Frailty Screening and Detection of Geriatric Syndromes in Acute Inpatient Care: Impact on Hospital Length of Stay and 30-Day Readmissions.

BACKGROUND: Frailty is prevalent in acute care and is associated with negative outcomes. While a comprehensive geriatric assessment to identify geriatric syndromes is recommended after identifying frailty, more evidence is needed to support this approach in the inpatient setting. This study examined the association between frailty and geriatric syndromes and their impact on outcomes in acutely admitted older adults. METHODS: A total of 733 individuals aged ≥65 years admitted to the General Surgery Service of a tertiary hospital were assessed for frailty using the Clinical Frailty Scale (CFS) and for geriatric syndromes using routine nursing admission assessments, including cognitive impairment, falls, incontinence, malnutrition, and poor oral health. Multinomial logistic regression and Cox regression were used to evaluate the associations between frailty and geriatric syndromes and their concomitant impact on hospital length of stay (LOS) and 30-day readmissions. RESULTS: Greater frailty severity was associated with an increased likelihood of geriatric syndromes. Individuals categorized as CFS 4-6 and CFS 7-8 with concomitant geriatric syndromes had 29% and 35% increased risks of a longer LOS, respectively. CFS 4-6 was significantly associated with functional decline (relative risk ratio =1.46; 95% confidence interval [CI], 1.03-2.07) and 30-day readmission (hazare ratio=1.78; 95% CI, 1.04-3.04), whereas these associations were not significant for CFS 7-8. CONCLUSION: Geriatric syndromes in frail individuals can be identified from routine nursing assessments and represent a potential approach for targeted interventions following frailty identification. Tailored interventions may be necessary to achieve optimal outcomes at different stages of frailty. Further research is required to evaluate interventions for older adults with frailty in a wider hospital context.

Concurrent and Predictive Validity of FRAIL-NH in Hospitalized Older Persons: An Exploratory Study.

OBJECTIVES: The FRAIL-NH was originally developed for frailty assessment of nursing home (NH) residents. We aimed to compare concurrent, predictive, and known-groups validity between FRAIL-NH and FRAIL, using the Frailty Index (FI) as gold standard reference. We also examined for ceiling effect of both measures in the detection of severe frailty. DESIGN: A secondary analysis of a prospective cohort study. SETTING & PARTICIPANTS: Older adults (mean age 89.4 years) hospitalized for an acute medical illness in a 1300-bed tertiary hospital. MEASUREMENTS: Baseline data on demographics, comorbidities, severity of illness, functional status, and cognitive status were gathered. We also captured outcomes of mortality, length of stay (LOS), institutionalization, and functional decline. For concurrent validity, we compared areas under the operating characteristic curves (AUCs) for both measures against the FI. For predictive validity, univariate analyses and multiple logistic regression were used to compare both measures against the adverse outcomes of interest. For known-groups validity, we compared both measures against comorbidities and functional status via 1-way analysis of variance, and dementia diagnosis via independent t test. Box plots were also derived to investigate for possible ceiling effect. RESULTS: Both measures had good concurrent validity (both AUC > 0.8 and P < .001), with FRAIL-NH detecting more frailty cases (79.5% vs 50.0%). Although FRAIL-frail was superior for in-hospital mortality [6.7% vs 1.0%, P = .031, odds ratio (OR) 9.29, 95% confidence interval (CI) 1.09-79.20, P < .042] and LOS (10 vs 8 days, P = .043), FRAIL-NH-frail better predicted mortality (OR 6.62, 95% CI 1.91-22.94, P = .003) and institutionalization (OR 6.03, 95% CI 2.01-18.09, P = .001) up to 12 months postenrollment. Known-groups validity was good for both measures with FRAIL-NH yielding greater F values for functional status and dementia. Lastly, box plots revealed a ceiling effect for FRAIL in the severely frail group. CONCLUSIONS AND IMPLICATIONS: This exploratory study highlights the potential for expanding the role of FRAIL-NH beyond NH to acute care settings. Contrasted to FRAIL, FRAIL-NH had better overall validity with less ceiling effect in discrimination of severe frailty.

Predictors for development of critical illness amongst older adults with COVID-19: Beyond age to age-associated factors.

INTRODUCTION: Older adults with COVID-19 have disproportionately higher rates of severe disease and mortality. It is unclear whether this is attributable to age or attendant age-associated risk factors. This retrospective cohort study aims to characterize hospitalized older adults and examine if comorbidities, frailty and acuity of clinical presentation exert an age-independent effect on COVID-19 severity. METHODS: We studied 275 patients admitted to the National Centre of Infectious Disease, Singapore. We measured: 1)Charlson Comorbidity Index(CCI) as burden of comorbidities; 2)Clinical Frailty Scale(CFS) and Frailty Index(FI); and 3)initial acuity. We studied characteristics and outcomes of critical illness, stratified by age groups (50-59,60-69 and ≥70). We conducted hierarchical logistic regression in primary model(N = 262, excluding direct admissions to intensive care unit) and sensitivity analysis(N = 275): age and gender in base model, entering CCI, frailty (CFS or FI) and initial acuity sequentially. RESULTS: The ≥70 age group had highest CCI(p<.001), FI(p<.001) and CFS(p<.001), and prevalence of geriatric syndromes (polypharmacy,53.5%; urinary symptoms,37.5%; chronic pain,23.3% and malnutrition,23.3%). Thirty-two (11.6%) developed critical illness. In the primary regression model, age was not predictive for critical illness when a frailty predictor was added. Significant predictors in the final model (AUC 0.809) included male gender (p=.012), CFS (p=.038), and high initial acuity (p=.021) but not CCI or FI. In sensitivity analysis, FI (p=.028) but not CFS was significant. CONCLUSIONS: In hospitalized older adults with COVID-19, geriatric syndromes are not uncommon. Acuity of clinical presentation and frailty are important age-independent predictors of disease severity. CFS and FI provide complimentary information in predicting interval disease progression and rapid disease progression respectively.

Epidemiological, Clinical, and Phylogenetic Characteristics of the First SARS-CoV-2 Transmission in a Nursing Home of Singapore: A Prospective Observational Investigation.

Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) transmission has resulted in a significant burden among nursing home facilities globally. This prospective observational cohort study aims to define the potential sources of introduction and characteristics of SARS-CoV-2 transmission of the first nursing home facility in Singapore. An epidemiological serial point-prevalence survey of SARS-CoV-2 was conducted among 108 residents and 56 healthcare staff (HCS). In the current study, 14 (13%) residents and two (3.6%) HCS were diagnosed with coronavirus disease 2019 (COVID-19), with a case fatality rate (CFR) of 28.6% (4/14) among the residents. The median age of the infected residents was 86.5 [interquartile range (IQR) 78.5-88] and 85.7% were women. Five residents were symptomatic (35.7%) and the others were asymptomatic (64.3%). A higher proportion of residents who succumbed to COVID-19 had hypertension than those who recovered. The SARS-CoV-2 whole-genome sequencing showed lineage B.6 which is rare globally but common regionally during the early phase of the pandemic. Household transmission is a potential source of introduction into the nursing home, with at least six epidemiologically linked secondary cases. Male residents were less implicated due to the staff segregation plan by block. Among residents, a higher proportion of the non-survivors were asymptomatic and had hypertension compared with survivors.

Heterogeneity in functional status among moderately frail older adults: improving predictive performance using a modified approach of subgrouping the Clinical Frailty Scale.

PURPOSE: Moderately frail individuals [Clinical Frailty Scale (CFS) 6] demonstrate heterogeneity in basic activities of daily living (bADL). We aimed to establish whether functional dependency in moderate frailty predicts poorer outcomes and examined the utility of subgrouping the CFS in predicting mortality and institutionalisation. METHODS: We prospectively studied 201 hospitalised frail patients (89.5 ± 4.7 years, female 70.1%). We examined Katz Index (KI) against adverse outcomes in CFS6 (n = 106). We then compared predictive performances of a modified CFS version 1 (mCFS-1; category 6A: CFS6 and KI ≥ 2; 6B: CFS6 and KI ≤ 1) and modified CFS version 2 (mCFS-2; category 6A: CFS6 and KI ≥ 2; 6B1: CFS6, KI ≤ 1 and feeding independent; 6B2: CFS6, KI ≤ 1 and feeding dependent) against the CFS. Multivariate analysis was used to compare each tool against mortality and institutionalisation. Receiver operator characteristic analysis was performed to determine area under curve and optimal cut-points for each tool. RESULTS: KI ≤ 1 in CFS6 was associated with higher 12-month mortality (39.3% vs. 15.6%, p = 0.01); amongst KI items, feeding dependent predicted 12-month mortality (p < 0.05). Using mCFS-1, category 6A did not increase 12-month mortality compared with category 5 (OR 1.83, 95% CI 0.52-6.47), unlike category 6B (OR 6.33, 95% CI 2.07-19.33). mCFS-2 produced higher mortality in category 6B1 (OR 5.19, 95% CI 1.30-20.69) and 6B2 (OR 6.92, 95% CI 2.14-22.35). Similar observations were seen for institutionalisation. Optimal cut-point for 12-month mortality was category 6 for CFS, and 6B and 6B1 for mCFS-1 and mCFS-2, respectively. CONCLUSION: This study corroborates the heterogeneity of functional status in moderately frail individuals and validates the use of a modified approach to subgrouping the CFS6 via bADL functional status for improved predictive performance.

Resource consumption in hospitalised, frail older patients.

INTRODUCTION: The objective of this study was to determine factors, other than the Diagnostic Related Grouping (DRG), that can explain the variation in the cost of hospitalisation and length of hospital stay (LOS) in older patients. MATERIALS AND METHODS: This was a prospective, observational cohort study involving 397 patients, aged 65 years and above. Data collected include demographic information, admission functional and cognitive status, overall illness severity score, number of referral to therapists, referral to medical social worker, cost of hospitalisation, actual LOS, discharge DRG codes and their corresponding trimmed average length of stay (ALOS). RESULTS: The mean age of the cohort was 80.2 years. The DRG's trimmed ALOS alone explained 21% of the variation in the cost of hospitalisation and actual LOS. Incorporation of an illness severity score, number of referral to therapists and referral to medical social worker into the trimmed ALOS explained 30% and 31% of the variation in the cost and actual LOS, respectively. CONCLUSION: The DRG model is able to explain 21% of the variation in the cost of hospitalisation and actual LOS in older patients. Other factors that determined the variation in the cost of hospitalisation and LOS include the degree of illness severity, the number of referral to therapists and referral to medical social worker.