How should we grade frailty in nursing home patients?

doi:10.1016/j.jamda.2007.07.012

Journal of the American Medical Directors Association

Volume 8, Issue 9, November 2007, Pages 595-603

https://doi.org/10.1016/j.jamda.2007.07.012 Get rights and content

Objectives

To compare 3 methods of describing the frailty of older adults in nursing homes.

Design

Secondary analysis of a prospective cohort study.

Setting

Canadian long-term care institutions.

Participants

Institutionalized older adults in the second clinical examination cohort of the Canadian Study of Health and Aging (CSHA-2; n = 728).

Measures

Frailty was measured using the Cardiovascular Health Survey definition (Frail-CHS); the CSHA- Clinical Frailty Scale (CSHA-CFS) and a frailty index (FI).

Results

The sample was very elderly (87.7 ± 6.7 years), disabled (83%), and showed a high level of mobility impairment (83%). Each frailty measure correlated moderately well with each other (0.61–0.71) and with a disability measure (–0.45 to –0.53) but only weakly with age (0.13–0.19). By each measure, frailty was significantly associated (P < .01) with an increased risk of mortality, disability and cognitive decline. In a model that included both the frailty-CHS definition and the Frailty Index only the latter was associated with a higher risk of mortality (P < .01 for FI, P = .18 for Frail-CHS) and decline in the 3MS (P < .01 for FI, P = .20 for the Frail-CHS definition). Both measures were significantly associated with new onset disability (P < .01). Similar results were found when both the CSHA-CFS and Frailty Index were included in the models. Random combinations of 15 variables used to make up alternate 5-item Frail-CHS definitions showed that any stratification based on 5 variables allowed tertiles of risk to be discriminated.

Conclusions

Frailty is a robust concept and however defined, elderly people who are frail have worse outcomes than those who are not frail. The 3 measures showed varying ability to express grades of frailty.

Section snippets

Sample/Setting

This is a secondary analysis of data from the clinical sample of the second wave (CSHA-2) of the Canadian Study of Health and Aging (CSHA), a population-based prospective cohort study.³¹ The CSHA chiefly aimed to document the prevalence of risk factors for cognitive impairment among elderly people. At baseline (CSHA-1) a community-based screening interview used extensive self-report data, and the Modified Mini-Mental State Examination (3MS)³² to screen elderly people for cognitive impairment.

Results

At baseline, the sample was largely female, quite elderly, and very disabled. Important degrees of cognitive and functional impairment, and impaired mobility were common (Table 1).

Each of the frailty measures was moderately correlated with each other and with age (Table 2). Each showed moderate correlations with baseline disability (–0.45 to –0.53). The frailty-CHS definition correlated less well with the 3MS (–0.22) than did the CSHA-CFS (–0.43) or the Frailty Index (–0.50).

Even within this

Discussion

We compared how 3 different frailty measures graded frailty among institutionalized individuals. Each measure was able to stratify the risk of death, and in multivariate analyses, each measure was significantly associated with mortality, decline in 3MS score, and incident disability. When pairs of frailty measures were included in the models, the Frailty Index was significantly associated with mortality and decline in the 3MS. All measures were significantly associated with incident disability.

Conclusion

The 3 measures of frailty studied here each identified people at an increased risk of adverse outcomes. Each has particular strengths. In our view, no one method is so self-evidently superior that it, and only it, can be held to be the only means of defining frailty. The precise definition of frailty remains a worthy challenge.

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The Association Between Habitual Tea Consumption and Frailty Transition in Community-Dwelling Older Adults: A Prospective Cohort Study
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To investigate the association between habitual tea consumption and transitions between frailty states among older adults in China.
A prospective cohort study based on the Chinese Longitudinal Healthy Longevity Study.
A total of 23,720 older adults aged ≥65 years with complete data regarding frailty status and tea consumption were recruited.
The frequency and consistency of tea consumption were introduced to evaluate levels of tea consumption. The frailty index was used to define frailty status (frail and nonfrail). Frailty transition was classified into remaining nonfrail, improvement, worsening, and remaining frail groups. Logistic regression models were applied.
The overall frailty prevalence at baseline was 19.1%, being lower among consistent daily tea drinkers (12.5%) and higher among non-tea drinkers (21.9%). Logistic regression analyses showed that the risk of frailty was significantly reduced among consistent daily tea drinkers after adjusting for all confounders [odds ratio (OR), 0.81; 95% CI, 0.67–0.98]. During the 3-year follow-up, improvement in frailty status was more common among consistent daily tea drinkers (50.9%) than non-tea drinkers (40.9%), and this trend was opposite in participants with worsened frailty status (consistent daily tea drinkers: 12.2%) vs non-tea drinkers: 19.2%). Further analysis showed that consistent daily tea drinkers were significantly associated with improvement in frailty status (OR, 3.24; 95% CI, 1.02–10.31) and remaining in a nonfrail state (OR, 1.35; 95% CI, 1.00–1.83). In addition, daily tea consumption was observed to be positively associated with remaining in a nonfrail state and inversely associated with worsened frailty status in men, but not in women.
Older people consuming tea daily tend to have an improved frailty status in the future. Men with daily tea consumption were less likely to have a worsened frailty status. Advocating for the traditional lifestyle of drinking tea could be a promising way to advance healthy aging for older adults.
Prognostic association of frailty with post-arrest outcomes following cardiac arrest: A systematic review and meta-analysis
2021, Resuscitation
To synthesize the current evidence examining the association between frailty and a series of post-arrest outcomes following the provision of cardiopulmonary resuscitation (CPR).
We searched MEDLINE, PubMed (exclusive of MEDLINE), EMBASE, CINAHL, and Web of Science from inception to August 2020 for observational studies that examined an association between frailty and post-arrest health outcomes, including in-hospital and post-discharge mortality. We conducted citation tracking for all eligible studies.
Our search yielded 20,480 citations after removing duplicate records. We screened titles, abstracts and full-texts independently and in duplicate.
The prognosis research strategy group (PROGRESS) and the critical appraisal and data extraction for systematic review of prediction modelling studies (CHARMS) guidelines were followed. Study and outcome-specific risk of bias were assessed using the Quality in Prognosis Studies (QUIPS) instrument. We rated the certainty of evidence using the Grading of Recommendations, Assessment, Development and Evaluations (GRADE) recommendations for prognostic factor research.
Four studies were included in this review and three were eligible for statistical pooling. Our sample comprised 1,134 persons who experienced in-hospital cardiac arrest (IHCA). The mean age of the sample was 71 years. The study results were pooled according to the specific frailty instrument. Three studies used the Clinical Frailty Scale (CFS) and adjusted age (our minimum confounder); the presence of frailty was associated with an approximate three-fold increase in the odds of dying in-hospital after IHCA (aOR = 2.93; 95% CI = 2.43–3.53, high certainty). Frailty was also associated with decreased incidence of ROSC (return of spontaneous circulation) and discharge home following IHCA. One study with high risk of bias used the Hospital Frailty Risk Score and reported a 43% decrease in the odds of discharge home for patients with frailty following IHCA.
High certainty evidence was found for an association between frailty and in-hospital mortality following IHCA. Frailty is a robust prognostic factor that contributes valuable information and can inform shared-decision making and policies surrounding advance care directives.
Registration: PROSPERO Registration # CRD42020212922
The utility of frailty indices in predicting the risk of health care associated infections: A systematic review
2021, American Journal of Infection Control
Health care associated infections (HAIs) are a major health concern associated with significant morbidity and mortality. The relationship between frailty, a syndrome often associated with older individuals, and HAIs has not been investigated.
To determine if frailty scoring systems can assist in predicting the risk of developing HAIs in health care settings.
A directed search was conducted across 4 databases (MEDLINE, Cochrane, Scopus, and CINAHL) for articles published between 1 January 1990 and 31 December 2019. All articles were screened for relevance to the research aims. The Newcastle-Ottawa Scale was utilised to assess the study quality and risk of bias.
The literature search yielded 290 results, with 14 articles meeting the inclusion criteria. Significant heterogeneity was present across the studies with regards to the frailty index employed and HAI definitions. Most studies were conducted in an acute health care setting (n = 12), while 2 studies were conducted in nursing homes. Eight studies demonstrated that frail individuals were at an increased risk of developing HAIs, in both surgical (n = 5) and medical patient populations (n = 2). Two of the 3 validated frailty scoring systems employed across the studies, the Clinical Frailty Scale and the Frailty Index demonstrated this relationship.
The results of this review demonstrate a potential association between frailty and the development of HAIs.
Investigating the prevalence of malnutrition, frailty and physical disability and the association between them amongst older care home residents
2020, Clinical Nutrition ESPEN
Malnutrition, frailty and physical disability are inter-related, more prevalent in the older population and increase the risk of adverse health outcomes. Thus, screening is essential, especially in the understudied care home setting where the population is vulnerable and at higher risk of malnutrition. Furthermore, prevalence may vary depending upon screening tools used. The aims of this study were to: 1) investigate the prevalence of 1) malnutrition risk using Mini Nutritional Assessment – Short Form (MNA-SF) and Malnutrition Universal Screening Tool (MUST), 2) frailty using the Edmonton Frailty Scale (EFS), 3) physical disability using the Barthel Index (BI) and (4) examine the association between variables and coexistence of states.
Screening for malnutrition (MNA-SF and MUST) and frailty (EFS) was performed as part of a comprehensive geriatric assessment (CGA) in 527 residents from 17 care homes in Lincoln, UK. Mean age of the group was 85.6 ± 7.6 years and body mass index, BMI 23.0 ± 5.1 kg/m².
A high prevalence of malnutrition risk was detected: 41.4% by MNA-SF and 25.5% by MUST (high risk/malnourished). Furthermore, there was a clear discordance between MNA-SF and MUST scoring of malnutrition; for example, the percentage of those identified as being at low risk was 18.8% using the MNA-SF and 57.0% using the MUST. In addition, there was a high prevalence of severe frailty by EFS (69.6%) and functional impairment by BI (62.0%). There was good association between some variables (P < 0.001) and 33.4% of residents had coexistence of all three states of malnutrition, frailty and physical disability.
Malnutrition risk, frailty and physical disability are highly prevalent in care home residents and interrelated. However, prevalence varies depending on the screening tool used. More research should be conducted in the care home setting to improve daily clinical practice as screening may impact upon subsequent treatment and care modalities and clinical outcomes.
The Prevalence of the Frailty Syndrome in a Hospital Setting—Is Its Diagnosis a Challenge? A Comparison of Four Frailty Scales in a Cross-Sectional Study
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Frailty impacts immune responses to Moderna COVID-19 mRNA vaccine in older adults
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: Funds for analysis came from the Canadian Institutes for Health Research (CIHR) grant MOP 628823 and the Dalhousie University Internal Medicine Research Foundation. Kenneth Rockwood is supported by the Dalhousie Medical Research Foundation as Kathryn Allen Weldon Professor of Alzheimer Research.

: The authors assert no financial conflict of interest.

View full text

Original studyHow should we grade frailty in nursing home patients?

Objectives

Design

Setting

Participants

Measures

Results

Conclusions

Section snippets

Sample/Setting

Results

Discussion

Conclusion

Lancet

Mech Age Dev

Mech Ageing Dev

Am J Clin Nutr

Mech Ageing Dev

Mech Ageing Dev

Mech Ageing Dev

The Lifespan of Animals

Biodemographic trajectories of longevity

Science

Reliability theory of aging and longevity

Why do we age?

Nature

Frailty in relation to the accumulation of deficits

J Gerontol A Biol Sci Med Sci

Frailty in elderly peopleAn evolving concept

CMAJ

Factors associated with institutionalization of older people in Canada: Testing a multifactorial definition of frailty

J Am Geriatr Soc

Long-term risks of death and institutionalisation of elderly people in relation to deficit accumulation at age 70

J Am Geriatr Soc

A global clinical measure of fitness and frailty in elderly people

CMAJ

Accumulation of deficits as a proxy measure of aging

The Scientific World

The mortality rate as a function of accumulated deficits in a frailty index

Mech Ageing Dev

, Relative fitness and frailty of elderly men and women in developed countries and their relationship with mortality

J Am Geriatr Soc

Cumulative index of health deficiencies as a characteristic of long life

J Am Geriatr Soc

Frailty index as a measure of biological age in a Chinese population

J Gerontol A Biol Sci Med Sci

What would make a definition of frailty successful?

Age Ageing

Frailty: An emerging research and clinical paradigm issues and controversies

J Gerontol A Biol Sci Med Sci

Original study
How should we grade frailty in nursing home patients?