Frailsafe was developed by the British Geriatrics Society as clinical criteria to accurately identify patients at risk of frailty-associated harm on admission to hospital. There is no single validated tool for assessing frailty in heart failure on admission to hospital. The aim is to determine the prevalence of frailty-associated harm and the outcomes of older persons admitted to hospital with decompensated heart failure using Frailsafe screening criteria.
A retrospective cohort study of consecutive patients aged 75 years and over, admitted to hospital with decompensated heart failure within a six-month period was performed. Frailsafe screening criteria were applied to each patient retrospectively and data on length of stay, inpatient mortality, six-month mortality and readmission at six months was collected for all patients. The outcomes were analysed using univariate analysis comparing the patients ‘at risk of frailty-associated harm’ with those ‘not at risk’.
There were 103 patients identified as 75 years or older and admitted with a primary diagnosis of heart failure, 27% (28) were identified as at risk of frailty-associated harm. This cohort had a significantly longer length of stay (3.5 days, p=0.0496), worse six-month mortality (57% vs. 33%, p=0.0274) and more frequent emergency readmissions (2.04 vs. 0.97, p=0.0031).
In conclusion, prevalence of patients at risk of frailty-associated harm measured by Frailsafe in an older population admitted with decompensated heart failure was 27%. Such patients had a longer length of stay, and were at increased risk of readmission and mortality within the following six months. Future research should include analysis of confounding variables, such as comorbidity, in a larger population to aim to identify how to improve outcomes in this particularly high-risk group.
Introduction
Frailty is a distinctive health state, related to the ageing process, in which multiple body systems gradually lose their in-built reserves, and is related to poorer outcomes.1 There have been numerous tools developed to identify frailty,2-4 often these tools are complex and not suitable for identifying patients at the time of admission to hospital, requiring a comprehensive geriatric assessment to validate them. The British Geriatrics Society developed the Frailsafe5,6 checklist, which was piloted across 12 UK hospitals in 2014 as part of the Frailsafe collaborative. The tool used three screening indicators to identify patients at risk of frailty-associated harm, any person scoring positive on any of these indicators then triggered completion of the full checklist. The indicators are evidence of confusion, reduced mobility, or resident in a care home. Research into frailty has flourished, including its relationship with chronic diseases showing enhanced adverse outcomes.7-9
Heart failure is a long-term condition, defined as a common complex clinical syndrome of symptoms and signs caused by impairment of the heart’s action as a pump supporting the circulation.10 It is caused by structural or functional abnormalities of the heart.10 Heart failure, like frailty, leads to poorer outcomes, high mortality rates,11 and high admission rates to hospital. Heart failure accounts for approximately 5% of all emergency admissions and 2% of total NHS expenditure.11 With technologically advancing cardiology interventions and a generally ageing UK population,12 it is inevitable that the prevalence of heart failure will increase, as will the likelihood of frailty as a concomitant comorbid diagnosis.
Frailty in a heart failure population is common,13-15 and associated with worse outcomes including mortality,15-20 hospitalisations15,18,19,21 and quality of life.22‑24 Despite the development of numerous identification tools, there is no single validated tool for assessing frailty in a heart failure population.25 Prognostication is notoriously difficult in such long-term conditions; the Frailsafe screening criteria may be a useful indicator for predicting poor outcomes, enabling superior care planning that could potentially reduce inappropriate emergency admission and facilitate individualised, holistic care.
Aim
To identify the incidence of patients at risk of frailty-associated harm in an older heart failure population, whose primary reason for admission to hospital is decompensated heart failure, and to evaluate whether Frailsafe screening criteria can be used as a prognostic indicator.
Method
We conducted a retrospective observational cohort study identifying outcomes in an older heart failure population at risk of harm associated with frailty.
Patients were identified using local data from the National Heart Failure Audit (NHFA) database between September 2015 and March 2016 and extracted into an Excel spreadsheet. Entry into the NHFA database necessitates a primary coded discharge diagnosis for heart failure and data entry completed by the Heart Failure Team following heart failure specialist review. The diagnosis was quality assured via discussion at a multi-disciplinary team (MDT) meeting. All patients were reviewed by a specialist heart failure nurse or pharmacist, and heart failure treatment optimised during their inpatient stay.
Patients meeting the following criteria were included in the study: aged 75 years and over and admitted to hospital with a primary diagnosis of heart failure. Excluded were patients under the age of 75 years. Frailsafe screening criteria were retrospectively applied to patients to assess the risk of frailty-associated harm. Hospital electronic medical records were used to find if the patients scored for any of the three parameters: decreased mobility, increased confusion and care home resident. This was completed using the nursing documentation, where, on admission, all patients over the age of 65 years have a cognitive screen using a 4AT (4 A’s test) assessment; a screening instrument designed for rapid initial assessment of delirium and cognitive impairment. Patient’s mobility and any deviation from normal are recorded, and patient address was screened for nursing home residency. Data collected for each patient included: sex, age, type of heart failure, New York Heart Association (NYHA) status, presence of oedema and Frailsafe screening criteria. Outcome data on length of stay, number of readmissions to hospital in the six-month period post-discharge, inpatient mortality (during their admission) and six-month mortality were also collected. Data were anonymised following data collection.
Outcomes data were compared between the cohort ‘at risk’ versus ‘not at risk’ of frailty-associated harm groups and statistical differences between the two groups were analysed using Chi-squared and t-test.
Results
There were 103 primary diagnosis heart failure admissions aged over 75 years and included in the study, representing 57% of heart failure patients admitted to hospital within the data collection period. The characteristics of patients are presented in table 1. From the 103 patients identified, 27% (28) scored as ‘at risk of frailty-associated harm’ when using Frailsafe screening criteria.
Patients ‘at risk’ of frailty-associated harm had a significantly longer length of stay than heart failure patients ‘not at risk’ (13.8 vs. 10.2 days, p=0.0496). Patients identified as ‘at risk’ had a significantly worse mortality at six months: 57% (n=16) vs. 33% (n=24), p=0.0274 (figure 1). The ‘at risk’ cohort of heart failure patients were also more likely to be readmitted to hospital within the six months following their initial admission with heart failure (p=0.0031).
Discussion
Previous studies have shown the prevalence of frailty in a heart failure population to be between 18–56%.13,14,18,21,26 This study showed 27% of patients to be at risk of frailty-associated harm; of this cohort the majority (60%, n=17) were female and were on average older, this is in keeping with previous findings.15,17 The ‘at risk’ cohort had an average age of 84 years, older than that of the ’not at risk’ heart failure population by three years; aligning with the consensus that frailty is a syndrome of advancing age.1
This study also showed a longer length of stay for patients in the ‘at risk’ group of 3.5 days. Similar findings have previously been observed in frail cohorts with atrial fibrillation,27 and all frail patients on an acute medical unit.28 An extended stay for a frail cohort puts them at increased risk of acquired harm, such as reduced muscle mass, hospital-acquired infection and delirium. Increased length of stay in older people has been shown to worsen outcomes and increase long-term care needs.29 Although the increase in long-term care needs was not looked at in this study, the similarities between increased stay and poorer outcomes were, and correlate with results from previous studies.27,28
The higher incidence of mortality within the ‘at risk’ population highlights that applying Frailsafe criteria can predict poorer prognosis in a population with concurrent heart failure. Similarly, other studies using different frailty measures have shown similar increased mortality of frail heart failure patients at 30 days1 and one year.15,17
Both six-month mortality and readmission rates within six months were worse, despite the same package of care being available to both groups during their inpatient stay, as follows: all patients received a heart failure specialist review and were discussed at a heart failure MDT meeting; had heart failure medications optimised as far as possible during their inpatient stay, within accepted parameters for blood pressure, heart rate, renal function and adverse drug reactions; and a clinical management plan generated for ongoing care, all of which are recommended by national guidelines10 for good quality care and have shown improved mortality11 in a general heart failure population.
No significant differences were seen in prevalence of reduced versus preserved ejection fraction symptoms, including oedema and NYHA class, when comparing the ‘at risk’ to the ‘not at risk’ groups, respectively. However, there were numerical differences in levels of oedema; 93% versus 79% in the ‘at risk’ compared with the ‘not at risk’ groups. The ‘at risk’ group also received numerically less disease-modifiable treatments. Unfortunately, loop diuretics were not looked at as part of this study.
Strengths and limitations
This is the first study to look at the use of the Frailsafe screening criteria in a heart failure cohort and its results are hypothesis generating. This study is limited by a relatively small population, and there is the potential of many unknown confounding variables between the two groups, including the impact of multiple comorbidities and the differences in treatment and symptoms between the groups.
Conclusion
Frailsafe screening criteria have been shown to identify a group of older heart failure patients at risk of frailty-associated harm who, following admission to hospital, have a longer length of stay and poor prognosis in this small pilot study. Further larger scale work should describe and analyse the presence of comorbidities and the differences in treatment tolerability and up-titration, and their impact on outcomes, including prognosis and quality of life, utilising regression analysis to take into account all confounding variables. Other potential differences between frail and non-frail patients, which may impact on outcomes warrant further investigation, including the mode by, and stage at, which patients are diagnosed with heart failure and the care received by both groups at each stage of the syndrome. More research and funding are vital to develop interventions appropriate for this ‘high-risk’ population.
Conflicts of interest
None declared.
Funding
No financial funding was sourced to support this work. The original Frailsafe collaboration was supported by a Health Foundation ‘Closing the Gap in Patient Safety’ award. The financial sponsors have played no role in this piece of work. The views expressed in this publication are solely those of the authors.
Acknowledgements
Thanks are due to the Frailsafe Collaborative for constructive comments on a previous draft of this article and The Health Foundation for their support.
Study approval
The Hospital research and audit committee did not deem ethical approval necessary for this retrospective cohort analysis.
Key messages
- The prevalence of frailty, as assessed by Frailsafe criteria, in older patients admitted with decompensated heart failure was established
- 27% of patients were deemed at risk of frailty-associated harm by Frailsafe criteria
- Length of stay, six-month mortality and number of readmissions in six months was greater in frail heart failure patients
- Frailsafe criteria identify older heart failure patients who subsequently have adverse outcomes
References
1. Turner G, Clegg A, Youde J. Fit for frailty. Consensus best practice guidance for the care of older people living with frailty in community and outpatient settings. London: British Geriatrics Society, 2014. Available from: https://www.bgs.org.uk/sites/default/files/content/resources/files/2018-05-23/fff_full.pdf
2. Rockwood K, Song X, MacKnight C et al. A global clinical measure of fitness and frailty. Can Med Assoc J 2005;173:489–95. https://doi.org/10.1503/cmaj.050051
3. Rolfson DB, Majumdar SR, Tsuyuki RT, Tahir A, Rockwood K. Validity and reliability of the Edmonton Frail Scale. Age Ageing 2006;35:526–9. https://doi.org/10.1093/ageing/afl041
4. Bieniek J, Wilczyński K, Szewieczek J. Fried frailty phenotype assessment components as applied to geriatric inpatients. Clin Interv Aging 2016;11:453–9. https://doi.org/10.2147/CIA.S101369
5. Sheffield Teaching Hospitals NHS trust on behalf of the British Geriatrics Society. Frailsafe: a safety checklist for frail older patients entering acute hospital care. London: The Health Foundation. Available from: https://www.health.org.uk/programmes/closing-gap-patient-safety/projects/frailsafe-safety-checklist-frail-older-patients
6. Papoutsi C, Poots A, Clements J, Wyrko Z, Offord N, Reed JE. Improving patient safety for older people in acute admissions: implementation of the Frailsafe checklist in 12 hospitals across the UK. Age Ageing 2018;47:311–17. https://doi.org/10.1093/ageing/afx194
7. Weiss CO. Frailty and chronic disease in older adults. Clin Geriatr Med 2011;27:39–52. https://doi.org/10.1016/j.cger.2010.08.003
8. Galizia G, Cacciatore F, Testa G et al. Role of clinical frailty on long-term mortality of elderly subjects with and without chronic obstructive pulmonary disease. Aging Clin Exp Res 2011;23:118. https://doi.org/10.1007/BF03351076
9. Afilalo J, Karunananthan S, Eisenberg MJ, Alexander KP, Bergman H. Role of frailty in patients with cardiovascular disease. Am J Cardiol 2009;103:1616–21. https://doi.org/10.1016/j.amjcard.2009.01.375
10. National Institute for Health and Care Excellence. Chronic heart failure in adults: diagnosis and management. NG106. London: NICE, 2018. Available from: https://www.nice.org.uk/guidance/ng106
11. National Institute for Cardiovascular Outcomes Research. National heart failure audit April 2014–March 2015. London: University College London, 2016. Available from: https://www.hqip.org.uk/resource/national-heart-failure-audit-2014-2015/
12. McDonagh TA, Blue L, Clark AL et al. European Society of Cardiology Heart Failure Association standards for delivering heart failure care. Eur J Heart Fail 2011;13:235–41. https://doi.org/10.1093/eurjhf/hfq221
13. Denfeld QE, Winters-Stone K, Mudd JO, Gelow JM, Kurdi S, Lee CS. The prevalence of frailty in heart failure: a systematic review and meta-analysis. Int J Cardiol 2017;236:283–9. https://doi.org/10.1016/j.ijcard.2017.01.153
14. Jha SR, Ha HS, Hickman LD et al. Frailty in advanced heart failure: a systematic review. Heart Fail Rev 2015;20:553–60. https://doi.org/10.1007/s10741-015-9493-8
15. Vidan MT, Blaya-Novakova V, Sanchez E, Ortiz J, Serra-Rexach JA, Bueno H. Prevalence and prognostic impact of frailty and its components in non-dependent elderly patients with heart failure. Eur J Heart Fail 2016;8:869–75. https://doi.org/10.1002/ejhf.518
16. Martín-Sánchez FJ, Rodríguez-Adrada E, Vidan MT et al. Impact of frailty and disability on 30-day mortality in older patients with acute heart failure. Am J Cardiol 2017;120:1151–7. https://doi.org/10.1016/j.amjcard.2017.06.059
17. Cacciatore F, Abete P, Mazzella F et al. Frailty predicts long-term mortality in elderly subjects with chronic heart failure. Eur J Clin Invest 2005;35:723–30. https://doi.org/10.1111/j.1365-2362.2005.01572.x
18. Martín-Sánchez FJ, Rodríguez-Adrada E, Mueller C et al. The effect of frailty on 30-day mortality risk in older patients with acute heart failure attended in the emergency department. Acad Emerg Med 2017;24:298–307. https://doi.org/10.1016/j.amjcard.2017.06.059
19. Rodríguez-Pascual C, Paredes-Galán E, Ferrero-Martínez AI et al. The frailty syndrome is associated with adverse health outcomes in very old patients with stable heart failure: a prospective study in six Spanish hospitals. Int J Cardiol 2017;236:296–303. https://doi.org/10.1016/j.ijcard.2017.02.016
20. Madan SA, Fida N, Barman P et al. Frailty assessment in advanced heart failure. J Cardiac Fail 2016;22:840–4. https://doi.org/10.1016/j.cardfail.2016.02.003
21. McNallan SM, Singh M, Chamberlain AM et al. Frailty and healthcare utilization among patients with heart failure in the community. JACC Heart Fail 2013;1:135–41. https://doi.org/10.1016/j.jchf.2013.01.002
22. Butts B, Gary R. Coexisting frailty, cognitive Impairment, and heart failure: implications for clinical care. J Clin Outcomes Manag 2015;22:38–46. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4650868/
23. Buck HG, Riegel B. The impact of frailty on health related quality of life in heart failure. Eur J Cardiovasc Nurs 2011;10:159–66. https://doi.org/10.1016/j.ejcnurse.2010.06.001
24. Denfeld QE, Winters-Stone K, Mudd JO, Hiatt SO, Lee CS. Identifying a relationship between physical frailty and heart failure symptoms. J Cardiovasc Nurs 2018;33:E1–E7. https://doi.org/10.1097/JCN.0000000000000408
25. McDonagh J, Martin L, Ferguson C, Macdonald PS, Davidson PM, Newton P. Frailty assessment instruments in heart failure: a systematic review. Eur J Cardiovasc Nurs 2018;17:23–35. https://doi.org/10.1177/1474515117708888
26. Reeves GR, Whellan DJ, Patel MJ et al. Comparison of frequency of frailty and severely impaired physical function in patients ≥60 years hospitalized with acute decompensated heart failure versus chronic stable heart failure with reduced and preserved left ventricular ejection fraction. Am J Cardiol 2016;117:1953–8. https://doi.org/10.1016/j.amjcard.2016.03.046
27. Nguyen TN, Cumming RG, Hilmer SN. The impact of frailty on mortality, length of stay and re-hospitalisation in older patients with atrial fibrillation. Heart Lung Circ 2016;25:551–7. https://doi.org/10.1016/j.hlc.2015.12.002
28. Juma S, Taabazuing M, Montero-Odasso M. Clinical frailty scale in an acute medicine unit: a simple tool that predicts length of stay. Can Geriatr J 2016;19:34–9. https://doi.org/10.5770/cgj.19.196
29. National Audit Office. Discharging older patients from hospital. London: Department of Health, 2016. Available from: https://www.nao.org.uk/report/discharging-older-patients-from-hospital/
