Machine learning analyses identify multi-modal frailty factors that selectively discriminate four cohorts in the Alzheimer's disease spectrum: a COMPASS-ND study.

BACKGROUND: Frailty indicators can operate in dynamic amalgamations of disease conditions, clinical symptoms, biomarkers, medical signals, cognitive characteristics, and even health beliefs and practices. This study is the first to evaluate which, among these multiple frailty-related indicators, are important and differential predictors of clinical cohorts that represent progression along an Alzheimer's disease (AD) spectrum. We applied machine-learning technology to such indicators in order to identify the leading predictors of three AD spectrum cohorts; viz., subjective cognitive impairment (SCI), mild cognitive impairment (MCI), and AD. The common benchmark was a cohort of cognitively unimpaired (CU) older adults. METHODS: The four cohorts were from the cross-sectional Comprehensive Assessment of Neurodegeneration and Dementia dataset. We used random forest analysis (Python 3.7) to simultaneously test the relative importance of 83 multi-modal frailty indicators in discriminating the cohorts. We performed an explainable artificial intelligence method (Tree Shapley Additive exPlanation values) for deep interpretation of prediction effects. RESULTS: We observed strong concurrent prediction results, with clusters varying across cohorts. The SCI model demonstrated excellent prediction accuracy (AUC = 0.89). Three leading predictors were poorer quality of life ([QoL]; memory), abnormal lymphocyte count, and abnormal neutrophil count. The MCI model demonstrated a similarly high AUC (0.88). Five leading predictors were poorer QoL (memory, leisure), male sex, abnormal lymphocyte count, and poorer self-rated eyesight. The AD model demonstrated outstanding prediction accuracy (AUC = 0.98). Ten leading predictors were poorer QoL (memory), reduced olfaction, male sex, increased dependence in activities of daily living (n = 6), and poorer visual contrast. CONCLUSIONS: Both convergent and cohort-specific frailty factors discriminated the AD spectrum cohorts. Convergence was observed as all cohorts were marked by lower quality of life (memory), supporting recent research and clinical attention to subjective experiences of memory aging and their potentially broad ramifications. Diversity was displayed in that, of the 14 leading predictors extracted across models, 11 were selectively sensitive to one cohort. A morbidity intensity trend was indicated by an increasing number and diversity of predictors corresponding to clinical severity, especially in AD. Knowledge of differential deficit predictors across AD clinical cohorts may promote precision interventions.

Edmonton Frail Scale predicts mortality in older patients with cancer undergoing radiotherapy-A prospective observational study.

BACKGROUND: Several screening tools are developed to identify frailty in the increasing number of older patients with cancer. Edmonton Frail Scale (EFS) performs well in geriatric settings but is less studied in oncology. We aimed to investigate if EFS score (continuous and categorical) predicts survival in patients referred for radiotherapy, and to assess the concurrent validity of EFS compared with a modified geriatric assessment (mGA). METHODS: Prospective observational, single-center study including patients ≥65 years, referred for curative or palliative radiotherapy for confirmed cancer. Patients underwent mGA (assessment of cognition, mobility, falls, comorbidity, polypharmacy, depression, nutrition, and activities of daily living) and screening with EFS prior to radiotherapy. The predictive value of EFS score of two-year overall survival (OS) was assessed by Kaplan-Meier plots and compared by log-rank test. Cox proportional hazards regression model was estimated to adjust the associations for major cancer-related factors. Concurrent validity of EFS in relation to mGA was estimated by Spearman`s correlation coefficient and ordinal regression. Sensitivity and specificity for different cut-offs was assessed. RESULTS: Patients' (n = 301) mean age was 73.6 (SD 6.3) years, 159 (52.8%) were men, 54% received curative-intent treatment, breast cancer (32%) was the most prevalent diagnosis. According to EFS≥6, 101 (33.7%) were classified as frail. EFS score was predictive of OS [hazard ratio (HR) 1.20 (95% confidence interval (CI) 1.10-1.30)], as was increasing severity assessed by categorical EFS (p<0.001). There was a strong correlation between EFS score and number of geriatric impairments (Spearman`s correlation coefficient 0.77). EFS cut-off ≥6 had a sensitivity of 0.97 and specificity of 0.57 for identifying patients with minimum two geriatric impairments. CONCLUSION: EFS predicts mortality in older patients with cancer receiving radiotherapy, and it is a quick (<5 minutes) and sensitive screening tool to identify patients who may benefit from a geriatric assessment.

Cognitive Trajectories in Older Patients with Cancer Undergoing Radiotherapy-A Prospective Observational Study.

Cognitive function can be affected by cancer and/or its treatment, and older patients are at a particular risk. In a prospective observational study including patients ≥65 years referred for radiotherapy (RT), we aimed to investigate the association between patient- and cancer-related factors and cognitive function, as evaluated by the Montreal Cognitive Assessment (MoCA), and sought to identify groups with distinct MoCA trajectories. The MoCA was performed at baseline (T0), RT completion (T1), and 8 (T2) and 16 (T3) weeks later, with scores ranging between 0 and 30 and higher scores indicating better function. Linear regression and growth mixture models were estimated to assess associations and to identify groups with distinct MoCA trajectories, respectively. Among 298 patients with a mean age of 73.6 years (SD 6.3), the baseline mean MoCA score was 24.0 (SD 3.7). Compared to Norwegian norm data, 37.9% had cognitive impairment. Compromised cognition was independently associated with older age, lower education, and physical impairments. Four groups with distinct trajectories were identified: the very poor (6.4%), poor (8.1%), fair (37.9%), and good (47.7%) groups. The MoCA trajectories were mainly stable. We conclude that cognitive impairment was frequent but, for most patients, was not affected by RT. For older patients with cancer, and in particular for those with physical impairments, we recommend an assessment of cognitive function.

The frailty, outcomes, recovery and care steps of critically ill patients (FORECAST) study: pilot study results.

INTRODUCTION: Frailty is common in critically ill patients and is associated with increased morbidity and mortality. There remains uncertainty as to the optimal method/timing of frailty assessment and the impact of care processes and adverse events on outcomes is unknown. We conducted a pilot study to inform on the conduct, design and feasibility of a multicenter study measuring frailty longitudinally during critical illness, care processes, occurrence of adverse events, and resultant outcomes. METHODS: Single-center pilot study enrolling patients over the age of 55 admitted to an Intensive Care Unit (ICU) for life-support interventions including mechanical ventilation, vasopressor therapy and/or renal replacement therapy. Frailty was measured on ICU admission and hospital discharge with the Clinical Frailty Scale (CFS), the Frailty Index (FI) and CFS at 6-month follow-up. Frailty was defined as CFS ≥ 5 and a FI ≥ 0.20. Processes of care and adverse events were measured during their ICU and hospital stay including nutritional support, mobility, nosocomial infections and delirium. ICU, hospital and 6 months were determined. RESULTS: In 49 patients enrolled, the mean (SD) age was 68.7 ± 7.9 with a 6-month mortality of 29%. Enrollment was 1 patient/per week. Frailty was successfully measured at different time points during the patients stay/follow-up and varied by method/timing of assessment; by CFS and FI, respectively, in 17/49 (36%), 23/49 (47%) on admission, 22/33 (67%), 21/33 (63%) on hospital discharge and 11/30 (37%) had a CFS ≥ 5 at 6 months. Processes of care and adverse events were readily captured during the ICU and ward stay with the exception of ward nutritional data. ICU, hospital outcomes and follow-up outcomes were worse in those who were frail irrespective of ascertainment method. Pre-existing frailty remained static in survivors, but progressed in non-frail survivors. DISCUSSION: In this pilot study, we demonstrate that frailty measurement in critically ill patients over the course and recovery of their illness is feasible, that processes of care and adverse events are readily captured, have developed the tools and obtained data necessary for the planning and conduct of a large multicenter trial studying the interaction between frailty and critical illness.

An international Delphi consensus process to determine a common data element and core outcome set for frailty: FOCUS (The Frailty Outcomes Consensus Project).

BACKGROUND: Despite increased recognition of frailty and its importance, high quality evidence to guide decision-making is lacking. There has been variation in reported data elements and outcomes which makes it challenging to interpret results across studies as well as to generalize research findings. The creation of a frailty core set, consisting of a minimum set of data elements and outcomes to be measured in all frailty studies, would allow for findings from research and translational studies to be collectively analyzed to better inform care and decision-making. To achieve this, the Frailty Outcomes Consensus Project was developed to reach consensus from the international frailty community on a set of common data elements and core outcomes for frailty. METHODS: An international steering committee developed the methodology and the consensus process to be followed. The committee formulated the initial list of data elements and outcomes. Participants from across the world were invited to take part in the Delphi consensus process. The Delphi consisted of three rounds. Following review of data after three rounds, a final ranking round of data elements and outcomes was conducted. A required retention rate of 80% between rounds was set a priori. RESULTS: One hundred and eighty-four panelists from 25 different countries participated in the first round of the Delphi consensus process. This included researchers, clinicians, administrators, older adults, and caregivers. The retention rate between rounds was achieved. Data elements and outcomes forming primary and secondary core sets were identified, within the domains of participant characteristics, physical performance, physical function, physical health, cognition and mental health, socioenvironmental circumstances, frailty measures, and other. CONCLUSION: It is anticipated that implementation and uptake of the frailty core set will enable studies to be collectively analyzed to better inform care for persons living with frailty and ultimately improve their outcomes. Future work will focus on identification of measurement tools to be used in the application of the frailty core set.

Geriatric assessment with management for older patients with cancer receiving radiotherapy. Protocol of a Norwegian cluster-randomised controlled pilot study.

About 50% of patients with cancer are expected to need radiotherapy (RT), and the majority of these are older. To improve outcomes for older patients with cancer, geriatric assessment (GA) with management (GAM) is highly recommended. Evidence for its benefits is still scarce, in particular for patients receiving RT. We report the protocol of a cluster-randomised pilot study designed to test the effect, feasibility and health economic impact of a GAM intervention for patients ≥65 years, referred for palliative or curative RT. The randomising units are municipalities and city districts. The intervention is municipality-based and carried out in collaboration between hospital and municipal health services from the start of RT to eight weeks after the end of RT. Its main constituents are an initial GA followed by measures adapted to individual patients' impairments and needs, systematic symptom assessments and regular follow-up by municipal cancer nurses, appointed to coordinate the patient's care. Follow-up includes at least one weekly phone call, and a house call four weeks after the end of RT. All patients receive an individually adapted physical exercise program and nutritional counselling. Detailed guidelines for management of patients' impairments are provided. Patients allocated to the intervention group will be compared to controls receiving standard care. The primary outcome is physical function assessed by the European Organisation of Research and Treatment of Cancer Quality of Life Questionnaire C-30. Secondary outcomes are global quality of life, objectively tested physical performance and use of health care services. Economic evaluation will be based on a comparison of costs and effects (measured by the main outcome measures). Feasibility will be assessed with mixed methodology, based on log notes and questionnaires filled in by the municipal nurses and interviews with patients and nurses. The study is carried out at two Norwegian RT centres. It was opened in May 2019. Follow-up will proceed until June 2022. Statistical analyses will start by the end of 2021. We expect the trial to provide important new knowledge about the effect, feasibility and costs of a GAM intervention for older patients receiving RT. Trial registration: ClinTrials.gov, ID NCT03881137, initial release 13th of March 2019.

Association between preoperative frailty and outcomes among adults undergoing cardiac surgery: a prospective cohort study.

BACKGROUND: The identification of frailty before complex and invasive procedures may have relevance for prognostic and recovery purposes, to optimally inform patients, caregivers and clinicians about perioperative risk and postoperative care needs. The aim of this study was to estimate the prevalence of frailty and describe the associated clinical course and outcomes of patients referred for nonemergent cardiac surgery. METHODS: A prospective cohort of patients aged 50 years and older referred for nonemergent cardiac surgery in Alberta, Canada, from November 2011 to March 2014 were screened preoperatively for frailty, defined as a Clinical Frailty Scale (CFS) score of 5 or greater. Postoperatively, patients were followed by telephone to assess CFS score, health services use and vital status. The primary outcome was all-cause hospital mortality. Secondary outcomes included health services use, hospital discharge disposition, 1-year health-related quality of life and all-cause 5-year mortality. RESULTS: The cohort (n = 529) had a mean age of 67 (standard deviation [SD] 9) years; 25.9% were female, and the prevalence of frailty was 9.6% (n = 51; 95% confidence interval [CI] 7.3%-12.5%). Frail patients were older (median age 75, interquartile range [IQR] 65-80 v. 67, IQR 60-73, yr; p < 0.001), were more likely to be female (51.0% v. 23.2%; p < 0.001), had a higher mean EuroSCORE II (8, SD 3 v. 5, SD 3; p < 0.001) and received combined coronary artery bypass grafting and valve procedures more frequently (29.4% v. 15.9%; p = 0.02) than nonfrail patients. Postoperatively, frail patients had a longer median duration of stay in the cardiovascular intensive care unit (median difference 2.2, 95% CI 1.60-2.79) and hospital (median difference 9.3, 95% CI 8.2-10.3). Hospital mortality was 9.8% among frail patients and 1.0% among nonfrail patients (adjusted hazard ratio 3.84, 95% CI 0.90-16.34). INTERPRETATION: Preoperative frailty was present in 10% of patients and was associated with a higher risk of morbidity and greater health services use. Preoperative frailty has important implications for the postoperative clinical course and resource utilization of patients undergoing cardiac surgery.

Customizing a Program for Older Adults Living with Frailty in Primary Care.

Coordination of primary care is essential to improving care delivery within health systems, especially for older adults with increased health/social needs. A program jointly funded by the Canadian Foundation for Healthcare Improvement and Canadian Frailty Network, was implemented in a nurse practitioner-led clinic to address the gap in frailty care for older adults. The clinic was situated within a health and social services organization with a mandate to enhance the quality of life of older adults living in the community. Through this program, a frailty assessment pathway and social/clinical prescriptions were implemented with necessary adaptations as a result of COVID-19.

Frailty inclusive care in acute and community-based settings: a systematic review protocol.

BACKGROUND: Frailty is a known risk factor for an array of adverse outcomes including more frequent and prolonged health services use and high health care costs. Aging of the population has implications for care provision across the care continuum, particularly for people living with frailty. Despite known risks associated with frailty, there has been limited research on care pathways that address the needs of persons living with frailty. Our study aims to review and examine, in a rigorous way, the quality of evidence for multi-component interventions and care pathways focused on frailty. METHODS: A comprehensive electronic search strategy will be used to identify studies that evaluate multi-component interventions or care pathways for persons living with frailty. The search strategy will include terms for frailty, multi-component interventions, effectiveness, and cost effectiveness applied to the following databases: MEDLINE (OVID), EMBASE (OVID), CINAHL (EBSCO), Cochrane Central Register of Controlled Trials (CENTRAL), and Cochrane Database of Systematic Reviews. An adapted search for Google Scholar and gray literature databases will also be used. References of included studies will be hand-searched for additional citations of frailty-inclusive care. Known experts and corresponding authors of identified articles will be contacted by email to identify further eligible studies. Risk of bias will be assessed using the Effective Public Health Practice Project Quality Assessment tool. Data will be extracted from eligible studies and it is anticipated that narrative analysis will be used. If studies with sufficient homogeneity are found, then pooled effects will be reported using meta-analysis. DISCUSSION: This review will appraise the evidence currently available on multi-component frailty interventions. Results will inform on clinical pathway development for people living with frailty across the care continuum and will guide future research to address gaps in the literature and areas in need of further development. SYSTEMATIC REVIEW REGISTRATION: PROSPERO CRD42020166733.

The Impact of Preoperative Frailty on the Clinical and Cost Outcomes of Adult Cardiac Surgery in Alberta, Canada: A Cohort Study.

BACKGROUND: There is limited information about the impact of frailty on public payer costs in cardiac surgery. This study aimed to determine quality-adjusted life-years (QALYs) and costs associated with preoperative frailty in patients referred for cardiac surgery. METHODS: We retrospectively compared costs of frailty in a cohort of 529 patients aged ≥ 50 years who were referred for nonemergent cardiac surgery in Alberta. Patients were screened preoperatively for frailty, defined as a score of 5 or greater on the Clinical Frailty Scale. The primary outcome measure was public payer costs attributable to frailty, calculated in a difference-in-difference (DID) model. RESULTS: The prevalence of frailty was 10% (n = 51; 95% confidence interval [CI], 7%-12%). Median (interquartile range) costs for frail patients were higher in the first year postsurgery ($200,709 [$146,177-$486,852] vs $147,730 [$100,674-$177,025]; P < 0.001) compared to nonfrail; the difference-in-difference attributable cost of frailty was $57,836 (95% CI, $-28,608-$144,280). At 1 year, frail patients had fewer QALYs realized compared to nonfrail patients (0.71 [0.57-0.77] vs 0.82 [0.75-0.86], P < 0.001), whereas QALYs gained were similar (0.02 [-0.02-0.05] vs 0.02 [0.00-0.04], P = 0.58, median difference 0.003 [95% CI, -0.01-0.02]) in frail and nonfrail patients. CONCLUSIONS: Frailty screening identified a population with greater impairment in quality-of-life and greater healthcare costs. Costs attributable to frailty represent opportunity costs that should be considered in future cardiac surgical services planning in the context of our aging population and the growing prevalence of frailty.

CONTEXTE: Il existe peu de renseignements concernant les répercussions de la fragilité sur les coûts pour les payeurs publics en chirurgie cardiaque. Cette étude visait à déterminer les années de vie pondérées par la qualité (QALY, pour Quality-Adjusted Life-Years) et les coûts associés à la fragilité préopératoire chez les patients dirigés vers un service de chirurgie cardiaque. MÉTHODOLOGIE: Nous avons comparé de façon rétrospective les coûts de la fragilité dans une cohorte de 529 patients âgés de 50 ans ou plus qui ont été dirigés vers un service de chirurgie cardiaque pour une intervention non urgente en Alberta. Un dépistage de la fragilité, définie comme un score de 5 ou plus à l'échelle CFS (Clinical Frailty Scale), a été effectué avant l'intervention. Le principal critère d'évaluation était le coût attribuable à la fragilité pour les payeurs publics, calculé selon un modèle d'écart des différences. RÉSULTATS: La prévalence de la fragilité a été de 10 % (n = 51; intervalle de confiance [IC] à 95 % : 7 à 12 %). Les coûts médians (écart interquartile) dans la première année suivant l'intervention chirurgicale ont été plus élevés chez les patients fragiles que chez les patients non fragiles (200 709 $ [146 177 $ à 486 852 $] contre 147 730 $ [100 674 $ à 177 025 $]; p < 0,001); le coût attribuable de la fragilité selon le modèle d'écart des différences a été de 57 836 $ (IC à 95 % : −28 608 $ à 144 280 $). À 1 an, les patients fragiles avaient moins de QALY réalisées que les patients non fragiles (0,71 [0,57 à 0,77] contre 0,82 [0,75 à 0,86]; p < 0,001), alors que le nombre de QALY gagnées était similaire (0,02 [−0,02 à 0,05] contre 0,02 [0,00 à 0,04]; p = 0,58; différence médiane : 0,003 [IC à 95 % : −0,01 à 0,02]) chez les patients fragiles et non fragiles. CONCLUSIONS: Le dépistage de la fragilité a permis de repérer une population associée à une perte plus importante de qualité de vie et à des coûts plus élevés en soins de santé. Les coûts attribuables à la fragilité représentent des coûts de renonciation qui doivent être considérés dans la planification future des services de chirurgie cardiaque, dans le contexte du vieillissement de notre population et de la prévalence croissante de fragilité.

Sex-specific prevalence and outcomes of frailty in critically ill patients.

BACKGROUND: The prevalence of frailty, an important risk factor for short- and long-term outcomes in hospitalized adults, differs by sex. Studies in critically ill adults have also found differences in mortality and organ support rates in males and females. The objective of this study was to determine if these observed differences in mortality and organ support rates can be explained by sex and frailty alone, or if the interaction between sex and frailty is an important risk factor. METHODS: This is a retrospective multi-centre population-based cohort study of all adult patients (≥ 18 years) admitted to the seventeen intensive care units (ICUs) across Alberta, Canada, between 2016 and 2017. On admission, physicians assigned a Clinical Frailty Scale (CFS) score (1 = very fit, 9 = terminally ill) to all patients. Patients with missing CFS scores or who died within 24 h of ICU admission were excluded. Frailty was defined as CFS ≥ 5. Outcomes included all-cause hospital mortality, ICU mortality, and organ support rates. A propensity score for female sex was generated and 1:1 matching on sex was performed. Multivariable Cox regression or logistic regression, as appropriate, was performed to evaluate the association between sex, frailty, and the sex-frailty interaction term with outcomes. RESULTS: Of 15,238 patients included in the cohort, after propensity score matching 11,816 patients remained (mean [standard deviation] age 57.3 [16.9]). In the matched cohort, females had a higher prevalence of frailty than males (32% vs. 27%, respectively) and higher odds of frailty (odds ratio [95% confidence interval (CI)] 1.29 [1.20-1.40]). Though females were less likely to receive invasive mechanical ventilation (hazard ratio [95% CI] 0.78 [0.71-0.86]), the interaction between sex and frailty (i.e., males and females with and without frailty) was not associated with differences in organ support rates. Receipt of dialysis and vasoactive support, as well as hospital mortality and ICU mortality were associated with frailty but were not associated with female sex or the interaction between sex and frailty. CONCLUSIONS: Although frailty and sex were individually associated with mortality and differences in organ support in the ICU, there does not appear to be a significant interaction between sex and frailty with regards to these outcomes.

Interrater Reliability of the Clinical Frailty Scale by Geriatrician and Intensivist in Patients Admitted to the Intensive Care Unit.

BACKGROUND: The Clinical Frailty Scale (CFS) is a commonly used frailty measure in intensive care unit (ICU) settings. We are interested in the test characteristics, especially interrater reliability, of the CFS in ICU by comparing the scores of intensivists to geriatricians. METHODS: We conducted a prospective cohort study on a convenience sample of newly admitted patients to an ICU in Edmonton, Canada. An intensivist and a resident in Geriatric Medicine (GM) independently assigned a CFS score on 158 adults within 72 hours of admission. A specialist in Geriatric Medicine assigned a CFS score independently of 20 of the 158 patients to assess agreement between the two raters trained in geriatrics. Predictive validity was captured using mortality and length of stay. RESULTS: Agreement on CFS score was fair for intensivists vs. GM resident (kappa 0.32) and for intensivists vs. GM specialist (0.29), but substantial for GM resident vs. staff (0.79). Despite this, the CFS remained prognostically relevant, regardless of rater background. Frailty (CFS ≥ 5) as assessed by either intensivist or GM resident was a strong predictor of in-hospital mortality (odds ratio [OR] 3.6; 95% CI, 1.6-8.4, p = .003 and OR 3.0; 95% CI 1.3-6.9; p = .01, respectively). Frailty was also positively correlated with age, illness severity measured by APACHE II score, and length of hospital stay. CONCLUSIONS: The interrater reliability of the CFS in ICU settings is fair for intensivists vs. geriatricians.

Implementation of population-level screening for frailty among patients admitted to adult intensive care in Alberta, Canada.

PURPOSE: A substantial proportion of patients admitted to intensive care units (ICUs) are frail; however, the epidemiology of frailty has not been explored at a population-level. Following implementation of a validated frailty measure into a provincial ICU clinical information system, we describe the population-based prevalence and outcomes of frailty in patients admitted to ICUs. METHODS: Retrospective cohort study of adult admissions to 17 ICUs. Data were captured using eCritical Alberta. A Clinical Frailty Scale (CFS) score assigned at ICU admission was used to define the exposure (CFS score ≥ 5). Primary outcome was hospital mortality. Secondary outcomes were ICU and hospital stay, and receipt of organ support. RESULTS: Fifteen thousand two hundred and thirty-eight patients (81%) were assigned a CFS score at ICU admission. Of these, 28% (95% confidence interval [CI], 27 to 28) were frail. Prevalence of frailty was 9-43% across ICUs. Frail patients were older [mean (standard deviation) 63 (15) vs 56 (17) yr; P < 0.001], more likely to be male (54% vs 46% female; P < 0.001), and had higher APACHE II scores [22 (8) vs 17 (8); P < 0.001] compared with non-frail patients. Frail patients received less mechanical ventilation (62% vs 68%; P < 0.001) and vasoactive therapy (24% vs 57%; P < 0.001), but more non-invasive ventilation (22% vs 9%; P < 0.001). Frail patients had higher hospital mortality (23% vs 9%; adjusted odds ratio, 1.80; 95% CI, 1.64 to 2.05, along with longer ICU stay (median [interquartile range] 4 [2-8] vs 3 [2-6] days; P < 0.001), and longer hospital stay (16 [8-36] vs 10 [5-20] days; P < 0.001) compared with non-frail patients. CONCLUSION: A validated measure of frailty can be implemented at the population level in ICU. Frailty is common in ICU patients and has implications for health service use and clinical outcomes.

Correction to: A cross-sectional study examining convergent validity of a frailty index based on electronic medical records in a Canadian primary care program.

Following the publication of this article [1], the authors reported a typesetting error in the "Results" section.

A cross-sectional study examining convergent validity of a frailty index based on electronic medical records in a Canadian primary care program.

BACKGROUND: An electronic frailty index (eFI) has been developed and validated in the UK; it uses data from primary care electronic medical records (EMR) for effective frailty case-finding in primary care. This project examined the convergent validity of the eFI from Canadian primary care EMR data with a validated frailty index based on comprehensive geriatric assessment (FI-CGA), in order to understand its potential use in the Canadian context. METHODS: A cross-sectional validation study, using data from an integrated primary care research program for seniors living with frailty in Edmonton, AB. Eighty-five patients 65 years of age and older from six primary care physicians' practices were recruited. Patients were excluded if they were under 65 years of age, did not provide consent to participate in the program, or were living in a long term care facility at the time of enrolment. We used scatter plots to assess linearity and Pearson correlation coefficients to examine correlations. RESULTS: Results indicate a strong statistically significant correlation between the eFI and FI-CGA (r = 0.72, 95% CI 0.60-0.81, p < 0.001). A simple linear regression showed good ability of the eFI scores to predict FI-CGA scores (F (1,83) = 89.06, p < .0001, R2 = 0.51). Both indices were also correlated with age, number of chronic conditions and number of medications. CONCLUSIONS: The study findings support the convergent validity of the eFI, which further justifies implementation of a case-finding tool that uses routinely collected primary care data in the Canadian context.

Predicting Hepatic Encephalopathy-Related Hospitalizations Using a Composite Assessment of Cognitive Impairment and Frailty in 355 Patients With Cirrhosis.

INTRODUCTION: Hepatic encephalopathy (HE) is the most common potentially modifiable reason for admission in patients with cirrhosis. Cognitive and physical components of frailty have pathophysiologic rationale as risk factors for HE. We aimed to assess the utility of a composite score (MoCA-CFS) developed using the Montreal Cognitive Assessment (MoCA) and the Clinical Frailty Scale (CFS) for predicting HE admissions within 6 months. METHODS: Consecutive adult patients with cirrhosis were followed for 6 months or until death/transplant. Patients with overt HE and dementia were excluded. Primary outcome was the prediction of HE-related admissions at 6 months. RESULTS: A total of 355 patients were included; mean age 55.9 ± 9.6; 62.5% male; Hepatitis C and alcohol etiology in 64%. Thirty-six percent of patients had cognitive impairment according to the MoCA (≤24) and 14% were frail on the CFS (>4). The MoCA-CFS independently predicted HE hospitalization within 6 months, a MoCA-CFS score of 1 and 2 respectively increasing the odds of hospitalization by 3.3 (95% CI:1.5-7.7) and 5.7 (95% CI:1.9-17.3). HRQoL decreased with increasing MoCA-CFS. Depression and older age were independent predictors of a low MoCA. CONCLUSIONS: Cognitive and physical frailty are common in patients with cirrhosis. In addition to being an independent predictor of HE admissions within 6 months, the MoCA-CFS composite score predicts impaired HRQoL and all-cause admissions within 6 months. These data support the predictive value of a "multidimensional" frailty tool for the prediction of adverse clinical outcomes and highlight the potential for a multi-faceted approach to therapy targeting cognitive impairment, physical frailty and depression.

Frailty and the Association Between Long-Term Recovery After Intensive Care Unit Admission.

Frailty is common, although infrequently screened for among patients admitted to intensive care. Frailty has been the focus of research in geriatric medicine; however, its epidemiology and interaction with critical illness have only recently been studied. Instruments to screen for and measure frailty require refinement in intensive care settings. Frail critically ill patients are at higher risk of poor outcomes. Frail survivors of critical illness are high users of health resources. Further research is needed to understand how frailty assessment can inform decision-making before and during an episode of critical illness and during an intensive care course for frail patients.

Review of risk assessment tools to predict morbidity and mortality in elderly surgical patients.

BACKGROUND: Informed surgical consent requires accurate estimation of risks and benefits. Multiple risk assessment tools are available; however, most are not widely used or are specific to certain interventions. Assessing surgical risk is especially challenging in elderly patients because of their range of comorbidities, level of frailty, or severity of illness and a number of available surgical interventions. DATA SOURCES: We searched MEDLINE from January 2014 to July 2017 for studies that used risk assessment tools in studies on elderly surgical patients. We then sought the original articles describing each assessment tool and subsequent validation studies. CONCLUSIONS: We identified risk assessment tools that can improve surgical risk assessment in elderly surgical patients. The majority of the identified tools are not commonly used for pre-operative risk assessment. NSQIP-PMP, mFI and SURPAS are promising tools. Age is commonly used to predict risk, but frailty may be a more appropriate measure.