key: cord-0830045-mz02gigz authors: Church, Sophie; Rogers, Emily; Rockwood, Kenneth; Theou, Olga title: A scoping review of the Clinical Frailty Scale date: 2020-10-07 journal: BMC Geriatr DOI: 10.1186/s12877-020-01801-7 sha: a5f7e150baea9a9ec934a8c0a222a76e0c06b545 doc_id: 830045 cord_uid: mz02gigz BACKGROUND: Frailty is increasingly recognized as an important construct which has health implications for older adults. The Clinical Frailty Scale (CFS) is a judgement-based frailty tool that evaluates specific domains including comorbidity, function, and cognition to generate a frailty score ranging from 1 (very fit) to 9 (terminally ill). The aim of this scoping review is to identify and document the nature and extent of research evidence related to the CFS. METHODS: We performed a comprehensive literature search to identify original studies that used the Clinical Frailty Scale. Medline OVID, Scopus, Web of Science, CINAHL, PsycINFO, Cochrane Library and Embase were searched from January 2005 to March 2017. Articles were screened by two independent reviewers. Data extracted included publication date, setting, demographics, purpose of CFS assessment, and outcomes associated with CFS score. RESULTS: Our search yielded 1688 articles of which 183 studies were included. Overall, 62% of studies were conducted after 2015 and 63% of the studies measured the CFS in hospitalized patients. The association of the CFS with an outcome was examined 526 times; CFS was predictive in 74% of the cases. Mortality was the most common outcome examined with CFS being predictive 87% of the time. CFS was associated with comorbidity 73% of the time, complications 100%, length of stay 75%, falls 71%, cognition 94%, and function 91%. The CFS was associated with other frailty scores 94% of the time. CONCLUSIONS: This scoping review revealed that the CFS has been widely used in multiple settings. The association of CFS score with clinical outcomes highlights its utility in the care of the aging population. Worldwide, the population of older adults is expected to grow from 8.5% of people aged 65 and older to nearly 25% by 2050 [1] . As the population ages, the concept of frailty becomes increasingly relevant in the provision of health care to the population. Frailty was introduced nearly three decades ago to the geriatric medicine literature as a method of understanding and discerning the complex health status of older adults. Frailty is defined as a state in which there is an increase in an individual's vulnerability for developing increased dependency and/ or mortality when exposed to a physiological or psychological stressor [2] . Frailty can also be thought of as tipping the balance between reserve and insults, or positive and negative influences, leading to increased vulnerability [3] . People living with frailty are more vulnerable to the effects of potential stressors, and to deterioration than others of the same chronological age. Frail individuals experience higher rates of adverse outcomes [4] . As such, assessing frailty early in the course of care is essential in order to identify those patients who are most vulnerable. Frailty measurement is integral for guiding patient care, as it helps clinicians determine which interventions will be more likely to be beneficial and which may be more harmful to particular individuals [5] , for example more aggressive medical treatments. It has been suggested that all individuals over the age of 70 be screened for frailty [6] . Despite agreement on it being a multiply determined state of increased risk, consensus on a frailty definition has yet to be reached. The Clinical Frailty Scale is a clinical judgementbased frailty tool developed for the Canadian Study of Health and Aging [7] . There it summarized the results of a Comprehensive Geriatric Assessment facilitating discussion of the impact of frailty when assessments had been conducted by physicians and nurses from a range of disciplines. The CFS evaluates specific domains including comorbidity, function, and cognition to generate a frailty score ranging from 1 (very fit) to 9 (terminally ill). Various reviews have been published on frailty suggesting the CFS is a promising frailty screening tool [8] [9] [10] , however none of these have focused specifically on the CFS. Although the CFS is used commonly in both research and clinical care, there is currently no synthesis of its use. The objective of this scoping review was to map and synthesize the literature around the use of the CFS. This included identifying and documenting the nature and extent of research evidence pertaining to the CFS, with the aim of providing a more comprehensive description of its use across settings. We also examined the ability of the CFS to predict adverse health outcomes. This knowledge could inform and support clinicians and policy makers in making decisions about resource allocation and service access. The search strategy for this scoping review was developed with assistance from a librarian, with the aim of identifying all original studies that assessed the Clinical Frailty Scale (Appendix 1). A variety of databases including Medline OVID, SCOPUS, Web of Science, CINAHL, Psy-cINFO, Cochrane Library and Embase were searched from 2005 when the original CFS paper was published to March 2017. All relevant articles retrieved from this search strategy were included for screening. Additional studies were identified by manually searching the reference lists of potentially relevant papers and other frailty systematic reviews. SCOPUS and Web of Science searches were also completed for all articles citing the article which described the development of the CFS tool [7] . All articles identified were imported into Covidence software for screening. Studies were only included when 1) they were original research and 2) the CFS was used. Due to the broad nature of this scoping review, we did not limit by language, study design, setting, age of participants or outcome measure. For non-English articles, members of the research team or colleagues with knowledge of the given language screened them and assisted in data extraction. Quality assessment is not a priority in scoping reviews; thus, studies were not excluded based on their quality. Title and abstract screening was completed in Covidence software. The only inclusion criterion for the title and abstract screening was whether the article described an original study. Review articles, conference abstracts, editorials and commentaries were excluded from the review. Screening was completed by two independent reviewers and conflicts were managed and resolved by discussion between the two reviewers, including a third reviewer when necessary. Full text screening was also completed in Covidence software. Studies that include the Clinical Frailty Scale in their methods were included for data extraction; protocol papers proposing the use of the CFS in a study were also included. Studies that reference the CFS but did not assess or plan to assess frailty with the CFS in a group of participants were excluded. Full text screening was completed by two independent reviewers, with conflicts managed by discussion to achieve consensus or by a third reviewer when necessary. A data extraction form on Microsoft Excel was used to guide the collection of information from each article. Data was first extracted from 10 articles, and then this form was modified before the completion of the data extraction. The following descriptive data was extracted from each article that satisfied the inclusion criteria: year of publication, language, country, study design, and study setting. For completed studies (not protocol studies) participant demographics were extracted, including number of participants, and participant age and sex. With respect to the CFS, we extracted information about persons who administered the CFS, cut points for identification of frailty, frailty prevalence, and the purpose of the CFS assessment. All outcomes and variables that studies assessed for a relationship with CFS were recorded. As numerous outcome variables were identified, outcomes were grouped according to overarching themes for the purpose of analysis. Analyses were conducted using IBM SPSS 21. Our database search retrieved 2907 articles and handsearching identified 5 additional articles for a total of 2912. After duplicates were removed, 1688 articles were included for title and abstract screening. We screened the full text of 1353 articles and 183 articles (Appendix 2) were identified for data extraction (Fig. 1) . The CFS was measured in hospitalized patients in 63% of the articles and in the community in 18% of the articles. Of the 97 in-hospital studies that reported the unit or ward, the most common units were Geriatric Medicine (15%) and Cardiology (11%) (Fig. 2 ). Of the 183 included studies, 168 were written in English (92%), most studies were conducted in Canada (29%) and in the United Kingdom (21%), and 62% of studies were conducted after 2015 (Table 1 ). In relation to study design, 85% of studies were observational and 14% were experimental; of these 25 experimental studies, 18 were randomized controlled trials ( Table 1) . The CFS was assessed by researchers (46% of articles) and by a variety of professionals with physicians being the most common (24%). The CFS was originally developed as a 7-point scale but there is currently an updated 9-point version. Among the included articles, 58% used the 7-point scale and 38% used the 9-point scale ( Figure 2 ). Of the 31 times the association between CFS score and age was examined, 77% found a significant relationship. Female sex was correlated with CFS score in 50% of the 18 times this association was tested (Supplementary Table 1 ). The association of the CFS with outcomes was examined 526 times and was a significant predictor in 390 (74%) (Fig. 3) . Several outcomes were examined, including mortality, comorbidity, disability, length of hospitalization, re-admission, institutionalization, cognitive function and falls. Mortality was the most common outcome measure, evaluated 68 times. The CFS was significantly associated with mortality in 87% of the cases. Of the 62 instances that looked at the association of CFS with comorbidity, 73% found a significant positive correlation. The CFS score was predictive of function (current function or functional decline) in 91% of the 45 times function was evaluated. The association of the CFS with the type of treatment received by patients was examined 37 times and the CFS was significantly associated in 73% of the cases. CFS score was significantly associated with mobility in 90% of the 31 instances. In addition, of the 18 studies that looked at the correlation between CFS scores and other measures of frailty 94% found significant association (Fig. 3) . A number of other outcomes and variables were examined for association with the Clinical Frailty Scale in smaller numbers of studies, and these are outlined in Supplementary Table 2 . In this scoping review, we have reviewed the research evidence pertaining to the CFS. The CFS has been used in a variety of contexts around the world. Although most administered in Canada and the United Kingdom use of this tool has reached Asia, South America, and other parts of Europe. The number of publications measuring the CFS has increased in recent years, possibly reflecting the medical community's interest in the topic of frailty as an important construct. The CFS is most often used in hospital settings, particularly on Geriatric Medicine and Cardiology units, however, has been applied to a range of inpatient and outpatient populations. The increase of its use in a variety of settings shows that researchers and clinicians value the ease and efficiency of using this judgement-based tool. In research, the CFS is commonly used to predict health outcomes. The outcomes with which it most has been reported to be significantly associated are mortality, comorbidity, functional decline, mobility, and cognitive decline. This study was scoping in nature, allowing us to capture a broad range of information about the use of the CFS in research. However, this study is limited by the Note that as one article did not specify setting, it is only included in the "All" column a Other staff includes personnel such as paramedics, LTC staff, junior medical staff and program evaluators # number; IQR interquartile range fact that it is not a meta-analysis and thus does not examine the quality of the evidence presented in each article. It was our aim to provide a high-level overview of this scale and its uses. In addition, the initial search was completed in 2017 and therefore does not incorporate articles published more recently. In recent years, as interest in frailty as a medical construct has increased, so too has the number of publications measuring the CFS. Overall, these studies have assessed the CFS in a range of different populations, which as a whole are representative of the general population of older adults. Preliminary analysis of this data demonstrated that the CFS has been found to be associated with a variety of important patient characteristics and clinical outcomes. Since the CFS combines clinical judgment with objective measurement and can be easily conducted, it has been seen as one of the most promising and practical ways of screening frailty in routine assessment [11] and especially in acute care [12] . This further supports the use of the CFS as a tool in clinical practice, as it provides valuable information to guide patient care and health policy development. Synthesizing the evidence around CFS and gaining a better understanding of its feasibility and psychometric properties, could assist with the development of education materials for clinicians about how the CFS can better inform the care they provide and how it can help them discuss with patients and their families the risks and benefits of potential treatments. This will assist clinicians to provide more informed and rational shared decision making. Most recently, beyond what had been imagined when designed, and not without controversy [13] [14] [15] [16] , the CFS has been suggested as a tool that can guide rationing of critical care resources if they become overwhelmed in the COVID-19 pandemic [17] . For this reason, we published a guide for using the Clinical Frailty Scale for people new to the scale [18] . The CFS is mostly used within geriatric medicine, cardiology, intensive care, general medicine, emergency medicine, surgery, and dialysis; information for other medical specialties is lacking. The CFS is also not commonly used to predict patient-oriented measures such as quality of life, which should be included in future observation studies using the CFS. Using the CFS to assess the degree of frailty in clinical settings extends beyond evaluating risk to mitigating frailty by understanding disease presentation, acute management, recovery time, and rehabilitation potential. Further research into the potential of this tool is warranted and will likely reveal novel applications to improve medical care of older adults. For example, investigation is warranted into whether implementing CFS in routine practice will improve care. In certain NHS centers in the United Kingdom, the CFS is routinely used to screen all patients over the age of 75 who are admitted to hospital via the Emergency Department [10] . Data from these institutions will be highly valuable in the advancement of frailty research. This scoping review revealed that the CFS has been widely used in multiple settings. Most of the included studies were conducted in hospital settings and most articles that examined the association of the CFS with adverse health outcomes showed that it has good predictive ability. The association of CFS score with clinical outcomes highlights its utility in the care of the aging population. SEARCH STRATEGY ((Clinical or "Canadian Study of Health and Aging" or CSHA or Rockwood or Videx or Dalhousie or "Capital District Health Authority" or CDHA) adj2 frailty adj2 (scale* or tool* or screen* or measure* or assess* or score* or index*)).tw. Included Articles Assessment of health status and program performance in patients on long-term oxygen therapy Prevalence of frailty and its association with mortality in general surgery Prevalence of multimorbidity and its association with outcomes in older emergency general surgical patients: an observational study Admission of the very elderly to the intensive care unit: Family members' perspectives on clinical decision-making from a multicenter cohort study The Very Elderly Admitted to ICU The prevalence of medical error related to end-of-life communication in Canadian hospitals: results of a multicentre observational study Predicting Performance Status 1 Year After Critical Illness in Patients 80 Years or Older READS: the Rapid Electronic Assessment Documentation System Characteristics of Older Adults Admitted to Hospital versus Those Discharged Home, in Emergency Department Patients Referred to Internal Medicine Probiotics for Antibiotic-Associated Diarrhoea (PAAD): a prospective observational study of antibiotic-associated diarrhoea (including Clostridium difficile-associated diarrhoea) in care homes. Health Technology Assessment Preoperative therapeutic exercise in frail elderly scheduled for total hip replacement: a randomized pilot trial The identification of frail older adults in primary care: comparing the accuracy of five simple instruments Comparison of the prognostic importance of diagnosed diabetes, co-morbidity and frailty in older people Delayed-Onset Left Main Coronary Artery Obstruction More than 24 Hours after Balloon-Expandable Transcatheter Aortic Valve Replacement Facilitating Frailty Identification: Comparison of Two Methods among Community-Dwelling Order Adults Quality of Life and Physical Function in Older Patients on Dialysis: A Comparison of Assisted Peritoneal Dialysis with Hemodialysis Undiagnosed long-term cognitive impairment in acutely hospitalised older medical patients with delirium: a prospective cohort study Acetylcholinesterase Activity Measurement and Clinical Features of Delirium Aging is associated with a numerical and functional decline in plasmacytoid dendritic cells, whereas myeloid dendritic cells are relatively unaltered in human peripheral blood Fractional flow reserve vs. angiography in guiding management to optimize outcomes in non-STsegment elevation myocardial infarction: the British Heart Foundation FAMOUS-NSTEMI randomized trial Components of the Risk Instrument for Screening in the Community (RISC) that Correlate with Public Health Nurses' Perception of Risk Return to the ED and hospitalisation following minor injuries among older persons treated in the emergency department: predictors among independent seniors within 6 months The Effect of Bleeding Risk and Frailty Status on Anticoagulation Patterns in Octogenarians With Atrial Fibrillation: The FRAIL-AF Study Enhancing elderly health examination effectiveness by adding physical function evaluations and interventions. Archives of Gerontology and Geriatrics Coronary angioplasty in octogenarians with emergent coronary syndromes: study protocol for a randomized controlled trial Fear of falling in robust community-dwelling older people: results of a cross-sectional study Bystander fatigue and CPR quality by older bystanders: a randomized crossover trial comparing continuous chest compressions and 30:2 compressions to ventilations Physical, social, psychological and existential trajectories of loss and adaptation towards the end of life for older people living with frailty: a serial interview study Recurrent hospitalisation with pneumonia is associated with higher 1-year mortality in frail older people Prevalence and impact of frailty on mortality in elderly ICU patients: a prospective, multicenter, observational study. Intensive Care Medicine Self-rated health: patterns in the journeys of patients with multi-morbidity and frailty Screening of frailty in elderly patients with disability by the means of Marigliano-Cacciafesta polypathology scale (MCPS) and Canadian Study of Health and Aging (CSHA) scales. Archives of Gerontology and Geriatrics The use of a frailty scoring system for burns in the elderly Hypertension among the elderly on the basis of nursing home residents population Severe frailty and cognitive impairment are related to higher mortality in 12-month follow-up of nursing home residents. Archives of Gerontology and Geriatrics Associations Between Dehydration, Cognitive Impairment, and Frailty in Older Hospitalized Patients: An Exploratory Study Comparative assessment of two frailty instruments for risk-stratification in elderly surgical patients: study protocol for a prospective cohort study A medication review and deprescribing method for hospitalised older patients receiving multiple medications An Exploratory Study of Long-Term Outcome Measures in Critical Illness Survivors Longitudinal evaluation of medication underuse in older outpatients and its association with quality of life Is Trunk Posture in Walking a Better Marker than Gait Speed in Predicting Decline in Function and Subsequent Frailty? Gut microbiota composition and Clostridium difficile infection in hospitalized elderly individuals: a metagenomic study Frailty syndrome in patients with heart rhythm disorders Frailty Syndrome in Heart Failure Patients who are Receiving Cardiac Resynchronization Palliative and Therapeutic Harmonization: A Model for Appropriate Decision-Making in Frail Older Adults Impact of frailty on outcomes after percutaneous coronary intervention: a prospective cohort study The prevalence of hyperglycaemia and its relationship with mortality, readmissions and length of stay in an older acute surgical population: a multicentre study PAlliative Care in chronic Kidney diSease: the PACKS study-quality of life, decision making, costs and impact on carers in people managed without dialysis Frailty and its association with rehabilitation outcomes in a post-acute older setting Comprehensive geriatric assessment of a mental health service user with safeguarding needs The prognostic value of high-sensitivity C-reactive protein and prealbumin for short-term mortality in acutely hospitalized multimorbid elderly patients: A prospective cohort study. The journal of nutrition, health & aging The association of serum procalcitonin and highsensitivity C-reactive protein with pneumonia in elderly multimorbid patients with respiratory symptoms: retrospective cohort study Early and Late Outcomes of Operation for Acute Type A Aortic Dissection in Patients Aged 80 Years and Older. The Annals of Thoracic Surgery Does specific interventional risk scoring better predict mortality than comorbidity in nonagenerians undergoing coronary angioplasty? Screening for markers of frailty and perceived risk of adverse outcomes using the Risk Instrument for Screening in the Community (RISC) Which Part of a Short, Global Risk Assessment, the Risk Instrument for Screening in the Community, Predicts Adverse Healthcare Outcomes? The Risk Instrument for Screening in the Community (RISC): a new instrument for predicting risk of adverse outcomes in community dwelling older adults Telemonitoring and Protocolized Case Management for Hypertensive Community-Dwelling Seniors With Diabetes: Protocol of the TECHNOMED Randomized Controlled Trial In-hospital treatment and outcomes of heart failure in specialist and non-specialist services: a retrospective cohort study in the elderly Characterizing End-of-Life Care after Geriatric Burns at a Verified Level I Burn Center Peroxidación lipídica en la membrana de los linfocitos y oxidación proteica en el suero de personas ancianas, ¿marcadores potenciales de fragilidad y dependencia? Resultados preliminares. Revista Española de Geriatría y Gerontología Decline in Activities of Daily Living After a Visit to a Canadian Emergency Department for Minor Injuries in Independent Older Adults: Are Frail Older Adults with Cognitive Impairment at Greater Risk? Frail older adults with minor fractures show lower health-related quality of life (SF-12) scores up to six months following emergency department discharge. Health and Quality of Life Outcomes Frailty and comorbidity are independent predictors of outcome in patients referred for pre-dialysis education Clinical frailty, subjective and objective measures in intensive care survivors Prediction of one-year mortality by five different frailty instruments: A comparative study in hospitalized geriatric patients High-technology based gait assessment in frail people: Associations between spatio-temporal and three-dimensional gait characteristics with frailty status across four different frailty measures. The journal of nutrition, health & aging Comparing the predictive accuracy of frailty, comorbidity, and disability for mortality: a 1-year follow-up in patients hospitalized in geriatric wards. Clinical Interventions in Aging How should we grade frailty in nursing home patients Physiological Redundancy in Older Adults in Relation to the Change with Age in the Slope of a Frailty Index Applying comprehensive geriatric assessment to investigate falls Clinical frailty adds to acute illness severity in predicting mortality in hospitalized older adults: An observational study Acute Hospital Use, Nursing Home Placement, and Mortality in a Frail Community-Dwelling Cohort Managed with Primary Integrated Interdisciplinary Elder Care at Home The time it takes … ' How doctors spend their time admitting a patient during the acute medical take Knowledge, attitudes, beliefs and behaviours of older adults about pneumococcal immunization, a Public Health Agency of Canada/Canadian Institutes of Health Research Influenza Research Network (PCIRN) investigation Fitness training for the old and frail Relationships between Frailty and Outcomes Following to Emergency Transportation in Elderly Patients in Rural Area Measurement of Disabilityfree Survival after Surgery Development of a risk score for outcome after transcatheter aortic valve implantation Measuring Frailty Can Help Emergency Departments Identify Independent Seniors at Risk of Functional Decline After Minor Injuries What weekday? How acute? An analysis of reported planned and unplanned GP visits by older multimorbid patients in the Patient Journey Record System database Management and outcomes of small bowel obstruction in older adult patients: a prospective cohort study Protocol for the PREHAB study--Pre-operative Rehabilitation for reduction of Hospitalization After coronary Bypass and valvular surgery: a randomised controlled trial A pragmatic triage system to reduce length of stay in medical emergency admission: Feasibility study and health economic analysis Relationship between input and output in acute medicine -secondary analysis of the Society for Acute Medicines benchmarking audit 2013 (SAMBA '13) Oneyear follow-up of patients undergoing elective cardiac surgery assessed with the Comprehensive Assessment of Frailty test and its simplified form. Interactive CardioVascular and Thoracic Surgery Comparison of 10 single and stepped methods to identify frail older persons in primary care: diagnostic and prognostic accuracy Prognostic value of simple frailty and malnutrition screening tools in patients with acute heart failure due to left ventricular systolic dysfunction Polypharmacy in chronic diseases-Reduction of Inappropriate Medication and Adverse drug events in older populations by electronic Decision Support (PRIMA-eDS): study protocol for a randomized controlled trial Comprehensive assessment of frailty for elderly high-risk patients undergoing cardiac surgery☆ A Rapid Bedside Screen to Predict Unplanned Hospitalization and Death in Outpatients with Cirrhosis: A Prospective Study of the Clinical Frailty Scale Operationalization of Frailty Using Eight Commonly Used Scales and Comparison of Their Ability to Predict All-Cause Mortality Lung ultrasound and chest x-ray for detecting pneumonia in an acute geriatric ward Performer fatigue and CPR quality comparing 30:2 to 15:2 compression to ventilation ratios in older bystanders: A randomized crossover trial Medication Reconciliation: Identifying Medication Discrepancies in Acutely Ill Hospitalized Older Adults Reducing Risk of Falling in Older People Discharged From Hospital: A Randomized Controlled Trial Comparing Seated Exercises, Weight-Bearing Exercises, and Social Visits. Archives of Physical Medicine and Rehabilitation Evidence of Detraining After 12-Week Home-Based Exercise Programs Designed to Reduce Fall-Risk Factors in Older People Recently Discharged From Hospital Association of the clinical frailty scale with hospital outcomes Urinary Incontinence and Its Association with Frailty Among Men Aged 80 Years or Older in Taiwan: A Cross-Sectional Study Thinking youre old and frail': a qualitative study of frailty in older adults Outcomes of burns in the elderly: Revised estimates from the Birmingham Burn Centre Large-Scale and Comprehensive Immune Profiling and Functional Analysis of Normal Human Aging Adverse outcomes following hospitalization in acutely ill older patients Comparison of Frailty Indicators Based on Clinical Phenotype and the Multiple Deficit Approach in Predicting Mortality and Physical Limitation Quality of life (QOL) among community dwelling older people in Taiwan measured by the CASP-19, an index to capture QOL in old age Risk factors for single and recurrent falls: A prospective study of falls in community dwelling seniors without cognitive impairment. Preventive Medicine Application of frailty index for comprehensive geriatric assessment in the elderly in China Into the night: Factors affecting response to abnormal Early Warning Scores out-of-hours and implications for service improvement What really matters in end-of-life discussions? Perspectives of patients in hospital with serious illness and their families An aging world Should frailty status always be considered when treating the elderly patient? Aging Health Frailty in elderly people: an evolving concept Frailty in elderly people Frailty consensus: a call to action A global clinical measure of fitness and frailty in elderly people The identification of frailty: a systematic literature review Importance of frailty in patients with cardiovascular disease The assessment of frailty in older people with chronic kidney disease The association of geriatric syndromes with hospital outcomes Frailty assessment in vascular surgery and its utility in preoperative decision making What do we know about frailty in the acute care setting? A scoping review Frailty in the face of COVID-19 Age alone is not adequate to determine health-care resource allocation during the COVID-19 pandemic Rationing care by frailty during the COVID-19 pandemic COVID-19: use of the clinical frailty scale for critical care decisions COVID-19 rapid guideline: critical care in adults. UK: National Institute for Health and Care Excellence Using the clinical frailty scale in allocating scarce health care resources A scoping review on the clinical frailty scale Publisher's Note Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations This work was previously presented as a poster at the 39th annual scientific meeting of the Canadian Geriatrics Society (CGS), Halifax, Nova Scotia, Canada [19] . The authors acknowledge the assistance of Emma Squires with literature search and screening, Robin Parker with search strategy, Kulapong Jayanama, and Iacopo Franconi with data extraction, and Takeshi Yabana with translation. Supplementary information accompanies this paper at https://doi.org/10. 1186/s12877-020-01801-7. Authors' contributions SC and OT directed and contributed to all aspects of this manuscript. KR contributed to study design, data interpretation and writing. ER contributed to literature search and data extraction. All authors read and approved the final manuscript. This project was funded by the Research in Medicine program at Dalhousie University. In-kind support was received from Geriatric Medicine Research of the Nova Scotia Health Authority and Dalhousie University. These bodies had no role in study design, data collection, analysis, or interpretation, or writing of the manuscript. The datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request.Ethics approval and consent to participate Not applicable. Not applicable.