Clinical Frailty Scale in an Acute Medicine Unit: a Simple Tool That Predicts Length of Stay

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Abstract

Background

Frailty is characterized by increased vulnerability to external stressors. When frail older adults are admitted to hospital, they are at increased risk of adverse events including falls, delirium, and disability. The Clinical Frailty Scale (CFS) is a practical and efficient tool for assessing frailty; however, its ability to predict outcomes has not been well studied within the acute medical service.

Objective

To examine the CFS in elderly patients admitted to the acute medical ward and its association with length of stay.

Design

Prospective cohort study in an acute care university hospital in London, Ontario, Canada, involving 75 patients over age 65, admitted to the general internal medicine clinical teaching units (CTU).

Measurements

Patient demographics were collected through chart review, and CFS score was assigned to each patient after brief clinician assessment. The CFS ranges from 1 (very fit) to 9 (terminally ill) based on descriptors and pictographs of activity and functional status. The CFS was collapsed into three categories: non-frail (CFS 1–4), mild-to-moderately frail (CFS 5–6), and severely frail (CFS 7–8). Outcomes of length of stay and 90-day readmission were gathered through the LHSC electronic patient record.

Results

Severe frailty was associated with longer lengths of stay (Mean = 12.6 ± 12.7 days) compared to mild-to-moderate frailty (mean = 11.2 ± 10.8 days), and non-frailty (mean = 4.1 ± 2.1 days, p = .014). This finding was significant after adjusting for age, sex, and number of medications. Participants with higher frailty scores showed higher readmission rates when compared with those with no frailty (31.2% for severely frail, vs. 34.2% for mild-to-moderately frail vs. 19% for non-frail) although there was no significant difference in the adjusted analysis.

Conclusion

The CFS helped identify patients that are more likely to have prolonged hospital stays on the acute medical ward. The CFS is an easy to use tool which can detect older adults at high risk of complicated course and longer stay. Objective early identification of seniors with frailty in acute care units can help to target interventions to prevent complications and to implement effective discharge planning in high risk older adults.

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Most cited references 17

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The frailty phenotype and the frailty index: different instruments for different purposes.

Matteo Cesari, Giovanni Gambassi, Gabor van Kan … (2014)

The integration of frailty measures in clinical practice is crucial for the development of interventions against disabling conditions in older persons. The frailty phenotype (proposed and validated by Fried and colleagues in the Cardiovascular Health Study) and the Frailty Index (proposed and validated by Rockwood and colleagues in the Canadian Study of Health and Aging) represent the most known operational definitions of frailty in older persons. Unfortunately, they are often wrongly considered as alternatives and/or substitutables. These two instruments are indeed very different and should rather be considered as complementary. In the present paper, we discuss about the designs and rationals of the two instruments, proposing the correct ways for having them implemented in the clinical setting.

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Change in disability after hospitalization or restricted activity in older persons.

Thomas Gill, Heather Allore, Evelyne A Gahbauer … (2010)

Disability among older persons is a complex and highly dynamic process, with high rates of recovery and frequent transitions between states of disability. The role of intervening illnesses and injuries (ie, events) on these transitions is uncertain. To evaluate the relationship between intervening events and transitions among states of no disability, mild disability, severe disability, and death and to determine the association of physical frailty with these transitions. Prospective cohort study conducted in greater New Haven, Connecticut, from March 1998 to December 2008 of 754 community-living persons aged 70 years or older who were nondisabled at baseline in 4 essential activities of daily living: bathing, dressing, walking, and transferring. Telephone interviews were completed monthly for more than 10 years to assess disability and ascertain exposure to intervening events, which included illnesses and injuries leading to either hospitalization or restricted activity. Physical frailty (defined as gait speed >10 seconds on the rapid gait test) was assessed every 18 months through 108 months. Transitions between no disability, mild disability, and severe disability and 3 transitions from each of these states to death, evaluated each month. Hospitalization was strongly associated with 8 of the 9 possible transitions, with increased multivariable hazard ratios (HRs) as high as 168 (95% confidence interval [CI], 118-239) for the transition from no disability to severe disability and decreased HRs as low as 0.41 (95% CI, 0.30-0.54) for the transition from mild disability to no disability. Restricted activity also increased the likelihood of transitioning from no disability to both mild and severe disability (HR, 2.59; 95% CI, 2.23-3.02; and HR, 8.03; 95% CI, 5.28-12.21), respectively, and from mild disability to severe disability (HR, 1.45; 95% CI, 1.14-1.84), but was not associated with recovery from mild or severe disability. For all 9 transitions, the presence of physical frailty accentuated the associations of the intervening events. For example, the absolute risk of transitioning from no disability to mild disability within 1 month after hospitalization for frail individuals was 34.9% (95% CI, 34.5%-35.3%) vs 4.9% (95% CI, 4.7%-5.1%) for nonfrail individuals. Among the possible reasons for hospitalization, fall-related injury conferred the highest likelihood of developing new or worsening disability. Among older persons, particularly those who were physically frail, intervening illnesses and injuries greatly increased the likelihood of developing new or worsening disability. Only the most potent events, ie, those leading to hospitalization, reduced the likelihood of recovery from disability.

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Multidimensional frailty score for the prediction of postoperative mortality risk.

Sun-wook Kim, Ho-Seong Han, Hee-won Jung … (2014)

The number of geriatric patients who undergo surgery has been increasing, but there are insufficient tools to predict postoperative outcomes in the elderly. To design a predictive model for adverse outcomes in older surgical patients. From October 19, 2011, to July 31, 2012, a single tertiary care center enrolled 275 consecutive elderly patients (aged ≥65 years) undergoing intermediate-risk or high-risk elective operations in the Department of Surgery. The primary outcome was the 1-year all-cause mortality rate. The secondary outcomes were postoperative complications (eg, pneumonia, urinary tract infection, delirium, acute pulmonary thromboembolism, and unplanned intensive care unit admission), length of hospital stay, and discharge to nursing facility. Twenty-five patients (9.1%) died during the follow-up period (median [interquartile range], 13.3 [11.5-16.1] months), including 4 in-hospital deaths after surgery. Twenty-nine patients (10.5%) experienced at least 1 complication after surgery and 24 (8.7%) were discharged to nursing facilities. Malignant disease and low serum albumin levels were more common in the patients who died. Among the geriatric assessment domains, Charlson Comorbidity Index, dependence in activities of daily living, dependence in instrumental activities of daily living, dementia, risk of delirium, short midarm circumference, and malnutrition were associated with increased mortality rates. A multidimensional frailty score model composed of the above items predicted all-cause mortality rates more accurately than the American Society of Anesthesiologists classification (area under the receiver operating characteristic curve, 0.821 vs 0.647; P = .01). The sensitivity and specificity for predicting all-cause mortality rates were 84.0% and 69.2%, respectively, according to the model's cutoff point (>5 vs ≤5). High-risk patients (multidimensional frailty score >5) showed increased postoperative mortality risk (hazard ratio, 9.01; 95% CI, 2.15-37.78; P = .003) and longer hospital stays after surgery (median [interquartile range], 9 [5-15] vs 6 [3-9] days; P < .001). The multidimensional frailty score based on comprehensive geriatric assessment is more useful than conventional methods for predicting outcomes in geriatric patients undergoing surgery.

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Author and article information

Journal

Journal ID (nlm-ta): Can Geriatr J

Journal ID (iso-abbrev): Can Geriatr J

Title: Canadian Geriatrics Journal

Publisher: Canadian Geriatrics Society

ISSN (Electronic): 1925-8348

Publication date Collection: June 2016

Publication date (Electronic): 29 June 2016

Volume: 19

Issue: 2

Pages: 34-39

Affiliations

[1 ]Department of Medicine, Internal Medicine, London Health Sciences Centre, The University of Western Ontario, London, ON;

[2 ]Department of Medicine, Division of Geriatric Medicine, The University of Western Ontario, London, ON;

[3 ]Gait and Brain Lab, Lawson Health Research Institute, Parkwood Hospital, London, ON;

[4 ]Department of Epidemiology & Biostatistics, The University of Western Ontario, London, ON, Canada

Author notes

Correspondence to: Dr. Manuel Montero-Odasso, Gait and Brain Lab, Parkwood Hospital, Room A-283, 801 Commissioners Road East, London, ON N6C 5J1, CANADA, E-mail: mmontero@ 123456uwo.ca

Article

Publisher ID: cgj-19-34

DOI: 10.5770/cgj.19.196

PMC ID: 4922366

PubMed ID: 27403211

SO-VID: 7f48c58a-f76e-4ddc-ad5a-45d7d71b8b1f

License:

This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial No-Derivative license ( http://creativecommons.org/licenses/by-nc-nd/2.5/ca/), which permits unrestricted non-commercial use and distribution, provided the original work is properly cited.

Clinical Frailty Scale in an Acute Medicine Unit: a Simple Tool That Predicts Length of Stay

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Most cited references 17

The frailty phenotype and the frailty index: different instruments for different purposes.

Change in disability after hospitalization or restricted activity in older persons.

Multidimensional frailty score for the prediction of postoperative mortality risk.

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