Explaining quality of life of older people in the Netherlands using a multidimensional assessment of frailty

Cognitive Frailty in Italian Community-Dwelling Older Adults: Prevalence Rate and Its Association with Disability

Cognitive frailty is the simultaneous clinical manifestation of both physical frailty and cognitive impairment. This paper aimed to propose and test an operational definition of cognitive frailty. The following specific aims were pursued: (i) to rate the prevalence of cognitive frailty; (ii) to evaluate differences in cognitive functioning among robust, pre-frail, and frail individuals; (iii) to examine the association of cognitive frailty with disability, in a sample of Italian community-dwelling older adults. Five hundred and ninety-four older adults (mean age 73.6 years, SD=5.8) were involved in this cross-sectional study. Cognitive frailty was operationalized using the Mini Mental State Examination (cut-off score equal or less than 25) for the evaluation of cognitive functions and the five criteria of the Cardiovascular Health Study (cut-off score equal or higher than 3) for the evaluation of physical frailty. Participants positive for both instruments were classified as cognitively frail. The outcome was disability measured with the Groningen Activity Restriction Scale. Descriptive statistics, one-way and two-way analysis of covariance (ANCOVA) were carried out. The prevalence rate of cognitive frailty was 4.4%. The one-way ANCOVA, controlling for age and gender, showed a significant difference (p< .001) among robust, pre-frail, and frail participants for the cognitive functioning. Moreover, cognitively frail individuals showed a difference (p<.001) in disability in comparison with non-frail participants. Our results are significant and provide empirical evidence about the usefulness of the cognitive frailty concept.

Association between Physical Frailty and Quality of Life in a Representative Sample of Community-Dwelling Swiss Older People

OBJECTIVE

Though the association between physical frailty and health is well established, little is known about its association with other domains of quality of life (QoL). This study investigated the association between physical frailty and multiple domains of QoL in community-dwelling older people.

DESIGN

Cross-sectional study.

SETTING AND PARTICIPANTS

Data of the 2011 annual assessment of 927 older people (age 73-77 years) from the Lc65+ cohort study were used.

MEASUREMENTS

Physical frailty was assessed by Fried's five criteria: 'shrinking'; 'weakness'; 'poor endurance, exhaustion'; 'slowness'; and 'low activity'. QoL was assessed using 28 items yielding a QoL score and seven domain-specific QoL subscores (Feeling of safety; Health and mobility; Autonomy; Close entourage; Material resources; Esteem and recognition; and Social and cultural life). Low QoL (QoL score or QoL subscores in the lowest quintile) was used as dependent variable in logistic regression analyses adjusted for age and sex (model 1), and additionally for socioeconomic (model 2) and health (model 3) covariates.

RESULTS

Physical frailty was associated with a low QoL score, as well as decreased QoL subscores in all seven specific domains, even after adjusting for socio-economic covariates. However, when performing additional adjustment for health covariates, only the domain Health and mobility remained significantly associated with physical frailty. Among each specific Fried's criteria, 'slowness' had the strongest association with a low QoL score.

CONCLUSION

Physical frailty is associated with all QoL domains, but these associations are largely explained by poor health characteristics. Longitudinal studies are needed to better understand temporal relationships between physical frailty, health and QoL.

Mobility, balance and frailty in community-dwelling older adults: What is the best 1-year predictor of falls?

AIM

The present study aimed, first, to compare the ability to predict falls over 12 months for three measures - mobility, balance and frailty. Second, among the three domains of frailty - physical, psychological and social - we investigated what is the strongest predictor of falls.

METHODS

A total of 192 community-dwelling older adults (age 73.0 ± 6.2 years; 62% women) were involved in this longitudinal study. The Timed Up and Go (TUG) test, One Leg Standing (OLS) test and the Tilburg Frailty Indicator (TFI) were respectively used to measure mobility, balance and frailty. The TFI is a questionnaire based on a multidimensional conceptualization of frailty consisting of 15 items in three domains (physical, psychological and social). Falls were self-reported during the 12-month follow up. Logistic regression models, adjusted for interesting variables, were carried out to predict the risk of falls.

RESULTS

History of falls and chronic conditions were the indicators more strongly related with falls over 12 months. The TFI resulted as a stronger predictor of falls when compared with the TUG and OLS tests. The explained variance of the three models was 31.2%, 22.4% and 22.2%, respectively. The TFI was significantly associated with falls (P < 0.001), whereas the TUG and the OLS were not (P > 0.05). Among the three frailty domains, physical (P < 0.001) and psychological (P = 0.041) domains were significant predictors of falls.

CONCLUSIONS

The findings showed that the TFI might be an effective tool for predicting falls at 12 months in aged populations, probably because it is able to capture the multifactorial facets that can lead to falls. Geriatr Gerontol Int 2017; 17: 1463-1469.

Psychometric properties of the Dutch WHOQOL-OLD

BACKGROUND

To assess the internal consistency reliability and construct validity of the Dutch version of the World Health Organization Quality of Life Instrument-Older Adults Module (WHOQOL-OLD).

METHODS

The psychometric properties of the Dutch WHOQOL-OLD were examined in a cross-sectional study using a sample of 1,340 people aged 60 years or older. Participants completed a Web-based questionnaire, the 'Senioren Barometer'. Reliability was evaluated using Cronbach's alpha and corrected item-total correlations. Construct validity of the Dutch WHOQOL-OLD was evaluated with confirmatory factor analyses, and correlations within and between scales, using scales WHOQOL-BREF, Short Form Health Survey (SF-12), Tilburg Frailty Indicator (TFI), and the Emotional and Social Loneliness Scale (ESLS).

RESULTS

The reliabilities of the six WHOQOL-OLD facets or subscales were sufficient to good (.66-.91). The convergent validity of the WHOQOL-OLD was good, whereas our findings on the divergent validity of the WHOQOL-OLD were somewhat mixed. Findings corroborating the divergent validity were that the 6-factor model fitted better than the second-order factor model, and WHOQOL-OLD facets sensory abilities, past, present and future activities, death and dying, intimacy correlated more strongly with similar than dissimilar scales. Not fully supporting divergent validity were the extremely high correlations between the factors corresponding to autonomy, past, present and future activities, and social participation.

CONCLUSION

We offer Dutch healthcare and social workers an instrument with good psychometric properties for measuring quality of life in older people. Further research on interrelations between WHOQOL-OLD facets is recommended.

Associations between daily physical activity, handgrip strength, muscle mass, physical performance and quality of life in prefrail and frail community-dwelling older adults

Purpose

The aim of this study was to examine the associations between daily physical activity (DPA), handgrip strength, appendicular skeletal muscle mass (ASMM) and physical performance (balance, gait speed, chair stands) with quality of life in prefrail and frail community-dwelling older adults.

Methods

Prefrail and frail individuals were included, as determined by SHARE-FI. Quality of life (QoL) was measured with WHOQOL-BREF and WHOQOL-OLD, DPA with PASE, handgrip strength with a dynamometer, ASMM with bioelectrical impedance analysis and physical performance with the SPPB test. Linear regression models adjusted for sex and age were developed: In model 1, the associations between each independent variable and QoL were assessed separately; in model 2, all the independent variables were included simultaneously.

Results

Eighty-three participants with a mean age of 83 (SD: 8) years were analysed. Model 1: DPA (ß = 0.315), handgrip strength (ß = 0.292) and balance (ß = 0.178) were significantly associated with ‘overall QoL’. Balance was related to the QoL domains of ‘physical health’ (ß = 0.371), ‘psychological health’ (ß = 0.236), ‘environment’ (ß = 0.253), ‘autonomy’ (ß = 0.276) and ‘social participation’ (ß = 0.518). Gait speed (ß = 0.381) and chair stands (ß = 0.282) were associated with ‘social participation’ only. ASMM was not related to QoL. Model 2: independent variables explained ‘overall QoL’ (R² = 0.309), ‘physical health’ (R² = 0.200), ‘autonomy’ (R² = 0.247) and ‘social participation’ (R² = 0.356), among which balance was the strongest indicator.

Conclusion

ASMM did not play a role in the QoL context of the prefrail and frail older adults, whereas balance and DPA were relevant. These parameters were particularly associated with ‘social participation’ and ‘autonomy’.

Explaining frailty by lifestyle

OBJECTIVE

To determine whether the effects of lifestyle factors on frailty can be adequately addressed by asking a single self-report question.

DESIGN

Cross-sectional study.

SETTING

A sample of Dutch citizens completed the web-based questionnaire "Seniorenbarometer".

PARTICIPANTS

610 persons aged 50 years and older.

MEASUREMENTS

Seven lifestyle factors were assessed: smoking, use of alcohol, intake of vegetables, intake of fruit, having breakfast, exercise, and teeth brushing. The single self-report question of lifestyle was: "Overall, how healthy would you say your lifestyle is?" Frailty was measured by the Tilburg Frailty Indicator.

RESULTS

Age was positively associated with a healthy lifestyle (less smoking, more intake of vegetables, fruit and eating breakfast). The lifestyle factors did not improve the prediction of total, physical, psychological, and social frailty, after controlling for the single self-report question.

CONCLUSION

Our study suggests that one general self-report lifestyle question, rather than a list of specific lifestyle factors, suffices for predicting frailty.

Frailty and quality of life in elderly patients with acute coronary syndrome

Background

Frail elderly people are at risk of developing adverse health outcomes such as disability, hospitalization, and mortality. In recent years, the literature has drawn attention to the role of frailty syndrome (FS) in acute coronary syndrome (ACS). There are few studies regarding the relationship between two multidimensional variables such as FS and quality of life (QoL).

Objective

The aim of the study was to investigate the relationship between FS and early QoL of elderly patients with ACS (≥65 years old).

Methods

The study was conducted among 91 patients aged 65 years and over with ACS. The MacNew questionnaire was used to evaluate QoL and the Tilburg frailty indicator to evaluate frailty.

Results

FS was present in 82.4% of patients. The average Tilburg frailty indicator score was 7.43±2.57. A negative correlation between the global values of FS and QoL was shown (r=−0.549, P<0.05). The vulnerability factors that negatively affected early QoL were: FS, marital status, conservative therapy, and hypertension. In multivariate analysis, FS was found to be the independent predictor of worse QoL (β ± standard error −0.277±0.122, P=0.026).

Conclusion

The presence of FS has a negative impact on early QoL in patients with ACS. The study suggests that in elderly patients with ACS, there is a need to identify frailty in order to implement additional therapeutic and nursing strategies in ACS.

Association between frailty and quality of life among community-dwelling older people: a systematic review and meta-analysis

BACKGROUND

With growing numbers of older people worldwide, improving and maintaining quality of life during the extended years of life are a major focus for healthcare providers and policymakers. Some studies have suggested frailty may be associated with worse quality of life.

OBJECTIVES

To review the associations between frailty and quality of life among community-dwelling older people.

METHODS

A systematic literature search was performed using five databases for cross-sectional and longitudinal studies examining associations between frailty and quality of life among community-dwelling older people published in 2000 or later. Reference lists of relevant studies were also manually searched. Authors were requested for data for a meta-analysis if necessary. Meta-analysis was attempted for studies using the same frailty criteria and quality-of-life instrument. Methodological quality, heterogeneity and publication bias were assessed.

RESULTS

The systematic review identified 5145 studies, among which 11 cross-sectional studies and two longitudinal studies were included in this review. Meta-analysis including four cross-sectional studies using the Fried Phenotype and 36-Item Short Form Health Survey showed that those classified as frail and prefrail had significantly lower mental and physical quality-of-life scores than those classified as non-frail. High heterogeneity and possible publication bias were noted.

CONCLUSIONS

This systematic review and meta-analysis has demonstrated the evidence of a consistent inverse association between frailty/prefrailty and quality of life among community-dwelling older people. Interventions targeted at reducing frailty may have the additional benefit of improving corresponding quality of life. More longitudinal analysis is required to determine this effect.

Associations of frailty and psychosocial factors with autonomy in daily activities: a cross-sectional study in Italian community-dwelling older adults

Frailty has been recognized as a risk factor for geriatric adverse events. Little is known of the role of psychosocial factors associated with frailty in explaining negative outcomes of aging. This study was aimed at 1) evaluating the differences in psychosocial factors among robust, prefrail, and frail individuals and 2) investigating whether there was any interaction effect of frailty status with empirically identified clusters of psychosocial factors on autonomy in the activities of daily living (ADLs). Two-hundred and ten older adults (age 73±6 years, 66% women) were involved in this study. Frailty was assessed using an adapted version of the frailty phenotype. The psychosocial factors investigated were depressive symptoms using the 20-item Center for Epidemiologic Studies Depression Scale, social isolation using the Friendship Scale, and loneliness feeling using the eight-item UCLA Loneliness Scale. The autonomy in ADLs was measured with the Groningen Activity Restriction Scale. Thirty-one percent of participants were robust, 55% prefrail, and 14% frail. We performed an analysis of covariance which showed differences between robust, prefrail, and frail individuals for all the psychosocial variables: Center for Epidemiologic Studies Depression Scale, F(2, 205)=18.48, P<0.001; Friendship Scale, F(2, 205)=4.59, P=0.011; UCLA Loneliness Scale, F(2, 205)=5.87, P=0.003, controlling for age and sex. Using the same covariates, the two-way analysis of covariance indicated an interaction effect of frailty with psychosocial factors in determining ADLs, F(4, 199)=3.53, P=0.008. This study demonstrates the close relationship between frailty and psychosocial factors, suggesting the need to take into account simultaneously physical and psychosocial components of human functioning.

Frailty predicts trajectories of quality of life over time among British community-dwelling older people

Purpose

To investigate associations between baseline frailty status and subsequent changes in QOL over time among community-dwelling older people.

Methods

Among 363 community-dwelling older people ≥65 years, frailty was measured using Frailty Index (FI) constructed from 40 deficits at baseline. QOL was measured using Older People’s Quality of Life Questionnaire (OPQOL) six times over 2.5 years. Two-level hierarchical linear models were employed to predict QOL changes over time according to baseline frailty.

Results

At baseline, mean age was 73.1 (range 65–90) and 62.0 % were women. Mean FI was 0.17 (range 0.00–0.66), and mean OPQOL was 130.80 (range 93–163). The hierarchical linear model adjusted for age, gender, ethnicity, education, and enrollment site predicted that those with higher FI at baseline have lower QOL than those with lower FI (regression coefficient = −47.64, p < 0.0001) and that QOL changes linearly over time with slopes ranging from 0.80 (FI = 0.00) to −1.15 (FI = 0.66) as the FI increases. A FI of 0.27 is the cutoff point at which improvements in QOL over time change to declines in QOL.

Conclusions

Frailty was associated with lower QOL among British community-dwelling older people. While less frail participants had higher QOL at baseline and QOL improved over time, QOL of frailer participants was lower at baseline and declined.

Electronic supplementary material

The online version of this article (doi:10.1007/s11136-015-1213-2) contains supplementary material, which is available to authorized users.

Health Promotion Can Postpone Frailty: Results from the RCT Elderly Persons in the Risk Zone

OBJECTIVE

Very old persons (80+) are often described as "frail", implying that they are particularly vulnerable to adverse health outcomes. Elderly Persons in the Risk Zone was designed to determine whether a preventive home visit or multiprofessional senior group meetings could postpone deterioration in frailty if the intervention is carried out when the person is not so frail.

DESIGN AND SAMPLE

The study was a RCT with follow-ups at 1 and 2 years. A total of 459 persons (80+), still living at home, were included. Participants were independent in activities of daily life and cognitively intact.

MEASURES

Frailty was measured in two complementary ways, with the sum of eight frailty indicators and with the Mob-T Scale measuring tiredness in daily activities.

RESULTS

Both interventions showed favorable effects in postponing the progression of frailty measured as tiredness in daily activities for up to 1 year. However, neither of the two interventions was effective in postponing frailty measured with the sum of frailty indicators.

CONCLUSIONS

The results in this study show the potential of health promotion to older persons. The multiprofessional approach, including a broad spectrum of information and knowledge, might have been an important factor contributing to a more positive view of aging.

The Italian Version of the Tilburg Frailty Indicator: Analysis of Psychometric Properties

This study aims to assess the reliability, construct validity (convergent/divergent), and criterion validity of the Italian version of the Tilburg Frailty Indicator (TFI). The TFI is a self-report questionnaire for screening frailty in older adults. Two hundred and sixty-seven community-dwelling older adults were involved. Psychometric properties were analyzed using validated instruments. Adverse outcomes such as disability, falls, and visits to a general practitioner were detected. Participants were mainly women (59.9%), with a mean age of 73.4 years (SD = 6.0). Internal consistency reliability was acceptable. Construct validity was good, since each item of the TFI correlated as expected with corresponding frailty measures. Convergent and divergent validity were adequate for all the domains of the TFI. Criterion validity was excellent for disability and mediocre for the other two outcomes. This study supports the validity of the Italian TFI and offers to clinicians and scientists a multidimensional instrument for identifying frail individuals in the Italian context.

Content validation of the Tilburg Frailty Indicator from the perspective of frail elderly. A qualitative explorative study

The Tilburg Frailty Indicator is a questionnaire with a bio-psycho-social approach, which measures frailty by 15 questions. A questionnaire about frailty should be in alignment with experiences of frail elderly themselves as a target population is an important source of knowledge in content validation.

AIM

To validate the Tilburg Frailty Indicator on content in relation to the physical, psychological and social domain by exploring the experience of daily life of community dwelling frail elderly.

METHODS

The design was a qualitative content validation study. The participants were acutely admitted frail elderly discharged to home and interviewed one week after discharge. A deductive content analysis, with categories structured in advance, was performed.

RESULTS

A total of 422 meaning units were extracted from the transcriptions; 131 units related to the physical domain, 106 units to the psychological domain and 185 units to the social domain. 56 units were not linked into the existing structure of the questionnaire. 14 of 15 questions were confirmed from a target population perspective. The four issues pain, sleep quality, spirituality and meaningful activities that seem to be important elements for frail elderly were not directly covered by the questionnaire.

DISCUSSION

It seems likely that the majority of important items related to frailty are covered in the questionnaire. The findings add to the scientific body of knowledge in relation to the validity of the questionnaire. Future research should investigate the importance of the four issues pain, sleep quality, spirituality and meaningful activities in relation to the screening of frailty.

Qualidade de vida do idoso fragilizado e institucionalizado

Objetivo Avaliar a qualidade de vida de idosos frágeis institucionalizados. Métodos Estudo transversal com a inclusão de 33 idosos frágeis e pré-frágeis, classificados a partir da Escala de Fragilidade de Edmonton. Foram aplicados: um instrumento para caracterização dos aspectos sociodemográficos e o instrumento World Health Organization Quality of Life for Older Persons para avaliação da qualidade de vida. Resultados Houve predomínio do sexo feminino (54,5%) e a média de idade foi de 76,8 anos (±9,3). Observou-se associação significativa entre a qualidade de vida e todas suas facetas, e houve forte relação entre qualidade de vida e “atividades passadas, presentes e futuras” (r=0,715; p<0,001). Conclusão A presença de fragilidade não interferiu diretamente na qualidade de vida de idosos e apresentou associação significativa com motivo de institucionalização.

Frailty as a predictor of short-term adverse outcomes

The objectives of this study were to compare how different frailty measures (Frailty Phenotype/FP, Groningen Frailty Indicator/GFI and Tilburg Frailty Indicator/TFI) predict short-term adverse outcomes. Secondarily, adopting a multidimensional approach to frailty (integral conceptual model–TFI), this study aims to compare how physical, psychological and social frailty predict the outcomes. A longitudinal study was carried out with 95 community-dwelling elderly. Participants were assessed at baseline for frailty, determinants of frailty, and adverse outcomes (healthcare utilization, quality of life, disability in basic and instrumental activities of daily living/ADL and IADL). Ten months later the outcomes were assessed again. Frailty was associated with specific healthcare utilization indicators: the FP with a greater utilization of informal care; GFI with an increased contact with healthcare professionals; and TFI with a higher amount of contacts with a general practitioner. After controlling for the effect of life-course determinants, comorbidity and adverse outcome at baseline, GFI predicted IADL disability and TFI predicted quality of life. The effect of the FP on the outcomes was not significant, when compared with the other measures. However, when comparing TFI’s domains, the physical domain was the most significant predictor of the outcomes, even explaining part of the variance of ADL disability. Frailty at baseline was associated with adverse outcomes at follow-up. However, the relationship of each frailty measure (FP, GFI and TFI) with the outcomes was different. In spite of the role of psychological frailty, TFI’s physical domain was the determinant factor for predicting disability and most of the quality of life.

Validation of an integral conceptual model of frailty in older residents of assisted living facilities

OBJECTIVE

The aim of this cross-sectional study was to examine the validity of an integral model of the associations between life-course determinants, disease(s), frailty, and adverse outcomes in older persons who are resident in assisted living facilities.

METHODS

Between June 2013 and May 2014 seven assisted living facilities were contacted. A total of 221 persons completed the questionnaire on life-course determinants, frailty (using the Tilburg Frailty Indicator), self-reported chronic diseases, and adverse outcomes disability, quality of life, health care utilization, and falls. Adverse outcomes were analyzed with sequential (logistic) regression analyses.

RESULTS

The integral model is partially validated. Life-course determinants and disease(s) affected only physical frailty. All three frailty domains (physical, psychological, social) together affected disability, quality of life, visits to a general practitioner, and falls. Contrary to the model, disease(s) had no effect on adverse outcomes after controlling for frailty. Life-course determinants affected adverse outcomes, with unhealthy lifestyle having consistent negative effects, and women had more disability, scored lower on physical health, and received more personal and informal care after controlling for all other predictors.

CONCLUSION

The integral model of frailty is less useful for predicting adverse outcomes of residents of assisted living facilities than for community-dwelling older persons, because these residents are much frailer and already have access to healthcare facilities.

PRACTICAL IMPLICATIONS

The present study showed that a multidimensional assessment of frailty, distinguishing three domains of frailty (physical, psychological, social), is beneficial with respect to predicting adverse outcomes in residents of assisted living facilities.

Quality of life of frail elderly users of the primary care

Objective Identifying the quality of life of frail elderly patients, users of primary care services. Methods A cross-sectional, quantitative study. The sample size was calculated based on the estimate of population proportion and consisted of 203 elderly. Data were collected by using a questionnaire of physical activity for the elderly, fatigue/exhaustion, quality of life, and by carrying out a test of gait speed, handgrip strength and anthropometric measurement. Results Among the 203 seniors, 39 were fragile. The mean scores for quality of life presented by the frail elderly were the following: 60.4 for pain, functional capacity 61.1, limitations due to physical aspects 71.1, general state of health 71.4, vitality 75, mental health 76.4, emotional aspects 81.1 and social aspects 85.6. Conclusion The dimensions of quality of life of the frail elderly that had lower mean scores were pain, functional capacity, limitations due to physical aspects and general state of health.

Portuguese version of the Tilburg Frailty Indicator: Transcultural adaptation and psychometric validation

AIM

To present the translation and validation process of the Portuguese version of the Tilburg Frailty Indicator (TFI).

METHODS

A cross-sectional study was designed using a non-probability sample of 252 community-dwelling older adults. Preliminary studies were carried out for face and content validity assessment. Internal consistency, test-retest reliability, construct (convergent/divergent) and criterion validity were subsequently analyzed.

RESULTS

The sample was mainly women (75.8%), with a mean age of 79.2 ± 7.3 years. TFI internal consistency was good (KR-20 = 0.78). Test-retest reliability for the total was also good (r = 0.91), with kappa coefficients showing substantial agreement for most items. TFI physical and social domains correlated as expected with concurrent measures, whereas the TFI psychological domain showed similar correlations with other psychological and physical measures. The TFI showed a good to excellent discrimination ability in regard to frailty criteria, and fair to good ability to predict adverse outcomes.

CONCLUSIONS

The psychometric properties of the TFI seem to be consistently good. These findings provide initial evidence that the Portuguese version is a valid and reliable measure for assessing frailty in the elderly.