COVID-19 is not over and age is not enough: Using frailty for prognostication in hospitalized patients.

BACKGROUND: Frailty screening using the Clinical Frailty Scale (CFS) has been proposed to guide resource allocation in acute care settings during the pandemic. However, the association between frailty and coronavirus disease 2019 (COVID-19) prognosis remains unclear. OBJECTIVES: To investigate the association between frailty and mortality over 6 months in middle-aged and older patients hospitalized with COVID-19 and the association between acute morbidity severity and mortality across frailty strata. DESIGN: Observational cohort study. SETTING: Large academic medical center in Brazil. PARTICIPANTS: A total of 1830 patients aged ≥50 years hospitalized with COVID-19 (March-July 2020). MEASUREMENTS: We screened baseline frailty using the CFS (1-9) and classified patients as fit to managing well (1-3), vulnerable (4), mildly (5), moderately (6), or severely frail to terminally ill (7-9). We also computed a frailty index (0-1; frail >0.25), a well-known frailty measure. We used Cox proportional hazards models to estimate the association between frailty and time to death within 30 days and 6 months of admission. We also examined whether frailty identified different mortality risk levels within strata of similar age and acute morbidity as measured by the Sequential Organ Failure Assessment (SOFA) score. RESULTS: Median age was 66 years, 58% were male, and 27% were frail to some degree. Compared with fit-to-managing-well patients, the adjusted hazard ratios (95% confidence interval [CI]) for 30-day and 6-month mortality were, respectively, 1.4 (1.1-1.7) and 1.4 (1.1-1.7) for vulnerable patients; 1.5 (1.1-1.9) and 1.5 (1.1-1.8) for mild frailty; 1.8 (1.4-2.3) and 1.9 (1.5-2.4) for moderate frailty; and 2.1 (1.6-2.7) and 2.3 (1.8-2.9) for severe frailty to terminally ill. The CFS achieved outstanding accuracy to identify frailty compared with the Frailty Index (area under the curve = 0.94; 95% CI = 0.93-0.95) and predicted different mortality risks within age and acute morbidity groups. CONCLUSIONS: Our results encourage the use of frailty, alongside measures of acute morbidity, to guide clinicians in prognostication and resource allocation in hospitalized patients with COVID-19.

Targeted Geriatric Assessment for Fast-Paced Healthcare Settings: Development, Validity, and Reliability.

OBJECTIVES: To develop and examine the validity and reliability of a targeted geriatric assessment (TaGA) for busy healthcare settings. DESIGN: The TaGA was developed through the consensus of experts (Delphi technique), and we investigated its construct validity and reliability in a cross-sectional study. SETTING: Geriatric day hospital specializing in acute care in Brazil. PARTICIPANTS: Older adults (N = 534) aged 79.5 ± 8.4, 63% female, consecutively admitted to the geriatric day hospital. MEASUREMENTS: The Frailty Index (FI), Physical Frailty Phenotype, and Identification of Seniors at Risk (ISAR) were used to explore the TaGA's validity. External scales were used to investigate the validity of each matched TaGA domain. The interrater reliability and time to complete the instrument were tested in a 53-person subsample. RESULTS: In 3 rounds of opinion, experts achieved consensus that the TaGA should include 10 domains (social support, recent hospital admissions, falls, number of medications, basic activities of daily living, cognitive performance, self-rated health, depressive symptoms, nutritional status, gait speed). They arrived at sufficient agreement on specific tools to assess each domain. A single numerical score from 0 to 1 expressed the cumulative deficits across the 10 domains. The TaGA score was highly correlated with the FI (Spearman coefficient = 0.79, 95% confidence interval (CI)=0.76-0.82) and discriminated between frail and nonfrail individuals better than the ISAR (area under the receiver operating characteristic curve 0.84 vs 0.72; P < .001). The TaGA score also had excellent interrater reliability (intraclass correlation coefficient = 0.92, 95% CI=0.87-0.95). Mean TaGA administration time was 9.5 ± 2.2 minutes. CONCLUSION: The study presents evidence supporting the TaGA's validity and reliability. This instrument may be a practical and efficient approach to screening geriatric syndromes in fast-paced healthcare settings. Future research should investigate its predictive value and effect on care.

The Geriatric Day Hospital: Preliminary Data on an Innovative Model of Care in Brazil for Older Adults at Risk of Hospitalization.

Older adults have a greater risk of experiencing functional decline and iatrogenic complications during hospitalization than younger individuals. Geriatric day hospitals (GDHs) have been implemented mainly for rehabilitation. The goal of the current study was to expand the GDH spectrum of care to prevent hospital admissions in this population. This study details an innovative model of GDH care that offers short-term, nonrehabilitative treatment to older adults who have experienced an acute event, those with a decompensated chronic disease, or those in need of a minor procedure that would be unattainable in a regular outpatient setting. During the 6-hour visits made weekly for up to 2 months, participants receive integrated evaluations of their various health domains, education, and rapid access to examinations and procedures based on a multidisciplinary approach. In the first 6 years, 2,322 individuals attended the GDH. The analysis of a representative sample (n = 645) revealed that 81% were treated in the GDH without the need for another type of hospital care. This percentage was high for the different reasons for referral (infection, 71%; delirium, 73%; decompensated chronic disease, 81%). Between baseline and discharge, participants maintained their functional status, and their self-reported health improved. This study represents the first step in describing the role of the GDH as a possible alternative to emergency department use or hospitalization for older adults. Future studies are needed to determine the optimal individual for this model of care and to ensure its cost-effectiveness.