Frailty assessment tools and associated postoperative outcomes in older patients undergoing elective surgery: A prospective pilot study.

BACKGROUND: There is a need for a feasible tool to assess the risk of frailty prior to surgery. We aimed to identify the ratio of abnormal results for three clinically applicable screening tools to assess the risk of frailty, and their association with adverse outcomes in a cohort of elderly surgical patients. METHODS: In this prospective pilot study, patients ≥65 years undergoing preoperative evaluation for elective surgery were included and subjected to three frailty screening tests; Program of Research to Integrate Services for the Maintenance of Autonomy 7-item questionnaire (PRISMA7), Timed Up and Go (TUG), and Clock Drawing Test (CDT). The primary outcome was the incidence of abnormal testing, and secondary outcomes were the association between abnormal tests and mortality, readmission, delirium, surgical complications and non-home discharge. RESULTS: Out of 99 patients, 41%, 37%, and 43% had abnormal PRISMA7, TUG, and CDT screening, respectively. Postoperative delirium was more likely to occur in patients with abnormal TUG screening (19% vs. 3%, p = .011) and CDT (17% vs. 2%, p = .019). When analyzing screening tool combinations, patients with abnormal PRISMA7 and TUG had a higher rate of non-home discharge (38% vs. 17%, p = .029); and patients with abnormal TUG and CDT had a higher rate of postoperative delirium (25% vs. 3%, p = .006) and any surgical complication (58% vs. 38%, p = .037); and patients with abnormal results from all three tools had a higher rate of postoperative delirium (21% vs. 5%, p = .045) and non-home discharge (42% vs. 18%, p = .034). CONCLUSION: Approximately 40% of elderly surgical patients have abnormal PRISMA7, TUG, and CDT screening tests for frailty, and they are associated individually or in combination with increased risk of adverse postoperative outcomes. The results will aid in designing studies to further risk-stratify patients at risk of frailty and attempt to modify associated outcomes.

Validation of a seven-question tool (PRISMA-7) in predicting prognosis of older adults in the emergency department: A prospective study.

OBJECTIVES: Older patients arrive at the emergency department (ED) with complex medical challenges, and the current ED triage models frequently undertriage the severity of illness in older adults. There is increasing awareness regarding the importance of identifying frailty in older patients in the context of urgent care. Therefore, this study aimed to assess the predictive accuracy of the seven-question tool of the Program on Research for Integrating Services of the Maintenance of Autonomy (PRISMA-7) in the ED for 28-day mortality among older adults. DESIGN: A prospective polycentric observational study. SETTING: West China Hospital of Sichuan University, Shangjinnanfu of West China Hospital, and People's Hospital of Henan Province. PARTICIPANTS: ED patients aged ≥65 years from the three tertiary care centers over an 8-week period. PRIMARY AND SECONDARY OUTCOMES: The primary outcome, 28-day all-cause mortality, was investigated using a Cox proportional hazards regression model to assess the predictive validity. The secondary endpoints, intensive care unit (ICU) transfer was investigated using multivariable logistic regression, compared with trained study assistants. RESULTS: The final study population comprised 1043 consecutive patients aged ≥65 years. The area under the receiver operating characteristic (ROC) curve (AUC) for 28-day mortality was 0.80 (95% confidence interval [CI]: 0.76-0.84), 0.73 (95% CI: 0.68-0.77), and 0.78 (95% CI: 0.73-0.83) for PRISMA-7, Emergency Severity Index (ESI), and quick Sepsis Related Organ Failure Assessment (qSOFA), respectively.There was no difference in the AUC between PRISMA-7 and qSOFA(p = 0.374).The AUC for ICU admission was 0.78 (95% CI: 0.75-0.80), 0.62 (95% CI: 0.59-0.66), and 0.68 (95% CI: 0.64-0.72) for PRISMA-7, ESI, and qSOFA, respectively.The AUC for ICU admission between PRISMA-7 and ESI(p<0.001), PRISMA-7 and qSOFA(p<0.001), qSOFA and ESI(p = 0.005) was statistically significant. CONCLUSION: Our findings reveal that PRISMA-7 improves the prediction of ICU admission, but there is no significant difference when it comes to all-cause mortality. PRISMA-7 appears to be a reliable and valid instrument for identifying frailty in the ED. TRIAL REGISTRATION NUMBER: ChiCTR2100046545.

Assessing the utility of frailty scores in triage: a comparative study of validated scales.

Currently, there is conflicting evidence regarding the efficacy of frailty scales and their ability to enhance or support triage operations. This study aimed to assess the utility of three common frailty scales (CFS, PRISMA-7, ISAR) and determine their utility in the triage setting. This prospective observational monocentric study was conducted at Merano Hospital's Emergency Department (ED) from June 1st to December 31st, 2023. All patients attending this ED during the 80-day study period were included, and frailty scores were correlated with three outcomes: hospitalization, 30-day mortality, and severity of condition as assessed by ED physicians. Patients were categorized by age, and analyses were performed for the entire study population, patients aged 18-64, and those aged 65 or older. Univariate analysis was followed by multivariable analysis to evaluate whether frailty scores were independently associated with the outcomes. In multivariable analysis, none of the frailty scores were found to be associated with the study outcomes, except for the CFS, which was associated with an increased risk of 30-day mortality, with an odds ratio of 1.752 (95% CI 1.148-2.674; p = 0.009) in the general population and 1.708 (95% CI 1.044-2.793; p = 0.033) in the population aged ≥ 65. Presently, available frailty scores do not appear to be useful in the triage context. Future research should consider developing new systems for accurate frailty assessment to support risk prediction in the triage assessment.

Pilot Testing of Useful Tools' Validity for Frailty Assessment in Greece: Translated PRISMA-7 Tool, Modified Fried Criteria and Clinical Frailty Scale.

The importance of frailty in older people is getting constant recognition as an important aspect both in terms of public health, as well as at a personal level, for the appropriate management of an older person's health condition. This is reflected by the continuously increasing number of research studies carried out in several settings across different countries. Sometimes, this is very solid, but in other cases, there is a considerable gap in terms of accurate and well-grounded documentation of frailty status. This is the case in Greece, where we are missing clinically validated tools to approach frailty. We are missing frailty screening tools, such as, for instance, Program of Research on Integration of Services for the Maintenance of Autonomy 7 (PRISMA 7), the gold standard tool of Fried criteria, is somehow problematic since the question referring to physical activity originates from a questionnaire that has not been translated and validated, while Clinical Frailty Scale (CFS) has been validated for translation but not for the capacity to detect frailty. The aim of this study is to validate these tools for their accuracy to detect frailty by using a measurable index of frailty, previously proposed for use in clinical studies: the Short Physical Performance Battery (SPPB). Seventy-four male and female participants (mean age 80.47 years SD = ±7.45 years, minimum-maximum age = 65-95) have been evaluated for their frailty status using different tools. We observed that the PRISMA 7 translation detects frailty only when one question is removed at a cut-off of ≥2 and indicates a sensitivity of 88.1% and specificity of 99.9% with a good correlation with SPPB measurements (r = -0.858; p < 0.001). When CFS was validated using SPPB, it demonstrated a very good correlation (r = -0.838; p < 0.001 respectively) as was the case for the modified Fried Criteria (r = -0.725; p < 0.001). All items demonstrated a good correlation between them. We here propose that we can accurately assess frailty status in the community setting by using a modified version of Fried criteria, Clinical Frailty Scale translation in Greek, and we can screen for frailty by using the Greek translation of PRISMA 7 only after removing item 6 of the questionnaire.

Predictive Value of PRISMA-7, qSOFA, ESI, and CFS for 28-Day Mortality in Elderly Patients in the Emergency Department.

Background: To explore the predictive value of the Programme on Research for Integrating Services for the Maintenance of Autonomy 7 (PRISMA-7), quick Sequential Organ Failure Assessment (qSOFA) score, Emergency Severity Index (ESI), and Clinical Frailty Scale (CFS) on the 28-day mortality risk in emergency elderly patients. Methods: A multicenter prospective observational study was conducted to select elderly patients (≥65 years old) admitted to the emergency department of three Grade-A hospitals in different regions of China from January 2020 to March 2022. Primary data were collected at the time of admission. All patients were followed up for 28 days. The primary outcome was 28-day mortality. The predictive value of four scoring systems for 28-day mortality in elderly emergency patients was assessed by receiver operating characteristic (ROC) and logistic regression analysis. Results: A total of 687 elderly emergency patients were enrolled, of whom 66 (9.61%) died within 28 days. Age, ICU admission rate, PRISMA-7, qSOFA, and CFS were significantly higher in the death group than in the survival group (P < 0.05), and ESI was lower than in the survival group (P < 0.001). The AUC for CFS was the largest of the four scoring systems at 0.80. According to the Youden index, the optimal cutoff values for PRISMA-7, qSOFA, ESI, and CFS were >3.5, >0.5, <2.5, and >4.5, respectively. Logistic regression revealed that qSOFA and CFS were the primary risk factors for increased 28-day mortality in elderly emergency patients (P < 0.001). The combined predictor L (L=X1+0.50X2, X1 and X2 are qSOFA and CFS values, respectively) had an AUC of 0.86 and a cutoff value >2.75. Conclusion: PRISMA-7, qSOFA, ESI, CFS, and the combined qSOFA+CFS predictor were all effective predictors of 28-day mortality risk in elderly emergency patients, with the combined qSOFA+CFS predictor having the best predictive power.

Validation of the Risk Instrument for Screening in the Community (RISC) among Older Adults in the Emergency Department.

Although several short-risk-prediction instruments are used in the emergency department (ED), there remains insufficient evidence to guide healthcare professionals on their use. The Risk Instrument for Screening in the Community (RISC) is an established screen comprising three Likert scales examining the risk of three adverse outcomes among community-dwelling older adults at one-year: institutionalisation, hospitalisation, and death, which are scored from one (rare/minimal) to five (certain/extreme) and combined into an Overall RISC score. In the present study, the RISC was externally validated by comparing it with different frailty screens to predict risk of hospitalisation (30-day readmission), prolonged length of stay (LOS), one-year mortality, and institutionalisation among 193 consecutive patients aged ≥70 attending a large university hospital ED in Western Ireland, assessed for frailty, determined by comprehensive geriatric assessment. The median LOS was 8 ± 9 days; 20% were re-admitted <30 days; 13.5% were institutionalised; 17% had died; and 60% (116/193) were frail. Based on the area under the ROC curve scores (AUC), the Overall RISC score had the greatest diagnostic accuracy for predicting one-year mortality and institutionalisation: AUC 0.77 (95% CI: 0.68-0.87) and 0.73 (95% CI: 0.64-0.82), respectively. None of the instruments were accurate in predicting 30-day readmission (AUC all <0.70). The Overall RISC score had good accuracy for identifying frailty (AUC 0.84). These results indicate that the RISC is an accurate risk-prediction instrument and frailty measure in the ED.

Frailty Screening in the Emergency Department: Comparing the Variable Indicative of Placement Risk, Clinical Frailty Scale and PRISMA-7.

Prompt recognition of frailty in the emergency department (ED) is important to identify patients at higher risk of adverse outcomes. Despite this, few studies examine the diagnostic accuracy of screening instruments for frailty, instead focusing on predictive validity. We compared three commonly used, short frailty screens to an independent comprehensive geriatric assessment (CGA) in an urban University Hospital ED. Consecutive attendees aged ≥70 years were screened by trained raters, blind to the CGA, with the Variable Indicative of Placement risk (VIP), 3 and 4-item versions, Clinical Frailty Scale (CFS) and PRISMA-7. Accuracy was measured from the area under the ROC curve (AUROC). In total, 197 patients were included, median age 79 (±10); 46% were female. Half (49%) were confirmed as frail after CGA. All instruments differentiated frail from non-frail states, although the CFS (AUROC: 0.91) and PRISMA-7 (AUROC: 0.90) had higher accuracy compared to the VIP-4 (AUROC: 0.84) and VIP-3 (AUROC: 0.84). The CFS was significantly more accurate than the VIP-3 (p = 0.026) or VIP-4 (p = 0.047). There was no significant difference between the CFS and PRISMA-7 (p = 0.90). The CFS and PRISMA-7 were more accurate and should be considered in preference to the VIP (3 or 4-item versions) to identify frailty in EDs.

The diagnostic and predictive accuracy of the PRISMA-7 screening tool for frailty in older adults: A systematic review protocol.

Background: Older adults are at risk of adverse outcomes due to frailty. A number of frailty screening instruments have been developed to identify older adults at increased risk of frailty. This systematic review and meta-analysis will look to examine the diagnostic accuracy of the Program of Research to Integrate the Services for the Maintenance of Autonomy 7 (PRISMA-7). Methods and analysis: A systematic literature search will be conducted from 2008-February 2020 in PubMed, EMBASE, CINAHL, EBSCO and the Cochrane Library to identify validation studies of the PRISMA-7 tool.  A pre-specified PRISMA-7 score of ≥3 (maximum score 7 points) will be used to identify frailty in older adults. Prospective or retrospective cohort studies, cross-sectional studies and the control arm of randomised controlled trials will be included that attempt to validate the diagnostic accuracy of the PRISMA-7 screening tool in older adults across all healthcare settings when compared to a reference standard. The predictive accuracy of the PRISMA-7 tool will also be explored. Study quality will be assessed by the QUADAS-2 tool. A bivariate random effects model will be used to generate pooled estimates of sensitivity and specificity. Statistical heterogeneity will be explored using validated methods. Ethics and dissemination: Formal ethical approval is not required as primary data will not be collected. The results will be disseminated through a peer-reviewed publication, conference presentation and the popular press. Protocol registration: Awaiting registration with the International Prospective Register for Systematic Reviews (PROSPERO).