Background: Hospital Emergency Departments (EDs) experience high presentation rates from older adults residing in Aged Care Facilities (ACFs), yet very few intervention studies have addressed the care needs of this population group. We designed and implemented a nurse-led model of care for older adults from ACFs, and determined its impact on patient outcomes.
Methods: This 12-month pre–post intervention study was conducted during 2013–2014, with follow-up during 2015–2016. Participants included all older adults presenting from ACFs to the ED of Mater Hospital Brisbane (MHB), Australia. Frailty status was determined using the Clinical Frailty Scale (CFS).
Results: All participants were frail (n = 1130), with 19% severely frail, 55% very-severely frail, and 26% terminally ill. The intervention resulted in several improvements in patient outcomes, including significant reductions in ward admissions and 28-day representation rates.
Conclusion: Significant improvements can be achieved by integration of an acute frail older person service into an ED.
BACKGROUND: Rapid frailty screening remains problematic in primary care. The diagnostic test accuracy (DTA) of several screening instruments has not been sufficiently established. We evaluated the DTA of several screening instruments against two reference standards: Fried's Frailty Phenotype [FP] and the Adelaide Frailty Index [AFI]), a self-reported questionnaire.
METHODS: DTA study within three general practices in South Australia. We randomly recruited 243 general practice patients aged 75+ years. Eligible participants were 75+ years, proficient in English and community-dwelling. We excluded those who were receiving palliative care, hospitalised or living in a residential care facility.We calculated sensitivity, specificity, predictive values, likelihood ratios, Youden Index and AUC for: Edmonton Frail Scale [EFS], FRAIL Scale Questionnaire [FQ], Gait Speed Test [GST], Groningen Frailty Indicator [GFI], Kihon Checklist [KC], Polypharmacy [POLY], PRISMA-7 [P7], Reported Edmonton Frail Scale [REFS], Self-Rated Health [SRH] and Timed Up and Go [TUG]) against FP [3+ criteria] and AFI [> 0.21].
RESULTS: We obtained valid data for 228 participants, with missing scores for index tests multiply imputed. Frailty prevalence was 17.5% frail, 56.6% pre-frail [FP], and 48.7% frail, 29.0% pre-frail [AFI]. Of the index tests KC (Se: 85.0% [70.2 - 94.3]; Sp: 73.4% [66.5 - 79.6]) and REFS (Se: 87.5% [73.2 - 95.8]; Sp: 75.5% [68.8 - 81.5]), both against FP, showed sufficient diagnostic accuracy according to our pre-specified criteria.
CONCLUSIONS: Two screening instruments - the KC and REFS, show the most promise for wider implementation within general practice, enabling a personalised approach to care for older people with frailty.
Frailty is a complex age-related clinical condition characterised by a decline in physiological capacity across several organ systems, with a resultant increased susceptibility to stressors. Because of the heterogeneity of frailty in clinical presentation, it is important to have effective strategies for the delivery of care that range across the continuum of frailty severity. In clinical practice, we should do what works, starting with frailty screening, case identification, and management of frailty. This process is unarguably difficult given the absence of an adequate evidence base for individual and health-system interventions to manage frailty. We advocate change towards individually tailored interventions that preserve an individual's independence, physical function, and cognition. This change can be addressed by promoting the recognition of frailty, furthering advancements in evidence-based treatment options, and identifying cost-effective care delivery strategies.
Frailty is a state of vulnerability resulting from cumulative decline in many physiological systems during a lifetime. It is progressive and considered largely irreversible, but its progression may be controlled and can be slowed down and its precursor -pre-frailty- can be treated with multidisciplinary intervention. The aim of this narrative review is to provide an overview of the different ways of measuring frailty in community settings, hospital, emergency, general practice and residential aged care; suggest occupational groups who can assess frailty in various services; discuss the feasibility of comprehensive geriatric assessments; and summarise current evidence of its management guidelines. We also suggest practical recommendations to recognise frail patients near the end of life, so discussions on goals of care, advance care directives, and shared decision-making including early referrals to palliative and supportive care can take place before an emergency arises. We acknowledge the barriers to systematically assess frailty and the absence of consensus on best instruments for different settings. Nevertheless, given its potential consequences including prolonged suffering, disability and death, we recommend identification of frailty levels should be universally attempted in older people at any health service, to facilitate care coordination, and honest discussions on preferences for advance care with patients and their caregivers.