LEKAN, DEBORAH ANN, Ph.D. Frailty in Hospitalized Adults. (2013) Directed by Dr. Debra C. Wallace. 393 pp. The purpose of this cross-sectional, retrospective, descriptive study was to characterize frailty in hospitalized adults 55 years of age and older admitted to medical units at one large academic medical center during a 15-month time frame and determine if level of frailty on admission predicted length of stay (LOS) and 30-day readmission. Frailty is a syndrome characterized by multisystem physiologic dysregulation due to intrinsic and extrinsic stressors resulting in decreased compensatory reserve and ability to effectively respond to destabilizing health events. Stressors associated with hospitalization may increase risk for frailty or accelerate its development. Frailty is a significant concern as it is associated with morbidity, functional decline, long LOS, readmission, institutionalization, and mortality. There is scant research on frailty in acutely-ill hospitalized adults, especially those ≥ 65 years of age. Understanding frailty in this population is imperative because frailty is potentially preventable, treatable, and reversible. Frailty was operationalized as 14 evidence-based frailty components defined by 26 indicator variables. Frailty components were Nutrition, Weakness, Fatigue, Chronic Pain, Dyspnea, Falls, Vision, Depression, Cognition, Social Support, low Hemoglobin, low Albumin, high C-reactive protein (CRP) or hs-CRP, and abnormal WBC count. Each frailty component was scored as one point if at least one indicator variable was present on admission, and summed to derive a Frailty Score, where a higher Frailty Score suggests greater level of frailty (range, 0 to 14). Sociodemographic, clinical, and laboratory data were retrieved from the electronic medical record through web-based data query tools and record review (N = 278). Mean age was 70.2 ( SD = 1.3; range, 55– 98), slightly over half were female, 64% were White, one-third were Black. The mean comorbidity count was 13 ( SD = 4.56; range. 1–26) and medication count was 12 ( SD = 5.2; range, 0–31). The most prevalent frailty components (> 81%) were Fatigue, Weakness, Nutrition, Hemoglobin, Albumin, and CRP or hs-CRP. The mean Frailty Score was 9.03 ( SD = 1.98; range, 2–13). Multiple linear regression was performed with 20 predictor variables and the Frailty Score and then with 14 of the 20 predictor variables that were significant in bivariate linear regression with the Frailty Score using the ENTER and STEPWISE method. All multiple regression models yielded seven significant predictor variables. Six predictors were common to all models: comorbidity, acute pain, ADL assistance, urinary incontinence, Braden Scale score, current tobacco use. In multiple regression with 20 predictors, age was a significant predictor however in multiple regression using ENTER and STEPWISE for 14 predictors, female gender was significant but not age. Results from STEPWISE regression yielded seven significant predictors that explained 27% of the variance in the Frailty Score (adj. R2 = .266, df (14, 263), F = 8.163, p = .000). Mean LOS was 9.92 days ( SD = 9.58; range, 1–72; median, 7; mode, 5). Simple linear regression for the Frailty Score and log 10 transformed LOS was statistically significant (adj. R2 = .090, df (1, 276), F = 29.293, p = .000). Twelve percent experienced 30-day readmission. Logistic regression conducted for the Frailty Score and 30-day readmission was not statistically significant ( X 2 = 4.121, df (5), p = .532; β coefficient = .100, df (1), 95% CI = .913–1.1337, p = .307). The Frailty Score characterized this hospitalized population as acutely ill with high comorbidity, symptom burden, nutrition deficits and evidence of physiologic vulnerability and inflammation. Study findings have implications for nursing practice, interdisciplinary collaboration, education, research, and public policy. Key words: frailty, stress, hospitalization, elderly, middle-aged, C-reactive protein, Braden Scale FRAILTY IN HOSPITALIZED ADULTS by Deborah Ann Lekan A Dissertation Submitted to the Faculty of The Graduate School at The University of North Carolina at Greensboro in Partial Fulfillment of the Requirements for the Degree Doctor of Philosophy Greensboro 2013 Approved by Debra C. Wallace Committee Chair © 2013 Deborah Ann Lekan APPROVAL PAGE This dissertation, written by Deborah Ann Lekan, has been approved by the following committee of the Faculty of The Graduate School at The University of North Carolina at Greensboro. Committee Chair Debra C. Wallace Committee Members Jie Hu Eileen M. Kohlenberg Heather E. Whitson July 11, 2013 Date of Acceptance by Committee June 17, 2013 Date of Final Oral Examination ii ACKNOWLEDGMENTS First and foremost I would like to acknowledge the contributions of my dissertation chair and committee who provided ongoing guidance, encouragement, and expert advice as I progressed on this scholarly journey. I extend deep appreciation to my chair, Debra C. Wallace, PhD, RN, FAAN, for her generosity of time, expertise, and goodwill, for traveling to meet with me at critical times to discuss conceptual and methodological issues to ensure that this research met high standards of quality, rigor, and clinical relevance, and laid the groundwork for future research. Dr. Wallace is a model of integrity. She appreciates differences among students as strengths and supports and capitalizes on those strengths by providing clear approaches to help students meet goals of scholarly work. I sincerely thank Jiu Hu, PhD, RN for introducing me to the national and global significance of health disparities and cultural meanings of health and illness since these topics significantly influenced my work. My interest in frailty at midlife came about from exposure to health disparities research and social determinants of health as contributors to frailty risk factors that develop over the life course. This perspective reflects core nursing values of justice, caring, beneficence, and duty, values that underpin this research and speak to nursing’s social responsibilities. I am grateful to Eileen M. Kohlenberg, PhD, RN for joining my committee at a crucial time and providing guidance about measurement of psychosocial-spiritual domains of frailty in hospitalized adults. This area is understudied in frailty research. In memorium, I honor committee member Carolyn Blue, PhD, RN who was known for her unconditional iii support of students and for the enthusiasm and joy she exuded in her teaching and interpersonal interactions. Dr. Blue’s expertise in health promotion models influenced my conceptualization of frailty as a life-course phenomenon. She will always be admired and fondly remembered. Heather Whitson, MD, a renowned expert in geriatric medicine and frailty at Duke University School of Medicine, Division of Geriatrics, significantly influenced how frailty was defined in this study. This study builds on prior research and clinical practice collaborations and provides a new opportunity to study frailty and develop practical tools for clinicians that promote interprofessional communication and care coordination for primary and secondary prevention. Dr. Whitson’s advice on conceptual and methodological issues related to frailty in this population and how to overcome challenges in EMR data retrieval and secondary analysis enhanced the validity and scientific rigor of this study. I offer special thanks to Susan Silva, PhD, external statistical consultant, Duke University School of Nursing, who generously shared her time and expertise during many late night discussions. Dr. Silva provided invaluable assistance in data transformation and advice about statistical models for analysis. I attribute my keen interest in statistics to Professor Thomas McCoy, biostatistician, whose expertise guided me and my classmates in understanding concepts and methods using a repertoire of learning activities, humor, and patience to gain a solid foundation. I extend sincere appreciation to the Research Nurses at Duke University who assisted in data collection: Donna Harris, BSN, RN, Angel Barnes, BSN, RN, Chelsea Cocce, BSN, RN, and Ashley Roberston, BSN, RN. I am indebted to Michelle Mitchell whose expertise in working with large datasets, and procedures for accurate data entry iv and validation was invaluable in construction of the dataset. Each of these individuals put forth tremendous effort under time sensitive circumstances. I am extremely grateful for the outstanding expertise of Richard Allen who provided hours of meticulous technical assistance in the final editing and formatting of this dissertation. The labyrinth of detailed specifications was navigated with his expert guidance and assistance. I would like to acknowledge important research collaborations during my doctoral program with Bradi Grander, PhD, RN, FAAN, FAHA, Duke University Heart Center and Duke Translational Nursing Institute, Duke School of Nursing and Karen Alexander, MD, Duke University Medical Center. Through these collaborations, I was able to conduct two pilot studies and a secondary data analysis on fatigue and other symptoms related to frailty in hospitalized adults with cardiovascular disease. As a result of these experiences, I became better prepared in the research process. To my colleagues, Kirsten Corazzini, PhD and Eleanor McConnell, PhD, RN, APRN-BC, I thank you for supporting my aspirations and goals and encouraging me to consider different perspectives for focusing my research and staying on track.