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

Applicability of laboratory deficit-based frailty index in predominantly older patients with end-stage renal disease under chronic dialysis: A pilot test of its correlation with survival and self-reported instruments

AIM

Laboratory deficit-based frailty index (LFI) exhibited outcome-prediction ability in the elderly, but not in those with end-stage renal disease (ESRD). We hypothesized that LFI results might have outcome correlation and correlate closely with other instruments in ESRD patients.

METHODS

We prospectively enroled ESRD patients between 2014 and 2015 and administered self-report frailty instruments (Strawbridge questionnaire, Edmonton frail scale (EFS), Groningen frailty indicator (GFI), Tilburg frailty indicator, G8 questionnaire and FRAIL scale), and Cardiovascular Health Study (CHS) scale, with two types of LFI calculated. They were followed up until June 30, 2017. Correlations between the results of six instruments, CHS scale, and those of LFI were identified, followed by Kaplan-Meier survival analyses and logistic regression analyses to compare those with high and low LFI.

RESULTS

The frailty prevalence was 33.3% (CHS), 78.8% Strawbridge questionnaire, 45.5% (EFS), 57.6% (GFI), 27.3% (Tilburg frailty indicator), 84.8% (G8) and 18.2% (FRAIL) among ESRD participants. LFI-1 results were significantly correlated with those of LFI-2 (P < 0.01), EFS (P = 0.04) and GFI (P < 0.01), while LFI-2 results were not. Those with CHS or GFI-identified frailty had significantly lower 1,25-(OH)₂ -D levels than those without. After 32.3 ± 5.4 months, patients with high LFI-1 scores, but not LFI-2, had a significantly higher mortality than those with lower scores. GFI and EFS scores were also independently associated with LFI-1, while CHS scores exhibited borderline association only.

CONCLUSION

Among a group of predominantly older ESRD patients, LFI differentiates patients with good and poor outcomes, supporting its applicability in these patients.

Frailty Assessment Scales for the Elderly and their Application in Primary Care: A Systematic Literature Review

Background

The increase in the elderly population is causing changes and challenges that demand a comprehensive public health response. A specific characteristic of the elderly is their frailty. Today’s problems with identifying levels of frailty are being resolved by numerous tools in the form of frailty assessment scales. This systematic review establishes which frailty assessment scales for the elderly are being used and what their applicability in primary care is like in Slovenia and around the world.

Methods

Documents published after 2010 were searched for in the PubMed database using keywords and other specific criteria.

Results

A total of 177 search hits were obtained based on various search strings. The final analysis included 28 articles, of which three were systematic literature reviews. These three covered quantitative studies, mainly consisting of observational cross-sectional surveys or cohort studies. Three other studies featured non-systematic literature reviews. Quantitative studies (mainly cross-sectional surveys or cohort studies) prevailed among the remaining 22 articles. One study had a qualitative design (Delphi method). The main outcome measures observed by all studies were frailty assessment scales for the elderly, the majority of which were evaluated on a sample of the elderly.

Conclusions

None of the assessment scales examined are used as the gold standard for primary care. A variety of tools are being used in clinical practice to assess frailty in elderly patients, highlighting the need for standardization and guidelines. This requires evaluating the current assessment scales in terms of validity and reliability, and suitably improving them.

Associations between a laboratory frailty index and adverse health outcomes across age and sex

OBJECTIVE

Early frailty may be captured by a frailty index (FI) based entirely on vital signs and laboratory tests. Our aim was to examine associations between a laboratory-based FI (FI-Lab) and adverse health outcomes, and investigate how this changed with age.

METHODS

Up to 8988 individuals aged 20+ years from the 2003-2004 and 2005-2006 National Health and Nutrition Examination Survey cohorts were included. Characteristics of the FI-Lab were compared to those of a self-reported clinical FI. Associations between each FI and health care use, self-reported health, and disability were examined in the full sample and across age groups.

RESULTS

Laboratory-based FI scores increased with age but did not demonstrate expected sex differences. Women aged 20-39 years had higher FI scores than men; this pattern reversed after age 60 years. FI-Lab scores were associated with poor self-reported health (odds ratio[95% confidence interval]: 1.46[1.39-1.54]), high health care use (1.35[1.29-1.42]), and high disability (1.41[1.32-1.50]), even among those aged 20-39 years.

CONCLUSION

Higher FI-Lab scores were associated with poor health outcomes at all ages. Associations in the youngest group support the notion that deficit accumulation occurs across the lifespan. FI-Lab scores could be utilized as an early screening tool to identify deficit accumulation at the cellular and molecular level before they become clinically visible.

Do sex differences in chronic disease underpin the sex-frailty paradox?

The 'male-female health-survival paradox' is a well-described clinical phenomenon. More recently, it has been conceptualized as a 'sex-frailty paradox': females may be considered to be more frail (because they have poorer health status) but also less frail (because they are less vulnerable to death) than males of the same age. Here, we review potential biological, behavioral and social mechanisms underpinning sex differences in morbidity, mortality and frailty before considering the question at the center of the sex paradox - why is it that females are able to tolerate poor health better than males? We explore, in detail, a frequently cited explanation for the sex paradox that centers on sex differences in chronic disease and conclude by presenting a new approach to this old hypothesis.

Prediction of mortality in Chinese very old people through the frailty index based on routine laboratory data

The increased risk of death in older adults can be successfully identified through frailty index (FI), based on comprehensive geriatric assessment data and self-reported data from the accumulated deficit, although the method depending on routine laboratory data (FI-LAB) remains uncertain. In the current study, the capacity of FI-LAB in evaluating the risk of mortality in a very old Chinese community cohort was analyzed. The 90-year- and above old individuals from a Dujiangyan community in Sichuan Province, China, who had completed a health assessment at baseline (in 2005) and whose laboratory data were analyzed (n = 736) from cumulative data from the Project of Longevity and Aging. The FI-LAB data was constructed from routine laboratory data and calculated as the ratio of abnormal factors in 22 variables (including red blood cells, white blood cells, and alanine transaminase) that can be assessed through blood tests. The multivariable Cox regression was used to evaluate the effect of frailty on death. In the four-year follow-up, 53.5% of the 736 participants (age = 93.6 ± 3.4 years; 67.5% women), were reported dead. The FI-LAB mean baseline value was 0.21 (standard deviation = 0.10; range = 0 to 0.55). Frailty (after adjusting for gender, age, and other confounders) could be directly correlated with increased death risk, with a hazard ratio of 1.31 (95% confidence interval (CI): 1.07–1.61) in comparison with those without frailty among the individuals. Frailty as defined by FI-LAB, established only on routine laboratory data, indicates a significant death risk in the very old people.

Self-Reported Cognitive Frailty Predicts Adverse Health Outcomes for Community-Dwelling Older Adults Based on an Analysis of Sex and Age

OBJECTIVES

The present study examined whether the combination of self-reported mobility decline (SR-MD) and cognitive decline (SR-CD) was associated with mortality and new long-term care insurance (LTCI) service certifications based on sex and age.

DESIGN

A prospective cohort study.

SETTING AND PARTICIPANTS

We analyzed cohort data from a sample of older adult residents in Kami Town, Japan. The response rate was 94.3%, and we followed 5,094 older adults for 3 years. Full analyses were conducted on 5,076 participants.

MEASURES

A total of four groups were determined through self-reported responses on the Kihon Checklist for SR-MD (a score of 3 or more on 5 items) and SR-CD (a score of 1 or more on 3 items): non-SR-cognitive frailty, non-SR-MD and SR-CD, SR-MD and non-SR-CD, and SR-cognitive frailty.

RESULTS

Main outcomes included mortality (n = 262) or new certifications for LTCI services (n = 708) during the 3-year period. Excluding overlapping, this included 845 older adults (16.6%). Among men, prevalence of non-SR-cognitive frailty, non-SR-MD and SR-CD, SR-MD and non-SR-CD, and SR-cognitive frailty (SR-MD and SR-CD) was 48.2%, 26.4%, 11.5%, and 13.8%, respectively. Respective rates for women were 45.7%, 15.5%, 23.1%, and 15.7%. Multivariate analyses revealed that for men, SR-MD and non-SR-CD significantly affected adverse health outcomes, leading to earlier negative outcomes relative to the non-SR-MD and SR-CD group. For women, non-SR-MD and SR-CD and SR-MD and non-SR-CD had similar slopes.

CONCLUSIONS

The impact of SR-MD or SR-CD on adverse health outcomes differed as a function of age and sex. Thus, we need to consider preventive approaches according to these specific target group features.

Sex And Prognostic Significance of Self-Reported Frailty in Non-ST-Segment Elevation Acute Coronary Syndromes: Insights From the TRILOGY ACS Trial

BACKGROUND

The effect of sex on self-reported frailty in acute coronary syndromes (ACS) is unclear. We examined the prevalence of self-reported frailty and its association with all-cause death among men and women.

METHODS

Elderly (≥ 65 years) male (n = 2691) and female (n = 2305) patients with ACS enrolled in the Targeted Platelet Inhibition to Clarify the Optimal Strategy to Medically Manage Acute Coronary Syndromes (TRILOGY ACS) trial were screened using the Fried Frailty Index. Sex differences in prevalence of frailty symptoms and categories (not frail; prefrail [1 to 2 symptoms]; and frail [≥ 3 symptoms]) and their prognostic importance were examined.

RESULTS

Women were older and had higher rates of comorbidities than men. A total of 739 (27.5%) men and 645 (28%) women reported ≥ 1 frailty symptom. Prevalence of frailty increased with age among men but not women. During a median follow-up of 17.3 months, 353 (13.1%) men and 266 (11.5%) women died. After adjusting for age, prefrail men had a 35% increased risk (hazard ratio [HR] 1.35; 95% confidence interval [CI], 1.07-1.71), and frail men had an 80% increased risk (HR 1.80; 95% CI, 1.22-2.67) of death relative to not-frail men. The age-adjusted HR for death in prefrail women was 1.40 (95% CI, 1.07-1.84), and 1.55 (95% CI, 0.96-2.49) in frail women relative to not-frail women. Self-reported slow walk time and decreased physical activity appeared to provide the most prognostic information.

CONCLUSION

Self-reported frailty was similar among men and women with ACS. Frailty increased with age only among men, in whom it added more prognostic information. Patient-reported frailty may identify elderly patients with ACS, particularly men, at high-risk of mortality.

Cardiovascular risk factors and frailty in a cross-sectional study of older people: implications for prevention

Objective

to examine the associations of cardiovascular disease (CVD) and cardiovascular risk factors with frailty.

Design

a cross-sectional study.

Setting

the Irish Longitudinal Study on Ageing (TILDA).

Participants

frailty measures were obtained on 5,618 participants and a subset of 4,330 participants with no prior history of CVD.

Exposures for observational study

cardiovascular risk factors were combined in three composite CVD risk scores (Systematic Coronary Risk Evaluation [SCORE], Ideal Cardiovascular Health [ICH] and Cardiovascular Health Metrics [CHM]).

Main outcome measures

a frailty index (40-items) was used to screen for frailty.

Methods

the associations of CVD risk factors with frailty were examined using logistic regression.

Results

overall, 16.4% of participants had frailty (7.6% at 50-59 years to 42.5% at 80+ years), and the prevalence was higher in those with versus those without prior CVD (43.0% vs. 10.7%). Among those without prior CVD, mean levels of CVD risk factors were closely correlated with higher frailty index scores. Combined CVD risk factors, assessed using SCORE, were linearly and positively associated with frailty. Compared to low-to-moderate SCOREs, the odds ratio (OR) (95% confidence interval, CI) of frailty for those with very high risk was 3.18 (2.38-4.25). Conversely, ICH was linearly and inversely associated with frailty, with an OR for optimal health of 0.29 (0.21-0.40) compared with inadequate health.

Conclusions

the concordant positive associations of SCORE and inverse associations of ICH and CHM with frailty highlight the potential importance of optimum levels of CVD risk factors for prevention of disability in frail older people.

Is frailty a stable predictor of mortality across time? Evidence from the Cognitive Function and Ageing Studies

Background

age-specific mortality reduction has been accompanied by a decrease in the prevalence of some diseases and an increase in others. Whether populations are becoming ‘healthier’ depends on which aspect of health is being considered. Frailty has been proposed as an integrative measure to quantify health status.

Objective

to investigate changes in the near-term lethality of frailty before and after a 20-year interval using the frailty index (FI), a summary of age-related health deficit accumulation.

Design

baseline data from the Cognitive Function and Ageing Studies (CFAS) in 1991 (n = 7,635) and 2011 (n = 7,762).

Setting

three geographically distinct UK centres (Newcastle, Cambridgeshire and Nottingham).

Subjects

individuals aged 65 and over (both institutionalised and community-living).

Methods

a 30-item frailty score was used, which includes morbidities, risk factors and subjective measures of disability. Missing items were imputed using multiple imputations by chained equations. Binomial regression was used to investigate the relationship between frailty, age, sex and cohort. Two-year mortality was modelled using logistic regression.

Results

mean frailty was slightly higher in CFAS II (0.19, 95% confidence interval (CI): 0.19–0.20) than CFAS I (0.18, 95% CI: 0.17–0.18). Two-year mortality in CFAS I was higher than in CFAS II (odds ratio (OR) = 1.16, 95% CI: 1.03–1.30). The association between frailty and 2-year mortality was non-linear with an OR of ~1.6 for each 0.10 increment in the FI.

Conclusions

the relationship between frailty and mortality did not significantly differ across the studies. Severe frailty as an indicator of mortality is shown to be a stable construct.

Diagnostic test accuracy of self-reported frailty screening instruments in identifying community-dwelling older people at risk of frailty and pre-frailty: a systematic review protocol

REVIEW QUESTION/OBJECTIVE

The question of this systematic review is: What is the diagnostic test accuracy of self-reported frailty screening instruments among community-dwelling older people against any of the following reference standard tests: the frailty phenotype, frailty index and comprehensive geriatric assessment?

Frailty and pre-frailty in middle-aged and older adults and its association with multimorbidity and mortality: a prospective analysis of 493 737 UK Biobank participants

BACKGROUND

Frailty is associated with older age and multimorbidity (two or more long-term conditions); however, little is known about its prevalence or effects on mortality in younger populations. This paper aims to examine the association between frailty, multimorbidity, specific long-term conditions, and mortality in a middle-aged and older aged population.

METHODS

Data were sourced from the UK Biobank. Frailty phenotype was based on five criteria (weight loss, exhaustion, grip strength, low physical activity, slow walking pace). Participants were deemed frail if they met at least three criteria, pre-frail if they fulfilled one or two criteria, and not frail if no criteria were met. Sociodemographic characteristics and long-term conditions were examined. The outcome was all-cause mortality, which was measured at a median of 7 years follow-up. Multinomial logistic regression compared sociodemographic characteristics and long-term conditions of frail or pre-frail participants with non-frail participants. Cox proportional hazards models examined associations between frailty or pre-frailty and mortality. Results were stratified by age group (37-45, 45-55, 55-65, 65-73 years) and sex, and were adjusted for multimorbidity count, socioeconomic status, body-mass index, smoking status, and alcohol use.

FINDINGS

493 737 participants aged 37-73 years were included in the study, of whom 16 538 (3%) were considered frail, 185 360 (38%) pre-frail, and 291 839 (59%) not frail. Frailty was significantly associated with multimorbidity (prevalence 18% [4435/25 338] in those with four or more long-term conditions; odds ratio [OR] 27·1, 95% CI 25·3-29·1) socioeconomic deprivation, smoking, obesity, and infrequent alcohol consumption. The top five long-term conditions associated with frailty were multiple sclerosis (OR 15·3; 99·75% CI 12·8-18·2); chronic fatigue syndrome (12·9; 11·1-15·0); chronic obstructive pulmonary disease (5·6; 5·2-6·1); connective tissue disease (5·4; 5·0-5·8); and diabetes (5·0; 4·7-5·2). Pre-frailty and frailty were significantly associated with mortality for all age strata in men and women (except in women aged 37-45 years) after adjustment for confounders.

INTERPRETATION

Efforts to identify, manage, and prevent frailty should include middle-aged individuals with multimorbidity, in whom frailty is significantly associated with mortality, even after adjustment for number of long-term conditions, sociodemographics, and lifestyle. Research, clinical guidelines, and health-care services must shift focus from single conditions to the requirements of increasingly complex patient populations.

FUNDING

CSO Catalyst Grant and National Health Service Research for Scotland Career Research Fellowship.

The association between bouts of moderate to vigorous physical activity and patterns of sedentary behavior with frailty

OBJECTIVES

To determine if bouts of moderate-vigorous physical activity (MVPA) and patterns of sedentary behavior are associated with frailty.

METHOD

Accelerometry from community-dwelling adults ≥50 years old (n = 2317) enrolled in the 2003-04 and 2005-06 National Health and Nutrition Examination Survey were used. Bouted (≥10 min) and sporadic (<10 min) durations of MVPA were analyzed based on meeting 0%, 1-49%, 50-99%, and ≥100% of physical activity guidelines (150 min/week of MVPA). Prolonged sedentary behavior were bouts lasting ≥30 min. Breaks from sedentary behavior were defined as any ≥1 min interruption in sedentary behavior. Average intensity (counts/min) and duration (minutes) during breaks were also analyzed. Frailty was measured with a 46-item frailty index.

RESULTS

Multivariable linear regression models adjusting for age, sex, education, ethnicity, income, marital status, smoking, alcohol consumption, body mass index, total sedentary time and accelerometer wear time indicated that meeting any percentage of the activity guidelines with bouted and sporadic MVPA was associated with reduced frailty. This relationship peaked at meeting 50-99% of guidelines and was associated with a 1.5 and 2.0 point reduction in the frailty index for bouted and sporadic MVPA, respectively. Two additional prolonged sedentary behavior bouts/day were associated with an additional frailty index deficit while every additional 100 cpm in average break intensity and every 2 min in average break duration were associated with one less deficit. Total sedentary breaks were not associated with frailty.

CONCLUSION

These population-level data give justification for determining if interventions which target short bouts of MVPA and interrupting prolonged, uninterrupted time spent in sedentary behaviors can treat or prevent frailty worsening.

Recognising older frail patients near the end of life: What next?

Frailty is a state of vulnerability resulting from cumulative decline in many physiological systems during a lifetime. It is progressive and considered largely irreversible, but its progression may be controlled and can be slowed down and its precursor -pre-frailty- can be treated with multidisciplinary intervention. The aim of this narrative review is to provide an overview of the different ways of measuring frailty in community settings, hospital, emergency, general practice and residential aged care; suggest occupational groups who can assess frailty in various services; discuss the feasibility of comprehensive geriatric assessments; and summarise current evidence of its management guidelines. We also suggest practical recommendations to recognise frail patients near the end of life, so discussions on goals of care, advance care directives, and shared decision-making including early referrals to palliative and supportive care can take place before an emergency arises. We acknowledge the barriers to systematically assess frailty and the absence of consensus on best instruments for different settings. Nevertheless, given its potential consequences including prolonged suffering, disability and death, we recommend identification of frailty levels should be universally attempted in older people at any health service, to facilitate care coordination, and honest discussions on preferences for advance care with patients and their caregivers.

Frailty prevalence and factors associated with the Frailty Phenotype and Frailty Index: Findings from the North West Adelaide Health Study

OBJECTIVE

To determine the prevalence of frailty and associated factors in the North West Adelaide Health Study (2004-2006) using the Frailty Phenotype (FP) and Frailty Index (FI).

METHODS

Frailty was measured in 909 community-dwelling participants aged ≥65 years using the FP and FI.

RESULTS

The FP classified 18% of participants as frail and the FI 48%. The measures were strongly correlated (r = 0.76, P < 0.001) and had a kappa agreement of 0.38 for frailty classification, with 37% of participants classified as non-frail by the FP being classified as frail by the FI. Being older, a current smoker, and having multimorbidity and polypharmacy were associated with higher frailty levels by both tools. Female, low income, obesity and living alone were associated with the FI.

CONCLUSION

Frailty prevalence was higher when assessed using the FI. Socioeconomic factors and other health determinants contribute to higher frailty levels.

The impact of frailty on healthcare utilisation in Ireland: evidence from the Irish longitudinal study on ageing

Introduction

To examine the impact of frailty on medical and social care utilisation among the Irish community-dwelling older population to inform strategies of integrated care for older people with complex needs.

Methods

Participants aged ≥65 years from the Irish Longitudinal Study on Ageing (TILDA) representative of the Irish community-dwelling older population were analysed (n = 3507). The frailty index was used to examine patterns of utilisation across medical and social care services. Multivariate logistic and negative binomial regression models were employed to examine the impact of frailty on service utilisation outcomes after controlling for other factors.

Results

The prevalence of frailty and pre-frailty was 24% (95% CI: 23, 26%) and 45% (95% CI: 43, 47%) respectively. Frailty was a significant predictor of utilisation of most social care and medical care services after controlling for the main correlates of frailty and observed individual effects.

Conclusions

Frailty predicts utilisation of many different types of healthcare services rendering it a useful risk stratification tool for targeting strategies of integrated care. The pattern of care is predominantly medical as few of the frail older population use social care prompting questions about sub-groups of the frail older population with unmet care needs.

Electronic supplementary material

The online version of this article (doi:10.1186/s12877-017-0579-0) contains supplementary material, which is available to authorized users.

Survival, disabilities in activities of daily living, and physical and cognitive functioning among the oldest-old in China: a cohort study

BACKGROUND

The oldest-old (those aged ≥80 years) are the most rapidly growing age group globally, and are most in need of health care and assistance. We aimed to assess changes in mortality, disability in activities of daily living, and physical and cognitive functioning among oldest-old individuals between 1998 and 2008.

METHODS

We used data from the Chinese Longitudinal Healthy Longevity Study. Three pairs of cohorts aged 80-89 years, 90-99 years, and 100-105 years (in total, 19 528 oldest-old participants) were examined; the two cohorts in each pair were born 10 years apart, with the same age at the time of the assessment in the 1998 and 2008 surveys. Four health outcomes were investigated: annual death rate, Activities of Daily Living (ADL), physical performance in three tests and cognitive function measured by Mini-Mental State Examination (MMSE). We used different tests and multivariate regression analyses to examine the cohort differences.

FINDINGS

Controlling for various confounding factors, we noted that annual mortality among oldest-old individuals was substantially reduced between 0·2% and 1·3% in 1998-2008 compared with individuals of the same age born 10 years previously, and that disability according to activities of daily living had significantly reduced annually between 0·8% and 2·8%. However, cognitive impairment in the later cohorts increased annually between 0·7% and 2·2% and objective physical performance capacity (standing up from a chair, picking up a book from the floor, and turning around 360°) decreased anually between 0·4% and 3·8%. We also noted that female mortality was substantially lower than male mortality among the oldest-old, but that women's functional capacities in activities of daily living, cognition, and physical performance were worse than their male counterparts.

INTERPRETATION

Advances in medications, lifestyle, and socioeconomics might compress activities of daily living disability, that is, benefits of success, but lifespan extension might expand disability of physical and cognitive functioning as more frail, elderly individuals survive with health problems, that is, costs of success.

FUNDING

National Natural Science Foundation of China, National Institute on Aging/National Institutes of Health, United Nations Funds for Population Activities.

Sex differences in frailty: A systematic review and meta-analysis

BACKGROUND

It is a well-described clinical phenomenon that females live longer than males, yet tend to experience greater levels of co-morbidity and disability. Females can therefore be considered both more frail (because they have poorer health status) and less frail (because they have a lower risk of mortality). This systematic review aimed to determine whether this ageing paradox is demonstrated when the Frailty Index (FI) is used to measure frailty.

METHODS

Medline, EMBASE and CINAHL databases were searched for observational studies that measured FI and mortality in community-dwellers over 65years of age. In five-year age groups, meta-analysis determined the sex differences in mean FI (MD=mean FI_female-mean FI_male) and mortality rate.

RESULTS

Of 6482 articles screened, seven articles were included. Meta-analysis of data from five studies (37,426 participants) found that MD values were positive (p<0.001; MD range=0.02-0.06) in all age groups, indicating that females had higher FI scores than males at all ages. This finding was consistent across individual studies. Heterogeneity was high (I²=72.7%), reflecting methodological differences. Meta-analysis of mortality data (13,127 participants) showed that male mortality rates exceeded female mortality rates up until the 90 to 94-years age group. Individual studies reported higher mortality for males at each level of FI, and higher risk of death for males when controlling for age and FI.

CONCLUSIONS

The pattern of sex differences in the FI and mortality of older adults was consistent across populations and confirmed a 'male-female health-survival paradox'.

Frailty as a predictor of disabilities among community-dwelling older people: a systematic review and meta-analysis

BACKGROUND

Frailty has been shown to be associated with disability in the previous studies. However, it is not clear how consistently or to how much degree frailty is actually associated with the future disability risks.

METHODS

A systematic review of the literature was conducted using Embase, MEDLINE, CINAHL, PsycINFO, and the Cochrane Library for any prospective studies published from 2010 to September 2015 examining associations between baseline frailty status and subsequent risk of developing or worsening disabilities among community-dwelling older people. A meta-analysis was performed to synthesize pooled estimates.

RESULTS

Of 7012 studies identified through the systematic review, 20 studies were included in the meta-analysis. Twelve studies examined activities of daily living (ADL) disability risks, two studies examined instrumental activities of daily living (IADL) disability risks, and six studies examined both ADL and IADL disability risks. Overall, frail older people were more likely to develop or worsen disabilities in ADL (12 studies, pooled OR = 2.76, 95% CI = 2.23-3.44, p < 0.00001; 5 studies, pooled HR = 2.23, 95% CI = 1.42-3.49, p < 0.00001) and IADL (6 studies, pooled OR = 3.62, 95% CI = 2.32-5.64, p < 0.00001; 2 studies, pooled HR = 4.24, 95% CI = 0.85-21.28, p = 0.08). Prefrailty was also associated with incident or worsening disability risks to a lesser degree in most pooled analyses. High heterogeneity observed among 12 studies with OR of ADL disability risks for frailty was explored using subgroup analyses, which suggested methodological quality and mean age of the cohort were the possible causes.

CONCLUSION

This systematic review meta-analysis quantitatively showed that frail older people are at higher risks of disabilities. These results are important for all related parties given population aging worldwide. Interventions for frailty are important to prevent disability and preserve physical functions, autonomy, and quality of life. Implications for Rehabilitation Although frailty has been shown to be associated with disability and considered as a precursor of disability, it is not clear how consistently or to how much degree frailty is actually associated with the future disability risks. This systematic review and meta-analysis quantitatively shows frailty is a significant predictor of incident and worsening ADL and IADL disabilities. It is a pressing priority to develop interventions for frailty to prevent disability and preserve older people's physical functions, autonomy, and quality of life.

Frailty as a predictor of hospitalisation among community-dwelling older people: a systematic review and meta-analysis

BACKGROUND

Owing to detrimental hazards and substantial healthcare burden and costs, hospitalisation of older people has become a major focus. Frailty has increasingly been recognised as an important predictor of hospitalisation. This study aims to identify studies on physical frailty as a predictor of hospitalisation risks and to pool the risk estimates among community-dwelling older people.

METHODS

A systematic literature search was performed in August 2015 using five databases: EMBASE, MEDLINE, CINAHL, PsycINFO and the Cochrane Library for prospective studies examining physical frailty as a predictor of hospitalisation published in 2000 or later. OR and HR were combined to synthesise pooled effect measures using fixed-effects models. The included studies were assessed for heterogeneity, methodological quality and publication bias. Subgroup analysis and meta-regression analysis were conducted to examine study characteristics in relation to the hospitalisation risks.

RESULTS

Of the 4620 studies identified by the systematic review, 13 studies with average follow-up period of 3.1 years were selected. Frailty and prefrailty were significantly associated with higher hospitalisation risks among 10 studies with OR (pooled OR=1.90, 95% CI 1.74-2.07, p<0.00001; pooled OR=1.26, 95% CI 1.18-1.33, p<0.00001, respectively) and 3 studies with HR (pooled HR=1.30, 95% CI 1.12-1.52, p=0.0007; pooled HR=1.13, 95% CI 1.04-1.24, p=0.005, respectively). Heterogeneity was low to moderate. No publication bias was detected. The studies with older populations and unadjusted outcome measures were associated with higher hospitalisation risks in the subgroup analysis.

CONCLUSIONS

This systematic review and meta-analysis demonstrated physical frailty is a significant predictor of hospitalisation among community-dwelling older people. Hospitalisation can potentially be reduced by treating or preventing frailty.

A frailty index predicts survival and incident multimorbidity independent of markers of HIV disease severity

OBJECTIVES

Aging with HIV is associated with multisystem vulnerability that might be well characterized by frailty. We sought to construct a frailty index based on health deficit accumulation in a large HIV clinical cohort and evaluate its validity including the ability to predict mortality and incident multimorbidity.

DESIGN AND METHODS

This is an analysis of data from the prospective Modena HIV Metabolic Clinic cohort, 2004-2014. Routine health variables were screened for potential inclusion in a frailty index. Content, construct, and criterion validity of the frailty index were assessed. Multivariable regression models were built to investigate the ability of the frailty index to predict survival and incident multimorbidity (at least two chronic disease diagnoses) after adjusting for known HIV-related and behavioral factors.

RESULTS

Two thousand, seven hundred and twenty participants (mean age 46 ± 8; 32% women) provided 9784 study visits; 37 non-HIV-related variables were included in a frailty index. The frailty index exhibited expected characteristics and met validation criteria. Predictors of survival were frailty index (0.1 increment, adjusted hazard ratio 1.63, 95% confidence interval 1.05-2.52), current CD4 cell count (0.48, 0.32-0.72), and injection drug use (2.51, 1.16-5.44). Predictors of incident multimorbidity were frailty index (adjusted incident rate ratio 1.98, 1.65-2.36), age (1.07, 1.05-1.09), female sex (0.61, 0.40-0.91), and current CD4 cell count (0.71, 0.59-0.85).

CONCLUSION

Among people aging with HIV in northern Italy, a frailty index based on deficit accumulation predicted survival and incident multimorbidity independently of HIV-related and behavioral risk factors. The frailty index holds potential value in quantifying vulnerability among people aging with HIV.