Her præsenteres videnskabelig artikel fra 2023 hvor man kombinerer frailty med sværhedsgraden af akut sygdom til at forudsige mortaliteten i FAM.
Clinical Frailty Scale (CFS) er igang med at blive udrullet i det danske sundhedsvæsen. Det er rigtig godt fordi der så kommer fokus på at bedømme skrøbelighed for patienter på tværs af afdelinger og sektorer. På nuværende tidspunkt vil alle patienter på 80 år og mere skulle have vurderet CFS, hvis de bliver indlagt på et sygehus i Danmark. Snart vil det også blive vurderet i almen praksis og i kommunerne. Men hvad kan man egentlig bruge CFS til?
I denne artikel sættes fokus på en videnskabelig artikel skrevet af Nissen et. al. i 2023, hvor de forsøger at kombinere vurderingen af frailty med sværhedsgraden af akut sygdom for ældre patienter der indlægges i FAM. Dette bruger de til at finde 30 dages mortaliteten for patienterne. Sværhedsgraden af akut sygdom vurderes ved NEWS og frailty ved CFS.
Dette kommer der nedenstående graf ud af, hvor man kan aflæse 30 dages mortaliteten som funktion af CFS og NEWS. Som man kan se er det specielt ved CFS 5-7 at sværhedsgraden af akut sygdom har stor betydning for 30 dages mortaliteten. Det ses også at hverken NEWS eller CFS er god i sig selv til at forudsige 30 dages mortaliteten, det er kombinationen af de to der er afgørende.
Det er også derfor at det er vigtigt at vurdere den akutte sygdom før man vurderer CFS når man skal vurdere den bedste plan for patientens behandling. Ved at starte med at vurdere CFS er der risiko for at man ikke medtager sværhedsgraden af akut sygdom i betragtningen. Dette giver en risiko for diskrimination på baggrund af frailty, såkaldt frailisme (som pendant til ageisme).
Søren Kabell Nissen, der har skrevet artiklen og har lavet PhD i Frailty, har også udviklet en gratis app til at finde 30 dages mortaliteten på baggrund af ovenstående graf. Den giver hurtigt et overblik hvis man står med en patient i FAM, hvor man gerne vil have vurderet den forventede 30 dages mortalitet.
Referencer
- Kabell Nissen S, Rueegg M, Carpenter CR, Kaeppeli T, Busch JM, Fournaise A, Dreher-Hummel T, Bingisser R, Brabrand M, Nickel CH. Prognosis for older people at presentation to emergency department based on frailty and aggregated vital signs. J Am Geriatr Soc. 2023 Apr;71(4):1250-1258. doi: 10.1111/jgs.18170. Epub 2022 Dec 13. PMID: 36511431.
- Frailty adjusted prognostication in ED tool (Søren Kabell Nissen)
Prognosis for older people at presentation to emergency department based on frailty and aggregated vital signs
METHODS: Single-center prospective cohort of undifferentiated ED patients aged 65 or older, consecutively sampled upon ED presentation from a tertiary Emergency Center. Vital signs were aggregated using the National Early Warning Score (NEWS) as a measure of illness or injury severity and frailty was assessed with the Clinical Frailty Scale (CFS). The FaP-ED was constructed by combining NEWS and CFS in multivariable logistic regression. The primary outcome was 30-day mortality. Measures of discrimination and calibration were assessed to evaluate predictive performance and internally validated using bootstrapping.
RESULTS: 2250 patients were included, 67 (1.8%) were omitted from analyses due to missing CFS, loss to follow-up, or terminal illness. Thirty-day mortality rate was 5.4% (N = 122, 95% CI = 4.5%-6.4%). Median NEWS was 1 (Inter-Quartile Range (IQR): 0-3) and median CFS was 4 (IQR: 3-5). The Area Under Receiver Operating Characteristic (AUROC) for FaP-ED was 0.86 (95% CI = 0.83-0.90). This was significantly higher than NEWS (0.81, 95% CI = 0.77-0.85, DeLong: Z = 3.5, p < 0.001) or CFS alone (0.82, 95% CI = 0.78-0.86, DeLong: Z = 4.4, p < 0.001). Bootstrapped estimates of FaP-ED AUROC, calibration slope, and intercept were 0.86, 0.95, and -0.09, respectively, suggesting internal validity. A decision-threshold of CFS 5 and NEWS 3 was proposed based on qualitative comparison of positive Likelihood Ratio at all relevant FaP-ED cutoffs.
CONCLUSION: Combining aggregated vital signs and frailty accurately predicted 30-day mortality at ED presentation and illustrated an important clinical interaction between frailty and illness severity. Pending external validation, the Fap-ED operationalizes the concept of such "geriatric urgency" for the ED setting.
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