Screening for Frailty

Lead investigator: Professor Justin Beilby

Population ageing is proceeding at an unprecedented pace within Australia and worldwide.  Among the many manifestations of population ageing, frailty is arguably one of the most significant challenges facing health care providers and policy makers. The consequences of frailty have an enormous impact on the lived experience of older people.  As frailty progresses, there is evidence to show it has been linked with increased risks to older people’s independence and wellbeing, including poorer quality of life, increased health service usage, emergency department admission, institutionalisation and premature death.  Despite this fact, frailty remains somewhat of a hidden issue, with many frail older people not receiving the preventative care and attention they need until their condition is well advanced.

Accordingly, a new wave of research has emerged that focuses on frailty prevention and management within primary health care and general practice settings.  It is widely acknowledged that general practitioners and their teams will be key in identifying and managing frailty. However, research into frailty within general practice populations remains at a relatively early stage, and there has been only minimal research conducted within Australia. As a consequence, our understanding of the mechanisms by which general practitioners can best address frailty progression, including how best to engage patients on the issue of frailty, remains extremely limited.

Screening Pathway Project 1 will compare the performance of several internationally validated frailty screening tools across two South Australian general practice sites in the aim of selecting the best performing and most feasible tool for potential introduction within the Australian general practice setting.

Publications

Ambagtsheer R.C., Archibald M.M., Lawless M, Mills P.D., Yu S., Beilby J. (in press). General practitioners’ perceptions, attitudes and experiences of frailty and frailty screening. Australian Journal of General Practice.  2019.

Ambagtsheer RC, Beilby JJ, Visvanathan R, Dent E, Yu S, Braunack-Mayer AJ. Should we screen for frailty in primary care settings? A fresh perspective on the frailty evidence base: A narrative review. Prev Med. 2019 Feb;119:63-69. doi: 10.1016/j.ypmed.2018.12.020. Epub 2018 Dec 27. Review.

Ambagtsheer, R.C, Thompson, M.Q., Archibald, M.M, Casey, M.G and Schultz, T.J. Diagnostic test accuracy of self-reported frailty screening instruments in identifying community-dwelling older people at risk of frailty and pre-frailty: a systematic review protocol. JBI Database of Systematic Reviews and Implementation Reports,2017 15(10), 2464-2468.doi: 10.11124/JBISRIR-2017-003363.

Ambagtsheer RC, Beilby J, Dabravolskaj J, Abbasi M, Archibald MM, Dent E. Application of an electronic Frailty Index in Australian primary care: data quality and feasibility assessment. Aging Clin Exp Res. 2018 Aug 21. doi: 10.1007/s40520-018-1023-9.

Ambagtsheer R.C., Beilby J, Dent E. 2018. [Letter to the Editor]. Frailty: Turning the Titanic. BMJ. 10 September 2018.

Ambagtsheer R, Visvanathan R, Cesari M, Yu S, Archibald M, Schultz T, Karnon J, Kitson A, Beilby J. Feasibility, acceptability and diagnostic test accuracy of frailty screening instruments in community-dwelling older people within the Australian general practice setting: a study protocol for a cross-sectional study. BMJ Open. 2017 Aug 3;7(8):e016663. doi: 10.1136/bmjopen-2017-016663.

Archibald MM, Ambagtsheer R, Beilby J, Chehade MJ, Gill TK, Visvanathan R, Kitson AL. Perspectives of Frailty and Frailty Screening: Protocol for a Collaborative Knowledge Translation Approach and Qualitative Study of Stakeholder Understandings and Experiences.  BMC Geriatr. 2017 Apr 17;17(1):87. doi: 10.1186/s12877-017-0483-7.

Media contact: Ms Rachel Ambagtsheer

Lead investigator: Professor Justin Beilby

Screening Pathway Project 2 will build on the results of Screening Pathway Project 1 in order to test the performance and feasibility of a well-performing frailty screening tool more broadly within a sample of 10 general practices across South Australia, spanning urban to rural and highly accessible to remote environments.

In terms of assessing the tool’s performance with respect to predictive validity, a prospective random sample of 250 patients will be recruited across the practice sites and screened by a blinded researcher who will conduct a frailty assessment (assessing the performance of the instrument against the reference standards of the Frailty Phenotype and Frailty Index). Subjects will be followed up 12 months later to determine the ability of the tool to predict changes in physical function.

A parallel project will employ a mixed-methods design to explore the feasibility of the tool with respect to its acceptability and feasibility for use within broader general practice. A number of screeners (general practitioners, practice nurses and non-specialists) will be recruited across the sites and will be surveyed pre- and post- implementation regarding their experiences of and attitudes towards using the tool.

One of the key objectives of Screening Pathway Project 2 is to explore in what ways the preferred instrument could complement or be integrated with existing funded Medicare items such as the 75+ health assessments.  An intended outcome of the project is to determine what model for a potential frailty screening care pathway for general practice is suggested by the project’s findings.

Media contact: Ms Rachel Ambagtsheer

Lead investigators: Professor Renuka Visvanathan, Dr Olga Theou, A/Prof Simon Bell, Professor John Morley and Professor Ken Rockwood

There has been very little high-quality research focused on frailty in nursing homes despite at least 85.2% of residents in one South Australian residential aged care organisation (6 facilities) being classified as frail and 14.8% as at-risk. Members of our research team (TQEH geriatrics advanced trainee Dr Thanuja Jayaweera) supported by Dr Umapathysivam from JBI are currently progressing a scoping review on frailty research in nursing homes.

Until 2015, no frailty screening tool for use in residential aged care existed. Following a discussion between Professors Morley and Visvanathan in Adelaide at the Adelaide GTRAC Centre in late 2014, a frailty screening tool (FRAIL-NH) for use in nursing homes was developed and published in an international journal.

Since that time point (early 2015), we have confirmed in Australia that a higher score on the FRAIL-NH which indicates a greater risk of frailty was associated with higher care needs, poorer quality of life and increased neuropsychiatric symptoms. Our team is currently investigating the ability of the FRAIL-NH to predict health outcomes such as mortality, falls and hospitalization.

Professor Morley’s group in the United States of America have also confirmed that the FRAIL-NH was able to predict long-term outcomes such as 6 month mortality and falls.

For some, frailty is treatable and quality of life can be improved. Therefore, screening for frailty even in residential aged care will support the identification of cost-effective strategies that may improve health and well-being of residents in residential aged care facilities (i.e. nursing homes).

Media contact: Professor Renuka Visvanathan or Dr Olga Theou

Lead investigators: Dr Agathe Daria Jadczak, Professor Renuka Visvanathan, Professor Jon Karnon, Professor Julie Ratcliffe, Professor Simon Bell, A/Prof Solomon Yu, A/Prof Maria Inacio, Prof David Wilson, Dr Olga Theou, Dr Graeme Tucker, Dr Hossein Hajiali Afzali, Dr Rachel Milte, Dr Janet Sluggett, Resthaven Inc

There is currently a paucity of research focused on frailty in residential aged care services (RACS), despite the fact that these institutions are home to frail older people. The FIRST Study will help to validate a new frailty screening tool, the FRAIL AC, which was developed specifically for its use in residential aged care.

The research will also look into residents’ health over time and collect important health data to better determine the prevalence and progression of frailty, associated health outcomes and health care costs. The FIRST Study is a prospective cohort study in cooperation with Resthaven Inc. Health data on medical status and diagnoses, cognitive functioning, nutrition, falls, sleep quality, quality of life, activities of daily living, hospitalisation and mortality will be collected from permanent residents living in Resthaven facilities.

Media contact: Dr Agathe Daria Jadczak

Lead investigators: Renuka Visvanathan, Agathe Daria Jadczak

We proposed and validated the FRAIL-NH for use in residential aged care. We demonstrated the scale was predictive of mortality. Since then there has been 31 research papers focused on the FRAIL-NH and the scale has been translated into Brazilian Portuguese, Chinese and Japanese. The scale is also being utilized in the New Zealand Health Quality and Safety Commission Frailty Care Guide.

Publications:

• Theou O…Visvanathan R. Frailty, hospitalization, and mortality in residential aged care. J Gerontol A Biol Sci Med Sci 2018; 73(8): 1090-1096.
• De Silva TR, Theou O…Visvanathan R. Frailty screening (FRAIL-NH) and mortality in French nursing homes: results from the incidence of pneumonia and related consequences in nursing home residents study. JAMDA 2018, 19(5): 411-414.
• Theou O…Visvanathan R. Frailty levels in residential aged care facilities measured using the frailty index and FRAIL-NH scale. JAGS 2016; 64(11):e207-e212.
• Kaehr R, Visvanathan R, Malmstrom TK, Morley JE. Frailty in nursing homes: the FRAIL-NH scale. JAMDA 2015; 16(2): 87-89. 

More recently, we have developed a FRAIL-NH for our longitudinal study and proposed cut-offs.

Publication:

• Jadczak AD…Visvanathan R. The frailty in residential sector over time (FIRST) study: methods and baseline cohort description. BMC Geriatr 2021; 21(1): 99.

Media contact: Renuka Visvanathan

Lead investigators: Dr Sally Ahip, Dr Olga Theou, Professor Visvanathan, Professor Sazlina Sharif Ghazali

Funded by the Malaysian Ministry of Health of Malaysia, this research has been conducted in Sarawak and Selangor, two states in Malaysia.

The Pictorial Fit Frail Scale developed by Dr Theou and colleagues was translated into Malay Language through research lead by Dr Sally Ahip.

Publications:

• Ahip SS, Shariff-Ghazali S, Lukas S, Samad AA, Mustapha UK, Theou O, Visvanathan R. Translation, adaptation and pilot testing of the Pictorial Fit-Frail Scale (PFFS) for use in Malaysia- The PFFS-Malay Version (PFFS-M). Malaysian Family Physician 2021; 16(2). doi:10.51866/oa1036
• Theou O, Andrew M, Ahip SS, Squires E, McGarrigle L, Blodgett JM, Goldstein J, Hominick K, Godin J, Hougan G, Armstrong JJ, Wallace L, Sazlina SG, Moorhouse P, Fay S, Visvanathan R, Rockwood K. The pictorial fit frail scale: developing a visual scale to assess frailty. Can Geriatr J 2019; 22(2): 64-74. doi: 10.5770/cgj.22.357

Media Contact: Prof Renuka Visvanathan