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

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 O’Neill, Sean Kennelly Department of Age-Related Healthcare, Tallaght Hospital, Dublin 24, Ireland @Age_Matters

CONFLICT OF INTEREST DISCLOSURE I have no potential conflict of interest to report @Age_Matters

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 outcomes @Age_Matters

Background Characteristics and outcomes of older Characteristics and outcomes of older persons attending the emergency patients attending an acute medical department: a retrospective cohort study assessment unit • • Retrospective cohort study A prospective cohort study • • 550 patients attending ED January 2012 1066 patients aged ≥65 attended AMAU in 2013 • 64% admitted • 60% admitted • Average length of stay 13.1 days • 62.4% of those screened at triage • 13.6% re-attendance at one month identified as being “at risk” of an adverse • 6.8% one year mortality outcome (Triage Risk Screening Tool) @Age_Matters

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

Background • The Survey of Health, Ageing and SHARE-FI Retirement in Europe Frailty Instrument (SHARE-FI) FRAIL Fatigue • Developed for use in the Loss of appetite PRE-FRAIL community Grip strength Slowness NON-FRAIL • Shown to be of use in predicting adverse outcomes in ED Low activity @Age_Matters

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

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

Methods • • Patient characteristics: Details of attendance: – Age – Time of attendance – Gender – Arrival by ambulance – Time in ED – Frailty (SHARE-FI) – Discharge outcomes/ In-hospital mortality – Cognition (MMSE, AD8) • 6 month and 12 month outcomes: – Delirium (AMT 4, CAM-ICU) – Re-attendance – Acute illness severity (MTS, EWS) – Mortality – Polypharmacy ( ≥5 medications) – Nursing home @Age_Matters

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

Results Frailty category % Mean age Gender (SHARE-FI) (p=0.518) (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

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

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

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

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

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

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

Screening for frailty in ED • Increasing age ( ≥ 80) was associated with decreased likelihood of 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

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

Conclusions • Frailty is an important concept in the management of older people • Acute hospital attendance may be a critical event regardless of 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

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 of 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 outcomes 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.

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