Abstract
Background
Frailty is linked to poor outcomes in older patients. We prospectively compared the
utility of the picture-based Clinical Frailty Scale (CFS9), clinical assessments,
and ultrasound muscle measurements against the reference FRAIL scale in older adult
trauma patients in the emergency department (ED).
Methods
We recruited a convenience sample of adults 65 yrs. or older with blunt trauma and
injury severity scores <9. We queried subjects (or surrogates) on the FRAIL scale,
and compared this to: physician-based and subject/surrogate-based CFS9; mid-upper
arm circumference (MUAC) and grip strength; and ultrasound (US) measures of muscle
thickness (limbs and abdominal wall). We derived optimal diagnostic thresholds and
calculated performance metrics for each comparison using sensitivity, specificity,
predictive values, and area under receiver operating characteristic curves (AUROC).
Results
Fifteen of 65 patients were frail by FRAIL scale (23%). CFS9 performed well when assessed
by subject/surrogate (AUROC 0.91 [95% CI 0.84–0.98] or physician (AUROC 0.77 [95%
CI 0.63–0.91]. Optimal thresholds for both physician and subject/surrogate were CFS9
of 4 or greater. If both physician and subject/surrogate provided scores <4, sensitivity
and negative predictive value were 90.0% (54.1–99.5%) and 95.0% (73.1–99.7%). Grip
strength and MUAC were not predictors. US measures that combined biceps and quadriceps
thickness showed an AUROC of 0.75 compared to the reference standard.
Conclusion
The ED needs rapid, validated tools to screen for frailty. The CFS9 has excellent
negative predictive value in ruling out frailty. Ultrasound of combined biceps and
quadriceps has modest concordance as an alternative in trauma patients who cannot
provide a history.
Abbreviations:
CFS9 (Clinical Frailty Scale), ED (emergency department), MUAC (mid-upper arm circumference), US (ultrasound), AUROC (area under receiver operating characteristic), AIS (abbreviated injury scale)Keywords
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References
- ([cited 2018 January 16]; Available from:)
- Frailty in older adults: evidence for a phenotype.J Gerontol A Biol Sci Med Sci. 2001; 56: M146-56
- Clinical Frailty Scale in an acute medicine unit: a simple tool that predicts length of stay.Can Geriatr J: CGJ. 2016; 19: 34-39
- Prediction of one-year mortality by five different frailty instruments: a comparative study in hospitalized geriatric patients.Arch Gerontol Geriatr. 2016; 66: 66-72
- Sarcopenia and frailty in elderly trauma patients.World J Surg. 2015; 39: 373-379
- Severe osteopenia and osteoporosis, sarcopenia, and frailty status in community-dwelling older women: results from the Women's Health and Aging Study (WHAS) II.Bone. 2011; 48: 952-957
- Association of Radiologic Indicators of Frailty With 1-Year Mortality in Older Trauma Patients: opportunistic screening for sarcopenia and osteopenia.JAMA Surg. 2017; 152e164604
- Sarcopenia as a predictor of mortality in elderly blunt trauma patients: comparing the masseter to the psoas using computed tomography.J Trauma Acute Care Surg. 2017; 82: 65-72
- Comparison of ultrasound-measured age-related, site-specific muscle loss between healthy Japanese and German men.Clin Physiol Funct Imaging. 2011; 31: 320-325
- Addition of frailty and disability to cardiac surgery risk scores identifies elderly patients at high risk of mortality or major morbidity.Circ Cardiovasc Qual Outcomes. 2012; 5: 222-228
- Are the frail destined to fail? Frailty index as predictor of surgical morbidity and mortality in the elderly.J Trauma Acute Care Surg. 2012; 72 ([discussion 30-1]): 1526-1530
- Frailty as a predictor of surgical outcomes in older patients.J Am Coll Surg. 2010; 210: 901-908
- Measuring frailty can help emergency departments identify independent seniors at risk of functional decline after minor injuries.J Gerontol A Biol Sci Med Sci. 2017; 72: 68-74
- Geriatric emergency department guidelines.Ann Emerg Med. 2014; 63: e7-25
- Frailty consensus: a call to action.J Am Med Dir Assoc. 2013; 14: 392-397
- The abbreviated injury scale 2005-Update 2008.American Association for Automotive Medicine (AAAM), Des Plaines, IL2008
- Frailty: toward a clinical definition.J Am Med Dir Assoc. 2008; 9: 71-72
- A global clinical measure of fitness and frailty in elderly people.CMAJ: Can Med Assoc J = journal de l'Association medicale canadienne. 2005; 173: 489-495
- Anthropometric standardization reference manual.in: Human kinetics books. 1992
- Mid-Arm circumference and all-cause, cardiovascular, and cancer mortality among obese and non-obese US adults: the National Health and Nutrition Examination Survey III.Sci Rep. 2017; 7: 2302
- Research electronic data capture (REDCap)—a metadata-driven methodology and workflow process for providing translational research informatics support.J Biomed Inform. 2009; 42: 377-381
- Fatty infiltration of skeletal muscle: mechanisms and comparisons with bone marrow adiposity.Front Endocrinol (Lausanne). 2016; 7: 69
- Frailty and cognitive impairment: unique challenges in the older emergency surgical patient.Ann R Coll Surg Engl. 2016; 98: 165-169
- Geriatricians and the older emergency general surgical patient: proactive assessment and patient centred interventions. Salford-POP-GS.Aging Clin Exp Res. 2018; 30: 277-282
- Detection of older people at increased risk of adverse health outcomes after an emergency visit: the ISAR screening tool.J Am Geriatr Soc. 1999; 47: 1229-1237
- Impact of the clinical frailty scale on outcomes after transcatheter aortic valve replacement.Circulation. 2017; 135: 2013-2024
- Validating trauma-specific frailty index for geriatric trauma patients: a prospective analysis.J Am Coll Surg. 2014; 219 ([e1]): 10-17
- A brief risk-stratification tool to predict repeat emergency department visits and hospitalizations in older patients discharged from the emergency department.Acad Emerg Med. 2003; 10: 224-232
- Pre-burn malnutrition increases operative mortality in burn patients who undergo early excision and grafting in a sub-Saharan African burn unit.Burns. 2018; 44: 692-699
- Age-related site-specific muscle wasting of upper and lower extremities and trunk in Japanese men and women.Age (Dordr). 2014; 36: 813-821
Article Info
Publication History
Published online: April 14, 2018
Accepted:
April 14,
2018
Received in revised form:
April 9,
2018
Received:
February 3,
2018
Identification
Copyright
© 2018 Elsevier Inc. All rights reserved.
