Can an Intervention with Testosterone and Nutritional Supplement Improve the Frailty Level of Under-Nourished Older People?

OBJECTIVE

To examine whether a testosterone and a high calorie nutritional supplement intervention can reduce frailty scores in undernourished older people using multiple frailty tools.

DESIGN

Randomized controlled trial.

SETTING/PARTICIPANTS

53 community-dwelling, undernourished men and women aged >65 years from South Australia, Victoria and New South Wales.

INTERVENTION

Intervention group received oral testosterone undecanoate and a high calorie supplement (2108-2416 kJ/day) whereas the control group received placebo testosterone and low calorie supplement (142-191 kJ/day).

MEASUREMENTS

Frailty was operationalized using three frailty indices (FI-lab, FI-self-report, FI-combined) and the frailty phenotype.

RESULTS

There were no significant differences in changes in frailty scores at either 6 or 12 months follow up between the two treatment groups for all scales. Participants at the intervention group were 4.8 times more likely to improve their FI-combined score at both time points compared to the placebo group.

CONCLUSION

A testosterone and a high calorie nutritional supplement intervention did not improve the frailty levels of under-nourished older people. Even so, when frailty was measured using a frailty index combining self-reported and lab data we found that participants who received the intervention were more likely to show persistent improvement in their frailty scores.

Aging, frailty and complex networks

When people age their mortality rate increases exponentially, following Gompertz's law. Even so, individuals do not die from old age. Instead, they accumulate age-related illnesses and conditions and so become increasingly vulnerable to death from various external and internal stressors. As a measure of such vulnerability, frailty can be quantified using the frailty index (FI). Larger values of the FI are strongly associated with mortality and other adverse health outcomes. This association, and the insensitivity of the FI to the particular health variables that are included in its construction, makes it a powerful, convenient, and increasingly popular integrative health measure. Still, little is known about why the FI works so well. Our group has recently developed a theoretical network model of health deficits to better understand how changes in health are captured by the FI. In our model, health-related variables are represented by the nodes of a complex network. The network has a scale-free shape or "topology": a few nodes have many connections with other nodes, whereas most nodes have few connections. These nodes can be in two states, either damaged or undamaged. Transitions between damaged and non-damaged states are governed by the stochastic environment of individual nodes. Changes in the degree of damage of connected nodes change the local environment and make further damage more likely. Our model shows how age-dependent acceleration of the FI and of mortality emerges, even without specifying an age-damage relationship or any other time-dependent parameter. We have also used our model to assess how informative individual deficits are with respect to mortality. We find that the information is larger for nodes that are well connected than for nodes that are not. The model supports the idea that aging occurs as an emergent phenomenon, and not as a result of age-specific programming. Instead, aging reflects how damage propagates through a complex network of interconnected elements.

A Frailty Index Based On Deficit Accumulation Quantifies Mortality Risk in Humans and in Mice

Although many common diseases occur mostly in old age, the impact of ageing itself on disease risk and expression often goes unevaluated. To consider the impact of ageing requires some useful means of measuring variability in health in animals of the same age. In humans, this variability has been quantified by counting age-related health deficits in a frailty index. Here we show the results of extending that approach to mice. Across the life course, many important features of deficit accumulation are present in both species. These include gradual rates of deficit accumulation (slope = 0.029 in humans; 0.036 in mice), a submaximal limit (0.54 in humans; 0.44 in mice), and a strong relationship to mortality (1.05 [1.04–1.05] in humans; 1.15 [1.12–1.18] in mice). Quantifying deficit accumulation in individual mice provides a powerful new tool that can facilitate translation of research on ageing, including in relation to disease.

Prevalence of and factors associated with frailty and disability in older adults from China, Ghana, India, Mexico, Russia and South Africa

BACKGROUND

The severe burden imposed by frailty and disability in old age is a major challenge for healthcare systems in low- and middle-income countries alike. The current study aimed to provide estimates of the prevalence of frailty and disability in older adult populations and to examine their relationship with socioeconomic factors in six countries.

METHODS

Focusing on adults aged 50+ years, a frailty index was constructed as the proportion of deficits in 40 variables, and disability was assessed using the World Health Organization Disability Assessment Schedule (WHODAS 2.0), as part of the Study on global AGEing and adult health (SAGE) Wave 1 in China, Ghana, India, Mexico, Russia and South Africa.

RESULTS

This study included a total of 34,123 respondents. China had the lowest percentages of older adults with frailty (13.1%) and with disability (69.6%), whereas India had the highest percentages (55.5% and 93.3%, respectively). Both frailty and disability increased with age for all countries, and were more frequent in women, although the sex gap varied across countries. Lower levels of both frailty and disability were observed at higher levels of education and wealth. Both education and income were protective factors for frailty and disability in China, India and Russia, whereas only income was protective in Mexico, and only education in South Africa.

CONCLUSIONS

Age-related frailty and disability are increasing concerns for older adult populations in low- and middle-income countries. The results indicate that lower levels of frailty and disability can be achieved for older people, and the study highlights the need for targeted preventive approaches and support programs.

How Might Deficit Accumulation Give Rise to Frailty?

Frailty is a multiply determined vulnerability state. People who are frail are at risk of many adverse health outcomes, including death. For any individual, this risk can only be expressed probabilistically. Even very fit people can suddenly die or become catastrophically disabled, but their risk of both is much lower than a very frail person, who might nevertheless suddenly succumb without worsening health. Frailty occurs with ageing, a stochastic, dynamic process of deficit accumulation. Deficits occur ubiquitously at subcellular levels, ultimately affecting tissues, organs and integrated organ action, especially under stress. Some people are disposed to accumulate deficits at higher rates, but on average, deficit accumulation varies across the life course and likely is mutable. In this way, the clinical definition of frailty is distinct from the statistical definition, which sees frailty as a fixed factor for an individual. Recent, early animal work links subcellular deficits to whole body frailty. In humans, clinically detectable health deficits combine to increase the risk of adverse health outcomes. The rate of deficit accumulation occurs with remarkable regularity around the world, as does a limit to frailty. Of note, when 20+ deficits are counted, these characteristics are indifferent to which deficits are considered. The expression of risk in relation to deficit accumulation varies systematically. For example, at any given level of deficit accumulation, men are more susceptible to adverse health outcomes than are women. Likewise, in China, the lethality of deficit accumulation appears to be higher than in Western countries. In consequence, it may be necessary to better distinguish between frailty and physiological reserve; the latter may apply chiefly in relation to microscopic deficits. The expression of frailty risk in relation to deficit accumulation depends on the environment, including both the physical and social circumstances in which people find themselves.

Understanding Risk in the Oldest Old: Frailty and the Metabolic Syndrome in a Chinese Community Sample Aged 90+ Years

OBJECTIVES

To investigate the relationship between frailty and the metabolic syndrome and to evaluate how these contribute to mortality in very old people.

DESIGN

Secondary analysis of data from the Project of Longevity and Aging in Dujiangyan.

SETTING

Community sample from Sichuan Province, China.

PARTICIPANTS

People aged 90+ years (n=767; baseline age=93.7±3.4 years; 68.0% women.

MEASUREMENTS

After a baseline health assessment, participants were followed for four years (54.0% died). A frailty index (FI) was calculated as the sum of deficits present, divided by the 35 health-related deficits considered. Relationships between the FI and the metabolic syndrome were tested; their effect on death was examined.

RESULTS

The mean FI was 0.26 ±0.11. Higher FI scores were associated with a greater risk of death, adjusted for age, sex, education, and metabolic syndrome items. The hazard ratio was 1.03 (95% confidence interval 1.02, 1.04) for each 1% percent increase of the FI. The mortality risk did not change with the metabolic syndrome (odds ratio=0.99; 0.71-1.36).

CONCLUSIONS

In the oldest old, frailty was a significant risk for near-term death, regardless of the metabolic syndrome. Even using age-adjusted models, the epidemiology of late life illness may need to account for frailty routinely.

Measuring frailty using self-report and test-based health measures

BACKGROUND

previously, frailty indices were constructed using mostly subjective health measures. The reporting error in this type of measure can have implications on the robustness of frailty findings.

OBJECTIVE

to examine whether frailty assessment differs when we construct frailty indices using solely self-reported or test-based health measures.

DESIGN

secondary analysis of data from The Irish LongituDinal study on Ageing (TILDA).

SUBJECTS AND METHODS

4,961 Irish residents (mean age: 61.9 ± 8.4; 54.2% women) over the age of 50 years who underwent a health assessment were included in this analysis. We constructed three frailty indices using 33 self-reported health measures (SRFI), 33 test-based health measures (TBFI) and all 66 measures combined (CFI). The 2-year follow-up outcomes examined were all-cause mortality, disability, hospitalisation and falls.

RESULTS

all three indices had a right-skewed distribution, an upper limit to frailty, a non-linear increase with age, and had a dose-response relationship with adverse outcomes. Levels of frailty were lower when self-reported items were used (SRFI: 0.12 ± 0.09; TBFI: 0.17 ± 0.15; CFI: 0.14 ± 0.13). Men had slightly higher frailty index scores than women when test-based measures were used (men: 0.17 ± 0.09; women: 0.16 ± 0.10). CFI had the strongest prediction for risk of adverse outcomes (ROC: 0.64-0.81), and age was not a significant predictor when it was included in the regression model.

CONCLUSIONS

except for sex differences, characteristics of frailty are similar regardless of whether self-reported or test-based measures are used exclusively to construct a frailty index. Where available, self-reported and test-based measures should be combined when trying to identify levels of frailty.

A Frailty Index predicts 10-year fracture risk in adults age 25 years and older: results from the Canadian Multicentre Osteoporosis Study (CaMos)

We created a 30-item Frailty Index in the Canadian Multicentre Osteoporosis Study. A Frailty Index is a sensitive measure that can quantify fracture risk according to degree of frailty. Our results indicated that at any age, frailty was an important independent risk factor for fracture over 10 years.

INTRODUCTION

In later life, frailty has been linked to fractures. It is likely that the antecedents of fracture are seen across the life course, in ways not entirely captured by traditional osteoporosis risk factors. Using data collected from the prospective, population-based Canadian Multicentre Osteoporosis Study (CaMos), we created the 30-item CaMos Frailty Index and examined whether it was associated with incident fractures over 10 years.

METHODS

All CaMos participants aged 25 years and older (n = 9,423) were included in the analysis. To examine the relationship between baseline Frailty Index scores and incident fractures, a competing risk proportional sub-distribution hazards model was used with death considered a competing risk. Analyses were adjusted for age, sex, body mass index, education level, femoral neck T-score, and antiresorptive therapy.

RESULTS

At baseline, the mean age was 62.1 years [standard deviation (SD) 13.4], and 69.4 % were women. The mean Frailty Index score was 0.13 (SD 0.11), ranging from 0 to 0.66. For every 0.10 increase in Frailty Index scores (approximately one SD), the hazard ratio was 1.25 (p < 0.001) for all fractures, 1.18 (p = 0.043) for hip fractures, and 1.30 (p ≤ 0.001) for clinical vertebral fractures.

CONCLUSION

The CaMos Frailty Index quantified fracture risk according to degree of frailty. Irrespective of age and bone mineral density, the Frailty Index was associated with hip, vertebral, and all-type clinical fractures. Predicting late onset illnesses may have to consider overall health status and not just traditional risk factors.

Evaluation of common structural brain changes in aging and Alzheimer disease with the use of an MRI-based brain atrophy and lesion index: a comparison between T1WI and T2WI at 1.5T and 3T

BACKGROUND AND PURPOSE

The Brain Atrophy and Lesion Index combines several common, aging-related structural brain changes and has been validated for high-field MR imaging. In this study, we evaluated measurement properties of the Brain Atrophy and Lesion Index by use of T1WI and T2WI at 1.5T and 3T MR imaging to comprehensively assess the usefulness of the lower field-strength testing.

MATERIALS AND METHODS

Data were obtained from the Alzheimer's Disease Neuroimaging Initiative. Images of subjects (n = 127) who had T1WI and T2WI at both 3T and 1.5T on the same day were evaluated, applying the Brain Atrophy and Lesion Index rating. Criterion and construct validity and interrater agreement were tested for each field strength and image type.

RESULTS

Regarding reliability, the intraclass correlation coefficients for the Brain Atrophy and Lesion Index score were consistently high (>0.81) across image type and field strength. Regarding construct validity, the Brain Atrophy and Lesion Index score differed among diagnostic groups, being lowest in people without cognitive impairment and highest in those with Alzheimer disease (F > 5.14; P < .007). Brain Atrophy and Lesion Index scores correlated with age (r > 0.37, P < .001) and cognitive performance (r > 0.38, P < .001) and were associated with positive amyloid-β test (F > 3.96, P < .050). The T1WI and T2WI Brain Atrophy and Lesion Index scores were correlated (r > 0.93, P < .001), with the T2WI scores slightly greater than the T1WI scores (F > 4.25, P < .041). Regarding criterion validation of the 1.5T images, the 1.5T scores were highly correlated with the 3T Brain Atrophy and Lesion Index scores (r > 0.93, P < .001).

CONCLUSIONS

The higher field and T2WI more sensitively detect subtle changes in the deep white matter and perivascular spaces in particular. Even so, 1.5T Brain Atrophy and Lesion Index scores are similar to those obtained by use of 3T images. The Brain Atrophy and Lesion Index may have use in quantifying the impact of dementia on brain structures.

Promoting access to innovation for frail old persons. IAGG (International Association of Gerontology and Geriatrics), WHO (World Health Organization) and SFGG (Société Française de Gériatrie et de Gérontologie) Workshop--Athens January 20-21, 2012

Frailty tends to be considered as a major risk for adverse outcomes in older persons, but some important aspects remain matter of debate.

OBJECTIVES

The purpose of this paper is to present expert's positions on the main aspects of the frailty syndrome in the older persons.

PARTICIPANTS

Workshop organized by International Association of Gerontology and Geriatrics (IAGG), World Health Organization (WHO) and Société Française de Gériatrie et de Gérontologie (SFGG).

RESULTS

Frailty is widely recognized as an important risk factor for adverse health outcomes in older persons. This can be of particular value in evaluating non-disabled older persons with chronic diseases but today no operational definition has been established. Nutritional status, mobility, activity, strength, endurance, cognition, and mood have been proposed as markers of frailty. Another approach calculates a multidimensional score ranging from "very fit" to "severely frail", but it is difficult to apply into the medical practice. Frailty appears to be secondary to multiple conditions using multiple pathways leading to a vulnerability to a stressor. Biological (inflammation, loss of hormones), clinical (sarcopenia, osteoporosis etc.), as well as social factors (isolation, financial situation) are involved in the vulnerability process. In clinical practice, detection of frailty is of major interest in oncology because of the high prevalence of cancer in older persons and the bad tolerance of the drug therapies. Presence of frailty should also be taken into account in the definition of the cardiovascular risks in the older population. The experts of the workshop have listed the points reached an agreement and those must to be a priority for improving understanding and use of frailty syndrome in practice.

CONCLUSION

Frailty in older adults is a syndrome corresponding to a vulnerability to a stressor. Diagnostic tools have been developed but none can integrate at the same time the large spectrum of factors and the simplicity asked by the clinical practice. An agreement with an international common definition is necessary to develop screening and to reduce the morbidity in older persons.

Frailty in relation to the risk of falls, fractures, and mortality in older Chinese adults: results from the Beijing Longitudinal Study of Aging

OBJECTIVES

Falls are well known to be associated with adverse health outcomes, especially when complicated by fracture. Falls are more common in people who are frail and readily related to several items in the frailty phenotype. Less is known about the relationship between falls and frailty defined as deficit accumulation. Our objective was to investigate the relationship between falls, fractures, and frailty based on deficit accumulation.

DESIGN

Representative cohort study, with 8 year follow-up.

SETTING

The Beijing Longitudinal Study of Aging (BLSA).

PARTICIPANTS

3,257 Chinese people aged 55+ years at baseline.

MEASUREMENTS

A frailty index (FI) was constructed using 33 health deficits, but excluding falls and fractures. The rates of falls, fractures and death as a function of age and the FI were analyzed. Multivariable models evaluated the relationships between frailty and the risk of recurrent falls, fractures, and mortality adjusting for age, sex, and education. Self or informant reported fall and fracture data were verified against participants' health records.

RESULTS

Of 3,257 participants at baseline (1992), 360 people (11.1%) reported a history of falls, and 238 (7.3%) reported fractures. By eight years, 1,155 people had died (35.3%). The FI was associated with an increased risk of recurrent falls (OR=1.54; 95% confidence interval (CI)=1.34-1.76), fractures (OR=1.07; 95% CI=0.94-1.22), and death (OR=1.50, 95% CI=1.41-1.60). The FI showed a significant effect on mortality in a multivariate Cox regression model (Hazard Rate=1.29, 95% CI=1.25-1.33). When adjusted for the FI, neither falls nor fractures were associated with mortality.

CONCLUSION

Falls and fractures were common in older Chinese adults, and associated with frailty. Only frailty was independently associated with death.

Transitions in cognitive status in relation to frailty in older adults: a comparison of three frailty measures

OBJECTIVES

Cognitive decline is related to frailty. Frailty can be operationalized in different ways, which have an unknown impact on the estimation of risk. Here, we compared 3 frailty measures in relation to cognitive changes and mortality in the Canadian Study of Health and Aging (CSHA).

DESIGN

Prospective population-based study, with 5 year follow up.

PARTICIPANTS/SETTING

2,305 subjects aged 70+ years.

METHODS

For each participant, cognitive status was measured by the errors in the Modified Mini-Mental State Examination (3MS) score. Three frailty measures were used: a Frailty Index based on the Comprehensive Geriatric Assessment (FI-CGA) evaluated from 47 potential deficits, a Clinical Frailty Score and the Fried frailty phenotype. Multivariate Poisson regression and multivariate logistic regression were used to examine the association between baseline cognitive errors and frailty and death, respectively, while controlling for possible confounders (age, sex, education, and baseline cognitive status).

RESULTS

Changes in cognitive status were strongly associated with baseline cognition and frailty, however defined. In multivariate models adjusted for age, sex and education, each frailty measure was associated with cognitive decline and with mortality. The frailest people (from the highest FI-CGA tertile) rarely showed cognitive improvement or stabilization (1.5%, 95% CI=0.002%-2.8%) compared with non-frail people (from the lowest tertile of the FI-CGA), of whom 27.8% (95% CI=24.5%-31.1%) did not deteriorate.

CONCLUSIONS

Frail elderly people have an increased risk of cognitive decline. All frailty measures allowed quantification of individual vulnerability and predict both cognitive changes and mortality.

Comparison of the prognostic importance of diagnosed diabetes, co-morbidity and frailty in older people

AIMS

To compare the relative prognostic importance in older people of diagnosed diabetes, the number and severity of co-morbidities and frailty.

METHODS

Two thousand three hundred and five people aged > or = 70 years comprised the clinical examination cohort of the Canadian Study of Health and Aging. Frailty was defined as a score of > or = 5 on a 7-point Clinical Frailty Scale. The cohort was followed for 5 years.

RESULTS

Diabetes was more likely to be associated with medium-term mortality (adjusted hazard ratio (HR) 1.42; 95% confidence interval (CI) 1.20-1.69) than co-morbidity (HR 1.03; 95% CI 1.01-1.05). Frailty most strongly predicted death (HR 2.72; 95% CI 2.34-3.16). Frail older adults were 2.62 times (95% CI 1.36-5.06) more likely to have a complication of diabetes, independent of age, sex and number of years living with diabetes. People with diabetes were younger than those without (81.3 vs. 83.3 years) but a similar proportion were frail (42.2 vs.43.4%). The median life expectancy for frail older adults with diabetes was 23 months (95% CI 18-28 months).

CONCLUSIONS

In this cohort, the risk of mortality in older people was defined more precisely by a clinical measure of frailty than by diabetes or burden of co-morbidity. Those with diagnosed diabetes were younger than those without but had the same frailty status; diabetes can therefore be considered to increase 'biological age' by 2 years in those aged over 70 years. The limited life expectancy of frail older people with diabetes highlights the importance of recognizing frailty and supports the individualization of care in older people with diabetes.

Comparison of two frailty measures in the Conselice Study of Brain Ageing

OBJECTIVES

Uncertainty about the definition of frailty is reflected by the development of many ways to identify frail people. We aimed to compare the validity of two frailty measures in participants of the Conselice Study of Brain Aging.

DESIGN

Prospective population-based study with 4 year follow up.

PARTICIPANTS/SETTING

1,016 subjects aged 65 and over in a rural Italian population.

METHODS

For each participant, a Frailty Index (FI) and a Conselice Study of Brain Aging Score (CSBAS) were determined. The FI was created from 43 deficits according to a standardized methodology; 7 variables derived from a previously validated Easy Prognostic Score comprised the CSBAS.

RESULTS

The FI had characteristic properties described in other population samples, with a gamma distribution, a 99% limit of about 0.64 and higher values in women than men. CSBAS and FI were strongly correlated with each other (r = 0.72) and both correlated with age (r = 0.32, r = 0.27, respectively). Each was independently predictive of death in a multivariate model, with greater specificity and sensitivity than age alone.

CONCLUSIONS

Frailty can be measured by different tools and facilitates a more direct quantification of individual vulnerability than chronological age alone. Though the Frailty Index and the Conselice Study of Brain Aging Score are underpinned by different rationales, clinical utility will continue to motivate their development.