The ability of eight frailty instruments to identify adverse outcomes across different settings: the FRAILTOOLS project

Evaluation of frailty in geriatric patients undergoing cardiac rehabilitation after cardiac procedure: results of a prospective, cross-sectional study

BACKGROUND

Frailty is an indicator of a decline in quality of life and functional capacity in cardiac rehabilitation (CR) patients. Currently, there is no standardized assessment tool for frailty used in CR. The aim of this study was to determine if the Clinical Frailty Scale (CFS) is feasible for assessing frailty in CR.

METHODS

Prospective, cross-sectional study within the framework of the ongoing multicenter prehabilitation study "PRECOVERY". Patients ≥75 years undergoing CR after cardiac procedure (n=122) were recruited in four German inpatient CR facilities. Assessments included: CFS, Katz-Index, hand grip strength (HGS), Short Physical Performance Battery (SPPB) and six-minute-walk test (6MWT). Outcomes were frailty (CFS≥4) and the correlation of frailty with assessments of functional capacity, activities of daily living and clinical parameters. Statistical analysis included descriptive statistics and correlations, using the spearman correlation coefficient and chi-square test to test for significance.

RESULTS

Data from 101 patients (79.9±4.0 years; 63% male) were analyzed. The mean CFS score was 3.2±1.4; 41.6% were defined as frail (CFS≥4). The mean time required to assess the CFS was 0.20 minutes. The findings show that CFS correlates significantly (p<0.001) with the following factors: Katz-Index, HGS, SPPB-Score and 6MWT (r≤-0.575). In addition, CFS correlated with small to moderate effects with co-morbidities (r=0.250), as-needed medications and need for nursing assistance (r≤0.248).

CONCLUSIONS

The CFS assessment can be performed in under one minute and it correlates significantly with assessments of functional capacity, activities of daily living and clinical parameters in the CR setting.

TRIAL REGISTRATION

German Clinical Trials Register (DRKS; http:// www. drks. de; DRKS00032256). Retrospectively registered on 13 July 2023.

Prognostic value of defining characteristics in frail elderly syndrome: Hospital readmission and mortality outcomes

OBJECTIVE

To identify the most relevant clinical characteristics of the nursing diagnosis frail elderly syndrome (FES) in hospitalized patients aged 65 or older and analyze their impact on 9-month mortality and hospital readmission.

METHODS

A prospective and prognostic accuracy study was conducted in patients aged 65 or older, who were admitted to hospital more than 24 h. A consecutive convenience sampling process was used. Assessment included defining characteristics (DCs) of FES, clinical fraility scale (CFS), frail scale (FS), and 9-month mortality and hospital readmission. Statistical tests were used to verify associations between variables. Binary logistic regression analysis and area under the curve were used, to identify significant predictors for the outcomes and evaluate the prognostic accuracy of the DCs.

FINDINGS

This study involved 150 patients. CFS scored 65 patients (43.3%, confidence interval 95% 35.2% a 51.6) as frail and proved a prognostic value of mortality at 9 month from pre-frail state (p = 0.020). The mean number of DCs for FES nursing diagnosis was 6.35 (SD = 3.14). Validated tools for measuring frailty were associated with all DCs, excepting nutritional imbalance: below body needs. The hospital readmission during the following 9 months was only statistically related to memory impairment (p = 0.07).

CONCLUSION

Clinical frailty scale showed good results as a predictor of mortality. The study suggests exploring including it, in clinical manifestations of elderly frail syndrome. This study found that only memory impairment defining characteristic was predictive of hospital readmission. Further research should identify other relevant and prognostic clinical manifestations.

IMPLICATION FOR NURSING PRACTICE

These findings highlight the importance of being vigilant on cognitive decline during hospital admissions. The most prevalent and determinant DCs identified in this study indicate that clinical should focus on preserving functional and mental abilities as well as mobility.

Genetic and phenotypic associations of frailty with cardiovascular indicators and behavioral characteristics

INTRODUCTION

Frailty Index (FI) is a common measure of frailty, which has been advocated as a routine clinical test by many guidelines. The genetic and phenotypic relationships of FI with cardiovascular indicators (CIs) and behavioral characteristics (BCs) are unclear, which has hampered ability to monitor FI using easily collected data.

OBJECTIVES

This study is designed to investigate the genetic and phenotypic associations of frailty with CIs and BCs, and further to construct a model to predict FI.

METHOD

Genetic relationships of FI with 288 CIs and 90 BCs were assessed by the cross-trait LD score regression (LDSC) and Mendelian randomization (MR). The phenotypic data of these CIs and BCs were integrated with a machine-learning model to predict FI of individuals in UK-biobank. The relationships of the predicted FI with risks of type 2 diabetes (T2D) and neurodegenerative diseases were tested by the Kaplan-Meier estimator and Cox proportional hazards model.

RESULTS

MR revealed putative causal effects of seven CIs and eight BCs on FI. These CIs and BCs were integrated to establish a model for predicting FI. The predicted FI is significantly correlated with the observed FI (Pearson correlation coefficient = 0.660, P-value = 4.96 × 10-62). The prediction model indicated "usual walking pace" contributes the most to prediction. Patients who were predicted with high FI are in significantly higher risk of T2D (HR = 2.635, P < 2 × 10-16) and neurodegenerative diseases (HR = 2.307, P = 1.62 × 10-3) than other patients.

CONCLUSION

This study supports associations of FI with CIs and BCs from genetic and phenotypic perspectives. The model that is developed by integrating easily collected CIs and BCs data in predicting FI has the potential to monitor disease risk.

Biomarkers of frailty

Several biomarkers have been proposed to identify frailty, a multisystemic age-related syndrome. However, the complex pathophysiology and the absence of a consensus on a comprehensive and universal definition make it challenging to pinpoint a singular biomarker or set of biomarkers that conclusively characterize frailty. This review delves into the main laboratory biomarkers, placing special emphasis on those associated with various pathways closely tied to the frailty condition, such as inflammation, oxidative stress, mitochondrial dysfunction, metabolic and endocrine alterations and microRNA. Additionally, we provide a summary of different clinical biomarkers encompassing different tools that have been proposed to assess frailty. We further address various imaging biomarkers such as Dual Energy X-ray Absorptiometry, Bioelectrical Impedance analysis, Computed Tomography and Magnetic Resonance Imaging, Ultrasound and D3 Creatine dilution. Intervention to treat frailty, including non-pharmacological ones, especially those involving physical exercise and nutrition, and pharmacological interventions, that include those targeting specific mechanisms such as myostatin inhibitors, insulin sensitizer metformin and with special relevance for hormonal treatments are mentioned. We further address the levels of different biomarkers in monitoring the potential positive effects of some of these interventions. Despite the availability of numerous biomarkers, their performance and usefulness in the clinical arena are far from being satisfactory. Considering the multicausality of frailty, there is an increasing need to assess the role of sets of biomarkers and the combination between laboratory, clinical and image biomarkers, in terms of sensitivity, specificity and predictive values for the diagnosis and prognosis of the different outcomes of frailty to improve detection and monitoring of older people with frailty or at risk of developing it, being this a need in the everyday clinical practice.

Relationship of endogenous plasma concentrations of β-hydroxy β-methyl butyrate (HMB) with frailty in community dwelling older adults with type-2 diabetes mellitus

BACKGROUND

Supplementation with β-hydroxy β-methyl butyrate (HMB) appears to be effective in preserving muscle in older adults. However, the association between endogenously produced HMB with frailty has not been studied in people with chronic disease.

OBJECTIVES

The purpose of this study is to explore whether an association exists between endogenous HMB levels and frailty status in older adults with type-2 diabetes mellitus (T2DM).

METHODS

Data were taken from the Toledo Study of Healthy Ageing, a community-dwelling aged (65 years+) cohort. Frailty was assessed at baseline and at 2.99 median years according to the Frailty Phenotype (FP) standardized to our population and the Frailty Trait Scale 12 (FTS12). The associations between HMB levels and frailty were assessed using three nested multivariate logistic regressions and segmented by sex. Glucose, HMB and glucose interaction, age and body composition were used as covariables.

RESULTS

255 participants (mean age 75.3 years, 52.94% men) were included. HMB levels showed an inverse cross-sectional association with frailty, which was modified when the interaction term HMB*glucose was included, remaining significant only for FTS12 [OR (95% CI): 0.436 (0.253, 0.751), p-value 0.003]. The association between HMB endogenous levels and FTS12 appears to be independent of sex, in which the association was maintained after adjusting for the covariates. However, there appears to be threshold points for glucose levels, above which the protective effect of HMB is lost: 145.4 mg/dl adjusted by gender for the whole sample and 149.6 mg/dl and 138.9 mg/dl for men and women, respectively. Endogenous HMB levels were not found to be associated with incident frailty.

CONCLUSIONS

Cross-sectional analysis revealed that endogenous HMB levels were inversely associated with frailty as assessed by the FTS12 in older people with T2DM. This association was found to be dependent on circulating fasted glucose levels.

Prevalence and population characteristics associated with frailty in a rural low socioeconomic area in Denmark: the Lolland-Falster Health Study

BACKGROUND

Frailty is a major geriatric syndrome that predicts increased vulnerability to minor stressor events and adverse outcomes such as falls, fractures, disability and death. The prevalence of frailty among individuals above the age of 65 varies widely with an overall weighted prevalence of 10.7%.

OBJECTIVES

The purpose of this study was to examine the prevalence of prefrailty and frailty in community-dwelling older adults from the regions of Lolland-Falster, which is one of the most socioeconomically disadvantaged areas of Denmark with lower income and lower life expectancy compared with the general Danish population. Moreover, the objective was to find selected individual characteristics associated with frailty.

DESIGN

An observational, cross-sectional registry-based population study with data from the regions of Lolland-Falster collected between February 2016 and February 2020.

RESULTS

The study included 19 000 individuals. There were 10 154 above the age of 50 included for analysis. Prevalence of frailty in the age group of 50-64 years was 4.7% and 8.7% in the age group of 65 years and above.The study demonstrates associations between frailty and high age, female gender, low education level, low income, smoking, living alone, frequency of seeing one's children and getting help when needed. These associations are comparable with findings from other studies.

CONCLUSION

The syndrome of frailty consists of not only physiological and medical issues but also education, life conditions such as living alone and living in poverty and how you evaluate your own health.

Association between the frailty index and readmission risk in hospitalised elderly Chinese patients: a retrospective cohort study

OBJECTIVES

Frailty is a common and important concern of the ageing population. This study examined the association between the frailty index and negative outcomes of hospitalised elderly Chinese patients.

DESIGN

Retrospective cohort study.

SETTING

Geriatrics Department of Peking University First Hospital.

PARTICIPANTS

470 hospitalised elderly patients.

MAIN OUTCOMES AND MEASURES

Frailty was measured using a 30-item deficit-accumulation frailty index. The outcomes were the hospitalisation duration and readmission.

RESULTS

The frailty index was available for 470 patients: 72 (15.32%) were categorised as robust, 272 (57.87%) as prefrail and 126 (26.81%) as frail. The frail group had a longer hospital stay than the robust and prefrail groups. After adjustment for age, sex and cause of hospitalisation at baseline, frailty remained a strong independent risk factor for all-cause readmission and cardiocerebrovascular disease readmission (HR 2.41, 95% CI 1.49 to 3.91, p<0.001; HR 4.92, 95% CI 1.47 to 6.31, p<0.001, respectively).

CONCLUSIONS

The frailty index predicted a longer length of stay and higher all-cause and cardiocerebrovascular disease readmission risk in hospitalised elderly patients.

Effectiveness of a randomized intervention by a geriatric team in frail hospital inpatients in non-geriatric settings: FRAILCLINIC project

BACKGROUND

Little research has been undertaken on the benefits of frailty management within different hospital settings. The objective of this study is to provide evidence on the viability and effectiveness of frailty management in non-geriatric hospital settings on mortality and functional decline after discharge.

METHODS

Data from the FRAILCLINIC (NCT02643069) study were used. FRAILCLINIC is a randomized controlled trial developed in non-geriatric hospital inpatient settings (emergency room, cardiology and surgery) from Spain (2), Italy (2) and the United Kingdom (1). Inpatients must met frailty criteria (according to the Frailty Phenotype and/or FRAIL scale), ≥75 years old. The control group (CG) received usual care. The intervention group (IG) received comprehensive geriatric assessment (CGA) and a coordinated intervention consisting in recommendations to the treating physician about polypharmacy, delirium, falls, nutrition and physical exercise plus a discharge plan. The main outcomes included functional decline (worsening ≥5 points in Barthel Index) and mortality at 3 months. We used multivariate logistic regression models adjusted by age, gender and the Charlson index. Intention-to-treat (ITT) and per-protocol (PP) analyses were used.

RESULTS

Eight hundred twenty one participants (IG: 416; mean age 83.00 ± 4.91; 51.44% women; CG: 405; mean age 82.46 ± 6.03; 52.35% women) were included. In the IG, 77.16% of the participants followed the geriatric team's recommendations as implemented by the treating physicians. The intervention showed a benefit on functional decline and mortality [OR: 0.67(0.47-0.96), P-value 0.027 and 0.29(0.14-0.57), P-value < 0.001, respectively) when fully followed by the treating physician. A trend to benefit (close to statistical significance) in functional decline and mortality were also observed when any of the recommendations were not followed [OR (95% CI): 0.72 (0.51-1.01), P-value: 0.055; and 0.64 (0.37-1.10), P-value: 0.105, respectively].

CONCLUSIONS

An individualized intervention in frail in-patients reduces the risk of functional deterioration and mortality at 3 months of follow-up when a care management plan is designed and followed.

Association between endogenous plasma beta-hydroxy-beta-methylbutyrate levels and frailty in community-dwelling older people

BACKGROUND

Frailty is a key element in healthy ageing in which muscle performance plays a main role. Beta-hydroxy-beta-methylbutyrate (HMB) supplementation has shown favourable effects in modulating protein synthesis, improving muscle mass and function in interventional studies. Decreased age-related endogenous HMB levels have been shown in previous studies. The aim of the present study is to assess whether there is an association between endogenous plasma HMB levels and frailty.

METHODS

Data from 1290 subjects (56.98% women; mean ± standard deviation age 74.6 ± 5.95 years) from the Toledo Study for Healthy Aging were obtained. Participants had their frailty status qualified according to Fried's Frailty Phenotype (FFP) score and the Frailty Trait Scale in its 12-domain version (FTS-12). Plasma HMB levels were analysed by an ultrahigh-performance liquid chromatography tandem mass spectrometry. Differences between groups (frail vs. non-frail) were tested using Mann-Whitney U test, Kruskal-Wallis test and chi-squared test. The association between HMB and frailty was assessed by multivariate linear and logistic regressions when frailty was analysed as continuous and binary, respectively. Models were adjusted by age, gender, comorbidity, body composition and protein intake.

RESULTS

HMB levels were lower in those aged ≥75 years than in those aged 65-74 years, with an inverse linear relationship between age and HMB levels (β = -0.031; P = 0.018), mainly accounted by males (β = -0.062; P = 0.002). HMB levels were higher in men (0.238 ± 0.065 vs. 0.193 ± 0.051 ng/mL; P ≤ 0.001). HMB levels were significantly lower in frail than in non-frail individuals: 0.204 ± 0.058 versus 0.217 ± 0.063 ng/dL (P = 0.001) according to the FFP and 0.203 ± 0.059 versus 0.219 ± 0.063 ng/mL (P < 0.001) according to FTS-12. These differences showed a dose-dependent profile when we compared them by quintiles of HMB (P for trend: 0.022; 0.012 and 0.0004, respectively, for FFP, FTS-12 binary and FTS-12 continuous). Variables associated with low HMB levels were body mass index, strength, exhaustion and weight loss. Frailty was associated with HMB levels in all the adjusted models, including the fully adjusted ones, no matter the tool used (odds ratio: 0.45 [0.26, 0.77] for FFP and 0.36 [0.20, 0.63] for FTS-12 binary; β = -4.76 [-7.29, -2.23] for FTS-12 score). This association was also observed when the analyses were done by quintiles, showing such association since Q4 (FFP), Q2 (FTS-12 binary) and Q3 (FTS-12 score). The associations were observed in the whole sample and in each gender.

CONCLUSIONS

There is an inverse association between HMB levels and frailty status. These findings support the design of targeted clinical trials to evaluate the effect of HMB supplementation in older frail people with low HMB levels.

Frailty and Survivability of Polish Caucasian Nonagenarians and Centenarians

Frailty is a major geriatric problem leading to an increased risk of disability and death. Prevention, identification, and treatment of frailty are important challenges in gerontology and public health. The study aimed to estimate the prevalence of the frailty phenotype (FP) among the oldest-old Polish Caucasians and investigate the relationship between the FP and mortality. Baseline data were collected from 289 long-lived individuals, including 87 centenarians and 202 subjects aged 94-99. Mortality was obtained from population registers over the following 5 years. Sixty percent of subjects were classified as frail, 33% as prefrail, and 7% as robust. Frailty was more common in women than men and among centenarians than nonagenarians. During the 5-year observation period, 92.6% of the frail women and all frail men died, while mortality rates were lower among prefrail, 78.8% and 66.7%, and robust individuals, 60% and 54.5%, respectively. In the survival analysis, frailty was the strongest negative risk factor: HR = 0.328 (95% CI: 0.200-0.539). The inability to perform handgrip strength measurement was an additional predictor of short survival. In conclusion, the FP is prevalent in nonagenarians and centenarians and correlates with lower survivability. Future studies should address differences between unavoidable age-associated frailty and reversible disability in long-lived individuals.

The Prevalence of the Frailty Syndrome in a Hospital Setting-Is Its Diagnosis a Challenge? A Comparison of Four Frailty Scales in a Cross-Sectional Study

The study aimed to assess the prevalence of the frailty syndrome in older patients hospitalized in the geriatric ward depending on the diagnostic criteria used, the feasibility of particular diagnostic scales in hospitalized patients, and their compatibility; 416 patients (81.2 ± 6.91 years) admitted to the Department of Geriatrics of Hospital of the Ministry of the Interior and Administration in Bialystok within eight months were included in the study. Four diagnostic scales were used to identify the frailty syndrome: Fried criteria, 7-point Clinical Frailty Scale (CFS), 40-item Frailty Index (FI), and FRAIL Scale. Depending on the scale, the prevalence of frailty syndrome varied from 26.8% (FRAIL Scale), 52.3% (Clinical Frailty Scale), and 58.1% (Fried criteria) up to 62.9% (Frailty Index). We observed the highest feasibility for CFS (100%) and the lowest for the Fried scale (79.8%). The highest level of agreement was found between the CFS and Frailty Index, with 80.3% consistent ratings (Cohen Kappa 0.6). Patients in the geriatric ward are characterized by a high prevalence of frailty, although it differs depending on the criteria. The most difficult to use in daily practice was the Fried scale, while the Clinical Frailty Scale was determined feasible in all patients.

A Narrative Review of the Utilisation of the SHARE Frailty Instruments (SHARE-FI and SHARE-FI75+) in the Literature

This narrative literature review aimed to examine the utilisation of the Survey of Health, Ageing and Retirement in Europe (SHARE) frailty instruments: SHARE-FI and SHARE-FI75+. We used the Google Scholar "cited by" function (accessed on February 20th, 2023) to identify all citations of the original SHARE-FI and SHARE-FI75+ studies. Included articles were categorised into four themes: epidemiological studies (prevalence and associated factors); associations with geriatric syndromes, diseases and health outcomes; randomised clinical trials (RCTs); and expert consensus and practice guidelines. Of 529 articles screened (446 citing SHARE-FI and 83 citing SHARE-FI75+), 64 (12.1%) were included. Sixteen (25.0%) were epidemiological; 35 (54.7%) described associations; 10 (15.6%) were RCTs; and 3 (4.7%) were expert consensus or practice guidelines. Frailty was associated with older age; female sex; higher morbidity; lower education; social isolation; worse nutrition and mobility; rheumatological, cardiovascular, and endocrine diseases; and greater healthcare utilisation and mortality. SHARE-FI was used in RCTs as entry criterion, controlling variable, and intervention outcome. SHARE-FI and SHARE-FI75+ have been recommended to aid the management of atrial fibrillation anticoagulation and hypertension, respectively. SHARE-FI and SHARE-FI75+, two open access phenotypical frailty measurement tools, have been utilised for a range of purposes, and mostly in epidemiological/associational studies.

New perspectives on frailty in light of the Global Leadership Initiative on Malnutrition, the Global Leadership Initiative on Sarcopenia, and the WHO's concept of intrinsic capacity: A narrative review

This review gathered the evidence on the epidemiology of frailty, as well as on screening and diagnostic tools, and new perspectives, in light of the latest global frameworks in malnutrition, sarcopenia, and the World Health Organization's concept of intrinsic capacity. Frailty is a worldwide health challenge and highly prevalent in older adults and the population with chronic diseases independent of age. Regardless of the particular concept of frailty, many screening and diagnostic tools are able to identify frailty in older people, but none of them has shown superiority in every population and healthcare setting. Physical, cognitive, and social components are part of the larger context of frailty. The latest evidence-based initiatives on frailty recommend the use of validated tools to identify frailty's different components, tailored to the needs of specific populations and healthcare systems. Unintentional weight loss is a shared criterion between physical frailty and malnutrition according to the Global Leadership Initiative on Malnutrition criteria. A new definition of sarcopenia by the Global Leadership Initiative on Sarcopenia is awaited, but at present physical frailty shares with sarcopenia the criteria of low muscle function and physical performance (severity grading) according to the revised consensus of the European Working Group on Sarcopenia in Older People (EWGSOP2). The EWGSOP2 includes both muscle mass and function, with most scientific groups agreeing that function is a key hallmark of sarcopenia. The concept of intrinsic capacity features the reserves and positive aspects of aging, and responds to ageism by addressing the deficit model approach. Intrinsic capacity is an emerging, person-centered and public health indicator, aimed at preserving health at mid-life and beyond, to move towards a better aging process in the Decade of Healthy Aging 2020-2030.

Association of frailty index with congestive heart failure, all-cause and cardiovascular mortality among individuals with type 2 diabetes: a study from National Health and Nutrition Examination Surveys (NHANES), 1999-2018

BACKGROUND

Both type 2 diabetes mellitus (T2DM) and frailty are strongly associated with congestive heart failure (CHF). Individuals with T2DM and CHF have a high frailty burden. The association of frailty with HF, all-cause, and cardiovascular mortality in patients with T2DM has not been thoroughly explored.

METHODS

This study included 2894 adults with T2DM from the National Health and Nutrition Examination Survey (NHANES) database over ten cycles (1999-2018) and followed up for all-cause and cardiovascular mortality through 31 December 2019. The frailty index (FI) was calculated using a 46-item deficit model to assess frailty status. Weighted multivariable logistic regression was performed to explore the relationship between frailty and CHF in patients with T2DM. Weighted restricted cubic splines were used to evaluate the non-linear relationship between FI and outcome. All-cause mortality and cardiovascular mortality association with FI was assessed using the Kaplan-Meier curve and COX proportional hazards regression accounting for sampling weights. Subgroup and sensitivity analyses were performed to evaluate the robustness of the results.

RESULTS

After the adjustment of essential confounders, a higher frailty index in T2DM was associated with increased odds of CHF (odds ratio [OR] for per 1-SD increase, 2.02, 95% confidence interval [CI] 1.67-2.45; P < 0.0001). The presence of frailty T2DM (OR, 3.60; 95% CI 2.34-5.54; P < 0.0001) was associated with a significant increase in the prevalence of CHF compared to non-frailty T2DM in a fully adjusted model. During the median follow-up of 6.75 years, per 1-SD increase in FI was associated with a 41% higher risk of all-cause mortality and a 30% higher risk of cardiovascular mortality after being adjusted for all confounders. Similar results were observed when sensitivity analyses were performed. There was also a non-linear relationship between FI and all-cause mortality. In a weighted multivariate COX proportional model adjusted for full confounders, frailty T2DM increased all-cause (HR, 1.86; 95% CI 1.55-2.24; P < 0.0001) and cardiovascular (HR 1.66; 95% CI 1.18-2.33; P = 0.003) mortality and compared to non-frailty T2DM. The positive association of frailty index and all-cause mortality was only in participants without CHF. The positive association of frailty index and cardiovascular mortality was only in non-anti-diabetic drug users.

CONCLUSIONS

Frailty index in T2DM was positively associated with CHF in linear fashions. The Frailty index was positively correlated with all-cause and cardiovascular death in patients with T2DM. Frailty T2DM was positively associated with CHF, all-cause mortality, and cardiovascular mortality compared to non-frailty T2DM. Promoting frailty measurement and management in T2DM may be beneficial to reduce the burden of CHF and mortality.

The Impact of Glucose-Lowering Strategy on the Risk of Increasing Frailty Severity among 49,519 Patients with Diabetes Mellitus: A Longitudinal Cohort Study

Patients with diabetes mellitus (DM) have a higher risk of incident and aggravating frailty over time. Frailty-initiating risk factors have been identified, but modulators of frail severity over time remain poorly defined. We aimed to explore the influences of glucose-lowering drug (GLD) strategy on DM patients' risk of increasing frail severity. We retrospectively identified type 2 DM patients between 2008 and 2016, dividing them into "no GLD", oral GLD (oGLD) monotherapy, oGLD combination, and those receiving insulin without or with oGLD at baseline. Increasing frail severity, defined as ≥1 FRAIL component increase, was the outcome of interest. Cox proportional hazard regression was utilized to analyze the risk of increasing frail severity associated with GLD strategy, accounting for demographic, physical data, comorbidities, medication, and laboratory panel. After screening 82,208 patients with DM, 49,519 (no GLD, 42.7%; monotherapy, 24.0%; combination, 28.5%; and insulin user, 4.8%) were enrolled for analysis. After 4 years, 12,295 (24.8%) had increasing frail severity. After multivariate adjustment, oGLD combination group exhibited a significantly lower risk of increasing frail severity (hazard ratio (HR) 0.90, 95% confidence interval (CI) 0.86 - 0.94), while the risk of insulin users increased (HR 1.11, 95% CI 1.02 - 1.21) than no GLD group. Users receiving more oGLD exhibited a trend of less risk reduction relative to others. In conclusion, we discovered that the strategy of oral glucose lowering drugs combination might reduce the risk of frail severity increase. Accordingly, medication reconciliation in frail diabetic older adults should take into account their GLD regimens.

Implementation and Core Components of a Multimodal Program including Exercise and Nutrition in Prevention and Treatment of Frailty in Community-Dwelling Older Adults: A Narrative Review

Increasing disability-free life expectancy is a crucial issue to optimize active ageing and to reduce the burden of evitable medical costs. One of the main challenges is to develop pragmatic and personalized prevention strategies in order to prevent frailty, counteract adverse outcomes such as falls and mobility disability, and to improve quality of life. Strong evidence reports the effectiveness of exercise interventions to improve various physical parameters and muscle function that are cornerstones of frailty. Other findings also suggest that the interactions between nutrition and physical exercise with or without health behavior promotion prevent the development of frailty. Multimodal programs, including structured exercise, adequate dietary intervention and health behavior promotion, appear increasingly consensual. However, in order for implementation in real-life settings, some pitfalls need to be addressed. In this perspective, structuring and tailoring feasible, acceptable and sustainable interventions to optimize exercise training responses are essential conditions to warrant short, medium and long-term individual benefits. The different components of exercise programs appear to be fairly consensual and effective. However, specific composition of the programs proposed (frequency, intensity, type, time, volume and progressiveness) have to be tailored to individual characteristics and objectives in order to improve exercise responses. The intervention approaches, behavioral strategies and indications for these programs also need to be refined and framed. The main objective of this work is to guide the actions of healthcare professionals and enable them to widely and effectively implement multimodal programs including exercise, nutrition and behavioral strategies in real-life settings.

Very Elderly Patients With Atrial Fibrillation Treated With Edoxaban: Impact of Frailty on Outcomes

Background

Age and frailty are associated with underuse of anticoagulation in elderly patients with atrial fibrillation (AF).

Objectives

This study aimed at assessing major clinical outcomes in very elderly patients with AF treated with recommended dose edoxaban and look for a possible relation with frailty measured by a validated score.

Methods

This prospective multicenter cohort study enrolled consecutive very elderly (age ≥80 years) anticoagulation-naïve patients starting recommended doses of edoxaban. Upon entry into the study, patients were categorized into nonfrail, prefrail and frail with the SHARE-FI (Survey of Health, Ageing, and Retirement in Europe-Frailty Index) score. The primary outcome was a composite incidence of stroke/systemic embolism, major bleeding, clinically relevant nonmajor bleeding, and death between frail and fitter patients over 2 years follow-up. Secondary outcomes were frailty-related incidence of the individual components part of the composite outcome.

Results

Of the 180 screened patients, 176 were enrolled in the study. Of these, 58 (32.9%) were frail, 35 (19.8%) prefrail, and 83 (47.2%) nonfrail. The composite outcome occurred in 49 patients (18.9% per patient-year). No difference in the primary endpoint between frail and fitter patients (incidence rate ratio: 1.2; 95% CI: 0.6-2.2) was observed. On multivariable analysis, anemia was significantly related to the primary outcome (HR: 3.6; 95% CI: 1.8-7.3; P < 0.001), while frailty was not (frail vs nonfrail HR: 0.9; 95% CI: 0.5-1.8). No difference across frailty categories of the individual components of composite events was observed, except for death.

Conclusions

Anticoagulation with recommended dose edoxaban is feasible in very elderly patients with AF even if frail. (ESCAPE [Edoxaban and Frailty in Senior Individuals]; NCT03524924).

Association Between Pulse Wave Velocity and Frailty, Disability, and Mortality in Community-Dwelling Older Adults

Background

Arterial stiffness leads to several adverse events in the older population, but there is a lack of data on its association with frailty, disability, and mortality in the same population.

Objectives

The purpose of this study was to evaluate the role of arterial stiffness in the loss of functional ability (frailty and disability) and mortality.

Methods

Data were taken from community-dwelling aged 65 years participants without diabetes in the Toledo Study of Healthy Ageing cohort. Pulse wave velocity (PWV), assessed through SphygmoCor, was recorded at baseline. Median follow-up time were 2.99 years for frailty (frailty phenotype [FP] and Frailty Trait Scale-5 [FTS5]) and disability (Katz Index) and 6.2 for mortality. Logistic regressions models were built for disability and frailty and Cox proportional hazards model for death, adjusted by age and sex, comorbidity, cardiovascular risk factors, asymmetric dimethylarginine levels, and polypharmacy.

Results

Overall, 978 (mean age 74.5 ± 5.6 years, 56.7% female) participants were included. Different cut-off points were shown for each outcome. PWV >11.5 m/s was cross-sectionally associated with frailty (FP: OR fully-adjusted model: 1.69, 95% CI: 1.45-1.97; FTS5: OR: 1.51, 95% CI: 1.22-1.87) and disability (OR: 1.51, 95% CI: 1.26-1.79); PWV >10 m/s with incident frailty by FP (OR: 1.36, 95% CI: 1.10-1.68) and FTS5 (OR: 1.40, 95% CI: 1.12-1.75), and PWV >11 m/s with death (HR: 1.28, 95% CI: 1.09-1.50). For incident (OR: 1.28, 95% CI: 1.06-1.55) and worsening disability (OR: 1.21, 95% CI: 1.02-1.45) the threshold was 12.5 m/s. Below these cut-off points, age was the best predictor of adverse outcomes.

Conclusions

Arterial stiffness predicts frailty, disability, and mortality in older people, with different cut-off points, ie,severity degrees, for each of the assessed outcomes.

The role of frailty in advanced HF and cardiac transplantation

Frailty is a complex, multi-system condition often associated with multimorbidity. It has become an important prognostic maker across a range of conditions and is particularly relevant in patients with cardiovascular disease. Frailty encompasses a range of domains including, physical, psychological, and social. There are currently a range of validated tools available to measure frailty. It is an especially important measurement in advanced HF, because frailty occurs in up to 50% of HF patients and is potentially reversible with therapies such as mechanical circulatory support and transplantation. Moreover, frailty is dynamic, and therefore serial measurements are important. This review delves into the measurement of frailty, mechanisms, and its role in different cardiovascular cohorts. Understanding frailty will help determine patients that will benefit from therapies, as well as prognosticate outcomes.

Sex Differences in Frailty Factors and Their Capacity to Identify Frailty in Older Adults Living in Long-Term Nursing Homes

Frailty is a phenomenon that precedes adverse health events in older people. However, there is currently no consensus for how to best measure frailty. Several studies report that women have a higher prevalence of frailty than men, but there is a gap in studies of the high rates of frailty in older people living in long-term nursing homes (LTNHs) stratified by sex. Therefore, we analyzed health parameters related to frailty and measured their capacity to identify frailty stratified by sex in older people living in LTNHs. According to the Fried Frailty Phenotype (FFP), anxiety increased the risk of frailty in women, while for men functionality protected against the risk of frailty. Regarding the Tilburg Frailty Indicator (TFI), functionality had a protective effect in men, while for women worse dynamic balance indicated a higher risk of frailty. The analyzed parameters had a similar capacity for detecting frailty measured by the TFI in both sexes, while the parameters differed in frailty measured by the FFP. Our study suggests that assessment of frailty in older adults should incorporate a broad definition of frailty that includes not only physical parameters but also psycho-affective aspects as measured by instruments such as the TFI.

Development and validation of retrospective electronic frailty index using operational data of aged care homes

Background

Although elderly population is generally frail, it is important to closely monitor their health deterioration to improve the care and support in residential aged care homes (RACs). Currently, the best identification approach is through time-consuming regular geriatric assessments. This study aimed to develop and validate a retrospective electronic frailty index (reFI) to track the health status of people staying at RACs using the daily routine operational data records.

Methods

We have access to patient records from the Royal Freemasons Benevolent Institution RACs (Australia) over the age of 65, spanning 2010 to 2021. The reFI was developed using the cumulative deficit frailty model whose value was calculated as the ratio of number of present frailty deficits to the total possible frailty indicators (32). Frailty categories were defined using population quartiles. 1, 3 and 5-year mortality were used for validation. Survival analysis was performed using Kaplan-Meier estimate. Hazard ratios (HRs) were estimated using Cox regression analyses and the association was assessed using receiver operating characteristic (ROC) curves.

Results

Two thousand five hundred eighty-eight residents were assessed, with an average length of stay of 1.2 ± 2.2 years. The RAC cohort was generally frail with an average reFI of 0.21 ± 0.11. According to the Kaplan-Meier estimate, survival varied significantly across different frailty categories (p < 0.01). The estimated hazard ratios (HRs) were 1.12 (95% CI 1.09–1.15), 1.11 (95% CI 1.07–1.14), and 1.1 (95% CI 1.04–1.17) at 1, 3 and 5 years. The ROC analysis of the reFI for mortality outcome showed an area under the curve (AUC) of ≥0.60 for 1, 3 and 5-year mortality.

Conclusion

A novel reFI was developed using the routine data recorded at RACs. reFI can identify changes in the frailty index over time for elderly people, that could potentially help in creating personalised care plans for addressing their health deterioration.

[Effectiveness and efficiency of acute geriatric units: A classic topic revisited]

Previous meta-analyses have shown that the hospital admission of older patients in acute geriatric units (AGU) compared to admission to other conventional units, significantly reduced the risk of functional deterioration during hospitalization, increasing the possibility of returning home, with an added reduction in cost of hospitalization. A new meta-analysis on the subject has recently been published in Age and Aging, which adds six new studies to the five clinical trials analyzed in previous meta-analyses. This article analyzes the results of this new meta-analysis, delving into the characteristics of the new studies included and making some considerations on the implications for care in the future development of AGU.

Frailty as a Predictor of Poor Rehabilitation Outcomes among Older Patients Attending a Geriatric Day Hospital Program: An Observational Study

Background: The Geriatric Day Hospital (GDH) is an important outpatient geriatric service, but there are few data on the role of frailty as a potential predictor of poor outcomes in this setting. Methods: Data were analyzed from 499 patients aged ≥ 60 years attending a 12-week GDH program between 2018 and 2021. Frailty status was defined as non-frail (68, 13.6%), mild/moderate frailty (351, 70.3%), and severe frailty (80, 16.0%) based on the Clinical Frailty Scale (CFS). Outcomes were defined as (1) poor outcome (hospital readmission, death, or medical deterioration) during the program and (2) admission to permanent nursing home care upon completion of the program. Multivariate logistic models were used for predictive analyses. Results: The mean age was 80.3 (standard deviation 7.0); 58.3% were women. Overall, 77 patients (15.4%) had a poor outcome, and 48 (9.6%) were admitted to permanent nursing home care. Poor outcome was experienced by none of the non-frail patients (0%), by 49 (14.0%) patients with mild/moderate frailty, and 22 (27.5%) patients with severe frailty (adjusted OR, 2.0; 95% CI 1.3, 3.2; p < 0.01). Admission to a permanent nursing home care was experienced by none of the non-frail patients (0%), 20 (5.7%) of those with mild/moderate frailty, and 28 (35.0%) with severe frailty (adjusted OR, 2.9; 95% CI 1.3, 6.3; p < 0.01). Conclusions: The CFS is a promising risk predictor of poor outcome and admission to permanent nursing home discharge among older patients attending a GDH program.