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A scoping review of evidence for measuring frailty in hospital settings

Olga Theou, PhDDalhousie University

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Kayla Mallery, BScDalhousie University

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Presenters

• Assistant Professor of Medicine at Dalhousie University• Affiliated Scientist of Geriatric Medicine with the Nova Scotia

Health Authority• Adjunct Senior Lecturer of Medicine with the University of

Adelaide in Australia

• First year medical student at Dalhousie University• Obtained her BSc in Neuroscience from Dalhousie University• Worked as a Research Assistant from 2014-2016 for Dalhousie

University’s Geriatric Medicine Research team under the supervision of Dr. Theou and Dr. Kenneth Rockwood

2017-02-15

A scoping review of evidence for measuring frailty in hospital settings

Olga Theou,PhD

Kayla Mallery,BSc

A scoping review of evidence for measur ing frailt y in hospital set t ings

Theou O, Mallery K, Squires E, Goldstein J, Lee J, Greene J, Devereaux B, Brown R, Armstrong J, Douglas B, Rockwood K

Geriatric Medicine, Dalhousie UniversityNova Scotia Health Authority

Halifax, NS, Canada

• Many older adults are frail, especially in clinical settings.

• Frail older adults often require individualized interventions and modification of standard protocols.

• Most frailty literature-reviews focus on the community setting.

• How to measure frailty in clinical settings and which tools should be used are questions of ongoing debate.

Why is it important to identify frailty in hospital?

• To conduct a scoping review focused on frailty identification and management in acutely ill hospitalized patients.

• To map the literature and identify and document the nature and extent of research evidence related to frailty measures in hospital settings.

What was the purpose of this study?

• Databases: MEDLINE, CINAHL, Embase, PscyhINFO, Eric, Cochrane

• Articles published up to September 2015

• Search terms: Frail Aged Pre-hospital Acute Care

How was the search conducted?

• Original research (and guidelines)

• Published after 2000

• Human participants

• Included ≥65 years

• Pre-hospital or in-hospital setting

• Acutely ill patients

• Authors identified participants as frail

• Not limited by: study design, quality, or outcome

What were the inclusion/exclusion criteria?

Database Search

N=8658

Title & Abstract ScreeningN= 6037

Full Text ScreeningN= 3240

Included StudiesN= 597

DuplicatesN=2621

ExcludedN=2797

ExcludedN=2643 Hand Search

N= 28

+

What was the screening process?

Descriptive Characteristics

1. In what settings were the studies done?

2. When were the studies published?

3. In what languages were the articles written?

4. In what countries were the studies done?

5. How many participants were in the studies?

6. What was the age of the participants?

7. What was the sex of the participants?

8. What was the study design?

What data did we extract?

Frailty Characteristics

9. How often was frailty measured?

10. When was frailty measured?

11. Who measured frailty?

12. What type of frailty measure was used?

13. What specific scales were used?

14. For what purpose was frailty used?

15. What was the prevalence of frailty?

16. What adverse outcomes did frailty predict?

How often was frailty measured?

66%

33%

1%

Not Measured (n=413)Measured (n=204)Guidelines (n=8)

of studies did not measure

frailty

Not Measured (n=413)

Measured (n=204)

Ger iat r ics 27% 14%

Emergency Depar tment 13% 14%

General Medicine 10% 11%

Orthopedics 11% 5%

Cardiology 5% 10%

ICU 2% 4%

Prehospital 3% 1%

Surgical 1% 2%

Oncology 0% 3%

GI 1% 0%

Neurology 1% 0%

Other Single Unit 1% 1%

General Medicine + Surgical 2% 9%

Geriatric + General Medicine 2% 3%

Other Combined Units 5% 8%

Unspecified Units 17% 13%

In what settings were the studies done?

Geriatrics23%

Emergency Department

13%

General Medicine

10%Orthopedics9%

Cardiology7%

ICU2%

Other Single Unit

7%

Combined Units14%

Unspecified Units16%

For all and by measured / not measured

All (n=625)

When were the studies published?

0%

20%

40%

60%

80%

100%

All (n=625) NotMeasured

(n=413)

Measured(n=204)

0%

20%

40%

60%

80%

100%

By measured / not measured and by setting

%of

stud

ies

%of

stud

ies

In what languages were the articles written?By measured / not measured

All (n=625) Not Measured (n=413) Measured (n=204)

N % N % N %

English 590 94 383 93 200 98

French 11 2 11 3 - -

Italian 8 1 5 1 2 1

Spanish 7 1 7 2 - -

Dutch 4 .6 4 1 - -

Portuguese 3 .5 1 .2 2 1

German 2 .3 2 .5 - -

In what countries were the studies done?

0%

20%

40%

60%

80%

100%

All (n=625) Not Measured(n=413)

Measured(n=204)

Other

Australia/New Zealand

Other Europe

Italy

UK

US

Canada

By measured / not measured%

of s

tudi

es

How many participants were in the studies?By setting

All measured

(n=204)

Geriatrics

(n=29)

Emergency Department

(n=29)

General Medicine

(n=22)

Orthopedics

(n=11)

Cardiology

(n=20)

ICU

(n=9)

N reported 201 28 29 21 11 19 9

Range 9-97,1434 44-20,933 40-7,532 34-3,479 16-36,900 24-111,023 22-47,427

Median (IQR)

206

(101-160)

164

(pp-490)

161

(100-278)

254

(119-562)

145

(47-284)

309

(135-773)

421

(119-982)

What was the age of the participants?By setting

40

50

60

70

80

90

100

All Measured(n=155)

Geriatrics(n=24)

EmergencyDepartment

(n=21)

GeneralMedicine

(n=18)

Orthopedics(n=9)

Cardiology(n=17)

ICU (n=9)

Mea

n ag

e of

stud

y pa

rtici

pant

s

What was the sex of the participants?By setting

0

20

40

60

80

100

120

All Measured(n=187)

Geriatrics(n=27)

EmergencyDepartment

(n=27)

GeneralMedicine

(n=20)

Orthopedics(n=11)

Cardiology(n=19)

ICU (n=9)

% F

emale

What was the study design?By setting

0%

20%

40%

60%

80%

100%

All (n=204) Geriatrics(n=29)

EmergencyDepartment

(n=29)

GeneralMedicine

(n=22)

Orthopedics(n=11)

Cardiology(n=20)

ICU (n=9)

QualitativeExperimentalObservational

% o

f stu

dies

When was frailty measured?

0%

20%

40%

60%

80%

100%

All (n=204) Geriatrics(n=29)

EmergencyDepartment

(n=29)

GeneralMedicine

(n=22)

Orthopedics(n=11)

Cardiology(n=20)

ICU (n=9)

Not reportedRetrospective ReviewMixedDuring HospitalizationAt DischargeAt Admission

By setting

% o

f stu

dies

Who measured frailty?

0%

20%

40%

60%

80%

100%

All (n=204) Geriatrics(n=29)

EmergencyDepartment

(n=29)

GeneralMedicine

(n=22)

Orthopedics(n=11)

Cardiology(n=20)

ICU (n=9)

Not ReportedOtherResearcherHealth Care Professional

By setting

% o

f stu

dies

What type of frailty measure was used?

0%

20%

40%

60%

80%

100%

ALL (n=240) Geriatrics(n=35)

EmergencyDepartment

(n=33)

GeneralMedicine

(n=24)

Orthopedics(n=18)

Cardiology(n=24)

ICU (n=10)

Non-Frailty Scale

Clinical Judgement

Ad Hoc Measure

Established FrailtyTool

By setting

% o

f stu

dies

What type of frailty measure was used?

0%

20%

40%

60%

80%

100%

2000-2005(n=24)

2006-2010(n=42)

2011-2015(n=174)

0%

20%

40%

60%

80%

100%

By year and by country

% of

stud

ies

% of

stud

ies

What specific scales were used?

0 5 10 15 20 25 30

Life Space AssessmentShort Physical Performance Battery

Multidimensional Prognosis IndexGronigen Frailty Indicator

FRAIL scaleTilburg Frailty Indicator

Study of Osteoporotic Fracture IndexRockwood Geriatric Frailty Status

Balducci criteriaVulnerable Elders Survey

Winodgrad IndexEdmonton Frail Scale

GEM drug study criteriaIdentification of Seniors at Risk

Frailty PhenotypeFrailty Index

Clinical Frailty Scale

Number of Studies

What specific scales were used?

Ranked Geriatrics (n=29)

Emergency Department

(n=29)

General Medicine (n=22)

Orthopedics (n=11)

Cardiology (n=20)

ICU (n=9)

1 Clinical Frailty Scale (17%) Frailty Index (21%)

Clinical Frailty Scale (17%),

Frailty Phenotype (17%),

Frailty Index (17%)

Frailty Index (22%) Frailty Phenotype (25%) CFS (60%)

2Identification of Seniors At Risk

(11%)Clinical Frailty Scale

(12%),Frailty Phenotype

(12%)

Mobility/Balance (11%)

Clinical Frailty Scale (13%)

Frailty Phenotype (20%)

3 Frailty Index (9%)

Frailty Phenotype (6%), Edmonton Frailty Scale (6%), Identification of

Seniors At Risk (6%), Strength (6%)

Edmonton Frailty Scale (8%),

Tilburg Frailty Indicator (8%)

Frailty Index (10%)

4Frailty Phenotype

(6%), Study ofOsteoporotic

Fracture Index (6%), Rockwood Geriatric Frailty Status (6%), Multidimensional

Prognosis Index (6%), Strength (6%)

Identification of Seniors At Risk (9%),

Vulnerable Elders Survey (9%)

Edmonton Frailty Scale (8%),

Identification of Seniors At Risk (8%)

-

5

Frailty Index (4%), Rockwood Geriatric Frailty Status (4%), FRAIL scale (4%), Identification of

Seniors At Risk (4%), Mobility/Balance (4%)

By setting

For what purpose was frailty used?By setting

% o

f stu

dies

0%

20%

40%

60%

80%

100%

All (n=625) Geriatrics(n=29)

EmergencyDepartment

(n=29)

GeneralMedicine

(n=22)

Orthopedics(n=11)

Cardiology(n=20)

ICU (n=9)

Descriptive

Mixed

Outcome

Inclusion/Exclusion

Risk Stratification

For what purpose was frailty used?By year and by design

% of

stud

ies

% of

stud

ies

0%

20%

40%

60%

80%

100%

2000-2005(n=24)

2006-2010(n=42)

2011-2015(n=174)

0%

20%

40%

60%

80%

100%

Observational(n=166)

Experimental(n=32)

Qualitative(n=6)

What was the prevalence of frailty?

0

20

40

60

80

100

ALL (n=122) Geriatrics(n=17)

EmergencyDepartment

(n=13)

GeneralMedicine

(n=12)

Orthopedics(n=5)

Cardiology(n=17)

ICU (n=8)

By setting%

Fra

il

What was the prevalence of frailty?By age, by % females, and by type of frailty measure

0

20

40

60

80

100

Mean Age<80(n=63)

Mean Age>80(n=42)

<50% Females(n=45)

>50% Females(n=72)

EstablishedFrailty Scale

(n=81)

Ad HocMeasure (n=19)

ClinicalJudgment (n=2)

Non-FrailtyScale (n=20)

% F

rail

What adverse outcomes did frailty predict?

0 10 20 30 40 50 60 70

Other

Quality of life decline

Cognitive decline

Treatment response

Delirium

Falls

Treatment change

Functional decline

Rehospitalization

Complications

Institutionalization

Length of stay

Mortality

Predictive

Not Predictive

Number of Studies

What adverse outcomes did frailty predict?By setting

0%

20%

40%

60%

80%

100%

ALL (n=228) Geriatrics(n=33)

EmergencyDepartment

(n=33)

GeneralMedicine

(n=23)

Orthopedics(n=16)

Cardiology(n=19)

ICU (n=33)

Not Predictive

Predictive% o

f stu

dies

What adverse outcomes did frailty predict?By type of frailty measure

0%

20%

40%

60%

80%

100%

Established FrailtyScales (n=164)

Ad Hoc Measure(n=19)

Clinical Judgement(n=2)

Non-Frailty Scales(n=43)

Not Predictive

Predictive

% o

f stu

dies

What adverse outcomes did frailty predict?By frailty tool

0%

20%

40%

60%

80%

100%

Clinical FrailtyScale (n=48)

Fraily Index(n=44)

FrailtyPhenotype

(n=30)

EdmontonFrailty Scale

(n=16)

Identificationof Seniors At

Risk (n=5)

Not Predictive

Predictive

% o

f stu

dies

SummaryDescriptive Characteristics – All studies

Q. In what settings were the studies done? A. Most common settings were geriatrics, emergency department, and general medicine.

Q. When were the studies published? A. Almost 50% of the studies between 2011-2015. Even higher % among studies that

measured frailty (70%).

Q. In what languages were the articles written? A. Majority in English.

Q. In what countries were the studies done? A. >50% in USA, UK, Canada and Italy.

Q. How many participants were in the studies? A. Great variability but median ~200.

Q. What was the age of the participants? A. Median ~80.

Q. What was the sex of the participants? A. Median ~55% of females included in study.

Q. What was the study design? A. More than 80% observational studies.

SummaryDescriptive Characteristics – Measured studies

Q. How often was frailty measured?A. Only 33% of the studies.

Q. When was frailty measured? A. More than 50% of the studies measured frailty at admission.

Q. Who measured frailty?A. Health care professionals (50%) and researchers (50%).

Q. What was the prevalence of frailty? A. ~50%.

SummaryFrailty Characteristics

Q. What type of frailty measure was used? A. Most used established frailty tool (50%) but big change over time

Q. What specific scales were used? A. The Clinical Frailty Scale, Frailty Index, and phenotype were most commonly used.

Q. For what purpose was frailty used? A. ~50% of the studies used frailty as a risk stratification tool.

Q. What adverse outcomes did frailty predict? A. The most common were mortality, LOS, institutionalization, and complications. In 80% of

the cases frailty was predictive.

SummaryFrailty Characteristics

Limitations

• Very broad scope

• No assessment of quality of studies

• No meta-analysis

• Limited non-English articles

• Only studies with acutely ill inpatients

• Only studies which included older adults

• Possible more studies measured frailty but did not report it

• Great variability on how frailty was measured

• No review of the grey literature

ConclusionKnown Knowns

• Most studies were done in non-geriatric settings in North America or Europe between 2011-2015.

• Most of studies identify participants as frail without measuring frailty.

• Over time, frailty has been studied in more settings and measured more often using established frailty tools.

• The most commonly used scales were the Clinical Frailty Scale, the Frailty Index and the Frailty Phenotype.

• Most studies are observational and use frailty tools for risk stratification.

• Most studies showed that frailty tools are predictive of adverse health outcomes especially mortality and institutionalization.

• The frailty index and the Edmonton Scale seem to have the best predictive ability.

ConclusionKnown Unknowns

• Frailty examined in experimental and qualitative studies.

• Frailty included as an outcome measure.

• Frailty measured in other clinical settings.

• Frailty predicting patient-oriented outcome measures.

• Frailty identification improving clinical decision making.

• Developing frailty management plans.

• Frailty identification and management improving care.

Next stepsCall to Action

Identify participants as frail only when it has been measured.

Report details of when and who measured frailty. Use established frailty tools and report details on

modifications. Conduct observational studies using patient-

oriented outcomes. Conduct qualitative studies about frailty. Conduct RCTs about modifying treatment plans

based on frailty level. Conduct RCTs using frailty as an outcome.

Acknowledgements

Lindsay WallaceEmiel HoogendijkAgathe Daria JadczakPeter HicoYe PengMark ThompsonFernando PenaOleg Zaslavsky

Sherri FaySacha NadeauElizabeth DoyleJudith GodinJosh WebbRoxanne SterniczukKaterina TheohariNika Dominika Seblova

Want to know more? Interested in collaborating?Contact

Olga Theou, Principal Investigatorolga.theou@dal.ca

Kayla Mallery, Research Assistant ky834773@dal.ca

Emma Squires, Research Assistant emmajean.squires@nshealth.ca