Emergency department interventions for frailty (EDIFY): improving functional outcomes in older persons at the emergency department through a multicomponent frailty intervention

Abstract

Objectives emergency department interventions for frailty (EDIFY) delivers frailty-centric interventions at the emergency department (ED). We evaluated the effectiveness of a multicomponent frailty intervention (MFI) in improving functional outcomes among older persons. Design a quasi-experimental study. Setting a 30-bed ED observation unit within a 1,700-bed acute tertiary hospital. Participants patients aged ≥65 years, categorised as Clinical Frailty Scale 4–6, and planned for discharge from the unit. Methods we compared patients receiving the MFI versus usual-care. Data on demographics, function, frailty, sarcopenia, comorbidities and medications were gathered. Our primary outcome was functional status—Modified Barthel Index (MBI) and Lawton’s iADL. Secondary outcomes include hospitalisation, ED re-attendance, mortality, frailty, sarcopenia, polypharmacy and falls. Follow-up assessments were at 3, 6 and 12 months. Results we recruited 140 participants (mean age 79.7 ± 7.6 years; 47% frail and 73.6% completed the study). Baseline characteristics between groups were comparable (each n = 70). For the intervention group, MBI scores were significantly higher at 6 months (mean: 94.5 ± 11.2 versus 88.5 ± 19.5, P = 0.04), whereas Lawton’s iADL scores experienced less decline (change-in-score: 0.0 ± 1.7 versus −1.1 ± 1.8, P = 0.001). Model-based analyses revealed greater odds of maintaining/improving MBI in the intervention group at 6 months [odds ratio (OR) 2.51, 95% confidence interval (CI) 1.04–6.03, P = 0.04] and 12 months (OR 2.98, 95% CI 1.18–7.54, P = 0.02). This was similar for Lawton’s iADL at 12 months (OR 4.01, 95% CI 1.70–9.48, P = 0.002). ED re-attendances (rate ratio 0.35, 95% CI 0.13–0.90, P = 0.03) and progression to sarcopenia (OR 0.19, 95% CI 0.04–0.94, P = 0.04) were also lower at 6 months. Conclusions the MFI delivered to older persons at the ED can possibly improve functional outcomes and reduce ED re-attendances while attenuating sarcopenia progression.

Strategies to improve care for older adults who present to the emergency department: a systematic review

“…Intervention participants were more likely to re-present to the ED within 30 days (OR: 1.6; 95% CI: 1.0 to 2.6) [ 63 ]. Three quasi-experimental studies explored interventions to attenuate functional decline [ 66 , 77 , 78 ] with mixed results over different measures. Older people who didn’t receive an intervention comprising review by an Advanced Practice Nurse followed by multidisciplinary geriatric assessment and follow-up care when discharged had a higher rate of progression to a poorer frailty category at 1, 3, and 6 months ( p < 0.05) compared to those that did receive the intervention.…”

“…However, there were no differences in ED re-attendance, hospital admission or mortality between the intervention and non-intervention group [ 66 ]. Older people receiving a multicomponent frailty intervention comprising CGA, frailty education, and a discharge transition package were more likely to maintain/improve independence in performing Activities of Daily Living (ADL) at 12 months and had lower ED re-attendance at 6 months (rate ratio: 0.35; 95% CI: 0.13 to 0.90; p = 0.03) compared to usual care [ 78 ]. A risk stratification followed by rapid geriatric screening intervention had significant preservation in function to perform ADL (Modified Barthel Index Score (MBI): − 0.99 vs − 0.24; p < 0.01; ADL: − 2.57 vs + 0.45; p < 0.01) at 12 months compared to usual care [ 77 ].…”

The Association Between Frailty Evaluated by Clinical Frailty Scale and Mortality of Older Patients in the Emergency Department: A Prospective Cohort Study

“…Another study evaluating the efficacy of a multicomponent frailty intervention was also executed in an ED observation unit, mirroring the setting of our research. 25 In published literature, high acuity was linked to a substantial risk of mortality even among individuals with lower levels of frailty. 24 Hence, the focus of our study was on validating the CFS among these relatively stable older ED patients.…”

“… 20 , 23 The addition of the CFS into ED patient triage and care may assist in risk stratification, disposition decisions, and the improvement of patient-centered outcomes. 25 , 38 However, further well-designed randomized clinical studies are needed to establish the benefits.…”

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“…The intervention group had significantly greater odds of maintaining or improving their Modified Barthel Index Score (a measure of performing activities independently) at 6 (OR 2.51, p=0.04) and 12 (OR 2.98, p=0.02) months. A limitation of the study was a high rate refusing study involvement (26.4%), although length of stay was not reported or compared between the two groups 3…”