Perspectives of frailty and frailty screening: Protocol for a collaborative knowledge translation approach and qualitative study of stakeholder understandings and experiences

Accompanying the unprecedented growth in the older adult population worldwide is an increase in the prevalence of frailty, an age-related clinical state of increased vulnerability to stressor events. This increased vulnerability results in lower social engagement and quality of life, increased dependency, and higher rates of morbidity, health service utilization and mortality. Early identification of frailty is necessary to guide implementation of interventions to prevent associated functional decline. Consensus is lacking on how to clinically recognize and manage frailty. It is unknown how healthcare providers and healthcare consumers understand and perceive frailty, whether or not they regard frailty as a public health concern; and information on the indirect and direct experiences of consumer and healthcare provider groups towards frailty are markedly limited.We will conduct a qualitative study of consumer, practice nurse, general practitioner, emergency department physician, and orthopedic surgeons' perspectives of frailty and frailty screening in metropolitan and non-metropolitan South Australia. We will use tailored combinations of semi-structured interviews and arts-based data collection methods depending on each stakeholder group, followed by inductive and iterative analysis of data using qualitative description.Using stakeholder driven approaches to understanding and addressing frailty and frailty screening in context is critical as the prevalence and burden of frailty is likely to increase worldwide. We will use the findings from the Perceptions of Frailty and Frailty Screening study to inform a context-driven identification, implementation and evaluation of a frailty-screening tool; drive awareness, knowledge, and skills development strategies across stakeholder groups; and guide future efforts to embed emerging knowledge about frailty and its management across diverse South Australian contexts using a collaborative knowledge translation approach. Study findings will help achieve a coordinated frailty and healthy ageing strategy with relevance to other jurisdictions in Australia and abroad, and application of the stakeholder driven approach will help illuminate how its applicability to other jurisdictions.Mandy M. Archibald, Rachel Ambagtsheer, Justin Beilby, Mellick J. Chehade, Tiffany K. Gill, Renuka Visvanathan, and Alison L. Kitso

Recent developments in frailty identification, management, risk factors and prevention : A narrative review of leading journals in geriatrics and gerontology

Funding The Frailty Epidemiology Research Network (EPI-FRAIL) is an international collaborative project aimed at filling knowledge gaps in the field of frailty epidemiology. The network was established as part of a NWO/ZonMw Veni fellowship awarded to E.O. Hoogendijk (Grant no. 91618067). P. Hanlon is funded through a Clinical Research Training Fellowship from the Medical Research Council (Grant reference: MR/S021949/1). Z. Liu was supported by the Soft Science Research Program of Zhejiang Province (2023KXCX-KT011). J. Jylhävä has received grant support from the Swedish Research Council (grant no. 2018-02077), the Academy of Finland (grant no. 349335), the Sigrid Jusélius Foundation, the Yrjö Jahnsson Foundation and the Instrumentarium Science Foundation. M. Sim is supported by a Royal Perth Hospital Research Foundation Career Advancement Fellowship and an Emerging Leader Fellowship from the Future Health Research and Innovation Fund (Department of Health, Western Australia). R. Ambagtsheer receives funding from the Australian Medical Research Future Fund (grant #MRF2016140). D. L. Vetrano receives financial support from the Swedish Research Council (2021-03324). S. Shi reports funding from the National Institute of Aging, R03AG078894-01. None of the funding agencies had any role in the conduct of the study; collection, management, analysis, or interpretation of the data; or preparation, review, or approval of the manuscript.Peer reviewedPublisher PD

Degree of tumour vascularity correlates with drug accumulation and tumour response upon TNF-α-based isolated hepatic perfusion

Isolated hepatic perfusion (IHP) with melphalan with or without tumour necrosis factor alpha (TNF-α) is currently performed in clinical trials in patients with hepatic metastases. Previous studies led to the hypothesis that the use of TNF-α in isolated limb perfusion causes specific destruction of tumour endothelial cells and thereby induces an increased permeability of tumour vasculature. However, whether TNF-α contributes to the therapeutic efficacy in IHP still remains unclear. In an in vivo rat liver metastas

Prerequisites for effective adenovirus mediated gene therapy of colorectal liver metastases in the rat using an intracellular neutralizing antibody fragment to p21-Ras

Ras mutations are present in 40–50% of colorectal cancers. Inactivating this oncogene may therefore reduce proliferation capacity. In order to target ras we studied the transduction efficacy and anti tumour activity of an adenoviral vector expressing an intracellular, neutralizing single chain antibody to p21-ras (Y28). In in vitro studies transfection levels of the K-ras mutated rat colon carcinoma cell line CC531 were studied using the LacZ marker gene. In our in vivo liver metastases model different routes of administration were evaluated to determine which regimen resulted in the best transfection levels and tumour responses: intravenous injection, intratumoural injection, isolated liver perfusion, or hepatic artery infusion. CC531 cells are readily transfected in vitro, resulting in significant inhibition of tumour cell proliferation by the Y28 construct. Intravenous injection did not result in any measurable transfection. Intratumoural injection resulted only in the transfection of tumour cells along the needle track. IHP as well as single HAI achieved low transfection levels of tumour tissue. Expression of Y28 was demonstrated in tumours after IT injection, HAI and IHP. Whereas, repeated HAI's clearly achieved expression in and around tumour associated vessels. Only five times repeated HAI's with Y28 resulted in a tumour response: in all animals tumour growth was inhibited, and in three rats out of eight a complete regression of the liver tumours was observed

Factors influencing communication about frailty in primary care: a scoping review

Objective: To summarise the available evidence on the factors influencing communication about frailty in the primary care setting. Methods: We conducted a scoping review, searching five electronic databases (PubMed, Scopus, CINAHL, PsycINFO, and ProQuest) for studies addressing communication about frailty in primary care practice. Reference list and grey literature searching was conducted to identify additional articles. A narrative descriptive method was used to synthesise the findings. Results: The search identified 3185 articles and 37 were included in the review. We identified five categories of factors influencing communication about frailty at the consumer, healthcare provider, and system levels: (1) consumer perceptions, information needs, and communication preferences; (2) healthcare providers’ knowledge, capacities, and attitudes; (3) clinical communication skills and training; (4) availability of information and communication technologies; and (5) care coordination, collaboration, and case management. Conclusion: Findings offer considerations for the design and delivery of initiatives to improve communication about frailty in primary care both at the local clinical level and at the broader level of healthcare service delivery. Practice implications: Healthcare providers and systems require practical, evidence-informed guidance regarding the development of a systematic approach to the quality and timing of communication about frailty in healthcare encounters.Michael T. Lawless, Mandy M. Archibald, Rachel C. Ambagtsheer, Alison L. Kitso

The application of artificial intelligence (AI) techniques to identify frailty within a residential aged care administrative data set

Introduction: Research has shown that frailty, a geriatric syndrome associated with an increased risk of negative outcomes for older people, is highly prevalent among residents of residential aged care facilities (also called long term care facilities or nursing homes). However, progress on effective identification of frailty within residential care remains at an early stage, necessitating the development of new methods for accurate and efficient screening. Objectives: We aimed to determine the effectiveness of artificial intelligence (AI) algorithms in accurately identifying frailty among residents aged 75 years and over in comparison with a calculated electronic Frailty Index (eFI) based on a routinely-collected residential aged care administrative data set drawn from 10 residential care facilities located in Queensland, Australia. A secondary objective included the identification of best-performing candidate algorithms. Methods: We designed a frailty prediction system based on the eFI identification of frailty, allocating 84.5% and 15.5% of the data to training and test data sets respectively. We compared the performance of 18 specific scenarios to predict frailty against eFI based on unique combinations of three ML algorithms (support vector machines [SVM], decision trees [DT] and K-nearest neighbours [KNN]) and six cases (6, 10, 11, 14, 39 and 70 input variables). We calculated accuracy, percentage positive and negative agreement, sensitivity, specificity, Cohen’s kappa and Prevalence- and Bias- Adjusted Kappa (PABAK), table frequencies and positive and negative predictive values. Results: Of 592 eligible resident records, 500 were allocated to the training set and 92 to the test set. Three scenarios (10, 11 and 70 input variables), all based on SVM algorithm, returned overall accuracy above 75 %. Conclusions: There is some potential for AI techniques to contribute towards better frailty identification within residential care. However, potential benefits will need to be weighed against administrative burden, data quality concerns and presence of potential bias.R.C. Ambagtsheer, N. Shafiabady, E. Dent, C. Seiboth, J. Beilb

Should we screen for frailty in primary care settings? A fresh perspective on the frailty evidence base: A narrative review

With older adults living longer, health service providers have increasingly turned their attention towards frailty and its significant consequences for health and well-being. Consequently, frailty screening has gained momentum as a possible health policy answer to the question of what can be done to prevent frailty's onset and progression. However, who should be screened for frailty, where and when remains a subject of extensive debate. The purpose of this narrative review is to explore the dimensions of this question with reference to Wilson and Jungner's time-tested and widely accepted principles for acceptable screening within community settings. Although the balance of the emerging evidence to support frailty screening is promising, significant gaps in the evidence base remain. Consequently, when assessed against Wilson and Jungner's principles, extensive population screening does not appear to be supported by the evidence. However, screening for the purpose of case-finding may prove useful among older adults.Rachel C. Ambagtsheer, Justin J. Beilby, Renuka Visvanathan, Elsa Dent, Solomon Yu, Annette J. Braunack-Ma

Does CGA Improve Health Outcomes in the Community? An Umbrella Review

Published June 2023Abstract not availableRachel C. Ambagtsheer, Mark Q. Thompson, Graeme R. Tucker, Timothy Schultz, Justin Beilby, Renuka Visvanatha

Commonly used screening instruments to identify frailty among community-dwelling older people in a general practice (primary care) setting: a study of diagnostic test accuracy

BACKGROUND:Rapid frailty screening remains problematic in primary care. The diagnostic test accuracy (DTA) of several screening instruments has not been sufficiently established. We evaluated the DTA of several screening instruments against two reference standards: Fried's Frailty Phenotype [FP] and the Adelaide Frailty Index [AFI]), a self-reported questionnaire. METHODS:DTA study within three general practices in South Australia. We randomly recruited 243 general practice patients aged 75+ years. Eligible participants were 75+ years, proficient in English and community-dwelling. We excluded those who were receiving palliative care, hospitalised or living in a residential care facility.We calculated sensitivity, specificity, predictive values, likelihood ratios, Youden Index and AUC for: Edmonton Frail Scale [EFS], FRAIL Scale Questionnaire [FQ], Gait Speed Test [GST], Groningen Frailty Indicator [GFI], Kihon Checklist [KC], Polypharmacy [POLY], PRISMA-7 [P7], Reported Edmonton Frail Scale [REFS], Self-Rated Health [SRH] and Timed Up and Go [TUG]) against FP [3+ criteria] and AFI [> 0.21]. RESULTS:We obtained valid data for 228 participants, with missing scores for index tests multiply imputed. Frailty prevalence was 17.5% frail, 56.6% pre-frail [FP], and 48.7% frail, 29.0% pre-frail [AFI]. Of the index tests KC (Se: 85.0% [70.2 - 94.3]; Sp: 73.4% [66.5 - 79.6]) and REFS (Se: 87.5% [73.2 - 95.8]; Sp: 75.5% [68.8 - 81.5]), both against FP, showed sufficient diagnostic accuracy according to our pre-specified criteria. CONCLUSIONS:Two screening instruments - the KC and REFS, show the most promise for wider implementation within general practice, enabling a personalised approach to care for older people with frailty.Rachel C. Ambagtsheer, Renuka Visvanathan, Elsa Dent, Solomon Yu, Timothy J. Schultz and Justin Beilb