Frailty, multimorbidity and adverse hospitalization outcomes: a cross-sectional study of geriatric patients in a low-resource setting

T. M. Shahanawaz Islam; Naylla Islam; Sanghita Banik Proma; Sabiha Yasmin; Saifun Nahar; Mohammad Shadman Sabab Tawsif; Md Rashidul Hasan; Naveed Rahman

doi:10.18203/2320-6012.ijrms20263519

Authors

T. M. Shahanawaz Islam Department of Medicine, Sir Salimullah Medical College, Dhaka, Bangladesh
Naylla Islam Department of Medicine, Mugda Medical College Hospital, Dhaka, Bangladesh
Sanghita Banik Proma Sir Salimullah Medical College Mitford Hospital, Dhaka, Bangladesh
Sabiha Yasmin Department of Obstetrics and Gynaecology, Sir Salimullah Medical College, Dhaka, Bangladesh
Saifun Nahar Department of Laboratory Medicine, Ibne Sina Diagnostic and Consultation Center, Dhaka, Bangladesh
Mohammad Shadman Sabab Tawsif Upazilla Health Complex, Monoharganj, Cumilla, Bangladesh
Md Rashidul Hasan Department of Gastroenterology, Sir Salimullah Medical College Mitford Hospital, Dhaka, Bangladesh
Naveed Rahman Department of Pulmonology, KPJ Specialized Hospital and Nursing Institute, Gazipur, Bangladesh

DOI:

https://doi.org/10.18203/2320-6012.ijrms20263519

Keywords:

Frailty, Clinical frailty scale, Discharge against medical advice, Geriatrics, Bangladesh, Multimorbidity

Abstract

Background: As the global population ages, frailty has emerged as a critical predictor of adverse hospitalization outcomes. In low-resource settings like Bangladesh, socioeconomic barriers frequently lead to Discharge Against Medical Advice (DAMA), yet the specific role of frailty in driving these premature discharges remains poorly understood.

Methods: A cross-sectional study was conducted at Sir Salimullah Medical College Mitford Hospital, Dhaka, involving 250 inpatients aged ≥ 50 years. Frailty was assessed using the 9-point Clinical Frailty Scale (CFS), categorized into three tiers: Low Risk/Vulnerable (CFS 2-4), Moderately Frail (CFS 5-6), and Severely/Terminally Frail (CFS 7-9). Multimorbidity and hospitalization outcomes (mortality, length of stay, and DAMA) were analyzed using Pearson's Chi-square and binary logistic regression.

Results: High levels of frailty were observed, with 60% of the cohort classified as moderately to severely frail. Multimorbidity was prevalent, led by diabetes (53.6%), hypertension (50.0%), and anemia (49.6%). The DAMA rate was alarmingly high at 61.6%. Logistic regression identified moderate frailty as a primary predictor of DAMA (AOR = 2.66, 95% CI: 1.26-5.64, p = 0.011), while severe frailty did not reach statistical significance (p = 0.313). Patients identified home health monitoring (81.2%) and financial support (57.2%) as the most critical needs to reduce future hospitalizations.

Conclusions: Moderate frailty serves as a critical tipping point where clinical needs and caregiver burden intersect, significantly increasing the risk of DAMA. Addressing geriatric outcomes in Bangladesh requires integrating clinical frailty assessments with socioeconomic support and home-based care strategies to mitigate premature hospital discharge.

References

Ferri-Guerra J, Aparicio-Ugarriza R, Salguero D, Baskaran D, Mohammed YN, Florez H, et al. The association of frailty with hospitalizations and mortality among community dwelling older adults with diabetes. J Frailty Aging. 2020;9(2):94-100.

Sadıç A, Şahiner Z, Eşme M, Balcı C, Doğu BB, Cankurtaran M, et al. Malnutrition and frailty as independent predictors of adverse outcomes in hospitalized older adults: a prospective single center study. Medicina (Kaunas). 2025;61(8):1354.

Basic D, Shanley C. Frailty in an older inpatient population: using the Clinical Frailty Scale to predict patient outcomes. J Aging Health. 2015;27(4):670-85.

Andres D, Imhoof C, Bürge M, Jakob G, Limacher A, Stuck AK. Frailty as a predictor of poor rehabilitation outcomes among older patients attending a geriatric day hospital program: an observational study. Int J Environ Res Public Health. 2022;19(10):6276.

Fox MT, Persaud M, Maimets I, O'Brien K, Brooks D, Tregunno D, et al. Effectiveness of acute geriatric unit care using Acute Care for Elders components: a systematic review and meta-analysis. J Am Geriatr Soc. 2012;60(12):2237-45.

Kahlon S, Pederson J, Majumdar SR, Belga S, Lau D, Fradette M, et al. Association between frailty and 30-day outcomes after discharge from hospital. CMAJ. 2015;187(11):799-804.

Chua XY, Toh S, Wei K, Teo N, Tang T, Wee SL. Evaluation of clinical frailty screening in geriatric acute care. J Eval Clin Pract. 2020;26(1):35-41.

Saravi BM, Reza Zadeh E, Siamian H, Yahghoobian M. Discharge against medical advice in the pediatric wards in Boo-ali Sina Hospital, Sari, Iran 2010. Acta Inform Med. 2013;21(4):253-6.

Church S, Rogers E, Rockwood K, Theou O. A scoping review of the Clinical Frailty Scale. BMC Geriatr. 2020;20(1):393.

Tehrani S, Killander A, Åstrand P, Jakobsson J, Gille-Johnson P. Risk factors for death in adult COVID-19 patients: frailty predicts fatal outcome in older patients. Int J Infect Dis. 2021;102:415-21.

Romero-Ortuno R, Forsyth DR, Wilson KJ, Cameron E, Wallis S, Biram R, et al. The association of geriatric syndromes with hospital outcomes. J Hosp Med. 2017;12(2):83-9.

Brummel NE, Bell SP, Girard TD, Pandharipande PP, Jackson JC, Morandi A, et al. Frailty and subsequent disability and mortality among patients with critical illness. Am J Respir Crit Care Med. 2017;196(1):64-72.

Owen RK, Conroy SP, Taub N, Jones W, Bryden D, Pareek M, et al. Comparing associations between frailty and mortality in hospitalised older adults with or without COVID-19 infection: a retrospective observational study using electronic health records. Age Ageing. 2021;50(2):307-16.

Han SJ, Jung HW, Lee JH, Lim J, Moon SD, Yoon SW, et al. Clinical Frailty Scale, K-FRAIL questionnaire, and clinical outcomes in an acute hospitalist unit in Korea. Korean J Intern Med. 2021;36(5):1233-41.

Huang F, Yang X, Yuan L, Wang M, Li R, Ye Z, et al. Development and validation of a predictive risk model for frailty in elderly patients with multimorbidity. Geriatr Gerontol Int. 2022;22(6):471-6.

Lv J, Li R, Yuan L, Yang XL, Wang Y, Ye ZW, et al. Research on the frailty status and adverse outcomes of elderly patients with multimorbidity. BMC Geriatr. 2022;22(1):560.

Conroy SP, Bardsley M, Smith P, Neuburger J, Keeble E, Arora S, et al. Comprehensive geriatric assessment for frail older people in acute hospitals: the HoW-CGA mixed-methods study. Health Serv Deliv Res. 2019;7(15):1-174.

Kwok CS, Walsh MN, Volgman A, Alasnag M, Martin GP, Barker D, et al. Discharge against medical advice after hospitalisation for acute myocardial infarction. Heart. 2019;105(4):315-21.

Boucher EL, Gan JM, Rothwell PM, Shepperd S, Pendlebury ST. Prevalence and outcomes of frailty in unplanned hospital admissions: a systematic review and meta-analysis of hospital-wide and general (internal) medicine cohorts. EClinicalMedicine. 2023;59:101947.

Bert F, Kakaa O, Corradi A, Mascaro A, Roggero S, Corsi D, et al. Predicting length of stay and discharge destination for surgical patients: a cohort study. Int J Environ Res Public Health. 2020;17(24):9490.

Stanbouly D, Stewart SJ, Harris JA, Arce K. Does alcohol use influence hospitalization outcomes in adults suffering craniomaxillofacial fractures from street fighting? Craniomaxillofac Trauma Reconstr. 2024;17(2):132-42.

Toyoshima K, Araki A, Tamura Y, Ishikawa J, Iwakiri R, Takei T, et al. Prognostic value of the electronic Multimorbidity Frailty Index for mortality, change in basic activities of daily living, length of hospital stay and discharge home in older hospitalized patients. Geriatr Gerontol Int. 2025;25(9):1185-93.

Sanchez D, Brennan K, Al Sayfe M, Shunker SA, Bogdanoski T, Hedges S, et al. Frailty, delirium and hospital mortality of older adults admitted to intensive care: the Delirium (Deli) in ICU study. Crit Care. 2020;24(1):609.

Leung C, Tahir W, Rosli Y, Lieber SB, Makris UE, Lee J, et al. Association between frailty status and readmissions in hospitalized patients with systemic lupus erythematosus. ACR Open Rheumatol. 2024;6(10):700-6.

Lin CF, Huang YH, Ju LY, Weng SC, Lee YS, Chou YY, et al. Health-related quality of life measured by EQ-5D in relation to hospital stay and readmission in elderly patients hospitalized for acute illness. Int J Environ Res Public Health. 2020;17(15):5333.

Rahman MI, Alam J, Emdad FB. Challenges of elderly caregiving in the Indian subcontinent: a scoping review. Public Health Chall. 2025;4(3):e70085.

Hoyer C, Stein P, Alonso A, Platten M, Szabo K. Uncompleted emergency department care and discharge against medical advice in patients with neurological complaints: a chart review. BMC Emerg Med. 2019;19(1):52.

Muscedere J, Waters B, Varambally A, Bagshaw SM, Boyd JG, Maslove D, et al. The impact of frailty on intensive care unit outcomes: a systematic review and meta-analysis. Intensive Care Med. 2017;43(8):1105-22.

Ahrenfeldt LJ, Møller S, Thinggaard M, Christensen K, Lindahl-Jacobsen R. Sex differences in comorbidity and frailty in Europe. Int J Public Health. 2019;64(7):1025-36.

Olasehinde O, Alatise O, Arowolo O, Adisa A, Wuraola F, Boutin-Foster C, et al. Safety and feasibility of early postmastectomy discharge and home drain care in a low resource setting. J Surg Oncol. 2018;118(6):861-6.

Talebpour A, Sadeghi-Bazargani H, Jannati A, Hosseinifard H, Gholizadeh M. Patient-level and physician-level predictors of discharge against medical advice: a multilevel modeling approach. Health Scope. 2024;13(2):e145131.

Onukwugha E, Saunders E, Mullins CD, Pradel FG, Zuckerman M, Loh FE, et al. A qualitative study to identify reasons for discharges against medical advice in the cardiovascular setting. BMJ Open. 2012;2(4):e000902.

Alshiakh SM, Algarni AS. Factors influencing patient decisions to discharge against medical advice from hospital emergency: insights from a Saudi tertiary hospital. J Patient Exp. 2025;12:23743735251385311.

Bosco AN, Shashidhar A, Rees CA, Wheeler AD, Britto CD, Rao PN S. Reducing rates of discharge against medical advice in the neonatal intensive care unit in a tertiary care hospital in South India: a mixed-methods study. Trop Med Int Health. 2021;26(7):743-52.

George EL, Arya S. The importance of incorporating frailty screening into surgical clinical workflow. JAMA Netw Open. 2019;2(5):e193538.

Tao X, Chow SKY, Zhang H, Huang J, Gu A, Jin Y, et al. Family caregiver's burden and the social support for older patients undergoing peritoneal dialysis. J Ren Care. 2020;46(4):222-32.

Baré M, Lleal M, Sevilla-Sánchez D, Ortonobes S, Herranz S, Ferrandez O, et al. Sex differences in multimorbidity, inappropriate medication and adverse outcomes of inpatient care: MoPIM cohort study. Int J Environ Res Public Health. 2023;20(4):3639.

Koroukian SM, Warner DF, Owusu C, Given CW. Multimorbidity redefined: prospective health outcomes and the cumulative effect of co-occurring conditions. Prev Chronic Dis. 2015;12:E55.

Goli S, Singh L, Jain K, Pou LMA. Socioeconomic determinants of health inequalities among the older population in India: a decomposition analysis. J Cross Cult Gerontol. 2014;29(4):353-69.

Cai M, Zhang S, Lin X, Qian Z, McMillin SE, Yang Y, et al. Association of ambient particulate matter pollution of different sizes with in-hospital case fatality among stroke patients in China. Neurology. 2022;98(24):e2474-86.

Ticinesi A, Nouvenne A, Folesani G, Prati B, Morelli I, Guida L, et al. Multimorbidity in elderly hospitalised patients and risk of Clostridium difficile infection: a retrospective study with the Cumulative Illness Rating Scale (CIRS). BMJ Open. 2015;5(10):e009316.

Landi F, Liperoti R, Russo A, Capoluongo E, Barillaro C, Pahor M, et al. Disability, more than multimorbidity, was predictive of mortality among older persons aged 80 years and older. J Clin Epidemiol. 2010;63(7):752-9.

Wung YT, Chen CC, Chen FC, Lin CH. Schizophrenia patients discharged against medical advice at a mental hospital in Taiwan. Psychiatry Clin Neurosci. 2010;64(4):415-20.