Date Published: July 23, 2018
Publisher: Springer International Publishing
Author(s): Amelie Lindh Mazya, Peter Garvin, Anne W. Ekdahl.
Multimorbidity and frailty are often associated and Comprehensive Geriatric Assessment (CGA) is considered the gold standard of care for these patients.
This study aimed to evaluate the effect of outpatient Comprehensive Geriatric Assessment (CGA) on frailty in community-dwelling older people with multimorbidity and high health care utilization.
The Ambulatory Geriatric Assessment—Frailty Intervention Trial (AGe-FIT) was a randomized controlled trial (intervention group, n = 208, control group n = 174) with a follow-up period of 24 months. Frailty was a secondary outcome. Inclusion criteria were: age ≥ 75 years, ≥ 3 current diagnoses per ICD-10, and ≥ 3 inpatient admissions during 12 months prior to study inclusion. The intervention group received CGA-based care and tailored interventions by a multidisciplinary team in an Ambulatory Geriatric Unit, in addition to usual care. The control group received usual care. Frailty was measured with the Cardiovascular Health Study (CHS) criteria. At 24 months, frail and deceased participants were combined in the analysis.
Ninety percent of the population were frail or pre-frail at baseline. After 24 months, there was a significant smaller proportion of frail and deceased (p = 0.002) and a significant higher proportion of pre-frail patients in the intervention group (p = 0.004). Mortality was high, 18% in the intervention group and 26% in the control group.
Outpatient CGA may delay the progression of frailty and may contribute to the improvement of frail patients in older persons with multimorbidity.
Frailty is associated with functional decline, adverse health outcomes, and mortality. Ten percent of all community-dwelling older people are frail, and the prevalence increases with age, affecting one-fourth of the oldest old. The prevention and treatment of frailty thus pose a great challenge to future healthcare systems [1–3]. Multimorbidity is a state with co-occurrence of multiple chronic diseases in the same person. Earlier studies often defines the state by the presence of two or more long-term conditions . Multimorbidity affects 70% of people older than 80 years, and as reported, 46% of frail persons [5, 6]. Many of the geriatric patients are however affected by more than two chronic diseases at the same time. An often used definition of older persons with the highest health care utilization in Sweden consists of an age criteria; 75 years or older, a multimorbidity criteria; three or more concomitant diseases, and a hospitalization criteria; three or more hospitalizations the previous year. This definition is often used by the Swedish National Board of Health and Welfare to describe the top 4% of people aged 75 years or older that have the most complex needs of care . This definition demarcates a population with a high level of multimorbidity and can easily be found in care databases, making it a useful definition of old people with multimorbidity to use in research aiming to evaluate interventions for this at-risk population. Frail older people and those with multimorbidity are at high risk of several negative health outcomes and require person-centered care that addresses their individual needs. The holistic approach of comprehensive geriatric assessment (CGA) suits the need of older at-risk patients, and its effectiveness is well-known [8–10]. CGA-based care results in improved function, decreased institutionalization, and less mortality in aged hospital inpatients [8, 9]. Few studies, however, have evaluated CGA or similar multidisciplinary interventions in outpatient settings. These kind of interventions can possibly slow functional decline, reduce disability, and improve mobility in pre-frail and frail individuals [11–13]. Knowledge of the effects of outpatient CGA on frailty in community-dwelling older individuals with a high level of multimorbidity is, however, limited.
The mean age of study participants was 82.5 years, and 52% of participants were women. No difference in baseline characteristic was observed between groups (Table 1). Baseline data on frailty were available for 360 (94%) participants (IG, n = 198; CG, n = 162). Of these, 187 (52%) participants were frail, 130 (36%) were pre-frail, and 43 (12%) participants were robust, with no significant difference between the IG and CG. Eleven participants in the IG did not receive the intervention because they later declined to participate. They were however included in the analysis. Frailty data at the 24-month time point were available for 232 participants (135 in the IG/97 in the CG) (Fig. 1). Of these participants, 108 (47%) were frail, 97 (42%) were pre-frail, and 27 (11%) were robust. At 24 months the IG contained a significantly greater proportion of pre-frail individuals than did the CG (p = 0.004; Fig. 2). The proportion of frail and deceased combined was also significantly lower in the IG (p = 0.002; Fig. 2). When frail and deceased participants were analyzed as separate groups, there were no significant differences in proportions between the IG and CG (frail, p = 0.19, deceased, p = 0.051). Mortality rates were high; 35 (18%) participants in the IG and 42 (26%) participants in the CG died, with no significant difference between groups (p = 0.051). Very few participants classified as robust at baseline became frail or died. Pre-frail participants mainly stayed pre-frail or became frail. The majority of those classified as frail at baseline, stayed frail or died. More frail participants in the IG improved to pre-frail or robust (n = 19, 24%), compared with the CG (n = 11, 13%) but this difference in proportions was not statistically significant (p = 0.09). The development of frailty status from baseline to 24 months follow-up is illustrated in Fig. 3.
This study showed that outpatient CGA affects frailty in older individuals. At follow-up, the IG contained significantly more pre-frail and less frail/deceased participants than expected. We attribute these results to the effect of the intervention, which was able to delay progression to frailty in pre-frail patients. Our findings support previous studies showing that intervention against frailty is possible, and that CGA, applied in the present study as outpatient care, could be care approach of choice for older at-risk patients . There was also a tendency to improvement of frailty, but not statistically significant in this small sample.
This study has shown that a multidisciplinary intervention in an outpatient setting had positive effects on frail older people with multimorbidity and high health care utilization. We conclude that outpatient CGA delays the progression of frailty and may contribute to the improvement of frailty status. Future studies should consider longer follow-up periods and also focus on what interventions within outpatient CGA are the most effective.