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The use of frailty questionnaires in inpatients in two neurorehabilitation units in the East Midlands – A cross-sectional cohort study with follow-up to 1-year after discharge from inpatient rehabilitation
Abstract
Background:
Frailty correlates with poor clinical outcomes and is not routinely assessed in neurorehabilitation inpatient settings.
Methods:
We
recruited adults from two neurorehabilitation units. We administered
six validated tools for assessing frailty and collected data around
length of stay, discharge, readmission and change in rehabilitation
outcome measures.
Results:
Seventy-eight
participants aged between 31 and 84 years were recruited with a range
of neurological diagnoses. Frailty prevalence ranged between 23% and
46%, depending on the scale used, with little agreement between tools.
Frailty status did not correlate with age, gender, length of stay,
discharge destination and rehabilitation outcome measures. One-year
readmission was higher in participants rated as frail by the
Frail-Non-Disabled Questionnaire, the FRESH-screening questionnaire and
the Clinical Frailty Scale.
Discussion:
Frailty
ascertainment was variable depending on the tool used. Three frailty
indices predicted readmission rate at 1 year but no other outcome
measures. Therefore, frailty tools may have limited utility in this
clinical population.
Introduction
Frailty
describes loss of physiological reserve and vulnerability to adverse
events. It was initially described in older people because it increases
in prevalence with age and has explanatory value in understanding how
older people respond differentially to acute illness.1 Frailty is associated with adverse outcomes regardless of age.2
The term ‘frailty’ should not be used in populations with life-long
impairments but may help understand other patient groups with acquired
disabilities who deteriorate physiologically in response to acute
insults.
Prognostication in neurorehabilitation is difficult because of multiple complex interacting exposures that determine outcomes.3
Identifying (and addressing) frailty may improve outcomes or help to
inform discussions around prognosis and treatment planning.
Two
main paradigms describe and measure frailty. The first describes a
cascade of homeostatic decompensation and is measured by the presence or
absence of physiological parameters (phenotypic frailty).4
The second counts deficits across a number of domains and expresses
severity of frailty as a ratio of deficits present to potential deficits
(accumulation of deficits).5 Both models select different individuals as being frail but predict adverse outcomes equally well and consensus papers6
have suggested that frailty indices should be selected based upon
feasibility and utility in a given clinical context. Most frailty
indices have been designed and are primarily used in older populations,
and caution should be used when applying them to younger populations.7
Against
this background, we set out to evaluate frailty indices in inpatients
undergoing neurorehabilitation with the following objectives:
•
To compare the prevalence of frailty as measured by different frailty measures
•
To assess differences in frailty between different diagnoses and ages
•
To assess whether frailty status impacted rehabilitation outcomes
•
To assess feasibility of assessing frailty using questionnaires during inpatient neurorehabilitation
•
To assess ease of use of commonly used questionnaires either with patient or next of kin
Methods
This
was a two-site study in the East Midlands of England. The sites
comprised a 19-bedded level 2b unit and a 25-bedded level 2a unit based
within large NHS acute provider trusts.
The
study was sponsored by the University of Nottingham and received ethical
approval from Yorkshire and The Humber – Leeds East Research Ethics
Committee (ref: 18/YH/0361).
Participants
were recruited between February 2019 and December 2020, with a hiatus
between March and July 2020 (Derby) and March and September 2020
(Nottingham) due to the COVID-19 pandemic.
Patients
were eligible for inclusion if they were inpatients in participating
units for purposes of neurorehabilitation and aged 18 years or older.
They were excluded if they or a consultee were unable or unwilling to
give consent.
Potential participants who had
capacity to consent to participate in the study gave written informed
consent. Participants who lacked capacity and could not give consent
were recruited following a discussion with a relevant consultee, such as
a family member or friend, in keeping with the provisions of the Mental
Capacity Act 2005.8
Baseline
constituted the date of admission to the rehabilitation unit. Data
collection at baseline comprised participant demographic and clinical
details, including diagnosis, comorbidities, age, gender, date of
admission to rehabilitation unit and frailty status.
We selected frailty assessment tools which:
•
Asked about the period of time before the hospital admission as being representative of a patient’s baseline function
•
Did not require invasive testing for example, blood tests/muscle biopsies
•
Did not rely on tests which could have been altered by recent inpatient stay or intercurrent illness (e.g. serum albumin)
•
Could be answered by next of kin/consultee if the participant was cognitively impaired and unable
•
Could be carried out quickly and simply on an inpatient unit, with minimal disruption to daily care
•
Had been used and validated in clinical settings
•
Required no special training to perform
On this basis we recorded:
•
The
Clinical Frailty Scale (CFS) – uses a nine-item scale to categorise
individuals on the spectrum of ‘very fit’ to ‘terminally ill’9
•
Fatigue/Resistance/Ambulation/Illness/Loss
of weight scale (FRAIL) – a five-item questionnaire (covers
fatigue/resistance/ambulation/illnesses/loss of weight); individuals are
divided into ‘frail’, ‘pre-frail’ or ‘robust’ depending on their score10
•
Frail
non-disabled questionnaire (FIND) – a brief, five item questionnaire
which asks about walking, climbing stairs, weight loss, fatigue and
physical activity; it categorises respondents into
‘robust/disabled/frail/frail and disabled’11
•
FRESH-screening
instrument – a four-question tool (around
mobility/fatigue/falls/assistance); individuals are characterised as
‘normal’ or ‘frail’12
•
Groningen
Frailty Index (GFI) – a 15-question questionnaire that covers the
domains of mobility, vision, hearing, nutrition, comorbidity, cognition,
psychosocial and physical fitness, with the total score dividing
respondents into ‘frail’ or ‘non-frail’13
•
Modified
Reported Edmonton Frail Scale (m-REFS) – removes the question which
asks the patient to draw a clock and instead replaces it with a question
around a history of cognitive impairment, shown to be equivalent to the
Reported Edmonton Frail Scale in a prospective cohort study.14 The original Edmonton frail scale is valid and reliable15;
this had been modified slightly to allow it to be answered by next of
kin and trialled successfully. Respondents are classified as ‘not
frail’/‘apparently vulnerable’/ ‘mildly frail’/‘moderately
frail’/‘severely frail’.14
For the sake of simplicity, the scores were divided into ‘frail’ and ‘non-frail’/‘robust’ as shown in Table 1:
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