Emergency department interventions for frailty (EDIFY): improving functional outcomes in older persons at the emergency department through a multicomponent frailty intervention.

OBJECTIVES: emergency department interventions for frailty (EDIFY) delivers frailty-centric interventions at the emergency department (ED). We evaluated the effectiveness of a multicomponent frailty intervention (MFI) in improving functional outcomes among older persons. DESIGN: a quasi-experimental study. SETTING: a 30-bed ED observation unit within a 1,700-bed acute tertiary hospital. PARTICIPANTS: patients aged ≥65 years, categorised as Clinical Frailty Scale 4-6, and planned for discharge from the unit. METHODS: we compared patients receiving the MFI versus usual-care. Data on demographics, function, frailty, sarcopenia, comorbidities and medications were gathered. Our primary outcome was functional status-Modified Barthel Index (MBI) and Lawton's iADL. Secondary outcomes include hospitalisation, ED re-attendance, mortality, frailty, sarcopenia, polypharmacy and falls. Follow-up assessments were at 3, 6 and 12 months. RESULTS: we recruited 140 participants (mean age 79.7 ± 7.6 years; 47% frail and 73.6% completed the study). Baseline characteristics between groups were comparable (each n = 70). For the intervention group, MBI scores were significantly higher at 6 months (mean: 94.5 ± 11.2 versus 88.5 ± 19.5, P = 0.04), whereas Lawton's iADL scores experienced less decline (change-in-score: 0.0 ± 1.7 versus -1.1 ± 1.8, P = 0.001). Model-based analyses revealed greater odds of maintaining/improving MBI in the intervention group at 6 months [odds ratio (OR) 2.51, 95% confidence interval (CI) 1.04-6.03, P = 0.04] and 12 months (OR 2.98, 95% CI 1.18-7.54, P = 0.02). This was similar for Lawton's iADL at 12 months (OR 4.01, 95% CI 1.70-9.48, P = 0.002). ED re-attendances (rate ratio 0.35, 95% CI 0.13-0.90, P = 0.03) and progression to sarcopenia (OR 0.19, 95% CI 0.04-0.94, P = 0.04) were also lower at 6 months. CONCLUSIONS: the MFI delivered to older persons at the ED can possibly improve functional outcomes and reduce ED re-attendances while attenuating sarcopenia progression.

Emergency Department Interventions for Frailty (EDIFY): Front-Door Geriatric Care Can Reduce Acute Admissions.

OBJECTIVES: The EDIFY program was developed to deliver early geriatric specialist interventions at the emergency department (ED) to reduce the number of acute admissions by identifying patients for safe discharge or transfer to low-acuity care settings. We evaluated the effectiveness of EDIFY in reducing potentially avoidable acute admissions. DESIGN: A quasi-experimental study. SETTING: ED of a 1700-bed tertiary hospital. PARTICIPANTS: ED patients aged ≥85 years. MEASUREMENTS: We compared EDIFY interventions versus standard care. Patients with plans for acute admission were screened and recruited. Data on demographics, premorbid function, frailty status, comorbidities, and acute illness severity were gathered. We examined the primary outcome of "successful acute admission avoidance" among the intervention group, which was defined as no ED attendance within 72 hours of discharge from ED, no transfer to an acute ward from subacute-care units (SCU) within 72-hours, or no transfer to an acute ward from the short-stay unit (SSU). Secondary outcomes were rehospitalization, ED re-attendance, institutionalization, functional decline, mortality, and frailty transitions at 1, 3, and 6 months. RESULTS: We recruited 100 participants (mean age 90.0 ± 4.1 years, 66.0% women). There were no differences in baseline characteristics between intervention (n = 43) and nonintervention (n = 57) groups. Thirty-five (81.4%) participants in the intervention group successfully avoided an acute admission (20.9% home, 23.3% SCU, and 44.2% SSU). All participants in the nonintervention group were hospitalized. There were no differences in rehospitalization, ED re-attendance, institutionalization and mortality over the study period. Additionally, we observed a higher rate of progression to a poorer frailty category at all time points among the nonintervention group (1, 3, and 6 months: all P < .05). CONCLUSIONS AND IMPLICATIONS: Results from our single-center study suggest that early geriatric specialist interventions at the ED can reduce potentially avoidable acute admissions without escalating the risk of rehospitalization, ED re-attendance, or mortality, and with possible benefit in attenuating frailty progression.

Frailty in Hospitalized Older Adults: Comparing Different Frailty Measures in Predicting Short- and Long-term Patient Outcomes.

OBJECTIVES: Data for the assessment of frailty in acutely ill hospitalized older adults remains limited. Using the Frailty Index (FI) as "gold standard," we compared (1) the diagnostic performance of 3 frailty measures (FRAIL, Clinical Frailty Scale [CFS], and Tilburg Frailty Indicator [TFI]) in identifying frailty, and (2) their ability to predict negative outcomes at 12 months after enrollment. DESIGN: Prospective cohort study. PARTICIPANTS: We recruited 210 patients (mean age 89.4 ± 4.6 years, 69.5% female), admitted to the Department of Geriatric Medicine in a 1300-bed tertiary hospital. MEASUREMENTS: Premorbid frailty status was determined. Data on comorbidities, severity of illness, functional status, and cognitive status were gathered. We compared area under receiver operator characteristic curves (AUC) for each frailty measure against the reference FI. Multiple logistic regression was used to examine the independent association between frailty and the outcomes of interest. RESULTS: Frailty prevalence estimates were 87.1% (FI), 81.0% (CFS), 80.0% (TFI), and 50.0% (FRAIL). AUC against FI ranged from 0.81 (95% confidence interval [CI] 0.72-0.90: FRAIL) to 0.91 (95% CI 0.87-0.95: CFS). Only FRAIL was associated with higher in-hospital mortality (6.7% vs 1.0%, P = .031). FRAIL and CFS were significantly associated with increased length of hospitalization (10 [6.0-17.5] vs 8 [5.0-14.0] days, P = .043 and 9 [5.0-17.0] vs 7 [4.25-11.75] days, P = .036, respectively). CFS and FI were highly associated with mortality at 12-month (CFS, frail vs nonfrail: 32.9% vs 2.5%, P < .001, and FI, frail vs nonfrail: 30.6% vs 3.7%, P < .001). CFS also conferred the greatest risk of 12-month mortality (odds ratio [OR] 5.78, 95% CI 3.19-10.48, P < .001) and composite outcomes of institutionalization and/or mortality (OR 3.69, 95% CI 2.31-5.88, P < .001), adjusted for age, sex, and severity of illness. CONCLUSION: Our study affirms the utility of frailty assessment tools among older persons in acute care. FRAIL conferred highest risk of in-hospital mortality. However, CFS had greatest risk of mortality and institutionalization within 12 months.

Frailty and Risk of Adverse Outcomes in Hospitalized Older Adults: A Comparison of Different Frailty Measures.

OBJECTIVES: There is a paucity of data for the assessment of frailty in acutely ill hospitalized older adults. We aim to (1) compare the performance of frailty measures [5-item scale of fatigue, resistance, ambulation, illnesses, and loss of weight) (FRAIL), Tilburg Frailty Indicator (TFI), and Clinical Frailty Scale (CFS)] in identifying frailty, using the widely adopted Frailty Index (FI) as "gold standard," and (2) compare their ability to predict negative outcomes among hospitalized older adults. DESIGN: Prospective cohort study. SETTING: Acute inpatient care. PARTICIPANTS: A total of 210 patients (mean age 89.4 ± 4.6 years, 69.5% female) admitted to the Department of Geriatric Medicine. MEASUREMENTS: Premorbid frailty status was assessed by FI, FRAIL, TFI, and CFS. We collected data on comorbidities, severity of illness, functional status, and cognitive status. We compared area under receiver operator characteristic curves for FRAIL, TFI, and CFS against the reference FI. Multiple logistic regression was performed to examine the association between frailty and the primary outcome of in-hospital mortality. RESULTS: Frailty prevalence estimates were 87.1% (FI), 50% (FRAIL), 80% (TFI), and 81% (CFS). Area under receiver operator characteristics against FI ranged from 0.81 [95% confidence interval (CI) 0.72-0.90: FRAIL] to 0.91 (95% CI 0.87-0.95: CFS), with no significant difference on receiver operating characteristic curve contrast. Frailty, as defined by FRAIL score ≥3, was associated with higher in-hospital mortality (6.7% vs 1.0%, P = .031) and length of hospitalization [10 days (6.0-17.5) vs 8 days (5.0-14.0), P = .043]. FI [odds ratio (OR) = 1.15, 95% CI 1.00-1.33, P = .05], FRAIL (OR = 3.31, 95% CI 1.43-7.67, P = .005), and CFS (OR = 2.57, 95% CI 1.14-5.83, P = .023) independently predicted in-hospital mortality adjusted for age, sex, and severity of illness. CONCLUSIONS: FRAIL and CFS are simple frailty measures that may identify older adults at highest risk of adverse outcomes of hospitalization. FRAIL performed better in predicting in-hospital mortality.