Clinical frailty adds to acute illness severity in predicting mortality in hospitalized older adults: An observational study

  • Roman Romero-Ortuno
    Corresponding author at: Department of Medicine for the Elderly, Box 135, Addenbrooke's Hospital, Hills Road, Cambridge CB2 0QQ, United Kingdom.
    Department of Medicine for the Elderly, Addenbrooke's Hospital, Cambridge, United Kingdom

    Clinical Gerontology Unit, Department of Public Health and Primary Care, University of Cambridge, United Kingdom
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  • Stephen Wallis
    Department of Medicine for the Elderly, Addenbrooke's Hospital, Cambridge, United Kingdom
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  • Richard Biram
    Department of Medicine for the Elderly, Addenbrooke's Hospital, Cambridge, United Kingdom
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  • Victoria Keevil
    Department of Medicine for the Elderly, Addenbrooke's Hospital, Cambridge, United Kingdom

    Clinical Gerontology Unit, Department of Public Health and Primary Care, University of Cambridge, United Kingdom
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Published:September 02, 2016DOI:


      • This was a retrospective observational study in a university hospital in England.
      • In 5505 older adults aged 75+ frailty and acuity independently predicted mortality.
      • Hospitals should undertake large scale assessment of frailty as well as acuity.



      Frail individuals may be at higher risk of death from a given acute illness severity (AIS), but this relationship has not been studied in an English National Health Service (NHS) acute hospital setting.


      This was a retrospective observational study in a large university NHS hospital in England. We analyzed all first non-elective inpatient episodes of people aged ≥75 years (all specialties) between October 2014 and October 2015. Pre-admission frailty was assessed with the Clinical Frailty Scale (CFS) of the Canadian Study on Health & Aging, and AIS in the Emergency Department was measured with a Modified Early Warning Score (ED-MEWS < 4 was considered as low acuity, and ED-MEWS ≥ 4 as high acuity). A survival analysis compared times to 30-day inpatient death between CFS categories (1–4: very fit to vulnerable, 5: mildly frail, 6: moderately frail, and 7–8: severely or very severely frail).


      There were 12,282 non-elective patient episodes (8202 first episodes, of which complete data was available for 5505). In a Cox proportional hazards model controlling for age, gender, Charlson Comorbidity Index, history of dementia, current cognitive concern, and discharging specialty (medical versus surgical), ED-MEWS ≥ 4 (HR = 2.87, 95% CI: 2.27–3.62, p < 0.001), and CFS 7–8 (compared to CFS 1–4, HR = 2.10, 95% CI: 1.52–2.92, p < 0.001) were independent predictors of survival time.


      We found frailty and AIS independently associated with inpatient mortality after adjustment for confounders. Hospitals may find it informative to undertake large scale assessment of frailty (vulnerability), as well as AIS (stressor), in older patients admitted to hospital as emergencies.


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        • Subbe C.P.
        • Kruger M.
        • Rutherford P.
        • Gemmel L.
        Validation of a modified Early Warning Score in medical admissions.
        QJM. 2001; 94: 521-526
        • Smith G.B.
        • Prytherch D.R.
        • Meredith P.
        • Schmidt P.E.
        Early warning scores: unravelling detection and escalation.
        Int J Health Care Qual Assur. 2015; 28: 872-875
        • Alam N.
        • Hobbelink E.L.
        • van Tienhoven A.J.
        • van de Ven P.M.
        • Jansma E.P.
        • Nanayakkara P.W.
        The impact of the use of the Early Warning Score (EWS) on patient outcomes: a systematic review.
        Resuscitation. 2014; 85: 587-594
        • Chotirmall S.H.
        • Picardo S.
        • Lyons J.
        • D'Alton M.
        • O'Riordan D.
        • Silke B.
        Disabling disease codes predict worse outcomes for acute medical admissions.
        Intern Med J. 2014; 44: 546-553
        • Soong J.
        • Poots A.J.
        • Scott S.
        • et al.
        Quantifying the prevalence of frailty in English hospitals.
        BMJ Open. 2015; 5e008456
        • Clegg A.
        • Young J.
        • Iliffe S.
        • Rikkert M.O.
        • Rockwood K.
        Frailty in elderly people.
        Lancet. 2013; 381: 752-762
        • Romero-Ortuno R.
        • O'Shea D.
        Fitness and frailty: opposite ends of a challenging continuum! Will the end of age discrimination make frailty assessments an imperative?.
        Age Ageing. 2013; 42: 279-280
        • Lloyd-Sherlock P.
        • McKee M.
        • Ebrahim S.
        • et al.
        Population ageing and health.
        Lancet. 2012; 379: 1295-1296
        • Dent E.
        • Kowal P.
        • Hoogendijk E.O.
        Frailty measurement in research and clinical practice: a review.
        Eur J Intern Med. 2016; 31: 3-10
        • Martin F.C.
        • Brighton P.
        Frailty: different tools for different purposes?.
        Age Ageing. 2008; 37: 129-131
        • Cesari M.
        • Gambassi G.
        • van Kan G.A.
        • Vellas B.
        The frailty phenotype and the frailty index: different instruments for different purposes.
        Age Ageing. 2014; 43: 10-12
        • Illsley A.
        • Clegg A.
        Assessment of frailty in the inpatient setting.
        Br J Hosp Med (Lond). 2016; 77: 29-32
        • Wyrko Z.
        Frailty at the front door.
        Clin Med (Lond). 2015; 15: 377-381
        • Conroy S.
        • Chikura G.
        Emergency care for frail older people-urgent AND important-but what works?.
        Age Ageing. 2015; 44: 724-725
        • Dent E.
        • Hoogendijk E.O.
        • Cardona-Morrell M.
        • Hillman K.
        Frailty in emergency departments.
        Lancet. 2016; 387: 434
        • Soong J.
        • Poots A.J.
        • Scott S.
        • Donald K.
        • Bell D.
        Developing and validating a risk prediction model for acute care based on frailty syndromes.
        BMJ Open. 2015; 5e008457
        • Charlson M.E.
        • Pompei P.
        • Ales K.L.
        • MacKenzie C.R.
        A new method of classifying prognostic comorbidity in longitudinal studies: development and validation.
        J Chronic Dis. 1987; 40: 373-383
        • Rockwood K.
        • Song X.
        • MacKnight C.
        • et al.
        A global clinical measure of fitness and frailty in elderly people.
        CMAJ. 2005; 173: 489-495
        • Subbe C.P.
        • Burford C.
        • Jeune I.L.
        • Masterton-Smith C.
        • Ward D.
        Relationship between input and output in acute medicine — secondary analysis of the Society for Acute Medicine's benchmarking audit 2013 (SAMBA '13).
        Clin Med. 2015; 15: 15-19
        • Wallis S.J.
        • Wall J.
        • Biram R.W.
        • Romero-Ortuno R.
        Association of the clinical frailty scale with hospital outcomes.
        QJM. 2015; 108: 943-949
        • Greiner M.
        • Pfeiffer D.
        • Smith R.D.
        Principles and practical application of the receiver-operating characteristic analysis for diagnostic tests.
        Prev Vet Med. 2000; 45: 23-41
        • Thompson D.
        • Rumley-Buss M.
        • Conroy S.
        Transforming emergency services for frail older people in hospital.
        Nurs Manag (Harrow). 2015; 22: 18-19
        • Cournane S.
        • Byrne D.
        • O'Riordan D.
        • Fitzgerald B.
        • Silke B.
        Chronic disabling disease—impact on outcomes and costs in emergency medical admissions.
        QJM. 2015; 108: 387-396
        • Maher J.M.
        • Markey J.C.
        • Ebert-May D.
        The other half of the story: effect size analysis in quantitative research.
        CBE Life Sci Educ. 2013; 12: 345-351
        • Romero-Ortuno R.
        • O'Shea D.
        • Silke B.
        Predicting the in-patient outcomes of acute medical admissions from the nursing home: the experience of St James's Hospital, Dublin, 2002–2010.
        Geriatr Gerontol Int. 2012; 12: 703-713
        • Wittenberg R.
        • Sharpin L.
        • McCormick B.
        • Hurst J.
        Understanding emergency hospital admissions of older people. Centre for Health Service Economics & Organisation (CHSEO) 2014; report no. 6.
        (Available online:)
        • Boyle A.A.
        • Ahmed V.
        • Palmer C.R.
        • Bennett T.J.
        • Robinson S.M.
        Reductions in hospital admissions and mortality rates observed after integrating emergency care: a natural experiment.
        BMJ Open. 2012; : 2(4)
        • Grossmann F.F.
        • Zumbrunn T.
        • Ciprian S.
        • et al.
        Undertriage in older emergency department patients—tilting against windmills?.
        PLoS One. 2014; 9e106203
        • Grossmann F.F.
        • Zumbrunn T.
        • Frauchiger A.
        • Delport K.
        • Bingisser R.
        • Nickel C.H.
        At risk of undertriage? Testing the performance and accuracy of the emergency severity index in older emergency department patients.
        Ann Emerg Med. 2012; 60: 317-25 e3
        • Ahmed S.
        • Leurent B.
        • Sampson E.L.
        Risk factors for incident delirium among older people in acute hospital medical units: a systematic review and meta-analysis.
        Age Ageing. 2014; 43: 326-333
        • Kojima G.
        Frailty as a predictor of hospitalisation among community-dwelling older people: a systematic review and meta-analysis.
        J Epidemiol Community Health. 2016;
        • Wou F.
        • Gladman J.R.
        • Bradshaw L.
        • Franklin M.
        • Edmans J.
        • Conroy S.P.
        The predictive properties of frailty-rating scales in the acute medical unit.
        Age Ageing. 2013; 42: 776-781
        • Huijberts S.
        • Buurman B.M.
        • de Rooij S.E.
        End-of-life care during and after an acute hospitalization in older patients with cancer, end-stage organ failure, or frailty: a sub-analysis of a prospective cohort study.
        Palliat Med. 2016; 30: 75-82
        • Rodriguez-Manas L.
        • Fried L.P.
        Frailty in the clinical scenario.
        Lancet. 2015; 385: e7-e9
        • Ellis G.
        • Whitehead M.A.
        • O'Neill D.
        • Langhorne P.
        • Robinson D.
        Comprehensive geriatric assessment for older adults admitted to hospital.
        Cochrane Database Syst Rev. 2011; 7CD006211