What do we know about frailty in the acute care setting? A scoping review

Abstract

Background: The ability of acute care providers to cope with the influx of frail older patients is increasingly stressed, and changes need to be made to improve care provided to older adults. Our purpose was to conduct a scoping review to map and synthesize the literature addressing frailty in the acute care setting in order to understand how to tackle this challenge. We also aimed to highlight the current gaps in frailty research.

Methods: This scoping review included original research articles with acutely-ill Emergency Medical Services (EMS) or hospitalized older patients who were identified as frail by the authors. We searched Medline, CINAHL, Embase, PsycINFO, Eric, and Cochrane from January 2000 to September 2015.

Results: Our database search initially resulted in 8658 articles and 617 were eligible. In 67% of the articles the authors identified their participants as frail but did not report on how they measured frailty. Among the 204 articles that did measure frailty, the most common disciplines were geriatrics (14%), emergency department (14%), and general medicine (11%). In total, 89 measures were used. This included 13 established tools, used in 51% of the articles, and 35 non-frailty tools, used in 24% of the articles. The most commonly used tools were the Clinical Frailty Scale, the Frailty Index, and the Frailty Phenotype (12% each). Most often (44%) researchers used frailty tools to predict adverse health outcomes. In 74% of the cases frailty predicted the outcome examined, typically mortality and length of stay.

Conclusions: Most studies (83%) were conducted in non-geriatric disciplines and two thirds of the articles identified participants as frail without measuring frailty. There was great variability in tools used and more recently published studies were more likely to use established frailty tools. Overall, frailty appears to be a good predictor of adverse health outcomes. For frailty to be implemented in clinical practice frailty tools should help formulate the care plan and improve shared decision making. How this will happen has yet to be determined.

Keywords: Acute care; Aging; Frail elderly; Frailty; Older adults; Scoping review.

Fig. 1

Flow chart. ¹The two reviewers agreed that these articles should be excluded but disagreed on the reason for exclusion. ²Additional articles were identified by manually searching the reference lists of systematic reviews focusing on frailty

Fig. 2

Proportion of articles that measured frailty by study design. We only stratified by disciplines that have been included in at least 2 articles

Fig. 3

Proportion of articles based on the reason frailty measures were used in the articles. Stratified by (a). Year (b). Study design. ¹Articles which only used frailty as a descriptive characteristic. For example, if an article used frailty both as an inclusion/exclusion criterion and a descriptive characteristic, it was only categorized as inclusion/exclusion criterion in our review. ²Inclusion/Exclusions criterion and outcome measure; risk stratification and outcome measure. ³Articles that examined the association of a frailty tool with a longitudinal adverse outcome

Fig. 4

Number of times that the association of a frailty tool with a longitudinal outcome was examined. ¹ For example, change in anticoagulant use. ² For example, antibody levels. ³ Adverse outcomes that were examined only once

Fig. 5

Proportion of articles demonstrating the association of frailty with longitudinal adverse outcomes stratified by frailty measure. We only presented the established frailty tools whose association with outcomes were examined at least 5 times