Multidimensional Approach to Frailty

A Novel Digital Nutrition Diary for Geriatric Patients at High Risk of Frailty Syndrome

Due to the physical, psychological, or socioeconomic changes that accompany aging, many people will be affected by geriatric frailty syndrome, which can lead to multimorbidity and premature death. Nutrition counseling is often used to prevent and intervene in frailty syndrome, especially in geriatric rehabilitation. To this end, the consumption behavior of geriatric patients is recorded using paper-based, as well as retrospective memory logs in face-to-face interviews between patients and nutritionists. To simplify this procedure, a digital nutrition diary was developed that is specially adapted to the needs of geriatric patients (>=70 years), enabling them to record their consumption behavior themselves. In an initial study (Study 1), conducted in a geriatric rehabilitation division with twelve subjects (ten male, two female, mean age 79.2 ±5.9 years), feedback about the usability of the digital nutrition diary, and how to improve it, was surveyed. In addition, the usability of an activity tracker and a body composition scale was surveyed to determine whether geriatric patients are generally able to use these devices. In a second study (Study 2), also conducted in the geriatric rehabilitation division, this time with sixteen subjects (ten male, six female, mean age 79.3 ±3.9 years), the usability of the digital nutrition diary was surveyed again to evaluate its modifications based on the feedback from Study 1. In Study 1, the usability rating of the system (0−100) was 82.5 for the activity tracker, 29.71 for the body composition scale, and 51.66 initially for the digital nutrition diary, which increased to 76.41 in Study 2.

Cognitive Impairment in Frail Hypertensive Elderly Patients: Role of Hyperglycemia

Endothelial dysfunction is a key hallmark of hypertension, which is a leading risk factor for cognitive decline in older adults with or without frailty. Similarly, hyperglycemia is known to impair endothelial function and is a predictor of severe cardiovascular outcomes, independent of the presence of diabetes. On these grounds, we designed a study to assess the effects of high-glucose and metformin on brain microvascular endothelial cells (ECs) and on cognitive impairment in frail hypertensive patients. We tested the effects of metformin on high-glucose-induced cell death, cell permeability, and generation of reactive oxygen species in vitro, in human brain microvascular ECs. To investigate the consequences of hyperglycemia and metformin in the clinical scenario, we recruited frail hypertensive patients and we evaluated their Montreal Cognitive Assessment (MoCA) scores, comparing them according to the glycemic status (normoglycemic vs. hyperglycemic) and the use of metformin. We enrolled 376 patients, of which 209 successfully completed the study. We observed a significant correlation between MoCA score and glycemia. We found that hyperglycemic patients treated with metformin had a significantly better MoCA score than hyperglycemic patients treated with insulin (18.32 ± 3.9 vs. 14.94 ± 3.8; p < 0.001). Our in vitro assays confirmed the beneficial effects of metformin on human brain microvascular ECs. To our knowledge, this is the first study correlating MoCA score and glycemia in frail and hypertensive older adults, showing that hyperglycemia aggravates cognitive impairment.

An association analysis between hypertension, dementia, and depression and the phases of pre-sarcopenia to sarcopenia: A cross-sectional analysis

Sarcopenia is intricately related to aging associated diseases, such as neuropsychiatric disorders, oral status, and chronic diseases. Dementia and depression are interconnected and also related to sarcopenia. The preliminary shift from robust to sarcopenia (i.e., pre-sarcopenia) is an important albeit underdiscussed stage and is the focus of this study. Identifying factors associated with pre-sarcopenia may lead to sarcopenia prevention. To separately examine the effects of dementia and depression on pre-sarcopenia/sarcopenia, we conducted multiple analyses. This cross-sectional study used health checkup data from a rural Japanese island. The participants were aged 60 years and above, and the data included muscle mass, gait speed, handgrip strength, oral status (teeth and denture), chronic diseases (e.g., hypertension), dementia (cognitive assessment for dementia, iPad Version), and depression (self-rating depression scale). A total of 753 older adult participants were divided into the sarcopenia (n = 30), pre-sarcopenia (n = 125), and robust (n = 598) groups. An ordered logit regression analysis indicated that age and depression were positively correlated with sarcopenia, while hypertension was negatively associated with it. A multiple logistic regression analysis between the robust and pre-sarcopenia groups showed significant associations between the same three variables. Depression was associated with pre-sarcopenia, but not dementia. There was also a significant association between hypertension and pre-sarcopenia. Further research is needed to reveal whether the management of these factors can prevent sarcopenia.

Muscle, endocrine, and immunological markers of frailty in older people

OBJECTIVE

To analyze muscle, endocrine, and immunological markers that influence frailty in older people assisted in primary care.

MATERIALS AND METHODS

Cross-sectional, analytical, and probabilistic study were linked to the institutional research "Integrated Health Care for Older People." The study population consisted of males and females aged 60 years or more and assisted in primary health care. The research protocol included an interview and physical examination to evaluate the frailty criteria. Analysis of the following were done: serum calcium and creatinine as muscle markers; vitamin D, parathyroid hormone, and insulin-like growth factor - 1 as endocrine markers; and interleukin-6, C-reactive protein, leukocytes, and neutrophil-lymphocyte ratio as immunological markers. Statistical analysis included the Mann-Whitney test to compare means, and linear regression to analyze the relationship between dependent and independent variables.

RESULTS

There was a relationship between creatinine and prediction of weight loss (p < 0.001), leukocytes and prediction of handgrip strength (p = 0.022), interleukin-6 and prediction of energy expenditure (p = 0.026), and vitamin D and prediction of gait time (p = 0.036). Also, sex influenced handgrip strength (p < 0.001), and age influenced handgrip strength (p < 0.001), gait time (p < 0.001) and energy expenditure (p < 0.001).

CONCLUSION

The joint use of muscle, endocrine, and immunological markers may be useful to diagnose frailty and to propose resolutive interventions to reduce negative outcomes for older people.

Differences in disability and nutritional status among older Brazilian and English adults: the Brazilian Longitudinal Study of Aging (ELSI-Brazil) and English Longitudinal Study of Aging (ELSA) cohorts

BACKGROUND

Brazil and England are 2 countries at different stages in their demographic, epidemiological, and nutritional transitions and with distinct socioeconomic and politic contexts, but with similar universal health systems. We aimed to examine disability and its association with objective anthropometric indicators of nutritional status, including BMI, waist circumference, and waist-to-height ratio, comparing older Brazilian and English adults.

METHODS

We used cross-sectional data from 2 nationally representative aging studies. For Brazil, we included 9412 participants who participated in the baseline (2015-2016) of the Brazilian Longitudinal Study of Aging (ELSI-Brazil). The English data were from 8024 participants of the wave 6 (2012-2013) of the English Longitudinal Study of Aging (ELSA). Disability was defined as difficulty to perform at least 1 activity of daily living. We used logistic regression models to examine the association between anthropometric indicators and disability, adjusted for sociodemographic and health-related characteristics, considering the interaction term between each anthropometric indicator and country.

RESULTS

All health-related characteristics were worse in Brazil than England, although the prevalence of disability was similar among Brazilian (17.85%) and English (16.27%) older adults. Fully adjusted models showed statistically significant interaction terms between country and anthropometric indicators. The strength of the associations in Brazil was weaker compared with England. All anthropometric indicators were positively associated with disability: elevated BMI, in Brazil (OR: 1.27; 95% CI: 1.06, 1.51) and in England (OR: 1.80; 95% CI: 1.51, 2.14); elevated waist circumference, in Brazil (OR: 1.21; 95% CI: 1.02, 1.44) and in England (OR: 1.90; 95% CI: 1.51, 2.37); and elevated waist-to-height ratio, in Brazil (OR: 1.20; 95% CI: 0.96, 1.52) and in England (OR: 1.83; 95% CI: 1.37, 2.44).

CONCLUSIONS

Elevated BMI and waist circumference increased the odds of disability in both populations. However, these associations were stronger in England than in Brazil.

The role of Frailty on Adverse Outcomes Among Older Patients with COVID-19

BACKGROUND

Diagnosis and screening of frailty, a condition characterized by an increased vulnerability to adverse outcomes of COVID-19, has emerged as an essential clinical tool which is strongly recommended by healthcare providers concerned with hospitalized elderly population. The data showing the role of frailty in patients infected with COVID-19 is needed.

METHODS

This was a nationwide cohort study conducted at all hospitals in Turkey. All COVID-19 hospitalized patients (≥ 65 years) were included. Patients who were alive and not discharged up to July 20, 2020, were excluded. The frailty was assessed by using the "Hospital Frailty Risk Score" (HFRS). Patients were classified into three risk groups of frailty based on previously validated cut points as low (<5 points), intermediate (5-15 points), and high (>15 points). Additionally, patients who had the HFRS of ≥5 were defined as frail. The primary outcome was in-hospital mortality rates by frailty group.

RESULTS

Between March 11, 2020, and June 22, 2020, a total of 18,234 COVID-19 patients from all of 81 provinces of Turkey were included. Totally, 12,295 (67.4%) patients were defined as frail (HFRS of >5) of which 2,801 (15.4%) patients were categorized in the highest level of frailty (HFRS of >15). Observed in-hospital mortality rates were 697 (12.0%), 1,751 (18.2%) and 867 (31.0%) in low, intermediate and high hospital frailty risk, respectively (p<0.001). Compared with low HFRS (<5), the adjusted odds ratios for in-hospital mortality were 1.482 (1.334-1.646) for intermediate HFRS (5-15) and 2.084; 95% CI, 1.799-2.413 for high HFRS (>15).

CONCLUSIONS

As a claims-based frailty model, the HFRS provides clinicians and health systems, a standardized tool for an effective detection and grading of frailty in patients in COVID-19. A frailty-based tailored management of the older population may provide a more accurate risk categorization for both therapeutic and preventive strategies.

Comprehensive Model for Physical and Cognitive Frailty: Current Organization and Unmet Needs

Aging is characterized by the decline and deterioration of functional cells and results in a wide variety of molecular damages and reduced physical and mental capacity. The knowledge on aging process is important because life expectancy is expected to rise until 2050. Aging cannot be considered a homogeneous process and includes different trajectories characterized by states of fitness, frailty, and disability. Frailty is a dynamic condition put between a normal functional state and disability, with reduced capacity to cope with stressors. This geriatric syndrome affects physical, neuropsychological, and social domains and is driven by emotional and spiritual components. Sarcopenia is considered one of the determinants and the biological substrates of physical frailty. Physical and cognitive frailty are separately approached during daily clinical practice. The concept of motoric cognitive syndrome has partially changed this scenario, opening interesting windows toward future approaches. Thus, the purpose of this manuscript is to provide an excursus on current clinical practice, enforced by aneddoctical cases. The analysis of the current state of the art seems to support the urgent need of comprehensive organizational model incorporating physical and cognitive spheres in the same umbrella.

Validation of "(fr)AGILE": a quick tool to identify multidimensional frailty in the elderly

Background

Several tools have been proposed and validated to operationally define frailty. Recently, the Italian Frailty index (IFi), an Italian modified version of Frailty index, has been validated but its use in clinical practice is limited by long time of administration. Therefore, the aim of this study was to create and validate a quick version of the IFi (AGILE).

Methods

Validation study was performed by administering IFi and AGILE, after a Comprehensive Geriatric Assessment (CGA) in 401 subjects aged 65 or over (77 ± 7 years). AGILE was a 10-items tool created starting from the more predictive items of the four domains of frailty investigated by IFi (mental, physical, socioeconomic and nutritional). AGILE scores were stratified in light, moderate and severe frailty. At 24 months of follow-up, death, disability (taking into account an increase in ADL lost ≥1 from the baseline) and hospitalization were considered. Area under curve (AUC) was evaluated for both IFi and AGILE.

Results

Administration time was 9.5 ± 3.8 min for IFi administered after a CGA, and 2.4 ± 1.2 min for AGILE, regardless of CGA (p < 0.001). With increasing degree of frailty, prevalence of mortality increased progressively from 6.5 to 41.8% and from 9.0 to 33.3%, disability from 16.1 to 64.2% and from 22.1 to 59.8% and hospitalization from 17.2 to 58.7% and from 27.0 to 52.2% with AGILE and IFi, respectively (p = NS). Relative Risk for each unit of increase in AGILE was 56, 44 and 24% for mortality, disability and hospitalization, respectively and was lower for IFi (8, 7 and 4% for mortality, disability and hospitalization, respectively). The AUC was higher in AGILE vs. IFi for mortality (0.729 vs. 0.698), disability (0.715 vs. 0.682) and hospitalization (0.645 vs. 0.630).

Conclusions

Our study shows that AGILE is a rapid and effective tool for screening multidimensional frailty, able to predict mortality, disability and hospitalization, especially useful in care settings that require reliable assessment instruments with short administration time.

Frailty assessment and postoperative complications in urologic oncology operations

Major urologic oncology procedures such as radical cystectomy (RC), radical prostatectomy (RP), radical nephroureterectomy (RNU) and radical or partial nephrectomy are the gold standard operations for the treatment of urological malignancies not suitable to be dealt with using minimal invasive procedures such as transurethral resection or other conservative approaches. However, these surgical procedures carry significant risk of complications, especially in elderly and frail patients. The purpose of this review is to highlight the use of a wide variety of preoperative frailty and health status indexes and calculators. Recent data from large population based studies confirm that these calculators can assist physicians and urologists to predict the postoperative morbidity of patients undergoing major operations. Moreover, these frailty calculators can help urologists choose the most suitable and safe treatment for every individual patient. However, the absence of widely accepted specific urologic oncology calculators to predict the association between frailty and postoperative complications emphasizes the necessity for the use of a combination of calculators.