Risk of cardiovascular disease morbidity and mortality in frail and pre-frail older adults: Results from a meta-analysis and exploratory meta-regression analysis

Circulating levels of adipose tissue-derived inflammatory factors in elderly diabetes patients with carotid atherosclerosis: a retrospective study

BACKGROUND

Inflammation has been recognized as a key feature of both type 2 diabetes mellitus (T2DM) and atherosclerosis. However, the relationships between circulating levels of novel adipose tissue-derived inflammatory factors, including resistin, vaspin, and visfatin, and the severity of atherosclerosis have not been determined. Moreover, the associations between these inflammatory factors and obesity and insulin resistance in elderly patients remain to be clarified.

METHODS

A cross-sectional study of 256 elderly patients with T2DM admitted in our center was performed. Baseline circulating levels of resistin, vaspin and visfatin were measured with enzyme-linked immunosorbent assays. Ultrasonic evaluations of the carotid arteries of the patients were performed to reflect the severity of systemic atherosclerosis. Patients were classified as having mild, moderate, or severe atherosclerosis according to the results of carotid ultrasonic examination. Circulating levels of the inflammatory factors listed above also were correlated with body mass index (BMI) and homeostasis model assessment of insulin resistance (HOMA-IR).

RESULTS

With more severe carotid atherosclerosis, circulating levels of resistin (mild: 2.01 ± 0.23; moderate: 2.89 ± 1.01; severe: 3.12 ± 1.12; p < 0.05) and visfatin (mild: 11.63 ± 7.48; moderate: 15.24 ± 2.19; severe: 17.54 ± 2.98; p < 0.05) gradually increased, while level of vaspin decreased (mild: 317 ± 23.12; moderate: 269 ± 32.12; severe: 229 ± 14.24; p < 0.05). Subsequent results of Pearson coefficient analyses indicated that all of the tested adipose tissue-derived inflammatory factors were positively correlated with the BMI and HOMA-IR of the patients (all p < 0.05), even after adjustment for hs-CRP.

CONCLUSIONS

The adipose tissue-derived inflammatory factors resistin, vaspin and visfatin may be involved in the pathogenesis of atherosclerosis in elderly T2DM patients.

Prevalence of frailty and prefrailty among community-dwelling older adults in low-income and middle-income countries: a systematic review and meta-analysis

OBJECTIVE

To systematically review the research conducted on prevalence of frailty and prefrailty among community-dwelling older adults in low-income and middle-income countries (LMICs) and to estimate the pooled prevalence of frailty and prefrailty in community-dwelling older adults in LMICs.

DESIGN

Systematic review and meta-analysis. PROSPERO registration number is CRD42016036083.

DATA SOURCES

MEDLINE, EMBASE, AMED, Web of Science, CINAHL and WHO Global Health Library were searched from their inception to 12 September 2017.

SETTING

Low-income and middle-income countries.

PARTICIPANTS

Community-dwelling older adults aged ≥60 years.

RESULTS

We screened 7057 citations and 56 studies were included. Forty-seven and 42 studies were included in the frailty and prefrailty meta-analysis, respectively. The majority of studies were from upper middle-income countries. One study was available from low-income countries. The prevalence of frailty varied from 3.9% (China) to 51.4% (Cuba) and prevalence of prefrailty ranged from 13.4% (Tanzania) to 71.6% (Brazil). The pooled prevalence of frailty was 17.4% (95% CI 14.4% to 20.7%, I2=99.2%) and prefrailty was 49.3% (95% CI 46.4% to 52.2%, I2=97.5%). The wide variation in prevalence rates across studies was largely explained by differences in frailty assessment method and the geographic region. These findings are for the studies with a minimum recruitment age 60, 65 and 70 years.

CONCLUSION

The prevalence of frailty and prefrailty appears higher in community-dwelling older adults in upper middle-income countries compared with high-income countries, which has important implications for healthcare planning. There is limited evidence on frailty prevalence in lower middle-income and low-income countries.

PROSPERO REGISTRATION NUMBER

CRD42016036083.

Mortality Risk Along the Frailty Spectrum: Data from the National Health and Nutrition Examination Survey 1999 to 2004

OBJECTIVES

To determine the relationship between frailty and overall and cardiovascular mortality.

DESIGN

Longitudinal mortality analysis.

SETTING

National Health and Nutrition Examination Survey (NHANES) 1999-2004.

PARTICIPANTS

Community-dwelling older adults aged 60 and older (N = 4,984; mean age 71.1 ± 0.19, 56% female).

MEASUREMENTS

We used data from 1999-2004 cross-sectional NHANES and mortality data from the National Death Index, updated through December 2011. An adapted version of Fried's frailty criteria was used (low body mass index, slow walking speed, weakness, exhaustion, low physical activity). Frailty was defined as persons meeting 3 or more criteria, prefrailty as meeting 1 or 2 criteria, and robust (reference) as not meeting any criteria. The primary outcome was to evaluate the association between frailty and overall and cardiovascular mortality. Cox proportional hazard models were used to evaluate the association between risk of death and frailty category adjusted for age, sex, race, smoking, education, coronary artery disease, heart failure, nonskin cancer, diabetes, and arthritis.

RESULTS

Half (50.4%) of participants were classified as robust, 40.3% as prefrail, and 9.2% as frail. Fully adjusted models demonstrated that prefrail (hazard ratio (HR) = 1.64, 95% confidence interval (CI) = 1.45-1.85) and frail (HR = 2.79, 95% CI = 2.35-3.30) participants had a greater risk of death and of cardiovascular death (prefrail: HR = 1.84, 95% CI = 1.45-2.34; frail: HR = 3.39, 95% CI = 2.45-4.70).

CONCLUSION

Frailty and prefrailty are associated with increased risk of death. Demonstrating the association between prefrail status and mortality is the first step to identifying potential targets of intervention in future studies.

The final word on nutritional screening and assessment in older persons

PURPOSE OF REVIEW

To provide an updated perspective of how nutritional screening and assessment in older persons should be performed and reasonably implemented in the near future.

RECENT FINDINGS

Although nutritional screening and assessment should be fast and easy procedures, there is increasing evidence that more time should be dedicated to them. This is probably an answer to the claim to a medicine being more preventive than curative. Increasing interest is currently given to healthy aging and nutritional status is more likely to be addressed for its implications on functional status and disability. Important prognostic conditions, such as frailty, sarcopenia, and cachexia, which are closely linked to the nutritional domain, are at the top of the agenda. Therefore, body composition is a key issue and functional status is suggested as primary endpoint of nutrition trials. In this scenario, there is also a rationale for systematic assessment of inflammation, protein intake, and vitamin D status as potential contributing factors to reduced muscle mass and function.

SUMMARY

A 'second-generation' multidimensional nutritional screening and assessment including the evaluation of body composition, frailty, sarcopenia, and cachexia could be hypothesized. Nutritional assessment should be also completed by the systematic evaluation of inflammation, protein intake, and vitamin D status.

Differences in Cardiovascular Aging in Men and Women

Cardiovascular diseases increase dramatically with age in both men and women. While it is clear that advanced age allows more time for individuals to be exposed to risk factors in general, there is strong evidence that age itself is a major independent risk factor for cardiovascular disease. Indeed, there are distinct age-dependent cellular, structural, and functional changes in both the heart and blood vessels, even in individuals with no clinical evidence of cardiovascular disease. Studies in older humans and in animal models of aging indicate that this age-related remodeling is maladaptive. An emerging view is that the heart and blood vessels accumulate cellular and subcellular deficits with age and these deficits increase susceptibility to disease in older individuals. Aspects of this age-dependent remodeling of the heart and blood vessels differ between the sexes. There is also new evidence that these maladaptive changes are more prominent in older animals and humans with a high degree of frailty. These observations may help explain why men and women are susceptible to different cardiovascular diseases as they age and why frail older adults are most often affected by these diseases.

Dietary Magnesium and Incident Frailty in Older People at Risk for Knee Osteoarthritis: An Eight-Year Longitudinal Study

Inadequate magnesium (Mg) intake is associated with lower physical performance, but the relationship with frailty in older people is unclear. Therefore, we aimed to investigate whether higher dietary Mg intake is associated with a lower risk of frailty in a large cohort of North American individuals. Details regarding Mg intake were recorded through a food-frequency questionnaire (FFQ) and categorized as greater than/equal to Recommended Dietary Allowance (RDA) vs. lower. Frailty was defined using the Study of Osteoporotic Fractures index. Multivariable Cox's regression analyses, calculating hazard ratios (HRs) with 95% confidence intervals (CIs), were undertaken by sex. In total, 4421 individuals with knee osteoarthritis or who were at high risk without frailty at baseline (mean age: 61.3, females = 58.0%) were followed for 8 years. After adjusting for 11 potential baseline confounders, reaching the RDA for Mg lowered risk of frailty among men (total n = 1857, HR = 0.51; 95% CI: 0.26-0.93), whilst no significant associations were found in women (total n = 2564). Each 100 mg of dietary Mg intake at baseline corresponded to a 22% reduction in men (HR = 0.78; 95% CI: 0.62-0.97; p = 0.03), but not in women (HR = 1.05; 95% CI: 0.89-1.23). In conclusion, higher dietary Mg intake appears to reduce the risk of frailty in men, but not in women.

The Relationship Between the Dietary Inflammatory Index and Incident Frailty: A Longitudinal Cohort Study

OBJECTIVE

Inflammation is key risk factor for several conditions in the elderly. However, the relationship between inflammation and frailty is still unclear. We investigated whether higher dietary inflammatory index (DII) scores were associated with higher incidence of frailty in a cohort of North Americans.

DESIGN

Longitudinal, with a follow-up of 8 years.

SETTING

Osteoarthritis Initiative.

PARTICIPANTS

A total of 4421 participants with, or at high risk of, knee osteoarthritis.

MEASUREMENTS

DII scores were calculated using the validated Block Brief 2000 Food-Frequency Questionnaire and categorized into sex-specific quartiles. Frailty was defined as 2 out of 3 of the criteria of the Study of Osteoporotic Fracture study (ie, weight loss, inability to rise from a chair 5 times, and poor energy). The strength of the association between baseline DII score and incident frailty was assessed through a Cox's regression analysis, adjusted for potential baseline confounders, and reported as hazard ratios.

RESULTS

A total of 4421 community-dwelling participants (2564 female participants; mean age: 61.3 years) without frailty at baseline were identified from the Osteoarthritis Initiative. During 8 years of follow-up, 356 individuals developed frailty (8.2%). Using Cox's regression analysis, adjusting for 11 potential confounders, participants with the highest DII score (quartile 4) had a significantly higher risk of experiencing frailty (hazard ratio 1.37; 95% confidence interval 1.01-1.89; P = .04) compared with participants with the lowest DII score (quartile 1). The association between DII score and frailty was significant only in men.

CONCLUSIONS

Higher DII scores, indicating a more proinflammatory diet, are associated with higher incidence of frailty, particularly in men.

Frailty and Risk of Cardiovascular Diseases in Older Persons: The Age, Gene/Environment Susceptibility-Reykjavik Study

Frailty is a risk factor for cardiovascular diseases (CVD), but the studies available have not considered the presence of subclinical atherosclerotic disease as potential confounders. We investigated the association between frailty and the onset of CVD independently of subclinical atherosclerotic disease. For this reason, a sample of 3818 older participants participating in the Age, Gene/Environment Susceptibility—Reykjavik Study without CVD at baseline was followed for a median of 8.7 years. Frailty was defined as the presence of ≥3 among five Fried's criteria (unintentional weight loss, low physical activity level, weakness, exhaustion, and slow gait speed). Incident CVD was defined as onset of coronary artery disease, heart failure, stroke, and CVD-related mortality identified using hospital, medical, and death records. Subclinical atherosclerotic disease was evaluated as the maximum value of carotid intima media thickness, presence of carotid plaque (moderate or high), and total coronary calcifications (CACs). At baseline, frail participants (n = 300) were more frequently obese, diabetic, and had a greater presence of metabolic syndrome than the nonfrail (n = 3518). Frail participants also showed a higher presence of carotid plaques and CACs. Using a Cox's regression analysis, adjusted for clinical, biochemical, and subclinical atherosclerosis estimates, frailty increased the risk of CVD (hazard ratio [HR] = 1.35; 95% confidence interval [CI]: 1.05–1.74), with results stronger for women than men (HR = 1.51, p = 0.006 and 1.19, p = 0.44, respectively). Among Fried's criteria, exhaustion was the only criterion significantly associated with the onset of new CVD events (HR = 1.30; 95% CI: 1.00–1.73). In conclusion, frailty was associated with the onset of CVD in older people even after adjusting for subclinical atherosclerotic disease.

Polypharmacy Is Associated With Higher Frailty Risk in Older People: An 8-Year Longitudinal Cohort Study

OBJECTIVE

To investigate whether polypharmacy is associated with a higher incidence of frailty in a large cohort of North Americans during 8 years of follow-up.

DESIGN

Longitudinal study, follow-up of 8 years.

PARTICIPANTS

A total of 4402 individuals at high risk or having knee osteoarthritis free from frailty at baseline.

MEASUREMENTS

Details regarding medication prescription were captured and categorized as 0-3, 4-6, and ≥7. Frailty was defined using the Study of Osteoporotic Fracture index as the presence of ≥2 out of (1) weight loss ≥5% between baseline and the subsequent follow-up visit; (2) inability to do 5 chair stands; and (3) low energy level according to the Study of Osteoporotic Fracture definition. Cox's regression models calculating a hazard ratio (HR) with 95% confidence intervals (CIs), adjusted for potential confounders, were undertaken.

RESULTS

During the 8-year follow-up, from 4402 participants at baseline, 361 became frail. Compared with participants taking 0-3 medications, the incidence of frailty was approximately double in those taking 4-6 medications and 6 times higher in people taking ≥7 medications. After adjusting for 11 potential baseline confounders, participants using 4-6 medications had a higher risk of frailty of 55% (HR = 1.55; 95% CI 1.22-1.96; P < .0001), whereas those using more than 7 drugs were at approximately 147% (HR = 2.47; 95% CI 1.78-3.43; P < .0001). Each additional drug used at the baseline increased the risk of frailty at the follow-up of 11% (HR = 1.11; 95% CI 1.07-1.15; P < .0001).

CONCLUSIONS

Polypharmacy is associated with a higher incidence of frailty over 8-year follow-up period. Our data suggest evidence of a dose response relationship. Future research is required to confirm our findings and explore underlying mechanisms.