Frailty assessment and acute frailty service provision in the UK: results of a national ‘day of care’ survey

Background The incorporation of acute frailty services into the acute care pathway is increasingly common. The prevalence and impact of acute frailty services in the UK are currently unclear. Methods The Society for Acute Medicine Benchmarking Audit (SAMBA) is a day of care survey undertaken annually within the UK. SAMBA 2019 (SAMBA19) took place on Thursday 27th June 2019. A questionnaire was used to collect hospital and patient-level data on the structure and organisation of acute care delivery. SAMBA19 sought to establish the frequency of frailty assessment tool use and describe acute frailty services nationally. Hospitals were classified based on the presence of acute frailty services and metrics of performance compared. Results A total of 3218 patients aged ≥70 admitted to 129 hospitals were recorded in SAMBA19. The use of frailty assessment tools was reported in 80 (62.0%) hospitals. The proportion of patients assessed for the presence of frailty in individual hospitals ranged from 2.2 to 100%. Bedded Acute Frailty Units were reported in 65 (50.3%) hospitals. There was significant variation in admission rates between hospitals. This was not explained by the presence of a frailty screening policy or presence of a dedicated frailty unit. Conclusion Two fifths of participating UK hospitals did not have a routine frailty screening policy: where this existed, rates of assessment for frailty were variable and most at-risk patients were not assessed. Responses to positive results were poorly defined. The provision of acute frailty services is variable throughout the UK. Improvement is needed for the aspirations of national policy to be fully realised.

Frailty-aware care: giving value to frailty assessment across different healthcare settings

Healthcare systems need to adapt to better serve an aging population with complex presentations. Frailty assessments are a potential means to address this heterogeneity in aging to identify individuals at increased risk for adverse health outcomes. Furthermore, frailty assessments offer an opportunity to optimize patient care in various healthcare settings. While the vast number of frailty assessment tools available can be a source of confusion for clinicians, each tool has features adaptable to the constraints and goals of different healthcare settings. This review discusses and compares barriers, facilitators, and the application of frailty assessments in primary care, the emergency department/intensive care unit and surgical care to cover a breadth of settings with different frailty assessment considerations. The implementation of frailty-aware care across healthcare settings potentiates better healthcare outcomes for older adults.

Clinical Significance of Frailty on Treatment Outcome in Nongeriatric Patients With Head and Neck Cancer and Esophageal Cancer Undergoing Curative-Intent Concurrent Chemoradiotherapy

Background Whether the prevalence of frailty and its clinical significance are relevant to treatment outcomes in younger (aged < 65 years) cancer patients remains uncertain. This study aimed to evaluate the impact of frailty on treatment outcomes in younger cancer patients with head and neck and esophageal malignancy. Material and methods This multicenter prospective study recruited 502 patients with locally advanced head and neck and esophageal cancer during 2016–2017 in Taiwan, aged 20–64 years who received curative-intent concurrent chemoradiotherapy (CCRT) as first-line antitumor treatment. Baseline frailty assessment using geriatric assessment (GA) was performed for each patient within 7 days before CCRT initiation. Results Frailty was observed in 169 (33.7%) of 502 middle-aged patients. Frail patients had significantly higher incidences of chemotherapy incompletion (16.6% versus 3.3%, P < .001) and radiotherapy incompletion (16.6% versus 3.6%, P < .001) than fit patients. During CCRT, frail patients had a significantly higher percentage of hospitalizations (42.0% versus 24.6%, P < .001) and a trend toward a higher percentage of emergency room visits (37.9% versus 30.0%, P = .08) than fit patients. Frail patients more likely had a significantly higher incidence of grade ≥ 3 adverse events than fit patients during CCRT. The 1-year survival rate was 68.7% and 85.2% (hazard ratio 2.56, 95% confidence interval 1.80–3.63, P < .001) for frail and fit patients, respectively. Conclusions This study demonstrated the significance of pretreatment frailty on treatment tolerance, treatment-related toxicity, and survival outcome in younger patients with head and neck and esophageal cancer undergoing CCRT. While GA is commonly targeted toward the older population, frailty assessment by GA may also be utilized in younger patients for decision-making guidance and prognosis prediction.

775 Impact of frailty on medium-term follow-up in patients undergoing transcatheter aortic valve implantation in a high flow referral centre with high volumes

Aims Transcatheter strategies to treat aortic stenosis (AS) are an established therapeutic option in older patients not candidate for open heart surgery. Guidelines recommend the adoption of surgical scores like the Society of Thoracic Surgeons (STS) as tools for risk stratification. However, these scores may have limited predictive value in older patients. To assess the impact of frailty status on a composite endpoint comprising all-cause death and cardiovascular (CV) events in patients with severe AS evaluated for transcatheter aortic valve implantation (TAVI) in a high-flow and high-volume tertiary care centre. Methods and results Consecutive patients &gt;80 years referred to TAVI from January to December 2019 at our institution were screened for frailty through a comprehensive geriatric assessment (CGA) based on physical function and the multidimensional prognostic index (MPI). Physical function was evaluated by the short physical performance battery (SPPB), a tool exploring balance, gait speed, strength and endurance that produces a score ranging from 0 to 12 (lowest to highest performance). The SPPB &lt;6 is an established strong predictor of mortality and disability. The MPI is a three-level score used to stratify risk of mortality (low, intermediate, or high risk) based on eight key domains for frailty assessment (functional and cognitive status, nutrition, mobility and risk of pressure sores, multimorbidity, polypharmacy, and co-habitation). Data on mortality and CV events at 6 and 12 months were retrieved via administrative records and/or telephone follow-up. Overall, 134 patients were referred for TAVI (mean age: 84 ± 4 years; &gt;90 years: 12%, women 67%). The STS risk score was 4.6 ± 3.0 (low risk: 49%; intermediate: 39%, high risk: 12%). Mean SPPB was 6.3 ± 3.7 (SPPB &lt;6: 32%). Ninety-five (71%) patients belonged to the MPI-low risk group, 30 (22%) to the MPI intermediate risk group and nine (7%) to the MPI high risk group. SPPB and MPI scores were moderately correlated with STS (Spearman correlation coefficient: SPPB R = 0.31, P = 0.01, MPI R = 0.29, P = 0.03, Figure 1A and B). At 1 year, 3 (2.2%) patients died, and 11 (8.2%) were hospitalized for CV events: major bleeding, N = 6(4.5%); stroke: N = 4 (3.0%); re-do: N = 1 (0.7%). The probability of the composite endpoint was higher for patients at intermediate/high MPI risk (HR intermediate/high risk vs. low risk: HR: 2.9, 95% CI: 1.1–6.8, P = 0.031, Figure 1C), while no association with STS (P = 0.332) was found. Conclusions In a prospective cohort of TAVI candidates, frailty stratified short- and medium-term prognosis. The integrated frailty assessment could be a useful tool for early detection of patients at risk of disability, and potentially, for preventing the futility of the TAVI procedure. 120 Figure