Assessing the mortality risk in older patients hospitalized with a diagnosis of sepsis: the role of frailty and acute organ dysfunction.

BACKGROUND: A prognostic stratification of mortality risk in older patients with sepsis admitted to medical wards is often challenging. AIMS: To evaluate the ability of the Sequential Organ Failure Assessment (SOFA) score, serum biomarkers (lactate and C-Reactive Protein, CRP), and measures of comorbidity and frailty in predicting in-hospital and 6-month mortality in a cohort of older patients admitted to an Acute Geriatric Unit (AGU) with a diagnosis of sepsis. METHODS: All patients aged 70 years and over consecutively admitted to our AGU with sepsis in the study period were included. At admission, a Comprehensive Geriatric Assessment including two measures of frailty (Clinical Frailty Scale [CFS], Frailty Index [FI]) was obtained. To assess the predictivity of candidate prognostic markers, the Area Under the Receiver-Operating Characteristic (AUROC) curves were analyzed. A multivariate logistic regression analysis was also performed. RESULTS: We included 240 patients (median age = 85, IQR = 80-89, 40.8% women), of whom 33.8% died before discharge, and 60.4% at 6 months. The SOFA score (AUROC = 0.678, 95% CI 0.610-0.747) and CRP serum levels (AUROC = 0.606, 95% CI 0.532-0.680) were good predictors of in-hospital mortality. The CFS (AUROC = 0.703, 95% CI 0.637-0.768) and the FI (AUROC = 0.677, 95% CI 0.607-0.746) better predicted 6-month mortality. Results of the regression analysis confirmed the findings of the AUROC study. The combined assessment of SOFA and measures of frailty improved the performance of the model both in the short and the long term. CONCLUSIONS: Both the severity of organ dysfunction and frailty scores should be addressed on AGU admission to establish the short- and long-term outcomes of older patients with sepsis.

Developing a Frailty Index from routinely collected data in the Emergency Department among of hospitalized patients.

PURPOSE: The number of frail patients admitted to Emergency Departments is increasing. The so-called Frailty Index based on the age-related accumulation of deficits models is often perceived as excessively burdening or not feasible in busy clinical settings due to its quantitative nature. We wanted to prove the possibility of generating a Frailty Index in the Emergency Department from data that are routinely collected during the standard clinical practice in this setting and to test its predictive capacity for adverse events. METHODS: A retrospective analysis of the medical records of 110 hospitalized patients (mean age = 67.4 ± 18.9 years; women 41.8%) admitted to our Emergency Department during 6 days of 2017. A 41-item Frailty Index was computed from vital signs, physical examination, anamnestic diseases, and blood tests routinely collected by Emergency Department physicians. The length of the subsequent hospital stay and the institutionalization of the patient at the hospital discharge were the dependent variables of interest. RESULTS: Median length of stay was 11.0 (interquartile range, IQR = 6.0-16.0) days. Institutionalization rate at discharge was 18.2%. The median Frailty Index was 0.22 (IQR = 0.17-0.30). The Frailty Index was significantly correlated with age (Spearman's r = 0.44, p < 0.001) and resulted significantly associated with length of stay and institutionalization. The receiver operating characteristics areas under the curve were 0.731 (Confidence Interval, 95%CI 0.601-0.860, p = 0.001) and 0.726 (95%CI 0.610-0.841, p < 0.001) in the prediction of institutionalization and prolonged hospital stay, respectively. No statistically significant association of age with a length of stay (p = 0.75) nor institutionalization (p = 0.09) was reported. CONCLUSIONS: The standard multidimensional assessment conducted at the Emergency Department admission has all the necessary features to generate a meaningful clinical Frailty Index, potentially supporting decisions since the first contact of the individual with the hospital system.