A scoping review of evidence for measuring frailty in pre-hospital and hospital settings

Theou, O., Mallery, K., Goldstein, J., Armstrong, J., Greene, J., Douglas, B., Devereaux, B., Lee, J., Rockwood, K. (March 2016). How is frailty identified and managed in emergency and acute care? A scoping review of evidence and policy. International Conference on Frailty and Sarcopenia Research, 30pp.

Mallery, K., Squires, E., Theou, O., Goldstein, J., Armstrong, J., Greene, J., Douglas, B., Devereaux, B., Lee, J., Rockwood, K. (March 2016). A scoping review: how is frailty identified in acutely ill hospitalized patients? Dalhousie University Department of Medicine Research Day.

Mallery, K., Theou, O., Goldstein, J., Armstrong, J., Webb, J., Greene, J., Douglas, B., Lee, J., Rockwood, K. (September 2015). Identifying and responding to frailty in emergency and acute care settings: a scoping review. The 3rd annual Technology Evaluation in the Elderly Network conference.

Rationale: No systematic reviews of the literature have been conducted with a general focus on frailty measures used in prehospital and in hospital settings. The ability of acute care settings to cope with the influx of frail older patients may be reaching a limit, and unless changes are made, it seems inevitable that care provided to frail older adult will suffer.

Hypothesis: Identifying frail elderly people at higher risk for adverse outcomes, within pre-hospital and in-hospital settings may lead to improvements in care.

Objectives: Our purpose is to conduct a systematic review to document the nature and extent of research evidence related to measuring frailty in acutely ill patients in prehospital and in-hospital settings.

Research plan: Academic literature databases were searched for publications that identified frailty in actually ill patients in prehospital or hospital settings. The title and abstracts of the articles were screened for inclusion and full text was retrieved for all publications that met the screening criteria. Descriptive data, study design (e.g. frailty measures) and outcome measures were documented.

Key Findings:

• Two thirds of all studies identified participants as frail without measuring frailty.
• The most common frailty measurements (14% each) were the Clinical Frailty Scale, the Frailty Index, and the Frailty Phenotype.
• The most common use of frailty assessment was to predict adverse health outcomes and, in 74% of the cases, frailty was predictive of an adverse outcome.
• We found 413 articles that identified participants as frail without measuring frailty, and 204 articles that measured frailty.
• The majority (81%) of research that measured frailty were observational studies.
• Most (60%) of the reported frailty measures were developed to measure frailty; however, 27% of frailty measures used operational definitions for the purpose of that study and 2% defined frailty using clinical judgement.
• The Clinical Frailty Scale, Frailty Index, and Frailty Phenotype were the most commonly reported scales.
• 44% of studies used frailty to predict adverse health outcomes, 20% used frailty as an inclusion and exclusion criterion, and 4% used frailty as an outcome measure. One third of studies used frailty for descriptive purposes only.
• Most studies showed that frailty tools are predictive of adverse health outcomes, specifically mortality (84% of cases) and institutionalization (93% of cases).

Why was this study needed?

This was the first comprehensive scoping review about frailty in acute care. We mapped the literature and identified the nature and extent of research evidence related to frailty measures in hospital settings. In addition, we identified gaps that need to be addressed in future research.

Suggestions on how administrators or policy makers could use the findings:

• Our summary reports can be used to make an informed decision about implementing a frailty assessment in a specific care setting.

Brief comment on type of study:

• We performed a literature review to determine how frailty assessment tools have been used in research to identify and manage acutely ill hospitalized patients.
• Our literature review included a search of five large health research databases for all articles published between 2000 and 2015 that include the words: frail, aged, pre-hospital, and acute care.
• The literature we reviewed was original research that studied acutely ill human participants age 65 or older, in pre-hospital or in-hospital settings where the authors identified patients as living with frailty.

Key Findings:

• Two thirds of all studies identified participants as frail without measuring frailty.
• The most common frailty measurements (14% each) were the Clinical Frailty Scale, the Frailty Index, and the Frailty Phenotype.
• The most common use of frailty assessment was to predict adverse health outcomes and, in 74% of the cases, frailty was predictive of an adverse outcome.
• We found 413 articles that identified participants as frail without measuring frailty, and 204 articles that measured frailty.
• The majority (81%) of research that measured frailty were observational studies.
• Most (60%) of the reported frailty measures were developed to measure frailty; however, 27% of frailty measures used operational definitions for the purpose of that study and 2% defined frailty using clinical judgement.
• The Clinical Frailty Scale, Frailty Index, and Frailty Phenotype were the most commonly reported scales.
• 44% of studies used frailty to predict adverse health outcomes, 20% used frailty as an inclusion and exclusion criterion, and 4% used frailty as an outcome measure. One third of studies used frailty for descriptive purposes only.
• Most studies showed that frailty tools are predictive of adverse health outcomes, specifically mortality (84% of cases) and institutionalization (93% of cases).

Why was this study needed?

This was the first comprehensive scoping review about frailty in acute care. We mapped the literature and identified the nature and extent of research evidence related to frailty measures in hospital settings. In addition, we identified gaps that need to be addressed in future research.

Brief overview of the methodology:

• We performed a scoping review that focused on frailty identification and management in acutely ill hospitalized patients.
• We searched Medline, CINAHL, Embase, PsycINFO, Eric, and Cochrane databases for articles published up to September 2015 using the search terms: frail, aged, pre-hospital, and acute care.
• We included articles that were original research, published after 2000, included acutely ill human participants aged 65y or older, in pre-hospital or in-hospital settings, and authors must have identified their patients as living with frailty.

Potential impact of findings on clinical practice/patient care and how this impact might be measured:

• Our findings highlight the importance of measuring frailty within clinical settings using established frailty tools.
• The findings may promote future research to use frailty in experimental studies as an outcome measure.

Remaining knowledge/research gaps:                                                                              

• It is unclear whether and how frailty identification can improve clinical decision making and overall care of a patient.
• Clinical trials are needed to understand how frailty can be prevented and/or reversed.

PUBLICATION CITATION:

BMC Geriatr. 2018 Jun 11;18(1):139. doi: 10.1186/s12877-018-0823-2.

CFN Webinars (February 15, 2017): A scoping review of evidence for measuring frailty in pre-hospital and hospital settings