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Introduction: risk-stratifying older people accessing urgent care is a potentially useful first step to ensuring that the most vulnerable are able to access optimal care from the start of the episode. While there are many risk-stratification tools reported in the literature, few have addressed the practical issues of implementation. This review sought evidence about the feasibility of risk stratification for older people with urgent care needs. Methods: medline was searched for papers addressing risk stratification and implementation (feasibility or evaluation or clinician acceptability). All search stages were conducted by two reviewers, and selected papers were graded for quality using the CASP tool for cohort studies. Data were summarised using descriptive statistics only. Results: about 1872 titles of potential interest were identified, of which 1827 were excluded on title/abstract review, and a further 43 after full-text review, leaving four papers for analysis. These papers described nine tools, which took between 1 and 10 minutes to complete for most participants. No more than 52% of potentially eligible older people were actually screened using any of the tools. Little detail was reported on the clinical acceptability of the tools tested. Discussion: the existing literature indicates that commonly used risk-stratification tools are relatively quick to use, but do not cover much more than 50% of the potential population eligible for screening in practice. Additional work is required to appreciate how tools are likely to be used, by whom, and when in order to ensure that they are acceptable to urgent care teams. [ABSTRACT FROM AUTHOR]

Background and Aim The aim of this systematic review was to quantify the association between frailty and COVID-19 in relation to mortality in hospitalised patients. Methods Medline, Embase, Web of Science and the grey literature were searched for papers from inception to 10 September 2020; the search was re-run in Medline up until the 9 December 2020. Screening, data extraction and quality grading were undertaken by two reviewers. Results were summarised using descriptive statistics, including a meta-analysis of overall mortality; the relationships between frailty and COVID-19 mortality were summarised narratively. Results A total of 2,286 papers were screened resulting in 26 being included in the review. Most studies were from Europe, half from the UK, and one from Brazil; the median sample size was 242.5, median age 73.1 and 43.5% were female. In total, 22/26 used the Clinical Frailty Scale; reported mortality ranged from 14 to 65%. Most, but not all studies showed an association between increasing frailty and a greater risk of dying. Two studies indicated a sub-additive relationship between frailty, COVID-19 and death, and two studies showed no association. Conclusions Whilst the majority of studies have shown a positive association between COVID-19-related death and increasing frailty, some studies suggested a more nuanced understanding of frailty and outcomes in COVID-19 is needed. Clinicians should exert caution in placing too much emphasis on the influence of frailty alone when discussing likely prognosis in older people with COVID-19 illness. [ABSTRACT FROM AUTHOR]

Background frailty is common in older adults and associated with poor outcomes following illness. Although stroke is predominantly a disease of older people, our knowledge of frailty in stroke is limited. We aimed to collate the literature on acute stroke and frailty to estimate the prevalence of pre-stroke frailty and its associations with outcomes. Methods paired researchers searched multidisciplinary electronic databases for papers describing frailty and acute stroke. We assessed risk of bias using Newcastle-Ottawa tools appropriate to study design. We created summary estimates of pre-stroke frailty using random effects models. We collated whether studies reported significant positive associations between frailty and clinical outcomes in adjusted models. Results we included 14 studies (n  = 27,210 participants). Seven studies (n  = 8,840) used a frailty index approach, four studies (n  = 14,924) used Hospital Frailty Risk Scores. Pooled prevalence of pre-stroke frailty was 24.6% (95% confidence interval, CI: 16.2–33.1%; low quality evidence, downgraded due to heterogeneity, bias). Combining frailty and pre-frailty (nine studies, n  = 23,827), prevalence of any frailty syndrome was 66.8% (95%CI: 49.9–83.7%). Seven studies were at risk of bias, from participant selection or method of frailty assessment. Pre-stroke frailty was associated with all adverse outcomes assessed, including longer-term mortality (positive association in 6 of 6 studies reporting this outcome; odds ratio: 3.75 [95%CI: 2.41–5.70]), length of admission (3 of 4 studies) and disability (4 of 6 studies). Conclusions despite substantial heterogeneity, whichever way it is measured, frailty is common in patients presenting with acute stroke and associated with poor outcomes. This has implications for the design of stroke services and pathways. [ABSTRACT FROM AUTHOR]

The frailty index (FI) quantifies frailty as deficit accumulation. It has been adapted to employ laboratory test data (FI-Lab). Our objective was to systematically review and meta-analyse the FI-Lab's ability to predict mortality. Secondary objectives were to review the FI-Lab's association with adverse health outcomes and whether FI-Lab scores differed between the sexes. A systematic literature search was carried out using six online databases to identify studies that measured the FI-Lab in humans. Hazard ratios (HRs) were combined in a meta-analysis to create a pooled risk estimate for mortality. Of the 1,201 papers identified, spanning January 2010 until 11 July 2022, 38 were included. FI-Lab scores per 0.01 unit increase predicted mortality overall (HR = 1.04; 95% confidence interval (CI) = 1.03–1.05) and for studies with a mean age of 81+ years (HR = 1.04; 95% CI = 1.03–1.05). The quality of evidence for these meta-analyses are moderate and high, respectively. Further, higher FI-Lab scores were associated with more frequent adverse health outcomes. Sex differences in FI-Lab scores varied, with no consistent indication of a sex effect. The FI-Lab is associated with mortality and with a variety of adverse health outcomes. No consistent sex differences in FI-Lab scores were observed, with several studies in disagreement. Notably, these conclusions were most relevant to older (65+ years old) individuals; further evidence in younger people is needed in both clinical and population representative studies. [ABSTRACT FROM AUTHOR]

Objectives The purpose of this paper is to investigate the utilisation of general practice Medicare Benefit Schedule (MBS) services aligned to Comprehensive Geriatric Assessment (CGA) within 6 months of an aged care eligibility assessment and its effects on mortality and transition to permanent residential aged care (PRAC). Design Retrospective cohort study from the Historical Cohort of the Registry of Senior Australians. Setting Community. Participants In total, 69,171 Individuals (aged 75+) receiving home care packages (HCPs) between 2011 and 2015. Outcome measures Mortality and transition to PRAC. Results The claims for a management plan with team care arrangement (TCA) within 3 months of the health assessment (i.e. CGA) was present in 5% and associated with 14% lower mortality (adjusted hazard ratio [aHR], 95%CI = 0.86, 0.80–0.93) compared to no claims, lower than that seen with partial CGA which was either health assessment claims only 7.0% (aHR, 95%CI = 0.93, 0.89–0.97) or management plan coupled with TCA claims only 9.0% (aHR, 95%CI = 0.91, 0.89–0.97). This pattern was seen in those frailer but not in those where the frailty index score was <0.21. Claims for management plans coupled with TCAs alone were associated with a 10% lower transition to PRAC (asHR, 95%CI = 0.90, 0.85–0.96) in those with FI score < 0.21 while this estimate was not significant in individuals with FI score ≥ 0.21. Conclusion It appears the conduct of a combination of interventions considered to be components of the CGA by GPs was associated with a lower risk of mortality that no claims or partial conduct of CGA. [ABSTRACT FROM AUTHOR]

Background COVID-19 has disproportionately affected older people. Objective The objective of this paper to investigate whether frailty is associated with all-cause mortality in older hospital inpatients, with COVID-19. Design Cohort study. Setting Secondary care acute hospital. Participants Participants included are 677 consecutive inpatients aged 65 years and over. Methods Cox proportional hazards models were used to examine the association of frailty with mortality. Frailty was assessed at baseline, according to the Clinical Frailty Scale (CFS), where higher categories indicate worse frailty. Analyses were adjusted for age, sex, deprivation, ethnicity, previous admissions and acute illness severity. Results Six hundred and sixty-four patients were classified according to CFS. Two hundred and seventy-one died, during a mean follow-up of 34.3 days. Worse frailty at baseline was associated with increased mortality risk, even after full adjustment (P  = 0.004). Patients with CFS 4 and CFS 5 had non-significant increased mortality risks, compared to those with CFS 1–3. Patients with CFS 6 had a 2.13-fold (95% CI 1.34–3.38) and those with CFS 7–9 had a 1.79-fold (95% CI 1.12–2.88) increased mortality risk, compared to those with CFS 1–3 (P  = 0.001 and 0.016, respectively). Older age, male sex and acute illness severity were also associated with increased mortality risk. Conclusions Frailty is associated with all-cause mortality risk in older inpatients with COVID-19. [ABSTRACT FROM AUTHOR]

Population Comprehensive evaluation of chronic pain in older adults is multifaceted. Objective and Methods Research on chronic pain in older adults needs to be guided by sound conceptual models. The purpose of this paper is to describe an adaptation of the Biopsychosocial Model (BPS) of Chronic Pain for older adults. The extant literature was reviewed, and selected research findings that provide the empiric foundation for this adaptation of the BPS model of chronic pain are summarized. The paper concludes with a discussion of specific recommendations for how this adapted model can be used to guide future research. Conclusions This adaptation of the BPS model of chronic pain for older adults provides a comprehensive framework to guide future research in this vulnerable population. [ABSTRACT FROM AUTHOR]

Background walking is crucial for an active and healthy ageing, but the perspectives of individuals living with walking impairment are still poorly understood. Objectives to identify and synthesise evidence describing walking as experienced by adults living with mobility-impairing health conditions and to propose an empirical conceptual framework of walking experience. Methods we performed a systematic review and meta-ethnography of qualitative evidence, searching seven electronic databases for records that explored personal experiences of walking in individuals living with conditions of diverse aetiology. Conditions included Parkinson's disease, multiple sclerosis, chronic obstructive pulmonary disease, hip fracture, heart failure, frailty and sarcopenia. Data were extracted, critically appraised using the NICE quality checklist and synthesised using standardised best practices. Results from 2,552 unique records, 117 were eligible. Walking experience was similar across conditions and described by seven themes: (i) becoming aware of the personal walking experience, (ii) the walking experience as a link between individuals' activities and sense of self, (iii) the physical walking experience, (iv) the mental and emotional walking experience, (v) the social walking experience, (vi) the context of the walking experience and (vii) behavioural and attitudinal adaptations resulting from the walking experience. We propose a novel conceptual framework that visually represents the walking experience, informed by the interplay between these themes. Conclusion a multi-faceted and dynamic experience of walking was common across health conditions. Our conceptual framework of the walking experience provides a novel theoretical structure for patient-centred clinical practice, research and public health. [ABSTRACT FROM AUTHOR]

Background Emergency laparotomy has high morbidity and mortality rates. Frailty assessment remains underutilized in this setting, in part due to time constraints and feasibility. The Clinical Frailty Scale has been identified as the most appropriate tool for frailty assessment in emergency laparotomy patients and is recommended for all older patients undergoing emergency laparotomy. The prognostic impact of measured frailty using the Clinical Frailty Scale on short- and long-term mortality and morbidity rates remains to be determined. Methods Observational cohort studies were identified by systematically searching Medline, Embase, Scopus and CENTRAL databases up to February 2024, comparing outcomes following emergency laparotomy for frail and non-frail participants defined according to the Clinical Frailty Scale. The primary outcomes were short- and long-term mortality rates. A random-effects model was created with pooling of effect estimates and a separate narrative synthesis was created. Risk of bias was assessed. Results Twelve articles comprising 5704 patients were included. Frailty prevalence was 25% in all patients and 32% in older adults (age ≥55 years). Older patients with frailty had a significantly greater risk of postoperative death (30-day mortality rate OR 3.84, 95% c.i. 2.90 to 5.09, 1-year mortality rate OR 3.03, 95% c.i. 2.17 to 4.23). Meta-regression revealed that variations in cut-off values to define frailty did not significantly affect the association with frailty and 30-day mortality rate. Frailty was associated with higher rates of major complications (OR 1.93, 95% c.i. 1.27 to 2.93) and discharge to an increased level of care. Conclusion Frailty is significantly correlated with short- and long-term mortality rates following emergency laparotomy, as well as an adverse morbidity rate and functional outcomes. Identifying frailty using the Clinical Frailty Scale may aid in patient-centred decision-making and implementation of tailored care strategies for these 'high-risk' patients, with the aim of reducing adverse outcomes following emergency laparotomy. [ABSTRACT FROM AUTHOR]

Background This study assessed the influence of age, co-morbidity and frailty on 5-year survival outcomes after breast conservation surgery (BCS) with radiotherapy (RT) versus mastectomy (with or without RT) in women with early invasive breast cancer. Methods Women aged over 50 years with early invasive breast cancer diagnosed in England (2014–2019) who had breast surgery were identified from Cancer Registry data. Survival estimates were calculated from a flexible parametric survival model. A competing risk approach was used for breast cancer–specific survival (BCSS). Standardized survival probabilities and cumulative incidence functions for breast cancer death were calculated for each treatment by age. Results Among 101 654 women, 72.2% received BCS + RT and 27.8% received mastectomy. Age, co-morbidity and frailty were associated with overall survival (OS), but only age and co-morbidity were associated with BCSS. Survival probabilities for OS were greater for BCS + RT (90.3%) versus mastectomy (87.0%), and the difference between treatments varied by age (50 years: 1.9% versus 80 years: 6.5%). Cumulative incidence functions for breast cancer death were higher after mastectomy (5.1%) versus BCS + RT (3.9%), but there was little change in the difference by age (50 years: 0.9% versus 80 years: 1.2%). The results highlight the change in baseline mortality risk by age for OS compared to the stable baseline for BCSS. Conclusion For OS, the difference in survival probabilities for BCS + RT and mastectomy increased slightly with age. The difference in cumulative incidence functions for breast cancer death by surgery type was small regardless of age. Evidence on real-world survival outcomes among older populations with breast cancer is informative for treatment decision-making. [ABSTRACT FROM AUTHOR]

Background Skeletal muscle wasting (SMW) is highly prevalent in patients with heart failure (HF) at left ventricular assist device (LVAD) implantation and is associated with morbidity and mortality. At the same time, SMW is clinically under-recognized, while exercise training (ET) studies in weak LVAD patients are lacking. Case summary A 60-year-old man with advanced HF, SMW, cardiac cachexia, and frailty was confined in bed for 6 months initially supported with intravenous inotropes and subsequently with an intra-aortic balloon pump. His frailty was recognized as an LVAD-responsive frailty, and patient was successfully implanted with a HeartWare (Medtronic). Post-surgery, patient was very weak, unable even to move in bed without assistance. We evaluated skeletal muscle using simple tools such as the Oxford scale, mid-thigh circumference, hand-held dynamometry, and maximum inspiratory pressure. Physical performance was assessed with the sit to stand test, gait speed test, pedal bike timing, and the 6 min walk test. On top of routine physiotherapy, patient underwent an 8-week modified aerobic/resistance/inspiratory (ARIS) ET programme at moderate intensity and showed significant improvements in skeletal muscle mass and strength and physical and functional capacity. Discussion We want to emphasize the importance of skeletal muscle evaluation at LVAD implantation and the feasibility and effectiveness of early ARIS training in very weak patients. [ABSTRACT FROM AUTHOR]

Furthermore, the fact that post-transplant outcome is overall worse for frail patients is importantly counterbalanced by the fact that sometimes frailty is improved in transplanted patients. One possibility is referring to frailty and CI to select and prioritize patients within a utilitarian framework, for instance giving priority to less frail and younger patients with life expectancy and potential quality of life that at first glance are better. In fact, data indicate that 'Frailty is more prevalent among older hemodialysis patients, KT candidates, and KT recipients; however, there is a high prevalence of frailty among younger patients as well' [[3]]. [Extracted from the article]

Background Frailty is a common, multi-factorial, age-related syndrome commonly observed in people with diabetes. Although older diabetics are prone to adverse healthcare outcomes and diabetes increases the risk of developing frailty, little is known about the effects of frailty on diabetes. This paper examines the association between diabetes, frailty, and mortality in Europeans aged ≥50 years. Methods Data were included from The Survey of Health, Ageing and Retirement in Europe (SHARE) waves one and six. A participant's first interview was taken as the baseline and subsequent waves were used for mortality follow-up (time and cause). Frailty and pre-frailty were measured using established cut-offs using the Physical Phenotype (SHARE-FI) and a 55-item Frailty Index (FI-55). Kaplan-Meier survival analysis was used to assess the relationship between frailty and mortality in people with diabetes and significance tested using log-rank test. Cox regression was used to adjust for potential confounders (age, sex, education, income, employment, alcohol use, smoking, hypertension, hypercholesterolaemia, myocardial infarction, stroke, metastatic cancer, chronic lung disease, polypharmacy, self-perceived health and depression). Results Data from 8,954 diabetics aged 50-99 years were included with 1,598 deaths (17.8%). According to the SHARE-FI, 1,971 (22.0%) were frail, 4,183 (46.7%) pre-frail and 2,800 (31.3%) robust. According to the Kaplan-Meier log-rank test survival varied significantly across frailty strata according to both indexes (p<0.001). At 10-year follow-up, adjusting for confounders SHARE-FI frailty and pre-frailty were significantly associated with mortality, adjusted Hazard Ratio (HR) 2.19, (95% CI:1.66-2.89), and 1.38 (95% CI:1.09-1.74), respectively. Results were similar using the FI-55, HR for frailty 1.66 (95% CI:1.09-2.54). Causes of mortality were significantly different according to frailty status (p<0.05). Conclusion Frailty and pre-frailty are independent risk factors for mortality in diabetics. The identification of frailty is important for the risk-stratification and management of middle aged and older patients with diabetes and should be included in the routine assessment of these high-risk individuals. [ABSTRACT FROM AUTHOR]

Background Frailty is an important marker of adverse outcomes for older people accessing the Emergency Department (ED). Older patients with frailty have a higher attendance rate to the ED, spend longer in the ED and have a higher rate of admission (HSE, 2017). Frailty Intervention Therapy Teams (FITT) are designed to screen and assess this population in the ED setting, with the aim of early assessment to help decrease length of stay or avoid admission. Two different FIT Teams have recently been formed within the Cork-Kerry region. The aim of this study was to evaluate staff's experience of these teams. Methods This was a mixed methods study. Structured surveys were developed to collect qualitative and quantitative data. The surveys were constructed using themes listed by Proctor et al. (2011) around implementation and service outcomes. Ward and ED staff were provided with paper surveys within the hospital setting and community staff were surveyed via post. Quantitative survey data was analysed using descriptive statistics and qualitative data was analysed with thematic content analysis. Results Data from 117 surveys was included for analysis (response rate 49%). Results showed that the majority of staff (89%) reported ED was a suitable setting for the FITT, with 85% reporting the information collected by the FITT impacted their involvement. Other themes emerging from staff's experience included timeliness, safety and comprehensive assessment. Conclusion Overall, staff reported the FITT provided a timely service that assisted with decision making and planning. This involved earlier comprehensive assessment, prompt identification of issues which lead to decreased workload for ward staff. It also created an increased volume of referrals to community and ward staff received in a timelier manner. [ABSTRACT FROM AUTHOR]

Background 10% of people over 65 years have frailty, rising to between a quarter and a half of those over 85. Comprehensive Geriatric Assessment (CGA) is the gold standard for the management of frailty in older people; it's a process that involves a holistic, interdisciplinary assessment of the older person. Evidence shows that CGA is effective in improving outcomes for older people. The National Clinical Programme for the Older Person outlines the role of the occupational therapist in CGA. A clinical audit was completed to investigate whether the occupational therapists in the Medicine for the Older Person service are adhering to guidelines for CGA. Methods Following a literature review, a retrospective audit of occupational therapy (OT) initial assessments was completed using paper count method. Data pertinent to CGA OT assessment was collected. Audit results were presented to the OT team alongside a CGA education session. A re-audit was completed, using above methods. Results 10 inpatient initial assessment forms reviewed pre and post audit. Activities of Daily Living Assessment: Pre result: 60%  Post Result: 90% Home Environment: Pre: 80% Post: 100% Performance Components Assessment: Vision: Pre:  90%  Post: 100% Hearing: Pre: 80% Post: 100% Upper Limb: Pre: 70% Post: 100% Mood: Pre: 60% Post: 80% Cognition: Pre: 90% Post: 100% Sleep: Pre: 70% Post: 80% Social Assessment: Pre: 60% Post:90% Falls Assessment: Pre: 60% Post: 90% Drving: Pre: 60% Post: 90% Conclusion This audit identified that the occupational therapists in the medicine for the older person service were not CGA compliant. CGA training now forms an important part of our OT induction programme. We are now "playing our part" in CGA with improvements in all domains. CGA is now commonplace practice within our team, in line with international and national best practice guidance for management of frailty. [ABSTRACT FROM AUTHOR]

Introduction Colonoscopy is the gold standard test for investigating lower gastrointestinal symptoms and is an important therapeutic tool for colonic polypectomy. This paper is aimed at the general physician and examines the role of colonoscopy in very elderly patients by exploring the particular risks in this population, the yield of colonoscopy and potential alternative investigations. Sources of data Original research and review articles were identified through selective PubMed searches. Guidelines were identified through interrogation of national and international society websites in addition to PubMed searches. Areas of agreement Advanced age alone is not a reason to avoid investigation. The decision to perform colonoscopy in this population must take into account indication and yield, risks of the procedure and bowel preparation, physical fitness of the patient, potential alternative and the ability to consent. As a general rule, the principle of ‘first doing no harm’ should be applied and requires balancing of the risks of the procedure and preparation with the benefits of doing the test. Areas of controversy There is no defined upper age limit at which colonoscopy is contraindicated, however; the National Health Service Bowel Cancer Screening Programme stops inviting patients for screening and surveillance colonoscopy at age 75. Growing points and areas timely for developing research The concepts of ‘first do no harm’ and shared decision-making are not new but are increasingly important, particularly in this patient group. It is crucial to provide patients with information about risks, benefits and alternative investigations to empower their decision-making. [ABSTRACT FROM AUTHOR]

Background Major emergency abdominal surgery is associated with a high risk of morbidity and mortality. Given the ageing and increasingly frail population, understanding the impact of frailty on complication patterns after surgery is crucial. The aim of this study was to evaluate the association between clinical frailty and organ-specific postoperative complications after major emergency abdominal surgery. Methods A prospective cohort study including all patients undergoing major emergency abdominal surgery at Copenhagen University Hospital Herlev, Denmark, from 1 October 2020 to 1 August 2022, was performed. Clinical frailty scale scores were determined for all patients upon admission and patients were then analysed according to clinical frailty scale groups (scores of 1–3, 4–6, or 7–9). Postoperative complications were registered until discharge. Results A total of 520 patients were identified. Patients with a low clinical frailty scale score (1–3) experienced fewer total complications (120 complications per 100 patients) compared with patients with clinical frailty scale scores of 4–6 (250 complications per 100 patients) and 7–9 (277 complications per 100 patients) (P < 0.001). A high clinical frailty scale score was associated with a high risk of pneumonia (P = 0.009), delirium (P < 0.001), atrial fibrillation (P = 0.020), and infectious complications in general (P < 0.001). Patients with severe frailty (clinical frailty scale score of 7–9) suffered from more surgical complications (P = 0.001) compared with the rest of the cohort. Severe frailty was associated with a high risk of 30-day mortality (33% for patients with a clinical frailty scale score of 7–9 versus 3.6% for patients with a clinical frailty scale score of 1–3, P < 0.001). In a multivariate analysis, an increasing degree of clinical frailty was found to be significantly associated with developing at least one complication. Conclusion Patients with frailty have a significantly increased risk of postoperative complications after major emergency abdominal surgery, especially atrial fibrillation, delirium, and pneumonia. Likewise, patients with frailty have an increased risk of mortality within 90 days. Thus, frailty is a significant predictor for adverse events after major emergency abdominal surgery and should be considered in all patients undergoing major emergency abdominal surgery. [ABSTRACT FROM AUTHOR]

Geriatric medicine is the clinical specialty that focuses upon the care of older people—especially those with frailty (a state of increased vulnerability). In hospital, older people living with frailty are at high risk of developing a range of unpleasant outcomes such as delirium, falls, fractures, pressure sores and death. Comprehensive geriatric assessment is a form of holistic care that incorporates a specific set of clinical competencies that are able to reduce these adverse outcomes. Over the years, geriatric medicine has moved from being more of a community-based service towards a more acute specialty—encroaching now upon emergency department care. The challenge now is to work out how best to deliver geriatric care across the whole hospital (older people with frailty are not just cared for in geriatric wards!). The themed collection published on the Age & Ageing journal website outlines key articles that are attempting to develop solutions to this challenging conundrum. We hope that you enjoy reading them. [ABSTRACT FROM AUTHOR]

Background frailty measurement may identify patients at risk of decline after hospital discharge, but many measures require specialist review and/or additional testing. Objective to compare validated frailty tools with routine electronic health record (EHR) data at hospital discharge, for associations with readmission or death. Design observational cohort study. Setting hospital ward. Subjects consented cardiology inpatients ≥70 years old within 24 hours of discharge. Methods patients underwent Fried, Short Physical Performance Battery (SPPB), PRISMA-7 and Clinical Frailty Scale (CFS) assessments. An EHR risk score was derived from the proportion of 31 possible frailty markers present. Electronic follow-up was completed for a primary outcome of 90-day readmission or death. Secondary outcomes were mortality and days alive at home ('home time') at 12 months. Results in total, 186 patients were included (79 ± 6 years old, 64% males). The primary outcome occurred in 55 (30%) patients. Fried (hazard ratio [HR] 1.47 per standard deviation [SD] increase, 95% confidence interval [CI] 1.18–1.81, P  < 0.001), CFS (HR 1.24 per SD increase, 95% CI 1.01–1.51, P  = 0.04) and EHR risk scores (HR 1.35 per SD increase, 95% CI 1.02–1.78, P  = 0.04) were independently associated with the primary outcome after adjustment for age, sex and co-morbidity, but the SPPB and PRISMA-7 were not. The EHR risk score was independently associated with mortality and home time at 12 months. Conclusions frailty measurement at hospital discharge identifies patients at risk of poorer outcomes. An EHR-based risk score appeared equivalent to validated frailty tools and may be automated to screen patients at scale, but this requires further validation. [ABSTRACT FROM AUTHOR]

Background and Objectives Social isolation (SI) and loneliness are key factors that contribute to frailty among older adults. Current estimates regarding how frailty affects SI and loneliness and how SI and loneliness affect frailty may be flawed due to reverse causality. This study aimed to investigate the bidirectional relationships and mediating effects among SI, loneliness, and frailty among older adults in China. Research Design and Methods The study analyzed data from 6 waves of the Chinese Longitudinal Healthy Longevity Survey conducted between 2002 and 2018. The sample included individuals aged 65 and older. The General Cross-Lagged Panel Model was used to account for confounding factors and reveal mediating effects. Results Our findings specifically indicate a direct effect of SI on frailty, although suggesting that loneliness may indirectly affect frailty through its influence on SI. Additionally, frailty can lead to increased SI and loneliness. Discussion and Implications SI and loneliness are strongly intertwined with frailty among older adults in China. To prevent the development of frailty, public health initiatives should prioritize reducing SI among older adults. Furthermore, efforts to decrease frailty levels can yield positive outcomes by mitigating both SI and loneliness among this population. [ABSTRACT FROM AUTHOR]

Background Following hip fracture surgery, patients from residential care are frequently excluded from inpatient rehabilitation. We aimed to assess the impact of place of residence and other factors such as frailty on rehabilitation outcomes after hip fracture surgery. Methods Retrospective cohort study. Outcome measures included Functional Independence Measure efficiency, discharge destination and recovery of pre-fracture mobility. Univariable and multivariable linear or logistic regression analyses were performed. Setting One general rehabilitation and two geriatric evaluation and management wards in a large public tertiary teaching hospital. Participants A total of 844 patients who underwent inpatient rehabilitation after hip fracture surgery from 2010 to 2018. Results There were 139 (16%) patients from residential care. Being from residential care was not an independent predictor of poor outcomes. Premorbid frailty (Clinical Frailty Scale) was the strongest independent predictor of poorer Functional Independence Measure efficiency, inability to recover pre-fracture mobility and return to community dwelling. Dementia and delirium were also independently predictive of poor outcomes across all measures. Age > 90 years was independently predictive of inability to recover pre-fracture mobility and return to community dwelling. Conclusion Being from residential care is not independently associated with poor outcomes following inpatient rehabilitation after hip fracture surgery and should not be the basis for excluding these patients from rehabilitation. Major predictors of poorer outcomes include premorbid frailty, dementia, delirium and age > 90 years. If able and motivated, those with potentially reversible functional limitations should be given the opportunity to participate in inpatient rehabilitation as even small gains can have a significant impact on quality of life. [ABSTRACT FROM AUTHOR]

The article comments on a systemic review and meta-analysis which looked at complex interventions for independent living of older people with frailty. It points out the effectiveness of holistic assessment along with coordinated, multidisciplinary care and follow-up for older people with frailty, the prevention of poor health outcomes, reduced mortality and improved cognition. It stresses the need to have a better understanding of which patients are likely to benefit from holistic treatment.

Introduction The prevalence of frailty at population level is unclear. We examined this in population-based studies, investigating sources of heterogeneity. Methods PubMed, Embase, CINAHL and Cochrane Library databases were searched for observational population-level studies published between 1 January 1998 and 1 April 2020, including individuals aged ≥50 years, identified using any frailty measure. Prevalence estimates were extracted independently, assessed for bias and analysed using a random-effects model. Results In total, 240 studies reporting 265 prevalence proportions from 62 countries and territories, representing 1,755,497 participants, were included. Pooled prevalence in studies using physical frailty measures was 12% (95% CI = 11–13%; n  = 178), compared with 24% (95% CI = 22–26%; n  = 71) for the deficit accumulation model (those using a frailty index, FI). For pre-frailty, this was 46% (95% CI = 45–48%; n  = 147) and 49% (95% CI = 46–52%; n  = 29), respectively. For physical frailty, the prevalence was higher among females, 15% (95% CI = 14–17%; n  = 142), than males, 11% (95% CI = 10–12%; n  = 144). For studies using a FI, the prevalence was also higher in females, 29% (95% CI = 24–35%; n  = 34) versus 20% (95% CI = 16–24%; n  = 34), for males. These values were similar for pre-frailty. Prevalence increased according to the minimum age at study inclusion. Analysing only data from nationally representative studies gave a frailty prevalence of 7% (95% CI = 5–9%; n  = 46) for physical frailty and 24% (95% CI = 22–26%; n  = 44) for FIs. Conclusions Population-level frailty prevalence varied by classification and sex. Data were heterogenous and limited, particularly from nationally representative studies making the interpretation of differences by geographic region challenging. Common methodological approaches to gathering data are required to improve the accuracy of population-level prevalence estimates. Protocol registration PROSPERO-CRD42018105431. [ABSTRACT FROM AUTHOR]

The author stresses the need for more education and training of trial personnel in conducting studies in older people with diabetes. Topics include his opinion on the absence of clinical trial evidence or first class real world observational data, the strong reliance by general practitioners and hospital specialists in Great Britain on the recommendations from the National Institute for Health and Care Excellence, and key step in the creation of the 2019 American Endocrine Society guideline.

An introduction to a paper published in this issue is presented, in which the editors mention services for older people, well-being in older people, and social care and housing for older people.

In this paper, we propose new methods for investigating the extent of heterogeneity in effective contact rates relevant to the transmission of infections. These methods exploit the correlations between ages at infection for different infections within individuals. The methods are developed for serological surveys, which provide accessible individual data on several infections, and are applied to a wide range of infections. We find that childhood infections are often highly correlated within individuals in early childhood, with the correlations persisting into adulthood only for infections sharing a transmission route. We discuss 2 applications of the methods: 1) to making inferences about routes of transmission when these are unknown or uncertain and 2) to estimating epidemiologic parameters such as the basic reproduction number and the critical immunization threshold. Two examples of such applications are presented: elucidating the transmission route of polyomaviruses BK and JC and estimating the basic reproduction number and critical immunization coverage of varicella-zoster infection in Belgium, Italy, Poland, and England and Wales. We speculate that childhood correlations stem from confounding of different transmission routes and represent heterogeneity in childhood circumstances, notably nursery-school attendance. In contrast, it is suggested that correlations in adulthood are route-specific. [ABSTRACT FROM PUBLISHER]

In this paper, we study panel count data with informative observation times. We assume nonparametric and semiparametric proportional rate models for the underlying event process, where the form of the baseline rate function is left unspecified and a subject-specific frailty variable inflates or deflates the rate function multiplicatively. The proposed models allow the event processes and observation times to be correlated through their connections with the unobserved frailty; moreover, the distributions of both the frailty variable and observation times are considered as nuisance parameters. The baseline rate function and the regression parameters are estimated by maximising a conditional likelihood function of observed event counts and solving estimation equations. Large-sample properties of the proposed estimators are studied. Numerical studies demonstrate that the proposed estimation procedures perform well for moderate sample sizes. An application to a bladder tumour study is presented. [ABSTRACT FROM PUBLISHER]

Summary. In semiparametric models, the dimension d of the maximum likelihood problem is potentially unlimited. Conventional estimation methods generally behave like O (d 3 ). A new O (d ) estimation procedure is proposed for a large class of semiparametric models. Potentially unlimited dimension is handled in a numerically efficient way through a Nelson–Aalen-like estimator. Discussion of the new method is put in the context of recently developed minorization–maximization algorithms based on surrogate objective functions. The procedure for semiparametric models is used to demonstrate three methods to construct a surrogate objective function: using the difference of two concave functions, the EM way and the new quasi-EM (QEM) approach. The QEM approach is based on a generalization of the EM-like construction of the surrogate objective function so it does not depend on the missing data representation of the model. Like the EM algorithm, the QEM method has a dual interpretation, a result of merging the idea of surrogate maximization with the idea of imputation and self-consistency. The new approach is compared with other possible approaches by using simulations and analysis of real data. The proportional odds model is used as an example throughout the paper. [ABSTRACT FROM AUTHOR]

There has been much research on analysing multivariate failure times, but little that has accommodated failures that arise in the presence of a competing failure process. This paper studies the problem of describing associations among times to such failures. It proposes a modified conditional hazard ratio measure of association that is tailored to competing risks data, develops frailty models and a nonparametric method for describing the proposed measure, and contrasts estimation by proposed methods with the ‘standard’ of treating competing risks as independently censoring failure times due to targeted causes. The methods are investigated on simulated and real data. [ABSTRACT FROM PUBLISHER]

Background Vitality capacity (VC) is a key domain of intrinsic capacity (IC) and is the underlying biophysiological aspect of IC. Energy and metabolism (E&M) is one of the domains of VC. Fatigue is one of the main characteristics of E&M. Objective The aims of this umbrella review are (i) to identify the available instruments suitable for measuring fatigue in community-dwelling older adults and (ii) to critically review the measurement properties of the identified instruments. Design Umbrella review. Setting Healthcare. Subjects Community-dwelling older adults. Methods PubMed and Web of Knowledge were systematically screened for systematic reviews and meta-analysis reporting on fatigue instruments resulting in 2,263 articles (last search 5 December 2022). The COSMIN checklist was used to appraise psychometric properties and the AMSTAR for assessing methodological quality. Data on fatigue instruments, construct, reference period, assessment method, validated population, reliability, validity, responsiveness and predictive validity on negative health outcomes were extracted. Results 10 systematic reviews and 1 meta-analysis were included in this study. 70 fatigue instruments were identified in the literature and 21 were originally designed for fatigue. The Fatigue Severity Scale (FSS), Pittsburgh Fatigability Scale (PFS) and Visual Analogue scale (VAS-F), Fatigue Impact Scale (FIS) and the Functional Assessment of Chronic Illness Therapy Fatigue (FACIT-F) presented good psychometric properties. Conclusions The FSS, FIS, FACIT-F, PFS and the VAS-F presented good psychometric properties in various conditions. Therefore, these instruments could be used to quantify trajectories in the domain E&M in the context of VC in community-dwelling older adults. [ABSTRACT FROM AUTHOR]

Introduction Unpaid carers are an increasing proportion of the UK population. One of the many ways in which they help those they care for is assisting with medication adherence. Many older adults have medicines dispensed in pharmacy-filled multi-compartment medication compliance aids (pMCAs). However, evidence suggests that pMCAs may increase medication-related harm, and little is known about the interaction between the user, medication adherence systems and the carer. Aim To explore the views of carers supporting older adults to manage their medications with and without a pMCA. Method A researcher-administered questionnaire survey of carers supporting older adults to manage their medicines with or without a pMCA. Participants were recruited from inpatient wards, outpatient clinics and community services in central London. Responses were analysed by two independent researchers to identify overarching themes. Results Eighty-eight unpaid carers were interviewed and responses were categorised according to the medication adherence method used; 47 supported a user with a pMCA and 41 supported without a pMCA. The main themes were: Time, Responsibility and Mistakes, Waste and Sustainability, and Polypharmacy, with sub-themes of design of multi-compartment medication compliance aids, organisation and reassurance. Conclusion Supporting medication adherence puts considerable burden on carers regardless of whether a self- or pharmacy-filled medication compliance aid is used or not. Prescribers could alleviate this burden through regular medication review by considering the prescribing frequency and duration and medication rationalisation. Redesign of both pMCAs and systems surrounding their use could also help reduce carer's burden and environmental burden. [ABSTRACT FROM AUTHOR]

Background and Objectives The relationship between social isolation/loneliness and oral health is unclear. This study investigated the association between social isolation/loneliness and tooth loss in older Japanese adults. Research Design and Methods This was a cross-sectional study of a population-based cohort (the Sukagawa Study); 5,490 cohort study participants aged ≥75 years and who were independent answered a self-administered questionnaire in 2018. Social isolation was defined based on the 6-item Japanese version of the Lubben Social Network Scale. Loneliness was measured by the 3-item Japanese version of the University of California, Los Angeles (UCLA) Loneliness Scale version 3. The primary outcome was tooth loss, defined as having fewer than 20 teeth. The secondary outcomes were decreased toothbrushing frequency and diminished ability to chew food. Prevalence ratios (PRs) were estimated using a modified Poisson regression analysis in 2 models—Model 1, which adjusted for age, gender, smoking status, alcohol consumption, low annual income, and short education period, and Model 2, which added history of depression, history of diabetes mellitus, history of stroke, and cognitive impairment to Model 1. Results The primary analysis included 4,645 participants. Adjusted PRs of social isolation and loneliness for tooth loss (Model 1) were 0.97 (95% confidence interval [CI] 0.92–1.01) and 1.06 (95% CI 1.01–1.12), respectively; those for decreased toothbrushing frequency were 1.13 (95% CI 0.95–1.36) and 1.56 (95% CI 1.26–1.92), respectively; and those for chewing difficulty were 1.61 (95% CI 1.06–2.43) and 2.94 (95% CI 1.91–4.53), respectively. The adjusted PRs in Model 2 demonstrated results similar to that of Model 1. Discussion and Implications Loneliness is associated with tooth loss among older adults, whereas social isolation is not. Our findings can inform plans for policymakers, professionals, and organizations to identify lonely older adults and provide social prescriptions to improve their access to oral health care services. [ABSTRACT FROM AUTHOR]

There are national and global moves to improve effective digital data design and application in healthcare. This New Horizons commentary describes the role of digital data in healthcare of the ageing population. We outline how health and social care professionals can engage in the proactive design of digital systems that appropriately serve people as they age, carers and the workforce that supports them. Key Points Healthcare improvements have resulted in increased population longevity and hence multimorbidity. Shared care records to improve communication and information continuity across care settings hold potential for older people. Data structure and coding are key considerations. A workforce with expertise in caring for older people with relevant knowledge and skills in digital healthcare is important. [ABSTRACT FROM AUTHOR]

Background: two popular operational definitions of frailty, the frailty phenotype and Frailty index (FI), are based on different theories. Although FI was shown to be superior in predicting mortality to the frailty phenotype, no meta-analysis on mortality risk according to FI has been found in the literature. Methods: an electronic systematic literature search was conducted in August 2016 using four databases (Embase, Medline, CINAHL and PsycINFO) for prospective cohort studies published in 2000 or later, examining the mortality risk according to frailty measured by FI. A meta-analysis was performed to synthesise pooled mortality risk estimates. Results: of 2,617 studies identified by the systematic review, 18 cohorts from 19 studies were included. Thirteen cohorts showed hazard ratios (HRs) per 0.01 increase in FI, six cohorts showed HRs per 0.1 increase in FI and two cohorts each showed odds ratios (ORs) per 0.01 and 0.1 increase in FI, respectively. All meta-analyses suggested that higher FI was significantly associated with higher mortality risk (pooled HR per 0.01 FI increase = 1.039, 95% CI = 1.033-1.044, P < 0.001; pooled HR per 0.1 FI increase = 1.282, 95% CI = 1.258-1.307, P < 0.001; pooled OR per 0.01 FI increase = 1.054, 95% CI = 1.040-1.068, P < 0.001; pooled OR per 0.1 FI increase = 1.706, 95% CI = 1.547-1.881, P < 0.001). Meta-regression analysis among 13 cohorts with HR per 0.01 increase in FI showed that the studies with shorter follow-up periods and with lower female proportion were associated with higher mortality risks by FI. Conclusions: this systematic review and meta-analysis was the first to quantitatively demonstrate that frailty measured by the FI is a significant predictor of mortality. [ABSTRACT FROM AUTHOR]

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. [ABSTRACT FROM PUBLISHER]

Background Anticholinergic medicines are associated with adverse outcomes for older people. However, little is known about their use in frailty. The objectives were to (i) investigate the prevalence of anticholinergic prescribing for older patients, and (ii) examine anticholinergic burden according to frailty status. Methods Cross-sectional analysis of Welsh primary care data from the Secure Anonymised Information Linkage databank including patients aged ≥65 at their first GP consultation between 1 January and 31 December 2018. Frailty was identified using the electronic Frailty Index and anticholinergic burden using the Anticholinergic Cognitive Burden (ACB) scale. Descriptive analysis and logistic regression were conducted to (i) describe the type and frequency of anticholinergics prescribed; and (ii) to estimate the association between frailty and cumulative ACB score (ACB-Sum). Results In this study of 529,095 patients, 47.4% of patients receiving any prescription medications were prescribed at least one anticholinergic medicine. Adjusted regression analysis showed that patients with increasing frailty had higher odds of having an ACB-Sum of >3 compared with patients who were fit (mild frailty, adj OR 1.062 (95%CI 1.061–1.064), moderate frailty, adj OR 1.134 (95%CI 1.131–1.136), severe frailty, adj OR 1.208 (95%CI 1.203–1.213)). Conclusions Anticholinergic prescribing was high in this older population. Older people with advancing frailty are exposed to the highest anticholinergic burden despite being the most vulnerable to the associated adverse effects. Older people with advancing frailty should be considered for medicines review to prevent overaccumulation of anticholinergic medications, given the risks of functional and cognitive decline that frailty presents. [ABSTRACT FROM AUTHOR]

Background frailty screening facilitates the stratification of older adults at most risk of adverse events for urgent assessment and subsequent intervention. We assessed the validity of the Identification of Seniors at Risk (ISAR), Clinical Frailty Scale (CFS), Programme on Research for Integrating Services for the Maintenance of Autonomy seven item questionnaire (PRISMA-7) and InterRAI-ED at predicting adverse outcomes at 30 days and 6 months amongst older adults presenting to the Emergency Department (ED). Methods a prospective cohort study of adults ≥65 years who presented to the ED was conducted. The ISAR, CFS, PRISMA-7 and InterRAI-ED were assessed. Blinded follow-up telephone interviews were completed at 30 days and 6 months to assess the incidence of mortality, ED re-attendance, hospital readmission, functional decline and nursing home admission. The sensitivity, specificity, negative predictive value and positive predictive value of the screening tools were calculated using 2 × 2 tables. Results a total of 419 patients were recruited; 47% female with a mean age of 76.9 (Standard deviation = 7.2). The prevalence of frailty varied across the tools (CFS 57% versus InterRAI-ED 70%). At 30 days, the mortality rate was 5.1%, ED re-attendance 18.1%, hospital readmission 14%, functional decline 47.6% and nursing home admission 7.1%. All tools had a high sensitivity and positive predictive value for predicting adverse outcomes. Conclusion older adults who screened positive for frailty were at significantly increased risk of experiencing an adverse outcome at 30 days with the ISAR being the most sensitive tool. We would recommend the implementation of the ISAR in the ED setting to support clinicians in identifying older adults most likely to benefit from specialised geriatric assessment and intervention. [ABSTRACT FROM AUTHOR]

Objective To investigate the 1-year functional outcomes after cardiopulmonary resuscitation (CPR) in adults aged ≥65 years with pre-existing long-term care needs. Methods This population-based cohort study was conducted in Tochigi Prefecture, one of 47 prefectures in Japan. We used medical and long-term care administrative databases, which included data on functional and cognitive impairment that were assessed with the nationally standardised care-needs certification system. Among individuals aged ≥65 years registered between June 2014 and February 2018, patients who underwent CPR were identified. The primary outcome was mortality and care needs at 1 year after CPR. The outcome was stratified by pre-existing care needs before CPR based on the total daily estimated care minutes: no care needs, support levels 1 and 2 and care-needs level 1 (estimated care time 25–49 min), care-needs levels 2 and 3 (50–89 min) and care-needs levels 4 and 5 (≥90 min). Results Among 594,092 eligible individuals, 5,086 (0.9%) underwent CPR. The 1-year mortalities after CPR in patients with no care needs, support levels 1 and 2 and care-needs level 1, care-needs levels 2 and 3 and care-needs levels 4 and 5 were 94.6% (n  = 2,207/2,332), 96.1% (n  = 736/766), 94.5% (n  = 930/984) and 95.9% (n  = 963/1,004), respectively. Among survivors, most patients had no change in care needs before and at 1 year after CPR. There was no significant association between pre-existing functional and cognitive impairment and 1-year mortality and care needs after adjusting for potential confounders. Conclusion Healthcare providers need to discuss poor survival outcomes after CPR with all older adults and their families in shared decision making. [ABSTRACT FROM AUTHOR]

Introduction The incidence of major trauma in older people is increasing. Frailty is likely to be a factor that influences the outcomes of trauma. We conducted a systematic review aiming to investigate whether frailty affects major trauma outcomes in older people and whether it is more predictive than age. Methods Observational studies investigating frailty, major trauma severity and outcomes were eligible. We searched electronic databases (Ovid MEDLINE, PubMed, Ovid EMBASE and CINAHL) from 2010 to 01 January 2023. We used Joanna Briggs Institute software to assess the risk of bias and conduct meta-analyses of the relationships between frailty status and outcomes. We used a narrative synthesis to compare the predictive value of frailty and age. Results Twelve studies were eligible for meta-analyses. In-hospital mortality (odds ratio (OR) = 1.12, 95% confidence interval (CI) 1.05, 1.19), length of stay (OR = 2.04, 95% CI 1.51, 2.56), discharge to home (OR = 0.58, 95% CI 0.53, 0.63) and in-hospital complications (OR = 1.17, 95% CI 1.10, 1.24) were all associated with frailty. Frailty was found to be a more consistent predictor of adverse outcomes and mortality in older trauma patients than injury severity and age in six studies that reported multivariate regression analysis. Discussion Older trauma patients with frailty have higher in-hospital mortality rates, prolonged hospital stays, in-hospital complications and adverse discharge disposition. Frailty is a better predictor of adverse outcomes than age in these patients. Frailty status is likely to be a useful prognostic variable in guiding patient management and stratifying clinical benchmarks and research trials. [ABSTRACT FROM AUTHOR]

Introduction frailty is common in older adults and is associated with increased health and social care use. Longitudinal information is needed on population-level incidence, prevalence and frailty progression to plan services to meet future population needs. Methods retrospective open cohort study using electronic health records of adults aged ≥50 from primary care in England, 2006–2017. Frailty was calculated annually using the electronic Frailty Index (eFI). Multistate models estimated transition rates between each frailty category, adjusting for sociodemographic characteristics. Prevalence overall for each eFI category (fit, mild, moderate and severe) was calculated. Results the cohort included 2,171,497 patients and 15,514,734 person-years. Frailty prevalence increased from 26.5 (2006) to 38.9% (2017). The average age of frailty onset was 69; however, 10.8% of people aged 50–64 were already frail in 2006. Estimated transitions from fit to any level of frailty were 48/1,000 person-years aged 50–64, 130/1,000 person-years aged 65–74, 214/1,000 person-years aged 75–84 and 380/1,000 person-years aged ≥ 85. Transitions were independently associated with older age, higher deprivation, female sex, Asian ethnicity and urban dwelling. Mean time spent in each frailty category decreased with age, with the longest period spent in severe frailty at all ages. Conclusions frailty is prevalent in adults aged ≥50 and time spent in successive frailty states is longer as frailty progresses, resulting in extended healthcare burden. Larger population numbers and fewer transitions in adults aged 50–64 present an opportunity for earlier identification and intervention. A large increase in frailty over 12 years highlights the urgency of informed service planning in ageing populations. [ABSTRACT FROM AUTHOR]

Frailty, characterized by a decreased physiological reserve and an increased vulnerability to stressors, is common among kidney transplant (KT) candidates and recipients. In this review, we present and summarize the key arguments for and against the assessment of frailty as part of KT evaluation. The key arguments for including frailty were: (i) sheer prevalence and far-reaching consequences of frailty on KT, and (ii) the ability to conduct a more holistic and objective evaluation of candidates, removing the inaccuracy associated with 'eye-ball' assessments of transplant fitness. The key argument against were: (i) lack of agreement on the definition of frailty and which tools should be used in renal populations, (ii) a lack of clarity on how, by whom and how often frailty assessments should be performed, and (iii) a poor understanding of how acute stressors affect frailty. However, it is the overwhelming opinion that the time has come for frailty assessments to be incorporated into KT listing. Although ongoing areas of uncertainty exist and further evidence development is needed, the well-established impact of frailty on clinical and experiential outcomes, the invaluable information obtained from frailty assessments, and the potential for intervention outweigh these limitations. Proactive and early identification of frailty allows for individualized and improved risk assessment, communication and optimization of candidates. [ABSTRACT FROM AUTHOR]

There is an increasing proportion of the general population surviving to old age with significant chronic disease, multi-morbidity, and disability. The prevalence of pre-frail state and frailty syndrome increases exponentially with advancing age and is associated with greater morbidity, disability, hospitalization, institutionalization, mortality, and health care resource use. Frailty represents a global problem, making early identification, evaluation, and treatment to prevent the cascade of events leading from functional decline to disability and death, one of the challenges of geriatric and general medicine. Cardiac arrhythmias are common in advancing age, chronic illness, and frailty and include a broad spectrum of rhythm and conduction abnormalities. However, no systematic studies or recommendations on the management of arrhythmias are available specifically for the elderly and frail population, and the uptake of many effective antiarrhythmic therapies in these patients remains the slowest. This European Heart Rhythm Association (EHRA) consensus document focuses on the biology of frailty, common comorbidities, and methods of assessing frailty, in respect to a specific issue of arrhythmias and conduction disease, provide evidence base advice on the management of arrhythmias in patients with frailty syndrome, and identifies knowledge gaps and directions for future research. [ABSTRACT FROM AUTHOR]

Background frailty is a condition of reduced function and health due to ageing processes and is associated with a higher risk of falls, hospitalisation, disability and mortality. Objective to determine the relationship between household wealth and neighbourhood deprivation with frailty status, independently of demographic factors, educational attainment and health behaviours. Design population-based cohort study. Setting communities in England. Subjects in total 17,438 adults aged 50+ from the English Longitudinal Study of Ageing. Methods multilevel mixed-effects ordered logistic regression was used in this study. Frailty was measured using a frailty index. We defined small geographic areas (neighbourhoods) using English Lower layer Super Output Areas. Neighbourhood deprivation was measured by the English Index of Multiple Deprivation, grouped into quintiles. Health behaviours included in this study are smoking and frequency of alcohol consumption. Results the proportion of respondents who were prefrail and frail were 33.8% [95% confidence interval (CI) 33.0–34.6%] and 11.7 (11.1–12.2)%, respectively. Participants in the lowest wealth quintile and living in the most deprived neighbourhood quintile had 1.3 (95% CI = 1.2–1.3) and 2.2 (95% CI = 2.1–2.4) times higher odds of being prefrail and frail, respectively, than the wealthiest participants living in the least deprived neighbourhoods Living in more deprived neighbourhood and poorer wealth was associated with an increased risk of becoming frail. Those inequalities did not change over time. Conclusions in this population-based sample, living in a deprived area or having low wealth was associated with frailty in middle-aged and older adults. This relationship was independent of the effects of individual demographic characteristics and health behaviours. [ABSTRACT FROM AUTHOR]

Background There is a need for effective primary care interventions that help older people combat frailty and build resilience. Objective To study the effectiveness of an optimised exercise and dietary protein intervention. Design Multicentre, randomised-controlled, parallel-arm trial. Setting Six primary care practices, Ireland. Methods Six general practitioners enrolled adults aged 65+ with Clinical Frailty Scale score ≤5 from December 2020 to May 2021. Participants were randomised to intervention or usual care with allocation concealed until enrolment. Intervention comprised a 3-month home-based exercise regime, emphasising strength, and dietary protein guidance (1.2 g/kg/day). Effectiveness was measured by comparing frailty levels, based on the SHARE-Frailty Instrument, on an intention-to-treat basis. Secondary outcomes included bone mass, muscle mass and biological age measured by bioelectrical impedance analysis. Ease of intervention and perceived health benefit were measured on Likert scales. Results Of the 359 adults screened, 197 were eligible and 168 enrolled; 156 (92.9%) attended follow-up (mean age 77.1; 67.3% women; 79 intervention, 77 control). At baseline, 17.7% of intervention and 16.9% of control participants were frail by SHARE-FI. At follow-up, 6.3 and 18.2% were frail, respectively. The odds ratio of being frail between intervention and control groups post-intervention was 0.23 (95% confidence interval: 0.07–0.72; P  = 0.011), adjusting for age, gender and site. Absolute risk reduction was 11.9% (CI: 0.8%–22.9%). Number needed to treat was 8.4. Grip strength (P  < 0.001) and bone mass (P  = 0.040) improved significantly. 66.2% found the intervention easy, 69.0% reported feeling better. Conclusion A combination of exercises and dietary protein significantly reduced frailty and improved self-reported health. [ABSTRACT FROM AUTHOR]

Frailty is a complex and multidimensional condition wherein declines in physiologic reserve and function place individuals in a state of heightened vulnerability and decreased resiliency. There has been growing interest in both research and clinical settings to understand how to best define, assess and characterise frailty in older adults. To this end, various models and clinical assessment tools have been used to define and measure frailty. While differences exist among these models and tools, a common unifying theme is a focus on physical function and activity. Notably absent across many available conceptual models and clinical tools are items directly related to oral and swallowing function. This is an important oversight as widespread changes to both oral and swallowing function are evident in older adults. Indeed, emerging evidence suggests many of the functional domains affected in frail older adults, such as nutrition and sarcopenia, have cyclical relationships with impairments in oral (oral hypofunction) and swallowing function (dysphagia) as well. The increasing appreciation for the interrelationships among oral hypofunction, dysphagia and frailty provides an opportunity for refinement of frailty assessment and characterisation in older adults to incorporate metrics specific to oral and swallowing function. [ABSTRACT FROM AUTHOR]

Background Frailty and depression are highly prevalent in haemodialysis recipients, exhibit a reciprocal relationship, and are associated with increased mortality and hospitalization, and lower quality of life. Despite this, there has been little exploration of the relationship between depression and frailty upon patient outcomes. We aimed to explore the relationship between depression and frailty, and their associations with mortality, hospitalization and quality of life. Methods We performed a prospective cohort study of prevalent haemodialysis recipients linked to national datasets for outcomes including mortality and hospitalization. Depression was assessed using the Patient Health Questionnaire-9 (PHQ-9), frailty using the Clinical Frailty Scale (CFS) and quality of life using the EuroQol 5-Dimension (EQ-5D) Summary Index. Results A total of 485 prevalent haemodialysis recipients were recruited, with 111 deaths and 1241 hospitalizations during follow-up. CFS was independently associated with mortality [hazard ratio (HR) 1.31; 95% confidence interval (CI) 1.08, 1.59; P  = .006], hospitalization [incidence rate ratio (IRR) 1.13; 95% CI 1.03, 1.25; P  = .010] and lower quality of life (Coef. −0.401; 95% CI −0.511, −0.292; P  < .001). PHQ-9 score was independently associated with lower quality of life (Coef. −0.042; 95% CI −0.063, −0.021; P  < .001), but not mortality (HR 1.00; 95% CI 0.96, 1.04; P  = .901) or hospitalization (IRR 0.99; 95% CI 0.97, 1.01; P  = .351). In an adjusted model including CFS, moderate depression was associated with reduced hospitalization (IRR 0.72; 95% CI 0.56, 0.93; P  = .013). Conclusions With the addition of frailty, depression was associated with lower hospital admissions, but poorer quality of life. The relationship between frailty and depression, and their influence on outcomes is complex, requiring further study. [ABSTRACT FROM AUTHOR]

Background Rising demand for Emergency and Urgent Care is a major international issue and outcomes for older people remain sub-optimal. Embarking upon large-scale service development is costly in terms of time, energy and resources with no guarantee of improved outcomes; computer simulation modelling offers an alternative, low risk and lower cost approach to explore possible interventions. Method A system dynamics computer simulation model was developed as a decision support tool for service planners. The model represents patient flow through the emergency care process from the point of calling for help through ED attendance, possible admission, and discharge or death. The model was validated against five different evidence-based interventions (geriatric emergency medicine, front door frailty, hospital at home, proactive care and acute frailty units) on patient outcomes such as hospital-related mortality, readmission and length of stay. Results The model output estimations are consistent with empirical evidence. Each intervention has different levels of effect on patient outcomes. Most of the interventions show potential reductions in hospital admissions, readmissions and hospital-related deaths. Conclusions System dynamics modelling can be used to support decisions on which emergency care interventions to implement to improve outcomes for older people. [ABSTRACT FROM AUTHOR]

Background Virtual wards are being rapidly developed within the National Health Service in the UK, and frailty is one of the first clinical pathways. Virtual wards for older people and existing hospital at home services are closely related. Methods In March 2022, we searched Medline, CINAHL, the Cochrane Database of Systematic Reviews and medRxiv for evidence syntheses which addressed clinical-effectiveness, cost-effectiveness, barriers and facilitators, or staff, patient or carer experience for virtual wards, hospital at home or remote monitoring alternatives to inpatient care. Results We included 28 evidence syntheses mostly relating to hospital at home. There is low to moderate certainty evidence that clinical outcomes including mortality (example pooled RR 0.77, 95% CI 0.60–0.99) were probably equivalent or better for hospital at home. Subsequent residential care admissions are probably reduced (example pooled RR 0.35, 95% CI 0.22–0.57). Cost-effectiveness evidence demonstrated methodological issues which mean the results are uncertain. Evidence is lacking on cost implications for patients and carers. Barriers and facilitators operate at multiple levels (organisational, clinical and patient). Patient satisfaction may be improved by hospital at home relative to inpatient care. Evidence for carer experience is limited. Conclusions There is substantial evidence for the clinical effectiveness of hospital at home but less evidence for virtual wards. Guidance for virtual wards is lacking on key aspects including team characteristics, outcome selection and data protection. We recommend that research and evaluation is integrated into development of virtual ward models. The issue of carer strain is particularly relevant. [ABSTRACT FROM AUTHOR]

The growing older population with advanced chronic kidney disease (ACKD stages 4–5) poses a challenge for healthcare worldwide. The high prevalence of frailty and associated adverse health outcomes highlights concerns for management and interventions specific to this population. The aim was to objectively review the evidence relating to older people (≥65 years) living with frailty and ACKD. More specifically how frailty is identified, what interventions have been studied and what outcomes have been reported including outcomes important to patients, families and carers. A scoping review was undertaken following the PRISMA-Scr guidelines. Nine databases were searched and a review team of five people followed a process using defined inclusion and exclusion criteria. Data were then analysed to answer the specific questions of the review. The World Health Organization's International Classification of Functioning Disability and Health was used to map outcomes across the domains. A total of 90 studies were included. The most reported frailty measure was the frailty phenotype. The most reported outcomes were mortality, hospitalisation and healthcare utilisation. Health-related quality of life was the most common patient-reported outcome measure. There were few intervention studies and limited evidence of patient and carer perspectives. This scoping review highlights important areas for further research in older people living with frailty and ACKD. This includes a 'gold standard' measure for identifying frailty, interventions and improvements in outcome measures that matter to patients (including studies that focus on carers and carer burden) and priority setting for future research. [ABSTRACT FROM AUTHOR]