To compare the effects of care based on comprehensive geriatric assessment (CGA) as a complement to usual care in an outpatient setting with those of usual care alone. The assessment was performed 36 ...months after study inclusion.
Randomized, controlled, assessor-blinded, single-center trial.
A geriatric ambulatory unit in a municipality in the southeast of Sweden.
Community-dwelling individuals aged ≥ 75 years who had received inpatient hospital care 3 or more times in the past 12 months and had 3 or more concomitant medical diagnoses were eligible for study inclusion. Participants were randomized to the intervention group (IG) or control group (CG).
Participants in the IG received CGA-based care for 24 to 31 months at the geriatric ambulatory unit in addition to usual care.
Mortality, transfer to nursing home, days in hospital, and total costs of health and social care after 36 months.
Mean age (SD) of participants was 82.5 (4.9) years. Participants in the IG (n = 208) lived 69 days longer than did those in the CG (n = 174); 27.9% (n = 58) of participants in the IG and 38.5% (n = 67) in the CG died (hazard ratio 1.49, 95% confidence interval 1.05-2.12, P = .026). The mean number of inpatient days was lower in the IG (15.1 SD 18.4) than in the CG (21.0 SD 25.0, P = .01). Mean overall costs during the 36-month period did not differ between the IG and CG (USD 71,905 SD 85,560 and USD 65,626 SD 66,338, P = .43).
CGA-based care resulted in longer survival and fewer days in hospital, without significantly higher cost, at 3 years after baseline. These findings add to the evidence of CGA's superiority over usual care in outpatient settings. As CGA-based care leads to important positive outcomes, this method should be used more extensively in the treatment of older people to meet their needs.
Purpose: Assessment of frailty is a key method to identify older people in need of holistic care. However, agreement between different frailty instrument varies. Thus, groups classified as frail by ...different instruments are not completely overlapping. This study evaluated differences in sociodemographic factors, cognition, functional status, and quality of life between older persons with multimorbidity who were discordantly classified by five different frailty instruments, with focus on the Clinical Frailty Scale (CFS) and Fried's Frailty Phenotype (FP). Participants and Methods: This was a cross-sectional study in a community-dwelling setting. Inclusion criteria were as follows: greater than or equal to75 years old, greater than or equal to3 visits to the emergency department the past 18 months, and greater than or equal to3 diagnoses according to ICD-10. 450 participants were included. Frailty was assessed by CFS, FP, Short Physical Performance Battery (SPPB), Grip Strength and Walking Speed. Results: 385 participants had data on all frailty instruments. Prevalence of frailty ranged from 34% (CFS) to 75% (SPPB). Nine percent of participants were non-frail by all instruments, 20% were frail by all instruments and 71% had discordant frailty classifications. Those who were frail according to CFS but not by the other instruments had lower cognition and functional status. Those who were frail according to FP but not CFS were, to a larger extent, women, lived alone, had higher cognitive ability and functional status. Conclusion: The CFS might not identify physically frail women in older community-dwelling people with multimorbidity. They could thus be at risk of not be given the attention their frail condition need. Keywords: geriatrics, frailty phenotype, clinical frailty scale, outpatient assessment
The Tilburg Frailty Indicator (TFI) is a questionnaire with 15 questions designed for screening for frailty in community-dwelling older people. TFI has a multidimensional approach to frailty, ...including physical, psychological, and social dimensions. The aim of this study was to translate TFI into Swedish and study its psychometric properties in community-dwelling older people with multimorbidity. A cross-sectional study of individuals 75 years and older, with ≥3 diagnoses of the ICD-10 and ≥3 visits to the Emergency Department in the past 18 months. International guidelines for back-translation were followed. Psychometric properties of the TFI were examined by determining the reliability (inter-item correlations, internal consistency, test–retest) and validity (concurrent, construct, structural). A total of 315 participants (57.8% women) were included, and the mean age was 83.3 years. The reliability coefficient KR-20 was 0.69 for the total sum. A total of 39 individuals were re-tested, and the weighted kappa was 0.7. TFI correlated moderately with other frailty measures. The individual items correlated with alternative measures mostly as expected. In the confirmatory factor analysis (CFA), a three-factor model fitted the data better than a one-factor model. We found evidence for adequate reliability and validity of the Swedish TFI and potential for improvements.
Background
Multimorbidity and frailty are often associated and Comprehensive Geriatric Assessment (CGA) is considered the gold standard of care for these patients.
Aims
This study aimed to evaluate ...the effect of outpatient Comprehensive Geriatric Assessment (CGA) on frailty in community-dwelling older people with multimorbidity and high health care utilization.
Methods
The Ambulatory Geriatric Assessment—Frailty Intervention Trial (AGe-FIT) was a randomized controlled trial (intervention group,
n
= 208, control group
n
= 174) with a follow-up period of 24 months. Frailty was a secondary outcome. Inclusion criteria were: age ≥ 75 years, ≥ 3 current diagnoses per ICD-10, and ≥ 3 inpatient admissions during 12 months prior to study inclusion. The intervention group received CGA-based care and tailored interventions by a multidisciplinary team in an Ambulatory Geriatric Unit, in addition to usual care. The control group received usual care. Frailty was measured with the Cardiovascular Health Study (CHS) criteria. At 24 months, frail and deceased participants were combined in the analysis.
Results
Ninety percent of the population were frail or pre-frail at baseline. After 24 months, there was a significant smaller proportion of frail and deceased (
p
= 0.002) and a significant higher proportion of pre-frail patients in the intervention group (
p
= 0.004). Mortality was high, 18% in the intervention group and 26% in the control group.
Conclusion
Outpatient CGA may delay the progression of frailty and may contribute to the improvement of frail patients in older persons with multimorbidity.
Background: As the population grows older, understanding and management of multimorbidity and frailty will become increasingly important. There is no consensus on how to define or measure frailty and ...awareness of frailty is limited in many healthcare settings. This impedes implementation of frailty assessment and management in routine care. The overall aim of this thesis was to contribute to the understanding of assessment and management of frailty in old people with multimorbidity. Study I Study I aimed to evaluate the effect of outpatient Comprehensive Geriatric Assessment (CGA) on frailty in community dwelling older people with multimorbidity and high health care utilization. Methods: The Ambulatory Geriatric Assessment—Frailty Intervention Trial (AGe-FIT) was a randomized controlled trial (intervention group n=208, control group n=174) with a follow-up period of 24 months. Frailty was a secondary outcome. Inclusion criteria: age ≥75 years, ≥3 current diagnoses in ICD-10, and ≥3 hospitalisations in the last 12 months. The intervention group received CGA-based care and tailored interventions by a multidisciplinary team in addition to usual care. The control group received usual care. Frailty was measured with the frailty phenotype (FP). At 24 months, frail and deceased participants were combined in the analysis. Results: Ninety percent of the population were frail or pre-frail at baseline. After 24 months, there was a significant smaller proportion of frail and deceased (p=0,002) and a significantly higher proportion of prefrail patients in the intervention group (p=0,004). Mortality was high, 18% in the intervention group and 26% in the control group. Conclusion: Outpatient CGA may delay the progression of frailty and may contribute to the improvement of frail patients in older persons with multimorbidity. Study II Study II aimed to evaluated differences in health-related factors between older persons with multimorbidity who were discordantly classified by five frailty instruments, with focus on the Clinical Frailty Scale (CFS) and the Frailty Phenotype (FP). Methods: A cross-sectional study in a community-dwelling setting. Inclusion criteria were: ≥75 years old, ≥3 visits to the emergency department in the past 18 months, and ≥3 diagnoses in 3 different ICD-10 chapters. Frailty was assessed by CFS, FP, Short Physical Performance Battery (SPPB), grip strength and walking speed. Results: 385 participants had data on all frailty instruments. Prevalence of frailty ranged from 34% (CFS) to 75% (SPPB). Nine percent of participants were non-frail by all instruments, 20% were frail by all instruments and 71% had discordant frailty classifications. Those who were frail according to CFS but not by the other instruments had lower cognition and functional status. Those who were frail according to FP but not CFS were, to a larger extent, women, lived alone, had higher cognitive ability and functional status. Conclusion: The CFS might not identify physically frail women in older community-dwelling people with multimorbidity. They could be at risk of not receiving the attention motivated by their frail condition. Study III Aim: The aims of study III was to translate TFI into Swedish and study its psychometric properties in community-dwelling older people with multimorbidity. The Tilburg Frailty Indicator (TFI) is a questionnaire with 25 questions (10 on background factors, 15 on frailty) suitable for frailty-screening in Primary Care. TFI measures physical, psychological, and social frailty. Method: A cross-sectional study with participants with the same inclusion criteria as study II. International guidelines for back-translation were followed. Reliability (inter-item correlations, internal consistency, test–retest) and validity (concurrent, construct, structural) was evaluated. Results: 315 participants (58% women) were included with a mean age of 83,3 years. The reliability coefficient KR-20 was 0,69 for the total sum. 39 individuals were re-tested, and the weighted kappa was 0,7. TFI correlated moderately with other frailty measures. The individual items correlated with alternative measures mostly as expected. In the confirmatory factor analysis (CFA), a three-factor model fitted the data better than a one-factor model. Conclusion: We found evidence for adequate reliability and validity of the Swedish TFI and potential for improvements.Study IVThe aim of study IV was to explore Primary Health Care Professionals’ (PHCP) experiences of frailty assessment with the TFI with focus on feasibility factors and their experiences of assessment and management of frailty. Methods: A qualitative semi-structured interview study. Participants were PHCPs (physicians, nurses, and physiotherapists). Interviews were thematically analysed using qualitative content analysis according to Graneheim and Lundman. Results: Nine interviews were performed. The PHCPs experiences were expressed in two themes: “Assessment of frailty with TFI is feasible if healthcare adjusts to older people” and “When the concept of frailty is unclear, interventions are uncertain.” TFI was described as easy to use and holistic. It was suggested that the TFI could be used as a self-administered questionnaire for the patient or by the PHCPs. The TFI provided useful information for care planning, although it took a long time. Some questions raised concerns. Conclusion: There was an overall positive perception of TFI’s clinical usefulness. The result highlights frailty as an elusive but important concept in care management of old people, which indicates a need of educational efforts aiming to increase knowledge about frailty in primary care.
PDF
