Cathy A. Maxwell

Feasibility of screening for preinjury frailty in hospitalized injured older adults

BACKGROUND Frailty assessment of injured older adults (IOAs) is important for clinical management; however, the feasibility of screening for preinjury frailty has not been established in a Level I trauma center. The aims of our study were to assess enrollment rates of IOAs and their surrogates as well as completion rates of selected brief frailty screening instruments. METHODS We conducted a prospective cohort study on patients, age 65 years and older with a primary injury diagnosis. Patients and/or surrogates were interviewed within 48 hours of admission using the Vulnerable Elders Survey (VES-13), Barthel Index (BI), and the Life Space Assessment (LSA). Data analysis included frequency distributions, &khgr;2 statistics, Mann-Whitney and Kruskal-Wallis tests, and general linear modeling (analysis of variance). RESULTS Of 395 admitted patients, 188 were enrolled with subsequent surrogate screening. Corresponding patient interviews were conducted for 77 patients (41%). Screening time was less than 5 minutes for each instrument, and item completion was 100%. Forty-two enrolled patients (22%) had nurse-reported delirium, and 69 (37%) patients either did not feel like answering questions or were unable to be interviewed secondary to their medical condition. The median score of surrogate responses for the VES-13 was 3.5 (interquartile range, 2–7), with 64% of the sample having a score of 3 or greater, indicating vulnerability or frailty. Median scores for the BI (19.0) and LSA (56.0) indicated high numbers with limitations in activities of daily living and limitations in mobilization. CONCLUSION Screening for preinjury frailty in IOAs is feasible yet highly dependent on the presence of a surrogate respondent. A clinically significant percentage of patients have functional deficits consistent with frailty, dependence in activities of daily living, and limitations in mobilization. Implementation of validated brief screening instruments to identify frailty in clinical settings is warranted for targeting timely, efficient, and effective care interventions. LEVEL OF EVIDENCE Epidemiologic study, level II.

Preinjury physical frailty and cognitive impairment among geriatric trauma patients determine postinjury functional recovery and survival.

BACKGROUND Injury is an external stressor that often initiates a cycle of decline in many older adults. The influence of physical frailty and cognitive decline on 6-month and 1-year outcomes after injury is unreported. We hypothesized that physical frailty and cognitive impairment would be predictive of 6-month and 1-year postinjury function and overall mortality. METHODS The sample involved patients who are 65 years or older admitted to a Level I trauma center between October 2013 and March 2014 with a primary injury diagnosis. Surrogates of 188 patients were interviewed within 48 hours of hospital admission to determine preinjury cognitive and physical frailty impairments using brief screening instruments. Follow-up was completed on 172 patients at 6 months and 176 patients at 1 year to determine posthospitalization status and outcomes. Data analysis involved frequencies, measures of central tendency, &khgr;2 analyses, linear and logistic regression. RESULTS The mean age of the patients was 77 years. The median Injury Severity Score (ISS) was 10. The mechanism of injury involved falls from standing (n = 101, 54%). Preinjury vulnerabilities included cognitive impairment (AD8 Dementia Screen [AD8] score ≥ 2, n = 93, 50%) and physical frailty (Vulnerable Elders Survey [VES-13] score ≥ 4, n = 94, 50%). Overall, median physical frailty scores did not return to baseline in the majority of survivors at 1 year. Multivariate regression analysis revealed that preinjury cognitive impairment (6 months, AD8, &bgr; = −0.20, p = 0.002) and preinjury physical frailty (6 months, Barthel Index, &bgr; = 0.60, p < 0.001; 1 year, Barthel Index, &bgr; = 0.52, p < 0.001) are independently associated with physical function (frailty). Multivariate logistic regression analysis revealed that age (odds ratio [OR], 1.09; 95% confidence interval [CI], 1.04–1.14), injury severity (OR, 1.07; 95% CI, 1.02–1.12), and preinjury physical frailty (OR, 1.28; 95% CI, 1.14–1.47) are independently associated with overall mortality at 1 year. CONCLUSION Preinjury physical frailty is the predominant predictor of postinjury functional status and mortality in geriatric trauma patients. Identification of frailty and appropriate follow-up are crucial for decision making by providers, patients, and family caregivers. LEVEL OF EVIDENCE Prognostic study, level II.

Hospitalized injured older adults: clinical utility of a rib fracture scoring system.

Introduction: A rib fracture scoring system (RFS) was proposed for risk assessment in hospitalized injured older adults. Development was limited to one site. Purpose: To validate the RFS for clinical utility in predicting outcomes in another hospital setting. Methods: Retrospective cohort design. Sample: Patients aged 50 years or older with rib fracture(s) (N = 81). Setting: Level II trauma center. Data collection: Trauma registry data (2002–2005). Data Analysis: Bivariate correlations, linear and logistic regression models. Results/Conclusions: While the RFS is associated with outcomes, explanatory value is low. Further research is needed to identify hospitalized injured older adults most likely to utilize health services.

Preinjury Physical Function and Frailty in Injured Older Adults: Self‐ Versus Proxy Responses

To determine the extent to which proxy respondents can provide reliable reports.

Screening hospitalized injured older adults for cognitive impairment and pre-injury functional impairment

Cognitive and functional impairments are leading predictors of poor outcomes among older adults, yet few hospitals collect these variables for injured older adults (IOAs). In this prospective descriptive study, we sought to determine the feasibility of screening IOAs for cognitive and pre-injury functional impairment; and to examine the prevalence of impairment at two acute care hospitals, using the Mini-Cog or Informant Questionnaire on Cognitive Decline in the Elderly (IQCDE), and Vulnerable Elder Survey (VES-13). Eighty patients were screened. Demographics included: mean age 78.7; female gender 83%; falls 89%. Cognitive impairment was present in 36 (44%) patients, and pre-injury functional impairment was present in 62 (78%) patients. Screening respondents included: patients: 53 (66%); adult children: 18 (23%); spouses: 5 (6%), and other 4 (5%). A combination of brief screening instruments for use with IOAs or surrogates is useful for capturing important variables for risk adjustment and care management.

A Position Paper: The Convergence of Aging and Injury and the Need for a Geriatric Trauma Coalition (GeriTraC).

As the U.S. population ages and more adults live into their eighties and nineties, health care providers and hospitals are increasingly challenged to address a broad range of issues from injury prevention to acute care management and postacute transitions of care. Most geriatric trauma represents the confluence of aging-related decline, resulting in injury, and the body’s physiologic response to maintain homeostasis during and after hospitalization. Older patients suffer greater morbidity, mortality, and functional decline than similarly injured younger adults, and even seemingly minor, low-impact injuries are associated with considerable mortality. Challenges in the care and treatment of older trauma patients differ from younger counterparts because of their unique physiology, and medical and psychosocial needs. A recent survey of trauma surgeons and a growing recognition of the complexity of caring for geriatric trauma patients gave rise to the call for a focused effort and agenda to address this public health crisis. The American Association for the Surgery of Trauma (AAST) responded by funding and

Trauma in the Geriatric Population

Injury in older adults is a looming public health crisis. This article provides a broad overview of geriatric trauma across the continuum of care. After a review of the epidemiology of geriatric trauma, optimal approaches to patient care are presented for triage and transport, trauma team activation and initial assessment, inpatient management, and injury prevention. Special emphasis is given to assessment of frailty, advanced care planning, and transitions of care.

Hospitalsʼ Adoption of Targeted Cognitive and Functional Status Quality Indicators for Vulnerable Elders

Cognitive and functional impairments are leading predictors of poor outcomes in hospitalized older adults. This study reports adoption rates of 9 Assessing Care of Vulnerable Elders quality indicators in a sample of US hospitals (N = 128). Chief nursing officers were surveyed using a 6-point scale (no activity to full implementation) for each Assessing Care of Vulnerable Elders quality indicator. Adoption rates were low, highlighting the need for greater efforts to heighten awareness among senior executives and nursing leaders.

Creating a tool to evaluate patient performance.

Patient education is a nursing responsibility that is often impromptu, spontaneous, and poorly documented. In many cases the patients ability to perform a skill or task in the management of an illness or disease process affects the patients outcome. A tool designed to evaluate patient performance guides the teaching process, promotes communication between the patient and nurse, and promotes communication among health care providers as it relates to patient performance. Nurses are in key positions to develop patient performance tools to ensure that the patient, or a patients family member, can manage the health care requisites.

Understanding Frailty: A Nurse’s Guide

Frailty is a public health crisis for an aging society. As a concept and condition, frailty is poorly understood and underrecognized in clinical settings. Nurses play an important role as frontline providers who care for aging adults. The aim of this article is to raise awareness among nurses about frailty and to discuss the recognition and management of this prevailing condition. The authors present conceptual definitions and models of frailty, a brief discussion of the underlying biological mechanisms and evidence-based interventions for frailty identification, and approaches to delay and decrease the burden of frailty.