Department of Age-Related Healthcare, Tallaght Hospital, Dublin 24, - - PowerPoint PPT Presentation

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Department of Age-Related Healthcare, Tallaght Hospital, Dublin 24, - - PowerPoint PPT Presentation

Feb 22, 2023 204 likes •452 views

Screening for frailty in the Emergency Department: the utility of the SHARE-FI in predicting outcomes in a cohort of older patients Aoife Fallon, Lorna Kilbane, Robert Briggs, Tara Coughlan, Ronan Collins, Des ONeill, Sean Kennelly Department

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Aoife Fallon, Lorna Kilbane, Robert Briggs, Tara Coughlan, Ronan Collins, Des O’Neill, Sean Kennelly Department of Age-Related Healthcare, Tallaght Hospital, Dublin 24, Ireland

Screening for frailty in the Emergency Department: the utility of the SHARE-FI in predicting outcomes in a cohort of older patients

@Age_Matters

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CONFLICT OF INTEREST DISCLOSURE

I have no potential conflict of interest to report

@Age_Matters

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Background

  • Greater numbers of older people are accessing acute hospital

services

  • Patients aged ≥ 65 years:

– Up to 20% of unscheduled hospital attendances – 40 – 50% of medical admissions – More likely to have a severe illness – Increased length of stay – Higher 6 month mortality rate – Comprehensive Geriatric Assessment (CGA) as an inpatient improves

  • utcomes

@Age_Matters

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Background

Characteristics and outcomes of older persons attending the emergency department: a retrospective cohort study

  • Retrospective cohort study
  • 550 patients attending ED January 2012
  • 64% admitted
  • Average length of stay 13.1 days
  • 13.6% re-attendance at one month
  • 6.8% one year mortality

Characteristics and outcomes of older patients attending an acute medical assessment unit

  • A prospective cohort study
  • 1066 patients aged ≥65 attended AMAU in

2013

  • 60% admitted
  • 62.4% of those screened at triage

identified as being “at risk” of an adverse

  • utcome (Triage Risk Screening Tool)

@Age_Matters

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Background

  • Frailty:

– A syndrome characterised by reduced functional reserve resulting in a cumulative decline across systems – Increases risk of an adverse outcome when exposed to a stressor

@Age_Matters

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Background

  • The Survey of Health, Ageing and

Retirement in Europe Frailty Instrument (SHARE-FI)

  • Developed for use in the

community

  • Shown to be of use in predicting

adverse outcomes in ED

SHARE-FI Fatigue Loss of appetite Grip strength Slowness Low activity

@Age_Matters

FRAIL PRE-FRAIL NON-FRAIL

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Aims

  • To measure frailty, review its prevalence in older

patients presenting to ED and compare characteristics and outcomes of frail patients with their non-frail counterparts

@Age_Matters

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Methods

  • Prospective cohort study
  • 600-bed university teaching hospital
  • Pre-specified convenience sampling
  • Patients aged ≥70 years
  • Presenting to ED on a 24/7 basis
  • January - August 2014
  • Follow-up at 6 months, 12 months

@Age_Matters

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Methods

  • Patient characteristics:

– Age – Gender – Frailty (SHARE-FI) – Cognition (MMSE, AD8) – Delirium (AMT 4, CAM-ICU) – Acute illness severity (MTS, EWS) – Polypharmacy (≥5 medications)

  • Details of attendance:

– Time of attendance – Arrival by ambulance – Time in ED – Discharge outcomes/ In-hospital mortality

  • 6 month and 12 month outcomes:

– Re-attendance – Mortality – Nursing home

@Age_Matters

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Results

  • 198 patients included
  • Mean age = 78.8 years
  • 48.5% male
  • 51.5% female

@Age_Matters

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Results

Frailty category (SHARE-FI) % Mean age (p=0.518) Gender (p=0.498) Frail 46.7% (64/198) 79.1 years M = 44.1% Pre-frail 20.7% (41/198) 78.8 years M = 51.2% Non-frail 32.3% (93/198) 78 M = 53.1%

@Age_Matters

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Results

Non-frail Pre-Frail Frail P-value

Presenting ‘out of hours’ (%) 37.5 (24/64) 34.2 (14/41) 44.1 (41/93) 0.497 Arrival by Ambulance (%) 31.3 (20/64) 31.7 (13/41) 43.0 (40/93) 0.241 Six Hours or less in ED (%) 31.3 (20/64) 26.8 (11/41) 21.5 (20/93) 0.384 Manchester Triage Category 1-3 (%) 78.1 (14/64) 68.3 (28/41) 73.1 (68/93) 0.527

@Age_Matters

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Results

Non-frail Pre-Frail Frail P-value

Polypharmacy (%) 57.8 (37/64) 70.7 (29/41) 86.0 (80/93) <0.001 Delirium (%) 3.1 (2/64) 2.4 (1/41) 15.1 (14/93) 0.009 AMT 4 Score (SD) 3.8 (0.6) 3.7 (0.8) 3.1 (1.1) <0.001

@Age_Matters

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Results

Non-Frail Pre-frail Frail p Value

In-hospital mortality (%) 12.5 (8/64) 12.2 (5/41) 7.5 (7/93) 0.527 Readmitted within 1 year (%) 57.8 (37/64) 75.6 (31/41) 61.3 (57/93) 0.161 Mean readmissions within 1 year (SD) 1.2 (1.7) 1.4 (1.4) 1.0 (1.2) 0.411 Mortality at 1 year (%) 21.9 (14/64) 14.6 (6/41) 22.6 (21/93) 0.556

@Age_Matters

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Results

Variable Odds Ratio p Value 95% Confidence interval Age ≥ 80 years 2.34 0.004 1.30 – 4.21 Male gender 0.49 0.056 0.24 – 1.02 ‘Out of Hours’ 1.32 0.459 0.63 – 2.78 Ambulance 0.65 0.303 0.29 – 1.47 MTS 1-3 0.94 0.878 0.42 – 2.09 Polypharmacy 2.17 0.111 0.84 – 5.61 Delirium 1.46 0.579 0.39 – 5.49 Hx dementia 1.44 0.511 0.49 – 4.26 Frail by SHARE-FI 0.89 0.614 0.58 – 1.38

Odds ratio – alive at 12 months

@Age_Matters

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Results

Variable Odds Ratio p Value 95% confidence Interval Age ≥ 80 years 0.49 0.009 0.28 – 0.83 Male gender 2.05 0.030 1.07 – 3.94 ‘Out of Hours’ 0.84 0.610 0.43 – 1.64 Ambulance 1.33 0.439 0.65 – 2.74 MTS 1-3 0.96 0.917 0.47 – 1.99 Polypharmacy 0.37 0.022 0.16 – 0.87 Delirium 1.05 0.936 0.31 – 3.63 Hx dementia 0.24 0.005 0.72 – 1.57 Frail by SHARE-FI 1.07 0.745 0.72 – 1.57

Odds ratio – composite outcome: alive and at home at 12 months

@Age_Matters

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Screening for frailty in ED

  • SHARE-FI:

– Proven to be of use in community setting – Easily administered in clinical setting

  • SHARE-FI in ED

– High prevalence of frailty seen population assessed in this study – Few significant differences between characteristics of frail and non- frail groups – No significant differences in outcomes identified

@Age_Matters

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Screening for frailty in ED

  • Increasing age (≥ 80) was associated with decreased likelihood
  • f being at alive or alive and at home at 12 months
  • Complex patient cohort:

– >2/3 of patients in the study group had a severe acute illness at presentation (MTS 1 - 3) – >20% mortality in frail and non-frail groups

@Age_Matters

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Limitations

  • Small study population
  • Single-centre trial
  • Only patients aged ≥70 included

@Age_Matters

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Conclusions

  • Frailty is an important concept in the management of older

people

  • Acute hospital attendance may be a critical event regardless
  • f frailty status
  • Need for new ways to identify and quantify risk for older

patients in ED

  • Important to educate and train those working in ED in the

management of older patients

@Age_Matters

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References:

1. Acute Medicines Programme Report, 2010. Royal College of Physicians of Ireland, Irish Association of Directors of Nursing and Midwifery, Therapy Professions Committee, Quality and Clinical Care Directorate, Health Service Executive 2. Fallon A, Armstrong J, Coughlan T, Collins DR, O’Neill D, Kennelly SP. Characteristics and Outcomes of Older Patients Attending an Acute Medical Assessment Unit. Ir Med J. 2015 Jul-Aug;108(7):210-1 3. Kennelly SP, Drumm B, Coughlan T, Collins R, O'Neill D, Romero-Ortuno R. Characteristics and outcomes of older persons attending the emergency department: a retrospective cohort study. QJM Dec 2014, 107 (12) 977-987; DOI: 10.1093/qjmed/hcu111 4. Ellis G, Whitehead MA, O'Neill D, Langhorne P, Robinson D. Comprehensive geriatric assessment for older adults admitted to hospital. Cochrane Database of Systematic Reviews 2011, Issue 7. Art. No.: CD006211. DOI: 10.1002/14651858.CD006211.pub2 5. Frailty in Older People. Lancet. 2013;381(9868):752-762. doi:10.1016/S0140-6736(12)62167-9 6. https://britishgeriatricssociety.wordpress.com/2017/08/02/the-frailty-industry-too-much-too-soon/ 7. https://britishgeriatricssociety.wordpress.com/2017/08/09/why-im-fine-with-frailty/ 8. Carpenter CR, Shelton E, Fowler S, Suffoletto B, Platts-Mills TF, Rothman RE, Hogan TM Risk factors and screening instruments to predict adverse outcomes for undifferentiated older emergency department patients: a systematic review and meta-analysis. Acad Emerg Med. 2015 Jan;22(1):1-21. doi: 10.1111/acem.12569. Review. 9. Romero-Ortuno R, Walsh CD, Lawlor BA, Kenny RA. A Frailty Instrument for primary care: findings from the Survey

  • f Health, Ageing and Retirement in Europe (SHARE). BMC Geriatrics. 2010;10:57. doi:10.1186/1471-2318-10-57.

10. Stiffler KA, Wilber ST, Frey J, McQuown CM Poland S. Frailty defined by the SHARE Frailty Instrument and adverse

  • utcomes after an ED visit. Am J Emerg Med. 2016 Dec;34(12):2443-2445. doi: 10.1016/j.ajem.2016.09.001. Epub

2016 Sep 3.

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Background

  • Emergency departments (ED)

traditionally developed to manage trauma and acute critical illness

  • Frail patients presenting to ED are at

high risk of poor outcomes

  • Older patients benefit from

comprehensive geriatric assessment (CGA) during admission

  • Identifying frail older patients at ED

presentation may allow them to benefit from early specialist intervention

@Age_Matters