Background

Frailty is generally considered to represent a state of decreased reserve and resistance to stressors, causing increased vulnerability to adverse health outcomes. Currently there is no internationally agreed definition of frailty in medical literature.1 The current thinking is that frailty develops from the interaction of cellular, genetic, physiological and environmental factors, which lead to multi systemic physiological decline.2 Frailty leads to increased adverse health outcomes, including falls, cognitive impairment, hospital admissions, disability and death.1-6 As frailty has a tremendous impact on older people, their families, carers and society, it is important to explore the impact of frailty in terms of prevalence, outcome, treatment options and its association with geriatric syndromes.

It is estimated that by 2020 at least 850,000 older Australians who live in the community will become frail, and, further, at least four million Australians aged 70 years and over will be either frail or at risk of frailty.7 It is known that socioeconomically, disadvantaged people are more commonly affected by frailty. For example, prevalence of frailty in those aged 50 years and over in wealthier northern European countries is 16% compared with 28% in less wealthy southern European countries.8

This scoping review will be confined to nursing home residents only as the clinical manifestations are different and the prevalence of frailty is higher in older adults living in nursing homes than in community based older adults.9,10

Geriatric syndromes are groups of clinical conditions in older persons that do not fit into discrete disease categories.11 The most common conditions encountered by geriatricians include delirium, cognitive impairment, depression, falls, sleep problems, dizziness, malnutrition, incontinence, visual and hearing impairment. These conditions are highly prevalent in frail elderly persons.

The current treatment modalities involve physical and cognitive training and nutritional supplementation which have been found to be effective in reversing frailty when managed individually or in combination.12 Further, a larger community-based study has shown that regular physical activity can reduce frailty, especially in older persons at higher risk of disability.13 In the case of frail individuals, any physical activity is better than none14 and they should be encouraged to limit the hours spent in sedentary behavior, such as watching television.

Although multiple frailty tools have been developed mainly for epidemiologic study and risk assessment, there is no gold standard for screening and diagnosing frailty.

Frailty screening tools for clinical use

Screening tools which have been developed for potential use in clinical settings include the FRAIL scale, the FRAIL-NH scale and the Clinical Frailty Scale.

The FRAIL scale consists of five variables: fatigue, resistance, ambulation, illness and loss of weight.15,16 A score of 3 or more indicates frailty and 1-2 indicates pre-frailty.

The FRAIL-NH is a screening tool which has been proposed more recently for use in nursing homes and includes seven variables: energy, difficulty with transfers, mobility, continence, weight loss, difficulty with feeding, and difficulty with dressing.17

The Clinical Frailty Scale is based on clinical judgment of the patient's status in the aspects of mobility, energy, physical activity and function. It has been expanded to include nine levels ranging from very fit to terminally ill.18

Frailty diagnostic tools

The majority of frailty diagnostic tools is based on two concepts, namely physical/phenotypic frailty and deficit accumulation/frailty index.19,20 Phenotypic frailty is based on a hypothesized cycle of frailty associating multiple inter-related core clinical components that constitute frailty. Five parameters have been identified: unintentional weight loss, self-reported exhaustion, low energy expenditure, slow gait speed and weak grip strength. Patients with three or more of these parameters are diagnosed as frail. Patients with one or two of these parameters are diagnosed as pre-frail and those with none are considered as non-frail or robust individuals.21 The deficit accumulation/frailty index approach combines scores of medical, cognitive, physiological and social factors to assess frailty status.22 A systemic review of all the frailty assessment tools has concluded that the frailty index is the most suitable tool for assessing frailty.23

Frailty is an important challenge for managing aging populations. Given its major impact on outcomes of health care, it has been suggested that frailty should always be considered when older patients are clinically managed.23 Frailty leads to loss of independence, increase in premature residential care placement and demand for aged care services. These consequences are mainly secondary to falls, cognitive impairment, recurrent hospital admissions and disability associated with frailty. Further, it increases the susceptibility to adverse drug events which eventually increases the risk of unnecessary hospitalizations among older Australians.24

In recent times there has been rigorous research in the field of frailty. A preliminary search conducted in PubMed, COCHRANE and CINAHL databases indicated that there is a large number of disparate international literature on this topic of frailty, therefore a scoping review is an appropriate approach for the purpose of mapping the existing literature. As frailty is more common among nursing home residents, it is important to review current evidence on frailty in nursing homes.

A preliminary search conducted in PubMed, Cochrane and CINAHL databases indicated that there were no existing scoping review protocols or finalized scoping reviews on this topic. However one systematic review was identified and has been included in the references. This systematic review evaluated frailty instruments as prognostic instruments to measure the level of frailty in community dwelling frail people.

Inclusion criteria

Population/studies

Studies that include nursing home residents only will be considered for this scoping review.

Further, only studies which have actually measured frailty rather than just referring to participants as frail will be considered for the review.

Concept

This scoping review will consider studies that provide information on:

* Tools that have been used to assess frailty in nursing home residents.

* Prevalence rates of frailty in nursing home residents.

* Treatment modalities for frailty in nursing homes

* Geriatric syndromes and various adverse outcomes related to frailty in nursing home residents.

Context

This scoping review will consider studies that have been conducted in frail nursing home residents, with no limitations to geographic location, race or gender.

Study types

This scoping review will consider only primary quantitative studies.

Search strategy

The search strategy aims to find studies published in English on frailty in nursing home residents since 2001 (when the concept of frailty was first introduced). A three-step search strategy will be utilized in this review. An initial limited search of databases will be undertaken using the terms listed in Appendix I. The initial search will be followed by an analysis of the text words contained in the title and abstract, and of the index terms used to describe the articles. A second search using all identified keywords and index terms will then be undertaken across all included databases. Thirdly, the reference lists of all identified reports and articles will be searched for additional studies.

Duplicates will be removed upon screening of the papers.

The databases to be searched will include:

Ovid MEDLINE

CINAHL

COCHRANE CENTRAL

SCOPUS

Embase.

Data extraction

Data will be extracted from papers included in the review using a data extraction form aligned to the objectives and questions of this research, as indicated by the methodology for scoping reviews developed by the Joanna Briggs Institute.25

A data extraction instrument has been developed specifically for this scoping review (Appendix II) which will be used to extract the relevant data from each paper. However this may be further refined during the review process.

Two reviewers will extract data independently and extracted data will be inputted into a specific software. Any disagreements that arise between the reviewers will be resolved through discussion or with a third reviewer. The use of the extraction form by reviewers will be piloted on two papers. The data extraction instrument will be modified and revised as necessary during the process of extracting data from each included study. Modifications will be detailed in the full scoping review report.

If necessary, primary authors will be contacted for further information/clarification of the data.

Presentation of the results/data mapping

The extracted data will be presented in diagrammatic or tabular form in a manner that aligns with the objective of this scoping review. A narrative summary will accompany the tabulated and/or charted results and will describe how the results relate to the review objectives. A data presentation table has been developed specifically for this scoping review (Appendix III). However this may be further refined for use during the review process.

Acknowledgements

We wish to thank the library staff at The Queen Elizabeth Hospital and Ms Maureen Bell, Research Librarian at the University of Adelaide, for their advice in conducting the literature search in the above mentioned databases.

Appendix I: Keywords for initial search

Appendix II: Data extraction form

Reviewer:

Date of data extraction:

Study publication bibliographical details:

* Authors:

* Year:

* Article title:

* Journal, volume, issue, page numbers:

Study design and conduct details:

* Setting (country; healthcare setting characteristics):

* Sampling procedure (probabilistic sampling; convenience sampling):

* Sample size:

* Details about study participants (age, gender, diagnoses, etc.):

* Design (RCT; survey, etc.):

* Data collection methods (interviews; observation, etc.)

* Data analysis methods:

Specific details of interest for the scoping review:

* frailty diagnostic tools used: name of the tool, abbreviation of the tool, details about the tool

* reported prevalence rates of frailty

* reported treatment modalities for frailty

* reported types of outcomes of the treatment of frailty

* types of Geriatric syndromes reported as associated with frailty (cognitive impairment; delirium; depression; incontinence; under nutrition; dizziness; sleep problems; visual impairment; hearing impairment)

Appendix III: Data presentation tool (mapping table)

References