is ‘non-frail’, 5-6 is ‘mild-moderately frail’ and 7-9 is ‘severely frail’ (2). For this study, ‘CVD’ was defined as having a history of either heart failure, stroke, or atrial fibrillation. The cumulative incidence of first rehospitalisation and/or death during the first 12 months post discharge was estimated using one minus the Kaplan-Meier estimate of the survival function. Association between CVD (history of CVD, and type of CVD condition) and the composite endpoint were analysed. Adjusted Hazard Ratios (HRs) and 95% confidence intervals (CIs) were estimated using multivariable Cox models incorporating variables of interest and potential confounders. Results A total of 592 participants were included, median age was 82 years, 59% (n= 349) were female. The majority were frail with 50% (n= 295) classified as mild-moderately frail and 21% (n= 123) classified as severely frail. Almost half (45%, n= 265) had a history of CVD. The incidence of frailty (CFS score ≥5, mild-severely frail) was higher in those with CVD compared to those without CVD (76% vs 66%). A history of CVD was significantly associated with higher rate of first readmission or death within 12 months, compared to no history of CVD (p=0.017) (Figure 1). Of the three CVD conditions, heart failure was the only independent predictor of the composite endpoint (HR 1.60 [CI 1.14 -2.24], p=0.007). A CFS score of mild-moderately frail (HR 1.51 [CI 1.18 - 1.93, p=0.001) and severely frail were also independent predictors of the composite endpoint (HR 1.83 [CI 1.35- 2.48], p=<0.001) (Table 1). Conclusions A history of CVD has a significant impact on adverse outcomes in frail older adults admitted to acute geriatric settings. Frailty according to the CFS was independently predictive of rehospitalisation and mortality in this cohort. Heart failure was the only independent predictor of the composite endpoint. These findings underscore the importance of identifying and addressing CVD and in the context of frailty, emphasising the need for targeted interventions to improve outcomes in this vulnerable population.Figure 1.Table 1.

Effects of exercise interventions on physical, psychological and social outcomes in frail older adults: An overview of systematic reviews.

To comprehensively synthesise existing evidence from systematic reviews regarding the effects of exercise interventions on physical, psychological and social outcomes in frail older adults to provide reference for clinical practice. Frailty is highly prevalent in older adults and associated with increased adverse health outcomes. Some systematic reviews have assessed the effectiveness of exercise interventions in frail older adults with varied inclusion criteria, methodology quality, types of exercise and outcome measures. An overview of systematic reviews reported following the PRISMA checklist. PubMed, Embase, CINAHL, Web of Science and Cochrane database were searched from inception until June 2023 to identify relevant systematic reviews with or without meta-analysis of randomised controlled trails. Two reviewers independently selected articles, extracted data, assessed quality and summarised findings. A total of 17 systematic reviews were included, with methodology quality varying from moderate to critically low. The most frequent types of exercise were multicomponent exercise and resistance-based exercise in community and long-term care facilities, respectively. Exercise interventions had positive effects on most physical outcomes and depression, but inconsistent effects on cognitive function and quality of life. The quality of the evidence for most outcomes was low and very low. This overview highlights the importance of exercise interventions to improve physical, psychological and social aspects in frail older adults and provides evidence on characteristics of exercise interventions for frailty in various settings. Multicomponent exercise and resistance-based exercise should be recommended for frail older adults. There is a need of more well-designed research with large sample size and validated definition of frailty. Long-term effects, adherence during and after exercise interventions, adverse events and cost-effectiveness should be emphasised in future studies. The overview protocol was registered on the International Prospective Register of Systematic reviews (CRD 42021281327). No patient or public contribution. The Preferred Reporting Items for Systematic Reviews and Meta-analysis (PRISMA) guidelines were applied to report the results.

Improving outcomes in frail older adults with complex care needs in an ambulatory setting through timely, integrated person-centered care. A case for rapid access frailty clinics in Singapore.

Background: Frailty is a significant risk factor for recurrent hospital admissions and emergency department presentations. Frail older adults are especially vulnerable to hospital related adverse outcomes recognisably functional decline, delirium, institutionalisation and mortality. Fragmentation of care resulting in poorly defined care responsibilities, together with the limitation of community resources to manage acute issues in this group of patients, increase the likelihood of them presenting to an acute care setting.
 Methods: A retrospective study evaluated frail older adults seen in an ambulatory Geriatric clinic in a government funded public hospital from 2021 to 2022. The aim of the study was to determine if timely evaluation of acute issues in an ambulatory setting could avoid a hospital admission or an emergency department presentation. 
 Results: Preliminary data in this study showed that (1) timely review of acute issues (<1 week from presentation) led to avoidance of hospital admission, emergency department presentation as well as admission in the next 30 days; (2) the common presentations successfully managed include worsening behavioral and psychological symptoms of dementia (BPSD), delirium, infections and falls; (3) majority of the patients seen were moderately to severely frail based on their clinical frailty score (CFS). Additionally, there was high level of patient and caregiver satisfaction reported.
 Conclusion: This study shows that hospital admissions and emergency department presentations can potentially be avoided in frail older adults whose acute medical issues are recognised and managed early. Important contributing factors to the effective management of these patients include: easy accessibility to the primary geriatrician involved, same day investigations, timely follow ups, good social/family support as well as the engagement of community services. Rapid access frailty clinics, a service model built upon the similar recognition that acute issues in frail older adults needed to be addressed promptly, has been described and shown to have benefit elsewhere. In Singapore, innovations in care delivery both within the hospital and in the community has become ever more crucial with an increasingly frail population and in already overwhelmed healthcare institutions. Rapid access frailty clinics can be a useful hospital-based service delivery model to improve care of our frail older adults.

EP08.02-02 Real World Chemoradiotherapy Outcomes for Frail Older Adults with Unresectable Stage III Non Small Cell Lung Cancer (NSCLC)

EP08.02-02 Real World Chemoradiotherapy Outcomes for Frail Older Adults with Unresectable Stage III Non Small Cell Lung Cancer (NSCLC)

Transitional care interventions for supporting frail older adults discharged from hospitals: An umbrella review.

Transitional care interventions have been shown to assist frail older adults; however, their true efficacy remains inconclusive. This umbrella review aimed (1) to summarize the components of transitional care interventions in support of frail older adults discharged from hospitals to community-based facilities that may have impacted healthcare outcomes and (2) to synthesize the impacts of these interventions. Systematic reviews published between January 2018 and September 2022 were screened using seven electronic databases. The review protocol followed the Joanna Briggs Institute Reviewers' Manual and was registered in the PROSPERO. Nine relevant systematic reviews were assessed for their methodological quality. Four of the measured primary healthcare outcomes improved as a result of transitional care interventions. In particular, evidence indicates that high-intensity transitional care or transitional care lasting at least one month can improve healthcare outcomes in frail older adults. Additional funding research and practical guidelines are warranted.

1288 IMPROVING STAFF AWARENESS OF FRAILTY IN THE EMERGENCY DEPARTMENT: A MULTI-DISCIPLINARY QUALITY IMPROVEMENT PROJECT

Abstract 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.

Oral nutritional interventions in frail older people who are malnourished or at risk of malnutrition: a systematic review.

Malnutrition worsens the health of frail older adults. Current treatments for malnutrition may include prescribed oral nutritional supplements, which are multinutrient products containing macronutrients and micronutrients. To assess the effectiveness and cost-effectiveness of oral nutritional supplements (with or without other dietary interventions) in frail older people who are malnourished or at risk of malnutrition. MEDLINE, EMBASE, Cochrane Library, Scopus, CINAHL (Cumulative Index to Nursing and Allied Health Literature) and grey literature were searched from inception to 13 September 2021. A systematic review and meta-analysis was conducted to evaluate the effectiveness and cost-effectiveness of oral nutritional supplements in frail older people (aged ≥ 65 years) who are malnourished or at risk of malnutrition (defined as undernutrition as per National Institute for Health and Care Excellence guidelines). Meta-analysis and network meta-analysis were undertaken, where feasible, along with a narrative synthesis. A cost-effectiveness review was reported narratively. A de novo model was developed using effectiveness evidence identified in the systematic review to estimate the cost-effectiveness of oral nutritional supplements. Eleven studies (n = 822 participants) were included in the effectiveness review, six of which were fully or partly funded by industry. Meta-analyses suggested positive effects of oral nutritional supplements compared with standard care for energy intake (kcal) (standardised mean difference 1.02, 95% confidence interval 0.15 to 1.88; very low quality evidence) and poor mobility (mean difference 0.03, p < 0.00001, 95% confidence interval 0.02 to 0.04; very low quality evidence) but no evidence of an effect for body weight (mean difference 1.31, 95% confidence interval -0.05 to 2.66; very low quality evidence) and body mass index (mean difference 0.54, 95% confidence interval -0.03 to 1.11; very low quality evidence). Pooled results for other outcomes were statistically non-significant. There was mixed narrative evidence regarding the effect of oral nutritional supplements on quality of life. Network meta-analysis could be conducted only for body weight and grip strength; there was evidence of an effect for oral nutritional supplements compared with standard care for body weight only. Study quality was mixed; the randomisation method was typically poorly reported. One economic evaluation, in a care home setting, was included. This was a well-conducted study showing that oral nutritional supplements could be cost-effective. Cost-effectiveness analysis suggested that oral nutritional supplements may only be cost-effective for people with lower body mass index (< 21 kg/m2) using cheaper oral nutritional supplements products that require minimal staff time to administer. The review scope was narrow in focus as few primary studies used frailty measures (or our proxy criteria). This resulted in only 11 included studies. The small evidence base and varied quality of evidence meant that it was not possible to determine accurate estimates of the effectiveness or cost-effectiveness of oral nutritional supplements. Furthermore, only English-language publications were considered. Overall, the review found little evidence of oral nutritional supplements having significant effects on reducing malnutrition or its adverse outcomes in frail older adults. Future research should focus on independent, high-quality, adequately powered studies to investigate oral nutritional supplements alongside other nutritional interventions, with longer-term follow-up and detailed analysis of determinants, intervention components and cost-effectiveness. This study is registered as PROSPERO CRD42020170906. This project was funded by the National Institute for Health and Care Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 26, No. 51. See the NIHR Journals Library website for further project information.

Effects of exercise interventions on physical and psychological outcomes in frail older adults: Protocol for an overview of systematic reviews.

To systematically summarize the existing evidence regarding the effects of exercise interventions on physical and psychological outcomes in frail older adults and appraise the quality and strength of the evidence. An overview protocol. A literature search of PubMed, Embase, Web of Science, CINAHL and Cochrane Database of Systematic Reviews will be conducted to identify relevant systematic reviews with or without meta-analysis on exercise interventions for frail older adults. Two independent reviewers will select articles, extract data and appraise the quality of included reviews. Physical and psychological outcomes will be synthesized using narrative summaries. The methodological quality of included reviews and the quality of evidence will also be assessed. This overview will present the evidence on the effects of exercise interventions on physical and psychological outcomes for frail older adults, contributing to the implementation of exercise interventions to improve health outcomes for this population.

Translation of the geriatric emergency department intervention into other emergency departments: a post implementation evaluation of outcomes for older adults

BackgroundIncreasing numbers of older adults with complex health deficits presenting to emergency departments has prompted the development of innovative models of care. One such model designed to reduce poor outcomes associated with acute healthcare, is the Geriatric Emergency Department Intervention. This intervention is a nurse-led, physician-championed, Emergency Department intervention that improves the health outcomes for frail older adults in the emergency department.MethodsThis quantitative cohort study aimed to evaluate the healthcare outcomes and costs associated with the implementation of the Geriatric Emergency Department Intervention (GEDI) for adults aged 70 years and over at two hospital sites that implemented the model using the integrated-Promoting Action on Research Implementation in Health Services (i-PARHIS) framework. Hospital A was large teaching hospital located in the tropical north of Australia. Hospital B was a medium sized teaching hospital near Brisbane, Queensland Australia.The effect of the intervention was examined in two ways. Outcomes were compared between: 1) all patients in the pre- and post- implementation periods, and 2) patients seen or not seen by the Geriatric Emergency Department Intervention team in the post-implementation period. The outcomes measured were disposition (discharged home, admitted); emergency department length of stay; hospital length of stay; all cause in-hospital mortality within 28 days; time to re-presentation up to 28 days post-discharge; emergency department and in-hospital costs.Survival analyses were used for the primary and secondary outcome variables and a Cox survival model was used to estimate the associations between variables and outcomes. Multiple regression models were used to examine other secondary outcomes whilst controlling for a range of confounders.ResultsThe Geriatric Emergency Department Intervention was successfully translated into two different emergency departments. Both demonstrated an increased likelihood of discharge, decreased emergency department length of stay, decreased hospital costs for those who were admitted, with an associated reduction in risk of mortality, for adults aged 70 years and over.ConclusionsThe Geriatric Emergency Department Intervention was successfully translated into new sites that adapted the model design. Improvement in healthcare outcomes for older adults presenting to the emergency department was demonstrated, although this was more subtle than in the original model setting.

Frailty among older surgical patients and risk of hospital acquired adverse events: The South-Western Sydney frailty and nurse sensitive indicators study.

While advances in healthcare mean people are living longer, increasing frailty is a potential consequence of this. The relationship between frailty among older surgical patients and hospital acquired adverse events has not been extensively explored. We sought to describe the relationship between increasing frailty among older surgical patients and the risk of hospital acquired adverse events. We included consecutive surgical admissions among patients aged 70years or more across the SWSLHD between January 2010 and December 2020. This study used routinely collected ICD-10-AM data, obtained from the government maintained Admitted Patient Data Collection. The relationships between cumulative frailty deficit items and risk of hospital acquired adverse events were assessed using Poisson regression modelling. This study followed the RECORD/STROBE guidelines. During the study period, 44,721 (57% women) older adults were admitted, and 41% (25,306) were planned surgical admissions. The risk of all adverse events increased with increasing number of frailty deficit items, the highest deficit items group (4-12 deficit items) compared with the lowest deficit items group (0 or 1 deficit item): falls adjusted rate ratio (adj RR) = 15.3, (95% confidence interval (CI) 12.1, 19.42); pressure injury adj RR = 21.3 (95% CI 12.53, 36.16); delirium adj RR = 40.9 (95% CI 31.21, 53.55); pneumonia adj RR = 16.5 (95% CI 12.74, 21.27); thromboembolism adj RR = 17.3 (95% CI 4.4, 11.92); and hospital mortality adj RR = 6.2 (95% CI 5.18, 7.37). The increase in number of cumulative frailty deficit items among older surgical patients was associated with a higher risk of adverse hospital events. The link offers an opportunity to clinical nursing professionals in the surgical setting, to develop and implement targeted models of care and ensure the best outcomes for frail older adults and their families.

Effects of resistance bands exercise for frail older adults: A systematic review and meta-analysis of randomised controlled studies.

Research examining the effectiveness of resistance band exercises for improving physical and psychological dimensions among frail older adults has been inconsistent. We aimed to examine the effects of resistance band exercises for improving outcomes in frail older adults. To provide robust evidence regarding the effectiveness of resistance band exercises and explore other potential outcomes in frail older adults, a systematic review of RCTs remains necessary. Systematic literature review and meta-analysis were conducted in accordance with the PRISMA guidelines. Four databases were searched. English language papers were retrieved from 2006 to 2020. Three reviewers reviewed the methodology of the selected studies using the Joanna Briggs Institute tool for randomised controlled trials. The pooled standardised mean difference was calculated using a random-effects model. Heterogeneity among pooled studies was assessed using the τ2 , Q and I2 statistics, and publication bias was evaluated using Egger's test and the visual inspection of funnel plots. A total of 15 studies met the eligibility criteria for this study. Overall, resistance band exercise reduced frailty after 24weeks (SMD: -0.29; 95% CI: -0.55 to -0.03) and reduced depression after both 12weeks (SMD: -0.19; 95% CI: -0.38 to -0.01) and 24weeks (SMD: -0.30; 95% CI: -0.52 to -0.09). However, no significant effects were observed for frailty after 12weeks, and no significant effects were observed for grip strength, leg strength, activities of daily living or quality of life at any time. Resistance band exercise might be considered a viable strategy for frail older adults in the community or in long-term care facilities. More research implementing a standardised protocol remains necessary to identify the effects of different training volumes and the dose-response relationship for the very old and frail population. As a safe complementary intervention for frail older adults, health providers should consider resistance band exercises when caring for frail older adults because this intervention has clinical benefits.

Do appetite stimulants improve outcomes in frail older adults?

Carl R. Darnall Army Medical Center Family Medicine Residency Program, Fort Hood, TX The authors declare no conflicts of interest. The opinions and assertions contained herein are those of the authors and are not to be construed as official or as reflecting the views of the US Army Medical Department, the Army at large, or the Department of Defense.

Multicomponent exercise and the hallmarks of frailty: Considerations on cognitive impairment and acute hospitalization.

Frailty syndrome encompasses several physical hallmarks such as loss of muscle strength, power output and mass, which leads to poor gait ability, fatigue, falls and overall difficulty to perform activities of daily living. On the other hand, physical exercise interventions induce marked improvements in frailty physical hallmarks (e.g., gait ability, muscle strength, balance and falls). In addition, because cognitive impairment is closely related to frailty syndrome, exercise is an effective intervention to counteract the physical consequences of mild cognitive impairment and dementia. Moreover, exercise and early rehabilitation programs are among the interventions through which functional decline is prevented in older patients during acute hospitalization. This narrative review provides a summary of the effectiveness of different exercise interventions in the hallmarks of frailty. Furthermore, this review addresses special considerations on exercise in frail older with cognitive impairment. Also, we review the role of exercise interventions in acute hospitalized older patients. There is strong evidence that exercise training is an effective intervention for improving muscle strength, muscle mass, incidence of falls, and gait ability in frail older adults. In addition, it seems that multicomponent exercise intervention programs including resistance, gait and balance training is the best strategy for improving the frailty hallmarks, as well as for reducing the rate of falls in frail individuals, and so maintaining their functional capacity during aging. This training modality also proved to be safe and effective to revert the functional decline and cognitive impairment in acutely hospitalized older adults of advanced age. Based on the association between muscle power output and physical function, explosive resistance training should be included in the exercise intervention in order to optimize the functional outcomes in frail older adults.

National Clinical Programme for Older People: National Frailty Education Programme "Fundamentals of Frailty"

Introduction: Although not an inevitable part of ageing, frailty is an increasingly common condition in older people (Savva et al., 2013). The associated potential for serious adverse outcomes means that even a relatively minor event such as an infection can result in a dramatic change in health status: from independent to dependent; mobile to immobile; postural stability to falling; lucid to delirious (Clegg, 2013). Furthermore, frailty has been shown to be a strong and independent predictor of emergency department visits and hospitalisations, hospital readmissions (Pugh et al., 2014) and in-hospital mortality (Bagshaw et al. 2013). Healthcare professionals need to understand the risk factors for frailty to enable them to implement effective programmes for detection, prevention and management. Frailty: What We Know The recognition of frailty is important and should form part of any interaction between an older person and a healthcare professional. An individual’s degree of frailty is not static. It may improve or deteriorate, and is influenced by factors including the care received when an individual presents to a health professional. One of the major challenges posed by an ageing population is the ability of healthcare professionals to understand, recognise and manage frailty Programme Aim: Frailty is an emerging science and this programme was developed to provide healthcare professionals with the knowledge and skills required to provide effective care to older people living with frailty, wherever they access health services. It aims to provide healthcare professionals with an enhanced understanding of frailty and frailty assessments, thereby ensuring earlier recognition , improved healthcare management and better health outcomes for frail older adults. The programme philosophy is based on the belief that education increases knowledge and enhances healthcare professional’s skills in the clinical area. Methodoogy: The National Frailty Education Programme (NFEP) is a collaboration between NCPOP and The Irish Longtitudinal Study on Aging (TILDA), in partnership with the Acute and Emergency Medicine Programmes. Using a proof of concept design the programme is being piloted in three Hospital Groups and corresponding Community Healthcare Organisations. The programme methodology involves: Step 1: Nominated facilitators from participating hospitals and CHOs attend a one day ”Insights into Frailty” education Programme with TILDA. These nominees are representitive of all members of the multidisciplinary team. Step 2: This group attend a one-day workshop with the NCPOP Step 3: These facilitators roll-out the NFEP in an integrated manner across their local organisation. Parallel to this a local governance group is established to support the programme roll-out and to consider new ways of working that will enhance outcomes for the frail older person accessing their services Evaluation: Survey of facilitators knowledge pre and post TILDA Analysis of NFEP participants learning Service outcome evaluation may include: implementation of an assessment tool, audit of the use of the chosen tool, documented referral pathways, initiation of CGA and audit of numbers undertaken. Further examination of impact may involve decreased length of stay, reduction in falls, and audit of delirium management. All outcome measures would be aligned to the NCPOP KPI’s and national strategy.

The My Active and Healthy Aging (My-AHA) ICT platform to detect and prevent frailty in older adults: Randomized control trial design and protocol

IntroductionFrailty increases the risk of poor health outcomes, disability, hospitalization, and death in older adults and affects 7%–12% of the aging population. Secondary impacts of frailty on psychological health and socialization are significant negative contributors to poor outcomes for frail older adults. MethodThe My Active and Healthy Aging (My-AHA) consortium has developed an information and communications technology–based platform to support active and healthy aging through early detection of prefrailty and provision of individually tailored interventions, targeting multidomain risks for frailty across physical activity, cognitive activity, diet and nutrition, sleep, and psychosocial activities. Six hundred adults aged 60 years and older will be recruited to participate in a multinational, multisite 18-month randomized controlled trial to test the efficacy of the My-AHA platform to detect prefrailty and the efficacy of individually tailored interventions to prevent development of clinical frailty in this cohort. A total of 10 centers from Italy, Germany, Austria, Spain, United Kingdom, Belgium, Sweden, Japan, South Korea, and Australia will participate in the randomized controlled trial. ResultsPilot testing (Alpha Wave) of the My-AHA platform and all ancillary systems has been completed with a small group of older adults in Europe with the full randomized controlled trial scheduled to commence in 2018. DiscussionThe My-AHA study will expand the understanding of antecedent risk factors for clinical frailty so as to deliver targeted interventions to adults with prefrailty. Through the use of an information and communications technology platform that can connect with multiple devices within the older adult's own home, the My-AHA platform is designed to measure an individual's risk factors for frailty across multiple domains and then deliver personalized domain-specific interventions to the individual. The My-AHA platform is technology-agnostic, enabling the integration of new devices and sensor platforms as they emerge.

Integrating Care and Improving Flow for Frail Older Adults through the Development of an Acute Inpatient Frailty Service

Introduction: The National Clinical Programme for Older People in Ireland recommends the implementation of methods to identify frailty in the Emergency Department (ED) and to integrate the care of frail older adults between primary, secondary and social care. Although several models of frailty assessment teams have been piloted nationally, research into their effects on healthcare outcomes is limited. Description of practice change implemented: An integrated care pathway, consisting of dedicated medical, nursing and health and social care professional (HSCP) staff, was developed through the department of geriatric medicine, to assess frail older adults at the earliest possible point following admission through the ED. All patients >75 years admitted over the preceeding 24 hours are screened for frailty using the PRISMA-7. Those screening positive are discussed by the Frailty Service Multi-Disciplinary Team (MDT) and those deemed frail are assessed by Comprehensive Geriatric Assessment (CGA) in the ED and managed as inpatients, if appropriate. The same MDT meet daily to review progress to provide consistent and integrated care linking in with community services and an intergrated care manager. Aim and theory of change: To evaluate the experience of developing and integrating a Frailty Medicine strand within an University Hospital with existing medical, nursing and HSCP models of caring for frail older adults and to investigate whether this new model has a positive impact on healthcare outcomes including hospital length of stay (LOS) and 30-day readmission rates. Targeted population: Consecutive older adults (aged ≥75 years) that were medically stable (not requiring immediate resuscitation, intensive care or specialist medical care) and admitted through a University Hospital ED, on service operational days, were targeted. Frailty was screened using the PRISMA-7 (cut-off ≥3) and confirmed by a Consultant Geriatrician using CGA. Those admitted overnight and remaining on ED trolleys were prioritized. Timeline: We examined differences in outcomes for frail older adults after the introduction of the new service during 14 days in October 2016. Highlights: In total, 102 older patients were screened for frailty; their median age was 81 years (interquartile +/-8) and their median PRISMA-7 score was 5 (+/-4). Of these, 22 frail inpatients admitted overnight and remaining on ED trolleys were assessed and managed on the new integrated frailty pathway. Of the remainder, 54/80 (67.5%) patients were confirmed as frail but were not managed due to limited service capacity or exclusionary criteria. There was no statistically significant difference in median age (82.5+/-6 versus 83+/-8, respectively, z=-0.46, p=0.65) or PRISMA-7 scores (5+/-2 versus 5+/-2, respectively, z=-0.49, p=0.63) between those managed on the frailty pathway and frail patients receiving usual care. The median LOS of those taken over and managed throughout their admission on the frailty pathway (n=21) was 7 days (9-5=+/-4) compared to 8.5 days (12-6=+/-6), for those receiving usual care, z=-1.2, p=0.23. Likewise, no significant differences in 30-day readmission rates were found. Comments on Sustainability: Sustainability of this Frailty Service is dependent on targeted goal setting, enhanced resources and the incorporation of patient important outcomes particularly the quality of care (access, effectiveness and patient-centeredness). Wider integration with community services is planned. Comments on Transferability: Different models of frailty assessment have been created as a response to the increasing numbers of older adults attending and admitted through Irish ED’s. This new model incorporating dedicated medical with nursing and HSCP resources shows potential but requires comparison and validation against existing models nationally and internationally. Conclusions: While no statistically significant differences in outcomes were shown, a trend towards reduced LOS and readmission rates over those receiving usual care was found. Discussions: These results suggest that targeting frail older adults (≥75), screening positive for frailty with CGA and management, directly after admission into an ED, may improve healthcare outcomes. Further research with larger samples (as the sample is likely underpowered), measured over longer periods, is now required to overcome potential sources of bias. Lessons learned: This project shows the potential to identify and manage frail older adults with interdisciplinary integrated care from ED admission throughout their inpatient stay until discharge. While the Frailty Service is yet limited, there is scope to further integrate with existing hospital and community-based services for older adults to improve patient flow and transitions of care.

The impact of age and frailty on ventricular structure and function in C57BL/6

Background: On average, cardiac hypertrophy and contractile dysfunction increase with age. Still, individuals age at different rates and their health status varies from fit to frail. We investigated the influence of frailty on age-dependent ventricular remodeling. Methods: Frailty was quantified as deficit accumulation in adult (≈7 mos) and aged (≈27 mos) C57BL/6 mice by adapting a validated frailty index (FI) tool. Hypertrophy and contractile function were evaluated in Langendorff-perfused hearts; cellular correlates/mechanisms were investigated in ventricular myocytes. Results: FI scores increased with age. Mean cardiac hypertrophy increased with age, but values in the adult and aged groups overlapped. When plotted as a function of frailty, hypertrophy was graded by FI score (r=0.67-0.55, p<0.0003). Myocyte area also correlated positively with FI (r=0.34; p=0.03). Left ventricular developed pressure (LVDP) plus rates of pressure development (+dP/dt) and decay (-dP/dt) declined with age and this was graded by frailty (r=-0.51, p=0.0007; r=-0.48, p=0.002; r=-0.56, p=0.0002 for LVDP, +dP/dt and -dP/dt). Smaller, slower contractions graded by FI score were also seen in ventricular myocytes. Contractile dysfunction in cardiomyocytes isolated from frail mice was attributable to parallel changes in underlying Ca2+ transients. These changes were not due to reduced sarcoplasmic reticulum stores, but were graded by smaller Ca2+ currents (r=-0.40, p=0.008), lower gain (r=-0.37, p=0.02) and reduced expression of Cav1.2 protein (r=-0.68, p=0.003). Conclusions: These results show that cardiac hypertrophy and contractile dysfunction in naturally-ageing mice are graded by overall health and suggest that frailty, in addition to chronological age, can help explain heterogeneity in cardiac ageing. This model system can ultimately be used to test interventions designed to improve cardiovascular outcomes in frail older adults.

Predicting risk and outcomes for frail older adults: an umbrella review of frailty screening tools.

EXECUTIVE SUMMARYBackgroundA scoping search identified systematic reviews on diagnostic accuracy and predictive ability of frailty measures in older adults. In most cases, research was confined to specific assessment measures related to a specific clinical model.ObjectivesTo summarize the best available evidence from systematic reviews in relation to reliability, validity, diagnostic accuracy and predictive ability of frailty measures in older adults.Inclusion criteria PopulationOlder adults aged 60 years or older recruited from community, primary care, long-term residential care and hospitals.Index testAvailable frailty measures in older adults.Reference testCardiovascular Health Study phenotype model, the Canadian Study of Health and Aging cumulative deficit model, Comprehensive Geriatric Assessment or other reference tests.Diagnosis of interestFrailty defined as an age-related state of decreased physiological reserves characterized by an increased risk of poor clinical outcomes.Types of studiesQuantitative systematic reviews.Search strategyA three-step search strategy was utilized to find systematic reviews, available in English, published between January 2001 and October 2015.Methodological qualityAssessed by two independent reviewers using the Joanna Briggs Institute critical appraisal checklist for systematic reviews and research synthesis.Data extractionTwo independent reviewers extracted data using the standardized data extraction tool designed for umbrella reviews.Data synthesisData were only presented in a narrative form due to the heterogeneity of included reviews.ResultsFive reviews with a total of 227,381 participants were included in this umbrella review. Two reviews focused on reliability, validity and diagnostic accuracy; two examined predictive ability for adverse health outcomes; and one investigated validity, diagnostic accuracy and predictive ability. In total, 26 questionnaires and brief assessments and eight frailty indicators were analyzed, most of which were applied to community-dwelling older people. The Frailty Index was examined in almost all these dimensions, with the exception of reliability, and its diagnostic and predictive characteristics were shown to be satisfactory. Gait speed showed high sensitivity, but only moderate specificity, and excellent predictive ability for future disability in activities of daily living. The Tilburg Frailty Indicator was shown to be a reliable and valid measure for frailty screening, but its diagnostic accuracy was not evaluated. Screening Letter, Timed-up-and-go test and PRISMA 7 (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) demonstrated high sensitivity and moderate specificity for identifying frailty. In general, low physical activity, variously measured, was one of the most powerful predictors of future decline in activities of daily living.ConclusionOnly a few frailty measures seem to be demonstrably valid, reliable and diagnostically accurate, and have good predictive ability. Among them, the Frailty Index and gait speed emerged as the most useful in routine care and community settings. However, none of the included systematic reviews provided responses that met all of our research questions on their own and there is a need for studies that could fill this gap, covering all these issues within the same study. Nevertheless, it was clear that no suitable tool for assessing frailty appropriately in emergency departments was identified.

Predicting risk and outcomes for frail older adults

Predicting risk and outcomes for frail older adults