Validation of the self-reported domains of the Edmonton Frail Scale in patients 65 years of age and older.

INTRODUCTION: In the era of virtual care, self-reported tools are beneficial for preoperative assessments and facilitating postoperative planning. We have previously reported the use of the Edmonton Frailty Scale (EFS) as a valid preoperative assessment tool. OBJECTIVE: We wished to validate the self-reported domains of the EFS (srEFS) by examining its association with loss of independence (LOI) and mortality. METHODS: This is a post-hoc analysis of a single-institution observational study of patients 65 years of age or older undergoing multi-specialty surgical procedures and assessed with the EFS in the preoperative setting. Exploratory data analysis was used to determine the threshold for identifying frailty using the srEFS. Procedures were classified using the Operative Stress Score (OSS) scored 1 to 5 (lowest to highest). Hierarchical Condition Category (HCC) was utilized to risk-adjust. LOI was described as requiring more support at discharge and mortality was defined as death occurring up to 30 days following surgery. Receiver operating characteristic (ROC) curves were used to determine the ability of the srEFS to predict the outcomes of interest in relation to the EFS. RESULTS: Five hundred thirty-five patients were included. Exploratory analysis confirmed best positive predictive value for srEFS was greater or equal to 5. Overall, 113 (21 percent) patients were considered high risk for frailty (HRF) and 179 (33 percent) patients had an OSS greater or equal to 5. LOI occurred in 7 percent (38 patients) and the mortality rate was 4 percent (21 patients). ROC analysis showed that the srEFS performed similar to the standard EFS with no difference in discriminatory thresholds for predicting LOI and mortality. Examination of the domains of the EFS not included in the srEFS demonstrated a lack of association between cognitive decline and the outcomes of interest. However, functional status assessed with either the Get up and Go (EFS only) or self-reported ADLs was independently associated with increased risk for LOI. CONCLUSION: This study shows that self-reported EFS may be an optional preoperative tool that can be used in the virtual setting to identify patients at HRF. Early identification of patients at risk for LOI and mortality provides an opportunity to implement targeted strategies to improve patient care.

Efficient and rapid assessment of multiple aspects of frailty using the Kyoto Frailty Scale, developed from the Edmonton Frail Scale.

[Purpose] Global aging has led to a dramatic increase in the number of frail people, who are likely to become bedridden. Since frailty can be partially reversed, early intervention would be beneficial for patients, family members, and clinicians. This study was designed to develop a screening tool for an accurate and comprehensive assessment of frailty by modulating the Edmonton Frail Scale (EFS). [Participants and Methods] The EFS, covering multiple domains, is one of the major diagnostic tools for frailty. Frail and non-frail participants (n=67) were evaluated for each diagnostic item of the EFS to identify the most efficient combination of questions by evaluating its sensitivity and specificity. [Results] The Kyoto Frailty Scale (KFS) was developed as a rapid frailty scale, based on the EFS. The KFS comprises nine questions about health status, polypharmacy, hospitalization, living with a reliable caregiver, shopping, transportation, housework, money management, and forgetting to take medicine. The KFS has an excellent negative predictive value (100%) for screening frailty and a positive predictive value (97%) for screening prefrailty and frailty if we regard KFS ≥4 as a test positive. [Conclusion] The KFS permits clinician to rapidly and accurately screen for frailty and prefrailty, or exclude frailty.

Applicability of laboratory deficit-based frailty index in predominantly older patients with end-stage renal disease under chronic dialysis: A pilot test of its correlation with survival and self-reported instruments.

AIM: Laboratory deficit-based frailty index (LFI) exhibited outcome-prediction ability in the elderly, but not in those with end-stage renal disease (ESRD). We hypothesized that LFI results might have outcome correlation and correlate closely with other instruments in ESRD patients. METHODS: We prospectively enroled ESRD patients between 2014 and 2015 and administered self-report frailty instruments (Strawbridge questionnaire, Edmonton frail scale (EFS), Groningen frailty indicator (GFI), Tilburg frailty indicator, G8 questionnaire and FRAIL scale), and Cardiovascular Health Study (CHS) scale, with two types of LFI calculated. They were followed up until June 30, 2017. Correlations between the results of six instruments, CHS scale, and those of LFI were identified, followed by Kaplan-Meier survival analyses and logistic regression analyses to compare those with high and low LFI. RESULTS: The frailty prevalence was 33.3% (CHS), 78.8% Strawbridge questionnaire, 45.5% (EFS), 57.6% (GFI), 27.3% (Tilburg frailty indicator), 84.8% (G8) and 18.2% (FRAIL) among ESRD participants. LFI-1 results were significantly correlated with those of LFI-2 (P < 0.01), EFS (P = 0.04) and GFI (P < 0.01), while LFI-2 results were not. Those with CHS or GFI-identified frailty had significantly lower 1,25-(OH)2 -D levels than those without. After 32.3 ± 5.4 months, patients with high LFI-1 scores, but not LFI-2, had a significantly higher mortality than those with lower scores. GFI and EFS scores were also independently associated with LFI-1, while CHS scores exhibited borderline association only. CONCLUSION: Among a group of predominantly older ESRD patients, LFI differentiates patients with good and poor outcomes, supporting its applicability in these patients.

A cohort study investigating the relationship between patient reported outcome measures and pre-operative frailty in patients with operable, non-palliative colorectal cancer.

BACKGROUND: Frailty refers to the reduction in homeostatic reserve resulting from an accumulation of physiological deficits over a lifetime. Frailty is common in older patients undergoing surgery and is an independent risk factor for post-operative mortality, morbidity and increased length of hospital stay. In frail individuals, stressors, such as surgery, can precipitate an acute deterioration in health, manifesting as delirium, falls, reduction in mobility or continence, rendering these individuals at an increased risk of adverse perioperative outcomes. However, little is known about how frailty affects the patient experience, functional ability and quality of life (QoL) after surgery. In addition, the distribution of frailty in this population is unknown. METHODS: We will conduct a multi-centre observational trial to investigate the relationship between patient reported outcome measures and preoperative frailty. We aim to recruit approximately two-hundred patients with operable, potentially curative colorectal cancer. Eligible patients will be identified at three hospital sites. QoL and functional ability (measured using EORTC QLQ-C30 and WHO-DAS 2.0 respectively) will be recorded at the pre-operative assessment clinic, and at 6 and 12 weeks postoperatively. Frailty scores including the Edmonton Frail Scale (EFS) and Rockwood clinical frailty scale (CFS) will be calculated both preoperatively, and at 12 weeks post-operatively. Secondary outcome measures including post-operative morbidity and mortality will be measured using Clavien Dindo classification and 90-day mortality. DISCUSSION: This observational feasibility study seeks to define the prevalence of frailty in older (> 65 years) colorectal cancer patients and understand how frailty impacts on patient reported outcome measures. This information will help to inform larger studies relating to treatment decision algorithms and promote shared decision making in this population.

Frailty in Elderly Patients Undergoing Cardiac Surgery Increases Hospital Stay and 12-Month Readmission Rate.

BACKGROUND: Cardiac surgery risk scoring systems predict operative mortality but not outcomes related to preoperative frailty. The aim of this study was to assess frailty in a cohort of older cardiac surgery patients as a predictor of postoperative outcomes. METHODS: Prospective data was collected on patients 65 years of age and older undergoing cardiac surgery between September 2015 and October 2016 at Dunedin Hospital. Frailty was assessed with the Edmonton frail scale and five-metre gait speed. The primary endpoint was length of hospital stay. Secondary outcomes included postoperative complications, major adverse events, death and 12-month readmission rate. RESULTS: Among the 96 patients, median age was 74 (interquartile range 10.5) and 65 (68%) were males. Of the sample 64 (67%) were scored as not frail, 22 (23%) as vulnerable, and 10 (10%) as frail. The median (interquartile range) postoperative days' stay were: not frail 6 (2), vulnerable 9.5 (8), and frail 15 (13). Survival analysis adjusting for EuroSCORE II, age, sex and surgery type showed that greater Edmonton Frail Scale scores were independently predictive of longer post-surgery hospital stay with a hazard ratio for discharge of 0.83 (95% confidence interval 0.76-0.91, p<0.001) per point. The Edmonton Frail Scale score was associated with the 12-month post discharge number of readmissions (adjusted incidence rate ratio 1.24 (95% confidence interval 1.13-1.37, p<0.001) per point. CONCLUSIONS: The Edmonton Frail Scale score predicts length of hospital stay post cardiac surgery and 12-month readmission rate in patients older than 65 years of age.

The Reported Edmonton Frail Scale-Thai version: Development and Validation of a Culturally-Sensitive Instrument.

Frailty may lead to increased vulnerability, disability, and adverse health outcomes in older adults. Early detection has been described as the best approach to manage frailty; however, frailty instruments are not widely available, particularly in the Thai language. The purpose of this cross-sectional study was to develop a culturally adapted Thai version of the Reported Edmonton Frail Scale and to validate the psychometric properties of the new instrument in hospitalized older Thai adults. Reliability and validity were examined. Participants completed questionnaires that included demographic and health information, and the Reported Edmonton Frail Scale-Thai version. Results revealed that the new instrument was reliable and had good content validity. Inter-rater reliability was strong. Confirmatory factor analysis showed a fair fit for the whole model, but most domains were strongly associated with frailty. On average, the instrument was completed under 7 minutes. The Thai version of the frailty instrument may be a practical tool for frailty evaluation, and could inform inpatient care, both locally and internationally; future research is needed to confirm predictability and feasibility in other clinical settings and populations.

The Edmonton Frail Scale Improves the Prediction of 30-Day Mortality in Elderly Patients Undergoing Cardiac Surgery: A Prospective Observational Study.

OBJECTIVES: To investigate whether the Edmonton Frail Scale (EFS), a multidimensional frailty assessment tool, improves the prediction of 30-day or in-hospital mortality over the use of the European System for Cardiac Outcome Risk Evaluation (EuroSCORE) II alone. DESIGN: Single-center prospective observational study. SETTING: University hospital. PARTICIPANTS: Patients aged 75 years or older undergoing cardiac surgery between February 2014 and May 2017. INTERVENTION: No intervention was performed. The EFS was administered the day before surgery. MEASUREMENTS AND MAIN RESULTS: The primary endpoint was 30-day or in-hospital mortality. Secondary endpoints were times to discharge from the intensive care unit (ICU) and from the hospital, discharge to a health care facility, and ability to return home by postoperative day 30. The EFS had a good discriminative ability for 30-day mortality (area under the receiver operating characteristic curve = 0.69; 95% confidence interval [CI], 0.56-0.82). Adding frailty, defined by an EFS ≥8, to the EuroSCORE II significantly improved the prediction of 30-day (p = 0.04) mortality. The integrated discrimination index was 0.03 (95% CI, 0.01-0.06, p = 0.01), meaning that the difference in predicted risk between patients who died and those who survived increased by 3% due to the addition of frailty determined by the EFS to the EuroSCORE II. Frailty also was associated significantly with a decreased cumulative probability of discharge from the ICU (p = 0.02) and an increased incidence of discharge to a health care facility (p = 0.01). CONCLUSION: The EFS has a good predictive ability for 30-day mortality after cardiac surgery in elderly patients and improves the prediction of 30-day mortality over the use of the EuroSCORE II.

Performance of Edmonton Frail Scale on frailty assessment: its association with multi-dimensional geriatric conditions assessed with specific screening tools.

BACKGROUND: The aim of this study was to evaluate the performance of Edmonton Frail Scale (EFS) on frailty assessment in association with multi-dimensional conditions assessed with specific screening tools and to explore the prevalence of frailty by gender. METHODS: We enrolled 366 hospitalised patients (women\men: 251\115), mean age 81.5 years. The EFS was given to the patients to evaluate their frailty. Then we collected data concerning cognitive status through Mini-Mental State Examination (MMSE), health status (evaluated with the number of diseases), functional independence (Barthel Index and Activities Daily Living; BI, ADL, IADL), use of drugs (counting of drugs taken every day), Mini Nutritional Assessment (MNA), Geriatric Depression Scale (GDS), Skeletal Muscle Index of sarcopenia (SMI), osteoporosis and functionality (Handgrip strength). RESULTS: According with the EFS, the 19.7% of subjects were classified as non frail, 66.4% as apparently vulnerable and 13.9% with severe frailty. The EFS scores were associated with cognition (MMSE: ß = 0.980; p < 0.01), functional independence (ADL: ß = -0.512; p < 0.00); (IADL: ß = -0.338; p < 0.01); use of medications (ß = 0.110; p < 0.01); nutrition (MNA: ß = -0.413; p < 0.01); mood (GDS: ß = -0.324; p < 0.01); functional performance (Handgrip: ß = -0.114, p < 0.01) (BI: ß = -0.037; p < 0.01), but not with number of comorbidities (ß = 0.108; p = 0.052). In osteoporotic patients versus not-osteoporotic patients the mean EFS score did not differ between groups (women: p = 0.365; men: p = 0.088), whereas in Sarcopenic versus not-Sarcopenic patients, there was a significant differences in women: p < 0.05. CONCLUSIONS: This study suggests that measuring frailty with EFS is helpful and performance tool for stratifying the state of fragility in a group of institutionalized elderly. As matter of facts the EFS has been shown to be associated with several geriatric conditions such independence, drugs assumption, mood, mental, functional and nutritional status.

Frailty in acute cardiology: comparison of a quick clinical assessment against a validated frailty assessment tool.

BACKGROUND: Increasingly frail patients are being to be referred for invasive cardiac interventions and cardiac surgery. We aimed to evaluate the utility of a quick clinical assessment of frailty against a validated frailty assessment tool in an acute cardiology setting. METHODS: Forty-seven cardiology in-patients ≥70 years were recruited in this prospective study. All patients were first assessed by a senior cardiology registrar as either not-frail or frail. This was based on general observation and brief discussions. Following this, patients were administered the Reported Edmonton Frail Scale (REFS) questionnaire. After a registrar assessment, the foot-of-the bed frailty assessment was independently repeated by one or two consultant cardiologists. RESULTS: None of the three clinicians showed satisfactory similarity to the REFS score. When the two consultants were compared with the registrar, and with each other, the Cohen's kappa was only above 0.7 for the comparison between Consultant 1 and the registrar. Consultant 1 and the registrar were also significantly more likely to disagree at higher REFS score with a mean REFS score of 8.8. CONCLUSION: A quick foot-of-the-bed clinical assessment is not a reliable way to determine frailty.

Higher Edmonton Frail Scale prior to transcatheter Aortic Valve Implantation is related to longer hospital stay and mortality.

BACKGROUND: International guidelines for the management of valvular heart disease recommend frailty assessment prior to Transcatheter Aortic Valve Implantation (TAVI), however there is no consensus how to assess frailty. We investigated whether frailty status assessed with the Edmonton Frail Scale (EFS, range 0-17 points) relates to length of stay (LOS), short- and long-term mortality and adverse outcomes after TAVI. METHODS: In this study we included 357 patients between April 2016 till December 2018. EFS was assessed at baseline. Patients were classified into low (0-3), intermediate (4-7) or high frailty status (8-17). LOS was defined as the number of days between admission and discharge. Mortality data were obtained up to four years after TAVI. Adverse events were defined by Valve Academic Research Consortium (VARC)-2 criteria and collected <30 days after TAVI. RESULTS: Patients with higher frailty status had longer median LOS (days (IQR): low 5 (3), intermediate 6 (4) and high 7 (5), p < 0.001) and higher mortality: low vs intermediate vs high at 30 days 0.5%, 2.2%, 7.0% (p = 0.050), 1 year 3.7%, 10.0%, 15.2% (p = 0.052), 2 years 9.2%, 17.8%, 31.7% (p = 0.003), 3 years 17.2%, 24.0, 47.0% (p = 0.001) and 4 years 19.6%, 30.8%, 55.6% (p < 0.001). Frail patients received more often a pacemaker (2.6%, 6.6%, 13.5%, p = 0.048). CONCLUSION: In clinical practice, the EFS is a useful tool to screen for frailty in TAVI patients. This tool may possibly be expanded to determine benefit versus harm-risk in these patients and whether specific pre-procedurally interventions are needed in order to reduce mortality.

The Impact of Radiotherapy on Frailty in Patients Aged 65 and Over.

Introduction and objective Frailty is characterized by the body's increased susceptibility to stressors due to aging and a concurrent decline in its resilience. A dominant hypothesis suggests that oncological interventions may amplify this vulnerability. Consequently, elderly individuals with cancer may pose challenges for conventional treatments. This research sought to assess the effects of radiotherapy (RT) on the frailty of elderly cancer patients by utilizing the Edmonton Frail Scale (EFS). Methods This research was designed as a prospective observational study. Patients aged 65 and older, receiving treatment at the radiation oncology clinic, were asked to complete the EFS form both before and at the end of their RT course. The scores achieved before and after the RT were obtained, and the medical histories of the patients were recorded. The difference between the pre- and post-RT scores was calculated by subtracting the post-RT score from the pre-RT score to determine any increase or decrease in the score. For the statistical evaluations, a suite of tests (including the Shapiro-Wilk test, Kolmogorov-Smirnov test, paired sample t-test, independent t-tests, analysis of variance {ANOVA}, and Pearson correlation) were implemented. All analyses were conducted using the Statistical Package for Social Sciences (SPSS) software (version 29.0) (IBM SPSS Statistics, Armonk, NY). Results From April 2021 to August 2023, a total of 121 patients participated in the study. Out of these, 81 underwent assessments both pre- and post-RT. The median age was 73; the median follow-up period was five months. The predominant diagnoses included prostate cancer, breast cancer, and gynecological malignancies. A significant proportion of patients was diagnosed with stage IV cancer and underwent palliative RT. Post-RT evaluations revealed a decline in scores for some patients, while an increase was observed for others. Certain score variations were statistically significant. Moreover, an inverse correlation was discerned between the RT dose and fraction number and the post-RT EFS score. Conclusion Our research confirmed that a substantial number of patients either experienced a decrease or maintained stability in their EFS scores after RT. This observation suggests that RT might not exacerbate frailty in the elderly in the short term. Nevertheless, to elucidate the long-term impact of RT on frailty, there is a pressing need for a comprehensive assessment correlating EFS scores with survival rates.

Usefulness of the Edmonton Frail Scale in Assessing the Impact of Heart Failure on Frailty.

BACKGROUND/AIM: The association of frailty with heart failure (HF) is common in the elderly, and its presence is a poor prognostic factor; it increases the risk of falls, disability, hospitalization, and mortality. The aim of this prospective study was to assess the incidence of physical frailty in patients with HF and the role of physical exercise in improving physical performance. PATIENTS AND METHODS: A total of 141 patients with musculoskeletal pathology, aged over 65 years, who followed a specific physical training program were included. The patients were assigned to two groups: HF patients -group HF (n=53) and patients without HF -group N-HF (n=88). RESULTS: At cohort level, mild and moderate frailty was detected in 20.56% of patients enrolled in the study (n=29). Severe form of frailty was identified in 2.83% of cases (n=4). The prevalence of mild, moderate, and severe frailty in the two groups differed significantly (p<0.05). Patients with mild frailty and moderate frailty in the HF group represented 24.52% compared to 18.18% in the N-HF group (p=0.007). Severe frailty was present in 5.66% in the HF group, not significantly different from the N-HF group (1.13%), p=0.317. The values obtained in the functional independence and functional performance domains were significantly improved at the reassessment after 6 months. CONCLUSION: Exercise-based rehabilitation is a primary therapy for improving physical performance, reflected by increased independence related to daily activities and functional performance in HF patients.

Reproducibility and validity of the Portuguese Edmonton Frail Scale version in cardiac surgery patients.

INTRODUCTION: Frailty is a multidimensional syndrome characterized by the loss of functional reserve, associated with higher mortality and less functional survival in cardiac surgery patients. The Edmonton Frail Scale (EFS) is a comprehensive tool devised for brief frailty detection. To the best of our knowledge, there are no culturally adapted and validated frailty screening tools that enable the identification of vulnerability domains suited for use in the preoperative setting in Portugal. This was the motivation for this study. OBJECTIVES: To assess the validity and reproducibility of the Portuguese version of the EFS. METHODS: Prospective observational study, in a sample of elective cardiac surgery patients. The Edmonton Frail Scale (EFS) translation and backtranslation were performed. Demographic and clinical data were collected, and the translated EFS translated, Geriatric Depression Scale, and Mini Mental State Examination Portuguese versions, Katz and Clinical Frailty Scales were administered. To assess validity Mann-Whitney test, Spearman's correlation coefficient, marginal homogeneity test and Kappa coefficient were employed. Reproducibility was assessed estimating kappa coefficient for the frailty diagnosis and the 11 EFS items. Intra-class correlation coefficients and the corresponding 95% confidence interval were estimated using linear mixed effects model. RESULTS: The EFS Portuguese version revealed construct validity for frailty identification, as well as criterion validity for cognition and mood domains. Reproducibility was demonstrated, with k=0.62 (95% confidence interval (CI) 0.42-0.82) and intraclass correlation (ICC)=0.94 (95% CI 0.89-0.97) in inter-observer test and k=0.48 (95% CI 0.26-0.70) and ICC=0.85 (95% CI 0.72-0.92) in intra-observer test. CONCLUSIONS: The EFS Portuguese version is valid and reproducible for use, suiting pre-operative frailty screening in a cardiac surgery setting.

Olfactory Dysfunction Predicts Frailty and Poor Postoperative Outcome in Older Patients Scheduled for Elective Non-Cardiac Surgery.

OBJECTIVES: Frailty has been suggested to take part in the recently demonstrated link between olfactory dysfunction and overall mortality risk. Preoperative assessment of frailty is essential to detect the most vulnerable patients scheduled for surgery. The aim of this study was to evaluate whether olfactory dysfunction is a reliable predictor of preoperative frailty and postoperative outcome. DESIGN: This was a single-center prospective observational study conducted between July and October 2020 in Brussels, Belgium. SETTING AND PARTICIPANTS: 155 preoperative patients aged from 65 years old and scheduled for elective non-cardiac surgery. MEASUREMENTS: Olfactory function was examined using the Sniffin' Sticks 12-item identification test. Frailty was assessed using the Edmonton Frail Scale (EFS) and handgrip strength. The clock drawing test (CDT) from the EFS was also analyzed separately to evaluate cognitive function. Patients were followed for postoperative complications and mortality over one year. RESULTS: Olfactory dysfunction was significantly associated with the EFS score, anosmic patients having a higher median EFS score than normosmic patients (6[4-7] vs 4[2-5], p = .025). Anosmic patients had an increased odds of being frail after adjusting for possible confounding factors (OR: 6.19, 95% CI: 1.65-23.20, p = .007) and were more at risk of poor postoperative outcome (including complications and death) (OR: 4.33, 95% CI: 1.28-14.67, p = .018). CONCLUSIONS: Olfactory dysfunction is associated with preoperative frailty determined by the EFS and with poor post-surgical outcome at one-year.

Frailty in the over 65's undergoing elective surgery (FIT-65) - a three-day study examining the prevalence of frailty in patients presenting for elective surgery.

BACKGROUND: Frailty increases the risk of perioperative complications, length of stay, and the need for assisted-living after discharge. As the UK population ages the number of frail patients presenting for elective surgery in the UK is likely to grow. Despite the potential benefits of early diagnosis, frailty is not uniformly screened for in UK elective surgical patients and its prevalence remains unclear. The primary aim of this study was to assess the prevalence of frailty in patients aged over 65 years undergoing elective surgery. METHODS: We performed a prospective cross-sectional observational study in eight UK hospitals. Data were collected over three consecutive days with follow-up at 30 days. HRA approval was obtained (REC 20/SC/0121) and signed informed consent obtained. Participants were eligible for inclusion if they were 65 years or older and undergoing elective surgery. Pre-operative data were collected from hospital notes by anaesthetic trainees. A member of the research team blinded to the pre-operative dataset screened each participant for frailty pre-operatively using the Reported Edmonton Frail Scale (REFS). Post-operative data were collected from the notes on day of surgery and at 30 days. Participants were defined as "frail" if they scored 8 or more on the REFS. RESULTS: Two hundred twenty eight participants were recruited during the study period of whom 218 proceeded to surgery. There were 103 females and 115 males. Median age was 75 years (interquartile range 70-80). Thirty-seven participants (17.0%) were identified as frail. Frail patients were older, had a higher ASA score, were more likely to have carers and were more likely to be anaemic or present with ECG abnormalities. There were no differences in gender, BMI, place of residence or smoking status for patients identified as frail versus non-frail. There was no difference in length-of-stay between frail and non-frail patients, although those identified as frail were less likely to be discharged to their own home. CONCLUSION: We found the prevalence of frailty in a mixed population of elective surgical patients aged 65 or over to be 17.0%. Furthermore, we found the REFS to be a practical tool for pre-operative frailty screening. Frail patients presented for elective surgery with modifiable co-morbidities which could have been optimised pre-operatively. Early screening could highlight frail patients, allowing time for pre-operative planning and evidence-based optimisations of comorbidities. We therefore encourage the adoption of frailty assessment as a routine part of pre-operative assessment.

Frailty and Risk of Falls in Community-Dwelling Older Adults Living in a Rural Setting. The Atahualpa Project.

BACKGROUND: Data supporting a link between frailty and risk of falls is mostly confined to individuals living in urban centers, where risk factors and lifestyles are different from that of rural settings. OBJECTIVE: To assess the association between frailty and risk of falls in older adults living in rural Ecuador. DESIGN: Population-based cross-sectional study. PARTICIPANTS: Community-dwellers aged ≥60 years living in a rural Ecuadorian village, in whom frail status and risk of falls were assessed. MEASUREMENTS: Frailty was evaluated by the Edmonton Frailty Scale (EFS) and risk of falls by the Downton Fall Risk Index (DFRI). Multivariate models were fitted to evaluate whether frailty was associated with risk of falls (dependent variable), after adjusting for demographics, alcohol intake, cardiovascular risk factors, sleep quality, symptoms of depression, and history of an overt stroke. Correlation coefficients were constructed to assess confounders modifying this association. RESULTS: A total of 324 participants (mean age: 70.5±8 years) were included. The mean EFS score was 4.4±2.5 points, with 180 (56%) participants classified as robust, 76 (23%) as pre-frail and 68 (21%) as frail. The DFRI was positive in 87 (27%) participants. In univariate analysis, the EFS score was higher among participants with a positive DFRI (p<0.001). The number of frail individuals was higher (p<0.001), while that of robust individuals was lower (p<0.001) among those with a positive DFRI. Adjusted logistic regression models showed no association between frailty and the DFRI. Correlation coefficients showed that age, high glucose levels, and history of an overt stroke tempered the association between frailty and the risk of falls found in univariate analyses. CONCLUSIONS: Frailty is not independently associated with risk of falls in older adults living in a remote rural setting. Further studies are needed to assess the impact of frailty on the risk of falls in these populations.

Dietary Oily Fish Intake and Frailty. A Population-Based Study in Frequent Fish Consumers Living in Rural Coastal Ecuador (the Atahualpa Project).

Oily fish are recommended as part of a healthy diet due to their high content of long-chain omega-3 polyunsaturated fatty acids (ω-3 PUFAs), proteins, and other nutrients. There is preliminary evidence of beneficial effects of ω-3 PUFAs in the prevention of sarcopenia (a major component of frailty). In this study, we aimed to assess the relationship between dietary oily fish intake and a measure of frailty - the Edmonton Frail Scale (EFS) score - in community-dwelling older adults living in rural coastal Ecuador. A total of 363 Atahualpa residents were enrolled. The mean fish servings per week were 8.8 ± 5.2 and mean EFS score was 5 ± 2.8 points. A linear regression model showed no association between the amount of oily fish intake and EFS scores. However, an interaction model, with participants stratified according to their median age and fish intake in quintiles, showed a significant effect for both variables on the EFS score (ß coefficient = 0.104; 95% C.I.: 0.003-0.206; p = 0.044). At the lowest quintile of fish intake, younger individuals have lower EFS scores than their older counterparts. As the consumption of oily fish increases, mean EFS scores margins were found to be progressively reduced in subjects aged 60-69 years but were largely unaffected in persons aged ≥70 years. It appears that oily fish intake has a positive effect on the frailty status of younger subjects but is superseded by the effects of age in the older population.

Major trauma in the elderly: Frailty decline and patient experience after injury.

INTRODUCTION: The prevalence of major trauma in the elderly is increasing with ageing western societies. Frailty is now a well-recognised predictor of poor outcome after injury; however, few studies have focused on the progression of frailty and patients' perceptions of their injuries after discharge. AIM: We hypothesised that the number of elderly patients that survive major trauma is low and, of those that do, frailty post injury worsens with overall negative views about quality of life. To investigate this, we examined mortality, frailty and patient experience for elderly major trauma admissions to a level 1 trauma centre at one year after admission. METHOD: All consecutive patients > 75 with an injury severity score of > 15 were included in the study. Patients were invited to participate in a structured telephone interview to assess change in frailty status as well as assess patient experience after injury. RESULTS: A total of 79 patients met inclusion criteria; 34 patients had died and 17 were uncontactable; 88% had become more frail (p < 0.05), and more than half commented positively on their overall quality of life following injury. CONCLUSIONS: These findings highlight the elevated mortality in elderly major trauma patients, but also indicate that preconceived opinions on quality of life, post injury, might not be appropriate.

Influence of Frailty on Cognitive Decline: A Population-Based Cohort Study in Rural Ecuador.

OBJECTIVE: To assess the influence of frailty on cognitive decline. DESIGN: Population-based prospective cohort study. SETTINGS/PARTICIPANTS: Community-dwelling older adults living in a rural Ecuadorian village, fulfilling the following criteria: age ≥60 years at baseline Montreal Cognitive Assessment (MoCA) and frailty assessment, a baseline brain magnetic resonance imaging, and a follow-up MoCA performed at least 12 months after the baseline. MEASURES: Frailty was evaluated by the Edmonton Frailty Scale (EFS) and cognitive performance by MoCA. The relationship between baseline EFS and MoCA decline was assessed by longitudinal linear and fractional polynomial models, adjusted for relevant confounders. The score of the cognitive component of the EFS was subtracted, and an alternative fractional polynomial model was fitted to settle the impact of such cognitive question on the model. RESULTS: A total of 252 individuals, contributing 923.7 person-years of follow-up (mean: 3.7 ± 0.7 years) were included. The mean EFS score was 4.7 ± 2.5 points. The mean baseline MoCA score was 19.5 ± 4.5 points, and that of the follow-up MoCA was 18.1 ± 4.9 points (P = .001). Overall, 154 (61%) individuals had lower MoCA scores in the follow-up. The best fitted longitudinal linear model showed association between baseline EFS score and MoCA decline (P = .027). There was a continuous increase in MoCA decline in persons with an EFS ≥7 points (nonlinear relationship). Fractional polynomials explained the effect of the EFS on MoCA decline. For the complete EFS score, the ß coefficient was 2.43 (95% confidence interval 1.22-3.63). For the effect of the EFS (without its cognitive component) on MoCA decline, the relationship was still significant (ß 4.86; 95% confidence interval 2.6-7.13). CONCLUSIONS/IMPLICATIONS: Over a 3.7-year period, 61% of older adults living in Atahualpa experienced cognitive decline. Such decline was significantly associated with frailty status at baseline. Region-specific risk factors influencing this relationship should be further studied to reduce its burden in rural settings.

Screening for Frailty and Sarcopenia Among Older Persons in Medical Outpatient Clinics and its Associations With Healthcare Burden.

OBJECTIVES: With an aging population and increase in multimorbidity, the importance of screening for frailty and sarcopenia has become a public health priority. Several tools to do so exist. This study aimed to examine whether the SARC-F and Edmonton frail screening tools are useful in clinical practice to identify at-risk patients for negative health outcomes who would benefit from intervention. DESIGN: This is a cross-sectional study of patients attending medical specialist outpatient clinics at the National University Hospital, Singapore from May 2015 to February 2016. MEASUREMENTS: Frailty and sarcopenia were identified using the Edmonton Frail Scale and SARC-F questionnaires, respectively. Other clinically relevant data including basic demographics, presence of caregiver, number of follow-ups, medications and hospital readmissions in the past 1 year, Charlson comorbidity index, and modified Barthel index were collected from chart review. RESULTS: A total of 115 patients 65 years old and older were screened. Of the sample, 44.3% (n = 51) of patients were sarcopenic, whereas 27.0% (n = 31) were classified as frail; 23.5% (n = 27) were both frail and sarcopenic; and 87.1% of frail patients were sarcopenic, whereas 47.1% of sarcopenic patients were frail. Sarcopenia and frailty were associated with a higher Charlson comorbidity index, higher likelihood of requiring a caregiver, more medical specialty follow-ups, polypharmacy, more than 2 hospital admissions within a year, a higher number of falls and falls with serious consequences. This affected their perceived health status with 50.0% of robust patients rating their health excellent compared with 19.6% of sarcopenic patients (P < .001), 9.7% of frail patients (P < .001) and sarcopenic and frail patients scoring the lowest with 3.7% (P < .001). CONCLUSIONS: The prevalence of frailty and sarcopenia among older adults attending medical outpatient clinic is high. Both syndromes are predictors of recurrent hospital admissions, polypharmacy, multiple medical clinic appointments, higher rate of falls, and falls with serious consequences. Early identification of older adults at risk of adverse health outcomes would aid in instituting timely intervention to reduce healthcare burden and improve quality of life.