Assessing the utility of simple measures of frailty in older hospital-based cardiology patients by Yong Yong Tew (medical student)
Declaration No conflict of interest. Ethical considerations Reviewed and approved by the South East Scotland Research Ethics Committee. All participants provided written informed consent.
Introduction Readmitted Cardiology ward Older Younger Died No poor outcomes
The link 1 Cardiovascular disease Frailty Poor outcomes
What is frailty? Frailty describes: A lack of physiological reserve in older adults that increases the risk of dependency or death. 2
Aim To identify simple health measures that can best predict poor clinical outcomes, i.e. readmission or mortality, in cardiovascular disease. Cardiovascular disease Frailty Poor outcomes
Study population Prospective study. 100 patients. 70 years old. Admitted to the cardiology department. Ready for hospital discharge within 24 hours. Royal Infirmary of Edinburgh, United Kingdom. Between January 23 rd and April 23 rd 2017.
Methods R: Rapid. E: Easy to interpret. A: Easy to Administer. L: Low cost.
PRISMA-7 Questionnaire Self-reported frailty questionnaire. 7 questions covering: Health limitations Carer assistance Mobility difficulties Social support
Frailty defined as 3
When used together Allow a direct comparison of the different methods to assess frailty, i.e: Using physical measures (Fried scale and SPPB) 3,4 Holistic nursing assessment (CFS) 5 Patient-reported activity (PRISMA-7) 6
Results Females 34% 100 patients 66% males Mean age 79.9 ± 6.3 years Males 66% Follow-up: Electronic health records Median : 25 days (range 13 46.5 days). Composite primary outcome of: Hospital readmission All-cause mortality after discharge.
Identification of frailty Frailty Tools Frailty Fried Criteria 28% Short Performance Physical Battery (SPPB) 79% Clinical Frailty Scale (CFS) 17% PRISMA-7 Questionnaire 65% Table 1: Identification of frailty using different frailty tools
Agreement between measures Figure 1: Prevalence of frailty in our cohort according to Clinical Frailty Scale (CFS), PRISMA-7 questionnaire, Fried Criteria and Short Physical Performance Battery (SPPB)
Outcomes Figure 2: Graph of cumulative readmission or death with time by Fried frailty status
Clinical outcomes by Fried frailty status Total (n=100) Frail (n=28) Non-frail (n=72) p value No. of readmissions 0.3 ± 0.8 0.6 ± 1.2 0.2 ± 1.4 0.02 a Total bed days readmitted 2.4 ± 7.9 5.3 ± 11.9 1.2 ± 5.4 0.02 a Death 2 (2%) 2 (7%) 0 (0%) 0.02 b Referred for cardiac rehabilitation 30 (30%) 5 (18%) 25 (35%) 0.10 b Notes: Values are mean ± SD or n (%). a Student t-test. b Pearson s chi-square test. Data in bold indicates statistical significance. Table 2: Clinical Outcomes by Frailty Status (Fried Critera 3) (n=100)
Strengths Done at the point of discharge, where patients were deemed to be fit-for-home. The first to compare four different frailty tools on an individual's risk of adverse outcomes. In terms of outcomes, our study also took into account the number of readmissions and the total bed days in readmissions. These findings are essential to estimate healthcarerelated costs.
Limitations A single-centre study in Edinburgh. Relatively small sample size. Currently, there is no true gold standard frailty tool. 2 The Fried scale is limited only to the physical aspects of frailty; when in fact frailty is more to just physical vulnerability.
Conclusions Measuring frailty in hospitalised patients with cardiovascular disease was feasible and acceptable to both patients and staffs. Individual frailty measures vary significantly with limited agreement. The Fried frailty status: Can be obtained in less than 3 minutes. Appears to identify patients at higher short-term risk after hospital discharge. Strategies to reduce hospital readmission or target anticipatory care planning could focus on this frail older group.
References 1. Singh M, Stewart R, White H. Importance of frailty in patients with cardiovascular disease. European Heart Journal. 2014; 35: 1726 1731. 2. Morley JE, Vellas B, van Kan GA, et al. Frailty consensus: A call to action. J Am Med Dir Assoc. 2013; 14(6): 392 397. 3. Fried LP, Tangen CM, Walston J, et al. Frailty in older adults: evidence for a phenotype. J Gerontol Med Sci 2001; 56: M146 156. 4. Guralnik JM, Simonsick EM, Ferrucci L, et al. A short physical performance battery assessing lower extremity function: Association with self-reported disability and prediction of mortality and nursing home readmission. J Gerontol. 1994; 49: M85 94. 5. Rockwood K, Song X, MacKnight C, et al. A global clinical measure of fitness and frailty in elderly people. CMAJ. 2005; 173(5): 489 495. 6. Hébert R, Bravo G, Korner-Bitensky N, et al. Refusal and information bias associated with postal questionnaires and face-to-face interviews in very elderly subjects. J Clin Epidemiol. 1996; 49(3): 373 381.
Acknowledgement Polly Keeling 1 Dr. Atul Anand 2,3 Prof. Alasdair MacLullich 3 Prof. Nicholas Mills 2 Dr. Susan Shenkin 3 Dr. Martin Denvir 2 Royal College of Physicians of Edinburgh 1 University of Edinburgh Medical School (medical student) 2 Centre for Cardiovascular Science, University of Edinburgh 3 Department of Geriatric Medicine, University of Edinburgh
Comparison of clinical outcomes
Comparison of clinical outcomes