Frailty and Malnutrition: Related and Distinct Syndrome Prevalence and Association among Community-Dwelling Older Adults: Singapore Longitudinal Ageing Studies

The Challenge of Managing Undernutrition in Older People with Frailty

Many older people with frailty are at risk of malnutrition and poor health, yet there is evidence that improving nutrition and weight loss can reduce frailty. This will become more important as the number of older people with frailty increases worldwide in future. Identifying those at risk is challenging due to the difficulty of reaching and screening those older people most at risk, the large number of nutritional assessment tools used, and the lack of consensus on the criteria to make a diagnosis of malnutrition. The management of older people with or at risk of malnutrition should be multi-modal and multi-disciplinary, and all care staff have an important role in delivering appropriate nutritional advice and support. This paper will highlight a number of practical approaches that clinicians can take to manage malnutrition in older people with frailty in community and acute settings, including environmental changes to enhance mealtime experience, food fortification and supplementation.

Mini Nutritional Assessment Scores Indicate Higher Risk for Prospective Mortality and Contrasting Correlation With Age-Related Epigenetic Biomarkers

The plasticity of the individual epigenetic landscape that goes to countless rearrangements throughout life is closely the reflection of environmental factors such as chemical exposure, socio-economic status and nutrient intakes both early and late in life. The Mini Nutritional Assessment (MNA) is a well-validated tool for assessing malnutrition in old people. It includes 6 (MNA-SF) or 18 (MNA-LF) self-reported questions derived from general, anthropometric, dietary, and self- assessment. We evaluated the association between the nutritional status, as measured by MNA, and methylation biomarkers we previously demonstrated to be associated with chronological and biological age in human. We found that malnutrition is positively correlated with DNA methylation status at the global level, in line with our previous reports. On the contrary, most of the sites located within specific genes, which were previously reported to be correlated with chronological and biological aging, showed to be not affected by malnutrition, or even to have correlations with malnutrition opposite to those previously reported with frailty. These results may suggest that malnutrition is among the first effects of disability and other age- related problems and a generalized non-specific epigenetic remodeling may be the initial response of the organism. By contrast, the fine remodeling of specific genomic sites is scarcely affected by malnutrition and may respond to a more complex interaction of different factors. Therefore, although malnutrition in the elderly is certainly a risk factor for survival, this is partially independent of the aging process of the organism which leads to the methylation remodeling previously described to measure chronological and biological aging.

Chewing Difficulty Should be Included as a Geriatric Syndrome

Recent studies have noted an association between chewing difficulties and frailty. In a pilot survey of primary care needs of older people living in the community using automated methods, we examined the prevalence of chewing difficulties and the cross-sectional association with other geriatric syndromes, chronic diseases, and the use of hospital services. A brief multi-domain geriatric assessment was administered to 2259 men and women using a mobile device, the data uploaded to the cloud and analyzed. A total of 37.8% had chewing difficulties, which were associated with older age, poor vision, frailty, sarcopenia, memory complaints, low subjective well-being, incontinence, and stroke. The results suggest that chewing difficulties should be included as a geriatric syndrome and should be included in primary care screening of geriatric syndromes as well as chronic diseases.

Identification and Measurement of Frailty: A Scoping Review of Published Research from Singapore

Introduction: The Asia-Pacific Clinical Practice Guidelines for the Management of Frailty recommended the use of validated measurement tools for identifying frailty. In an effort to contribute to the development of best practice guidelines in frailty identification and measurement, our scoping review aimed to present a summary of published research on this topic among older adults in Singapore. Our findings are important given the need to consider the context of use and the goals of measurement in using validated tools. Materials and Methods: We searched PubMed and CINAHL® for articles describing the identification and measurement of frailty among older adults (≥60 years) in Singapore and mined the bibliographies of eligible articles. An article was eligible if it involved empirical research on frailty using a structured frailty definition. We described such articles and the conceptual definitions they used, and summarised their operationalisation of frailty. Results: Our search yielded 165 records. After 2-stage screening of titles/abstracts and full-text articles, we retained 32 eligible articles for data extraction and thematic analysis. The extant literature in Singapore includes observational cross-sectional and longitudinal studies and intervention studies across community and tertiary care settings. Eligible articles commonly used the frailty phenotype and the deficit accumulation models in defining frailty, and reported measuring components of physical, cognitive, and/or social frailty. Conclusion: Our scoping review provided a broad evidence synthesis of the underpinnings of research on frailty identification and measurement in Singapore. Consistently applying standard methods and approaches in frailty identification and measurement can support evidence-based practice and policies in Singapore. Key words: Conceptual definitions, Evidence synthesis, Frailty research, Older adults

Approach to frailty in the elderly in primary care and the community

Frailty is a distinct clinical syndrome wherein the individual has low reserves and is highly vulnerable to internal and external stressors. Although it is associated with disability and multiple comorbidities, it can also be present in individuals who seem healthy. Frailty is multidimensional and its pathophysiology is complex. Early identification and intervention can potentially decrease or reverse frailty, especially in the early stages. Primary care physicians, community nurses and community social networks have important roles in the identification of pre-frail and frail elderly through the use of simple frailty screening tools and rapid geriatric assessments. Appropriate interventions that can be initiated in a primary care setting include a targeted medical review for reversible medical causes of frailty, medication appropriateness, nutritional advice and exercise prescription. With ongoing training and education, the multidisciplinary engagement and coordination of care of the elderly in the community can help to build resilience and combat frailty in our rapidly ageing society.

Influenza Vaccine-Induced Antibody Responses Are Not Impaired by Frailty in the Community-Dwelling Elderly With Natural Influenza Exposure

Background: Elderly adults over 65 years of age are recommended to receive seasonal influenza vaccination as they are at a higher risk of infection and its complications than the younger community. The elderly are often stratified according to frailty status where frail individuals are more susceptible to adverse health outcomes than their non-frail counterparts, however, it is not known whether immunity induced by influenza vaccination is impaired in the frail elderly.

Study Design: Two hundred and five elderly subjects of Chinese ethnicity in Singapore (mean age 73.3 ± 5.3 years, 128 females and 77 males) were administered the recommended trivalent inactivated 2013–14 seasonal influenza vaccine (Vaxigrip™) containing A/H1N1, A/H3N2, and B strains. The elderly subjects were stratified into three groups according to Fried's frailty criteria (59 frail, 85 pre-frail, 61 robust) and were also ranked by Rockwood's frailty index (RFI). Statistical associations were evaluated between frailty status and pre- and post-vaccination antibody titres in sera measured by Hemagglutination inhibition (HAI) and microneutralization (MN) assays. Immunological responses across frailty strata were also studied in terms of leukocyte cellular distribution, cytokine levels and gene expression.

Results: Post-vaccination, 83.4% of the subjects seroconverted for A/H1N1, 80.5% for A/H3N2, and 81% for the B strain. The seroconversion rates were comparable across frailty groups (A/H1N1, ANOVA, p = 0.7910; A/H3N2, ANOVA, p = 0.8356, B, ANOVA, p = 0.9741). Geometric mean titres of HAI and MN as well as seroprotection rates were also similar in all three frailty groups and uncorrelated with RFI (Spearman, r = 0.023, p = 0.738). No statistically significant differences were observed between the frailty groups in vaccine-induced modulation of leukocyte populations, cytokine responses, and gene expression profiles of peripheral blood mononuclear cells (PBMCs). Whereas, post- and pre-vaccination HAI titres were positively correlated after adjusting for age and gender (A/H1N1, R² = 0.216, p = 9.1e−11; A/H3N2, R² = 0.166, p = 3.4e−8; B, R² = 0.104, p = 3.1e−5). With most subjects lacking previous history of influenza vaccination, the pre-vaccination titres were likely due to natural exposure and seen to match the pattern of influenza subtype prevalence in the time period of vaccination.

Conclusion: The majority of the elderly subjects seroconverted for seasonal influenza upon vaccination, and importantly, influenza vaccination-induced humoral immune responses and seroprotection were similar across the frailty strata, indicating that frail individuals may also benefit from influenza vaccination. Pre-existing antibodies due to natural exposure appeared to positively influence vaccine-induced antibody responses.

Association of Frailty and Malnutrition With Long-term Functional and Mortality Outcomes Among Community-Dwelling Older Adults: Results From the Singapore Longitudinal Aging Study 1

IMPORTANCE

Physical frailty and malnutrition are prevalent among older adults and may be associated with functional and mortality outcomes.

OBJECTIVE

To assess the health outcomes associated with physical frailty and malnutrition singly and in combination among older adults.

DESIGN, SETTING, AND PARTICIPANTS

Population-based cohort study (Singapore Longitudinal Aging Study 1). Included were 2804 community-dwelling adults in Singapore aged 55 years or older at baseline (September 1, 2003, to December 23, 2005), with 2 follow-ups at 2- to 3-year intervals (from March 7, 2005, to September 10, 2007, and from November 13, 2007, to December 12, 2009) and a 12-year mortality follow-up to March 31, 2017. Data analysis was from July 1 to September 28, 2017.

MAIN OUTCOMES AND MEASURES

Baseline physical frailty (Fried criteria) with participants categorized according to the total score as frail (3-5 points), prefrail (1-2 points), or robust (0 point), and nutritional status (Nutrition Screening Initiative DETERMINE Your Nutritional Health Checklist and Mini Nutritional Assessment Short-Form [MNA-SF]). Baseline (prevalent) and follow-up (incident) instrumental/basic activities of daily living (IADL/ADL) disability, poor quality of life (QOL), and mortality were measured. Estimates of association were by odds ratios (ORs) and hazard ratios (HRs) and their 95% CIs.

RESULTS

The participants (mean [SD] age, 66.0 [7.7] years; 1033 [36.8%] male; 2611 [93.1%] Chinese) included 1021 (37.6%) categorized as robust with MNA-SF normal nutrition (R-NN), 330 (12.2%) robust with MNA-SF at risk/malnourished (R-ARM), 734 (27.0%) prefrail/frail with MNA-SF normal nutrition (PFF-NN), and 631 (23.2%) prefrail/frail with MNA-SF at risk/malnourished (PFF-ARM). Among these 2804 participants, 44 had missing frailty status, and 78 had missing MNA-SF nutritional status; therefore, 88 participants in total had missing frailty-nutritional status. In cross-sectional analyses, the prevalence of IADL/ADL disability was lowest among the R-NN group (169 [16.9%]) and increased substantially only among the PFF-ARM group (249 [40.2%]) (OR, 1.88; 95% CI, 1.40-2.53). Poor QOL prevalence was lowest among the R-NN group (142 [14.1%]), and the increase in other frailty and nutritional status groups was highest in the PFF-ARM group (255 [41.3%]) (OR, 2.61; 95% CI, 1.96-3.49). In longitudinal analyses, significant association with only incident poor QOL across frailty and nutritional status groups was highest in the PFF-ARM group (89 [34.8%]) compared with the R-NN group (132 [19.2%]) (OR, 1.70; 95% CI, 1.17-2.48). The mortality rate was lowest in the R-NN group (0.54 per 100 person-years) and highest in the PFF-ARM group (3.04 per 100 person-years) (HR, 1.72; 95% CI, 1.01-2.92). The results based on the Nutrition Screening Initiative measure of nutritional status were similar.

CONCLUSIONS AND RELEVANCE

Reported adverse health outcomes attributed to poor nutrition often appear more likely to be associated with physical frailty. Prefrail/frail older persons with poor nutrition might be targeted for interventions to prevent or delay adverse functional and mortality outcomes.

Feasibility of a community-based Functional Power Training program for older adults

Purpose

Community-based programs can increase and sustain physical activity participation in older adults, even for those who are physically frail. We studied the feasibility and potential effect of a 12-week structured Functional Power Training (FPT) program involving high velocities and low loads for older adults conducted in a common area of their housing estate.

Patients and methods

The structured FPT program was conducted in collaboration with a health promotion social enterprise and a community service provider based in a public housing site. We recruited nine inactive residents as participants to the single, group-based, twice-weekly program. Attendance and adverse event(s) were recorded throughout the program. The Short Physical Performance Battery, Timed Up and Go (TUG), and 30s Sit-to-Stand tests were used to assess functional outcomes pre- and postprogram. The FRAIL Scale was used to assess their frailty status, and a postprogram experience survey was conducted.

Results

Eight subjects (aged 74±10 years) completed the program with an average overall attendance of 90.3%, with at least five participants present for each session. Changes in functional outcomes showed a moderate-to-large effect with significant improvement in TUG (p<0.01). In addition, participants either reversed or maintained their frailty status (p<0.01). Overall, the program was perceived to be well structured, engaging, as well as providing physical and psychosocial benefits. No exercise-related adverse events occurred during the program, and participants were keen to recommend this program to others.

Conclusion

Community-based structured FPT is safe and feasible for frail older adults, with the potential to improve function and reverse frailty status.

Nutritional and Frailty State Transitions in the Singapore Longitudinal Aging Study

BACKGROUND

Malnutrition is a major determinant of the physical frailty syndrome. Dynamic transitions in frailty states over time is well documented, but few studies have documented temporal changes in nutritional states and whether they influence frailty outcomes.

DESIGN

Longitudinal cohort study.

SETTING AND PARTICIPANTS

Community-dwelling older Singaporeans aged ≥55y with a 5-year follow-up (n=1162) in the Singapore Longitudinal Ageing Study 2 (SLAS-2).

MEASUREMENTS

The Mini Nutritional Assessment Short-Form (MNA-SF) was used to determine nutritional status, and the Fried's criteria (shrinking, weakness, slowness, exhaustion and inactivity) was used to assess physical frailty phenotype at both baseline and follow-up. Odds ratios (ORs) and 95% confidence intervals (95% CIs) were adjusted for multiple baseline co-variables.

RESULTS

At baseline, being at risk of malnutrition/malnourished was associated with increased odds of prevalent pre-frailty (OR=2.76, 95% CI=1.86-4.10) and frailty (OR=4.10, 95% CI=1.41-11.9). Baseline robust individuals who were persistently at risk of malnutrition/malnourished showed an increased odds of conversion to being pre-frail/frail at follow-up (OR=3.45, 95% CI=1.00-11.9). Among baseline pre-frail/frail individuals, reversion to being robust were significantly less likely among those who were persistently at risk of malnutrition/malnourished (OR=0.26, 95% CI=0.10-0.67) and those whose baseline normal nutrition worsened at follow-up (OR=0.20, 95% CI=0.06-0.74).

CONCLUSION

Changes in nutritional states are associated with frailty state transitions, and monitoring changes in nutritional status is recommended for the prevention and severity reduction of frailty among older people in the community.

Nutritional Status and Frailty in Community-Dwelling Older Korean Adults: The Korean Frailty and Aging Cohort Study

OBJECTIVES

To examine the association between nutritional status and frailty in older adults.

DESIGN

Cross-sectional study.

SETTING

Community-dwelling older adults were recruited from 10 study sites in South Korea.

PARTICIPANTS

1473 volunteers aged 70-84 years without severe cognitive impairment and who participated in the Korean Frailty and Aging Cohort Study (KFACS) conducted in 2016.

MEASUREMENTS

Nutritional status was measured using the Mini Nutritional Assessment Short Form (MNA-SF). Frailty was assessed with the Fried's frailty index. The relationship between nutritional status and frailty was examined using the multinomial regression analysis, adjusting for covariates.

RESULTS

Of the respondents 14.3% had poor nutrition (0.8% with malnutrition, 13.5% at risk of malnutrition). There were 10.7% who were frail, with 48.5% being prefrail, and 40.8% robust. Poor nutrition was related to a significantly increased risk of being prefrail (odds ratio [OR]: 1.59, 95% confidence interval [CI]: 1.09-2.32) and frail (OR: 3.30, 95% CI: 1.96-5.54).

CONCLUSION

Poor nutritional status is strongly associated with frailty in older adults. More research to understand the interdependency between nutritional status and frailty may lead to better management of the two geriatric conditions.